NColge - 1373 - Counselling Psychology

Introduction to Counseling
UNIT 1 INTRODUCTION TO COUNSELING and Characteristics of a

Counselor
AND CHARACTERISTICS OF A
COUNSELOR
Structure
1.0 Introduction
1.1 Objectives
1.2 Definition of Counseling
1.2.1 Counseling and Guidance
1.2.2 Characteristics of Guidance
1.2.3 Counseling and Psychotherapy
1.3 Halmark of a Counselor
1.4 Characteristics of a Counselor
1.4.1 Educational Qualities of a Counselor
1.4.2 Education and Training
1.4.3 Licensure
1.4.4 Other Qualifications
1.4.5 Certification and Advancement
1.4.6 Counselor and Values
1.5 Let Us Sum Up
1.6 Unit End Questions
1.7 Suggested Readings
1.0 INTRODUCTION
This unit deals with counsllor, counseling and guidance issues. We start with the
definition of Counseling and guidance and differentiate guidance from
counseling. Then we take up characteristics of counseling and guidance and
differentiate counseling from psychotherapy. Then we deal with the counsellor
and the important aspects of a cousnellor. Then we take up the characteristics of
a counsellor. We elucidate the typical training and educational qualifications to
make a person a counsellor and provide information regarding licensing of
counselors to practice both in India and other countries. Then we elucidate the
other qualifications of counselors, the certification and advancement in the field.
Then we deal with the values of the counselors and how they use the same in the
profession.
1.1 OBJECTIVES
After reading this unit, you will be able to:
• Describe the concept of counseling;
• Define counseling psychology;
• Explain the difference between counseling and guidance;
• Explain the role and characteristics of a counselor;
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Introduction • Describe the personal and academic qualification and training required of a
counselor; and
• Analyse the role of values in counseling.
1.2 DEFINITION OF COUNSELING

Counseling is distinguished from other mental health disciplines by both its history
and its emphasis. It focuses on development and the prevention of serious mental
health problems through education and short term treatments. It emphasises on
growth as well as remediation. It focuses on providing therapeutic treatments to
clients who experience a wide variety of symptoms. It is also one of the largest
specialty areas within psychology.
Counseling as a profession is relatively new. It grew out of the guidance

movement, in opposition to traditional psychotherapy. In order to understand
what counseling is, you must first understand these concepts.
Counseling is often performed face to face in confidential sessions between the

counselor and client(s). However, counselling can also be undertaken by
telephone, in writing and, in these days of the Internet, by email or video
conferencing. Counselling can and may take many different formats to bring a
person to a better understanding of himself and others. It can therefore be seen
that counselling can be of benefit to a person experiencing problems in finding,
forming, and maintaining relationships.
It is the ability to listen and respond in a way that will help others solve their own
problems and attain their potential. It is the art of helping others arrive at the
right answer by their own analysis of the situation and the facts. It has to be done
skillfully without an attempt to influence the values and beliefs of the client.
Counseling involves talking with a person in a way that helps the person solve
a problem or helps to create conditions that will cause the person to understand
and/or improve his behaviour, character, values or life circumstances. It is
a process that enables a person to sort out issues and reach decisions affecting
their life. Often counselling is sought out at times of change or crisis, however it
need not be so as counselling can also help us at any time of our life.
It emphasises on exploration and understanding the problem and stresses the

idea of professional relationship and the importance of self determined goals (of
course by the client). It should be differentiated from advice giving or directing.
It should be noted that counselling is a principled profession.
Biswalo (1996) defines counselling as a process of helping an individual to

accept and to use information and advice so that he/she can either solve his/her
present problem or cope with it successfully. Counselling depends heavily on
information.
According to British Association for Counseling and Psychotherapy (2002),

counseling takes place when a counselor sees a client in a private and confidential
setting to explore a difficulty a client is having, distress that the client may be
experiencing or perhaps the client’s dissatisfaction with life or loss of a sense or
direction and purpose.
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Both the American Counseling Association (ACA) and Division 17 of the Introduction to Counseling
and Characteristics of a
American Psychology Association have defined counseling on numerous Counselor
occasions. These definitions contain a number of common points, some of which
are as follows:
• Counseling is a profession.
• Counseling deals with personal, social, vocational empowerment, and
educational concerns.
• Counseling is conducted with persons who are considered to function within
the normal range.
• Counseling is theory based and takes place in a structured setting.
• Counseling is a process in which clients learn how to make decision and
formulate new ways of behaving, feeling and thinking.
• Counseling encompasses various subspecialties.
Now let us see how counseling is different from guidance.
1.2.1 Counseling and Guidance

Let us now see the difference between counseling and guidance. “Guidance is a
term used to denote the process of helping an individual to gain self understanding
and self direction (self decision making) so that he can adjust maximally to home,
schools or community environment.” (Biswalo, 1996).
Guidance is giving leadership, supervision, direction, or professional guidance

for future actions. Guidance has more to do with something that you are not sure
of or something that you don‘t know about and you have some one who is familiar
with explaining it to you while counselling has something do do with something
that you have trouble with.
Someone who provides guidance offers you suggestions how to explore various
alternatives. Counseling may also offer suggestions, but it also tries to teach you
methods for reaching your goals and can help you determine what your goals
are. In practice there may be no difference between the two, because it depends
how people practice each technique and how they interpret their skills
Guidance is pre problem, that is there is no specific problem that is identified in

an individual.
Counseling is post problem, meaning a problem has already been identified and
therefore the counselor helps to address the problem but not to solve it.
Counseling is not giving opinion, instruction or advice, it is using facilitative

listening and questioning to allow the client to choose the best solution for a
problem. Counseling is based on a wellness model rather than a medical model.
Authors such as Hershenson and Strein (1991); and Palmo, Shosh and Weikel
(2001) emphasised that counselors are concerned about the client’s environment
with a more global view than other professionals as well as a concern that goes
beyond treating dysfunction or pathology and dealing with the clients’ self-
awareness, personal growth, and wellness.
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Introduction Guidance refers to the act or process of guiding. Guidance is a type of counseling,
such as that provided for students seeking advice about vocational and educational
matters.
1.2.2 Characteristics of Guidance

Guidance is a continuous process such that it a regular service, which is required
at every stage for every person, not only for the problematic situations and
abnormal people. It is a positive program geared to meet the needs of all people.
It is needed right from early childhood, adolescence through adulthood and old
age.
It is both generalised and a specialised service. It is a generalised service because

teachers, lecturers, advisors, deans, parents and elders, all play a part in guidance.
It is a generic term as it includes information giving and research activities. It is

a specialised service because specially qualified personnel as counselors,
psychiatrists, psychologists join hands to help Individuals to adjust to the
environment.
Thus we see that guidance is more information oriented and addresses the
developmental issues. On the other hand, counseling is more remedial in nature,
aimed at helping the person deal with the problems and conflicts in his life.
1.2.3 Counseling and Psychotherapy

Psychotherapy, or personal counselling with a psychotherapist, is an intentional
interpersonal relationship used by trained psychotherapists to aid a client or patient
in problems of living. Traditionally it focuses on serious problems associated
with intrapsychic, internal, and personal issues and conflicts. Characteristically,
it emphasises the following issues:
• The past more than the present
• Insight more than change
• The detachment of the therapist
• The therapist’s role as an expert
Psychotherapy usually involves a long term relationship that focuses on
reconstructive change. It is provided in both outpatient and inpatient settings
whereas counseling deals with minor problems of daily living and is usually
provided in outpatient settings.
Self Assessment Questions

1) Define counseling.
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Introduction to Counseling
2) Discuss the difference between guidance and counseling. and Characteristics of a
Counselor
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3) What is the difference between psychotherapy and counseling?
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4) Discuss the characteristics of guidance.
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1.3 HALLMARKS OF A COUNSELLOR

Effective counseling is a two way street. It takes a cooperative effort by both the
person receiving counseling and the counselor and it takes a commitment to
make sometimes difficult changes in behaviour or thinking patterns.
The term counselor has numerous meanings. Most often it is used to describe
someone who is a therapist, which could mean a licensed clinical social worker,
a marriage and family counselor, a psychologist or even a psychiatrist who
conducts regular therapy sessions. Counselor is also a term used to describe
lawyers, who advocate for others in court or give legal advice, a person working
as a representative of a state, a person working at a children’s camp, at a school
to give academic advice, or for a church.
An effective counselor can identify negative thinking patterns such as feelings
of sadness, depression or anxiety. By encouraging you to build upon personal
strengths and suggesting skills that can overcome self inflicted feelings of
hopelessness, a counselor can help you develop a more positive attitude.
A good counselor can assist you in making positive changes in your relationships
with others, helping you recognise behaviours that may be contributing to a
troublesome relationship. Your counselor can teach you effective ways of
communicating, clearing the way for honest exchanges with people in your life
who may be causing you emotional pain. 9
Introduction Counselor skills would certainly include knowledge of the psychological theories
underpinning our understanding of the human experience. Without that
understanding, using the techniques proponents of a particular theory offer
becomes robotic, and can diminish a client’s experience of counseling. Counselor
must have an awareness of theories of personality and abnormal personality.
Counselor should be aware of multi-cultural issues.
1.4 CHARACTERISTICS OF A COUNSELOR

A counselor’s personality is a crucial ingredient in determining the effectiveness
of counseling. The skills needed for effective counseling are non-negotiable and
not open to compromise: all are necessary and when understood and internalised,
form the value base for our profession.
Effective counselling requires an understanding of self and a detailed awareness

of the impact of oneself on others.
A counselor needs to be equipped with advanced listening skills. They must be

able to recognise the various levels of empathy of their responses, (i.e. reflecting
an accurate understanding of the feeling being expressed by the client). It is
necessary to develop the ability to listen with an open mind, to refrain from
judgmental responses and to actively check with the client that the understanding
of the feelings being expressed is correct.
Counselling demands a process of negotiation and problem solving. A clear goal

needs to be set so that the client is able to take appropriate action in their own
life space and also to take responsibility for the consequences of their action.
Self disclosure is a powerful tool that can be used by an effective communicator

but when it is used within the constraints of the therapeutic encounter it needs to
be done with considerable care.
An understanding of the complexity of communication is a basic foundation

within the development of an effective counselling framework. An ability to
read, interpret and respond non-verbally is critical. The use of conscious use of
paralinguistic signals, postures and gestures to pace a distressed client for a sense
of greater emotional self-control are just some examples of skills required.
Counselling will generally use a conversational style. As Eric Berne pointed out
there is plenty left if you remove the solemn face and the big words. Counselors
need not be afraid of ordinariness.
The effective counsellor requires the skills of assertiveness and the ability to
confront a client when it is therapeutically appropriate.
Counsellors must be competent in their communication to be credible and must

be able to self- monitor – they must have the ability to concentrate their messages
so that they are immediate i.e. they relate to the here and now) and refer to
concrete interpersonal issues.
He or she has an internal source of motivation and drive and seeks growth instead
of external approval.
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Counselors must recognise the impact of their own personal values, attitudes Introduction to Counseling
and self- esteem. The effective counsellor must develop and use the ability to Counselor
model his or her behaviour for the client; this is one of the most potent media for
personal growth and change. This brings us to the all important question of values.
Confidentiality is the key of successful counseling. The ability to uphold a

therapist-patient relationship in which you do not talk about your clients outside
of your office or in a professional setting with your colleagues is required as a
practicing counselor. The American Counseling Association reminds that “clients
must be able to trust the counselor and have faith in the therapeutic relationship
if growth is to occur . . . the counselor must take care neither to threaten the
therapeutic relationship nor to leave obligations unfulfilled.”
The little time you spend with your client each week should allow him to feel he
can express his concerns and feelings without reservation. Whether you are in
school training towards your degree or you are running a private practice, you
should always respect your client’s privacy as if it were your own.
Empathy allows you to see the situation from the other person’s view. It provides
a grounding effect on the plan of action, ensuring that it is feasible and achievable
from the perspectives of the employer and employee.
Counselors achieve credibility by being honest and consistent in their statements

and actions.
Counselors take risks everyday and face rejection by their clients or face clients
or situations they may not be prepared to face.
He or she is not racist and does not discriminate against others who are different
from himself or herself.
He or she is not ego-centered but chooses to help others out of concern for others
and not for glorification of the self.
1.4.1 Educational Qualifications of a Counselor

Education and training requirements for counselors are often very detailed in the
Western countries and vary by State and specialty, but a master’s degree usually
is required to become a licensed counselor. Prospective counselors should check
with State and local governments, prospective employers, and national voluntary
certification organisations to determine which requirements apply.
1.4.2 Education and Training

Education requirements vary with the occupational specialty and State licensure
and certification requirements. A master’s degree usually is required to be licensed
or certified as a counselor. Counselor education programs in colleges and
universities often are found in departments of education, psychology, or human
services. Fields of study may include college student affairs, elementary or
secondary school counseling, education, gerontological counseling, marriage and
family therapy, substance abuse or addictions counseling, rehabilitation
counseling, agency or community counseling, clinical mental health counseling,
career counseling, and related fields. Courses frequently are grouped into core
areas, including human growth and development, social and cultural diversity,
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Introduction relationships, group work, career development, counseling techniques,
assessment, research and program evaluation, and professional ethics and identity.
In an accredited master’s degree program, 48 to 60 semester hours of graduate
study, including a period of supervised clinical experience in counseling, typically
are required.
Some employers provide training for newly hired counselors. Others may offer
time off or tuition assistance to complete a graduate degree. Often, counselors
must participate in graduate studies, workshops, and personal studies to maintain
their certificates and licenses.
The processes involved in the training of counselors are given below:
1) Ability to explain the micro skills.
2) Demonstrate the skills involved in commencing the counselling process.
3) Evaluation of non verbal responses and minimal responses.
4) Demonstrate reflection of content, feeling.
5) Demostrate the appropriateness of both content and feeling in the counselling
process.
6) Develop different questioning techniques.
7) Understand risks involved with some types of questioning.
8) Show how to use various micro skills including summarising, confrontation,
and reframing.
9) Demonstrate self destructive beliefs and show methods of challenging them,
including normalising.
10) Explain how counselling a client can improve their psychological well-being
through making choices, overcoming psychological blocks and facilitating
actions.
11) Demonstrate effective ways of terminating a counselling session and to
explain ways of addressing dependency.
As for the student trainees
1) They have to report on an observed counselling session, simulated or real.
2) Identify the learning methods available to the trainee counsellor.
3) Demonstrate difficulties that might arise when first learning and applying
micro skills.
4) Identify why trainee counsellors might be unwilling to disclose personal
problems during training.
5) Identify risks that can arise for trainee counsellors not willing to disclose
personal problems.
6) Discuss different approaches to modelling, as a form of counselling .
7) Evaluate verbal and non verbal communication in an observed interview.
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8) Identify the counsellor’s primary role (in a generic sense). Introduction to Counseling
9) Show how to use minimal responses as an important means of listening Counselor
with intent.
10) Explain the importance of different types of non verbal response in the
counselling procedure.
11) Report on the discussion of a minor problem with an anonymous person
which that problem relates to.
12) Identify an example of paraphrasing as a minimal response to reflect feelings.
13) Discuss the use of paraphrasing in counselling.
14) Differentiate catharsis from confused thoughts and feelings.
15) Identify an example of reflecting back both content (thought) and feeling in
the same phrase.
16) Demonstrate/observe varying responses to a variety of closed questions in a
simulated counselling situation.
17) Demonstrate/observe varying responses to a variety of open questions in a
simulated counselling situation.
18) Compare student’s use of open and closed questions in a counselling
situation.
19) Student should identify the main risks involved in asking too many questions.
20) Learn to explain the importance of avoiding questions beginning with ‘why’
in counselling.
21) Identify in observed communication (written or oral), the application of
different micro skills which would be useful in counselling.
22) The student should demonstrate examples of when it would be appropriate
for the counsellor to use confrontation.
23) List the chief elements of good confrontation and discuss appropriate use of
confrontation, in case studies.
24) The student should show how reframing can be used to change a client’s
perspective on things.
25) The student must develop a method for identifying the existence of self
destructive beliefs (SDB’s) and identify self destructive beliefs (SDB’s)
amongst individuals within a group. They should be able to explain the
existence of self destructive beliefs in an individual. They should be able to
list methods that can be used to challenge SDB’s.
26) Explain what is meant by normalising, in a case study. Be able to demonstrate
precautions that should be observed when using normalising.
27) The student should be able to determine optional responses to different
dilemmas and evaluate those optional responses to different dilemmas.
28) The student should develop the ability to explain how the ‘circle of awareness’
can be applied to assist a client, in a case study. 13
Introduction 29) Explain why psychological blockages may arise, and demonstrate how a
counsellor might help a client to overcome psychological blockages.
30) Describe the steps a counsellor would take a client through to reach a desired
goal, in a case study.
31) The student should be able to identify inter dependency in observed
relationships and explain why good time management is an important part
of counseling.
32) The student should know the difference between terminating a session and
terminating the counseling process and be able to compare the same.
33) Demonstrate dangers posed by client counsellor inter-dependency and
explain how dependency can be addressed and potentially overcome. Also
the student should explain any negative aspects of dependency in a case
study.
The students will gain a range of skills and knowledge necessary to apply
counselling concepts to a range of situations as given below:
• Family support services
• NGOs
• Government agencies
• Community Health centers
• Outreach services
• Women health centers
• Counselling young people and children.
• Issues in family therapy
• Substance abuse: alcohol and drugs counselling
• The elderly. Death and bereavement counselling
• Counselling at work
Some of skills that the students will learn in the process include Cognitive
Behaviour Therapy and Counselling clients with AIDS.
1.4.3 Licensure
Licensure requirements differ greatly by State, occupational specialty, and work
setting. Some States require school counselors to hold a State school counseling
certification and to have completed at least some graduate coursework; most
require the completion of a master’s degree. Some States require school counselors
to be licensed, which generally entails completing continuing education credits.
Some States require public school counselors to have both counseling and teaching
certificates and to have had some teaching experience.
Counselors working in certain settings or in a particular specialty may face

different licensure requirements. For example, a career counselor working in
private practice may need a license, but a counselor working for a college career
center may not. In addition, substance abuse and behaviour disorder counselors
generally are governed by a different State agency or board than are other
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counselors. The criteria for their licensure can vary greatly, and in some cases Introduction to Counseling
these counselors may need only a high school diploma and certification. Those Counselor
interested in entering the field must research State and specialty requirements to
determine what qualifications are necessary.
In India, the Rehabilitation Council of India provides these services for licensing
persons with the appropriate qualifications to serve as counselors. The
Rehabilitation Council of India (RCI) was set up as a registered society in 1986.
On September, 1992 the RCI Act was encacted by Parliament and it became a
Statutory on 22 June 1993. The Act was amended by Parliament in 2000 to make
it more broadbased. The mandate given to RCI is to regulate and monitor services
given to persons with disability, to standardise syllabi and to maintain a Central
Rehabilitation Register of all qualified professionals and personnel working in
the field of Rehabilitation and Special Education. The Act also prescribes punitive
action against unqualified persons delivering services to persons with disability.
RCI trains master trainers, rehabilitation professionals and personnel for creating
better service delivery facilities for the persons with disability. However, it does
not offer any direct benefit, financial or material help to the persons with disability.
One of the main functions of the Council is to standardise the training courses
for various categories of Professionals/Personnel for ensuring quality services
to the people with disabilities. The Council keeps on modifying/revising the
existing syllabus and adopt new training programmes incorporating new
developments.
The Council has so for standardised 80 Long Term/ Short Term Training Courses,
which include 11 Courses developed during the current year, with the help of
respective Expert Committees constituted by the Council.
These RCI sponsored Training Courses are being adopted from time to time by
various Universities/Institutions.
The persons registered with RCI shall be entitled to practice as a rehabilitation
professionals/ personnel in any part of India and to recover in due course of law
in respect of such practice any expenses, charges in respect of medicaments or
other appliances or any fees to which he may be entitled. There are certain
conditions also attached to these personnel who are working as rehabilitation
professionals and these are given below:
No person, other than the rehabilitation professionals/ personnel who possess a
recognised rehabilitation qualification and is enrolled on the Central
Rehabilitation Register:
1) Shall hold office as rehabilitation professional or any such office (by whatever
designation called) in Government or in any institution maintained by a
local or other authority;
2) Shall practice as rehabilitation professional anywhere in India;
3) Shall be entitled to sign or authenticate any certificate required by any law
to be signed or authenticated by a rehabilitation professional.
4) Shall be entitled to give any evidence in any court as an expert under Section
45 of the Indian Evidence Act, 1872 on any matter relating to the
handicapped:
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Introduction RCI is responsible for development and standardisation of training courses in
the field of Disability Rehabilitation and Special Education and to update and
upgrade the knowledge and skills of professionals working in different areas of
disability.
The information regarding Continuing Rehabilitation Education (CRE) topics

and programmes being conducted at selected RCI approved training institutions
nationwide is given underneath for the Rehabilitation professionals and personnel
working in disability areas, so that they can join the nearby centre to upgrade
their skills.
The Council supports relevant CRE programmes with the following objectives :
To upgrade the knowledge and skills of in service and practicing Rehabilitation

Professionals and Personnel already registered with the RCI u/s 19 of the RCI
Act of 1992.
To update Professional knowledge of masters trainers working in the field of

Rehabilitation and Special Education
1.4.4 Other Qualifications

In other countries aside from India, people interested in counseling should have
a strong desire to help others and should be able to inspire respect, trust, and
confidence. They should be able to work independently or as part of a team.
Counselors must follow the code of ethics associated with their respective
certifications and licenses. Counselors must possess high physical and emotional
energy to handle the array of problems that they address. Dealing daily with
these problems can cause stress.
1.4.5 Certification and Advancement

In advanced countries, some counselors elect to be certified by the National
Board for Certified Counselors, which grants a general practice credential of
National Certified Counselor. This national certification is voluntary and is distinct
from State licensing. However, in some States, those who pass the national exam
are exempt from taking a State certification exam. The board also offers specialty
certifications in school, clinical mental health, and addiction counseling.
The Commission on Rehabilitation Counselor Certification offers voluntary

national certification for rehabilitation counselors. Many State and local
governments and other employers require rehabilitation counselors to have this
certification. To become certified, rehabilitation counselors usually must graduate
from an accredited educational program, complete an internship, and pass a
written examination.
Certification requirements vary, however, according to an applicant’s educational

history. Employment experience, for example, is required for those with a
counseling degree in a specialty other than rehabilitation. To maintain their
certification, counselors must successfully retake the certification exam or
complete 100 credit hours of acceptable continuing education every 5 years.
Other counseling organisations also offer certification in particular counseling

specialties. Usually, becoming certified is voluntary, but having certification may
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enhance one’s job prospects. Prospects for advancement vary by counseling field. Introduction to Counseling
School counselors can become directors or supervisors of counseling, guidance, Counselor
or pupil personnel services; or, usually with further graduate education, they
may become counselor educators, counseling psychologists, or school
administrators.
Some counselors choose to work for a State’s department of education. Some

marriage and family therapists, especially those with doctorates in family therapy,
become supervisors, teachers, researchers, or advanced clinicians in the discipline.
Counselors also may become supervisors or administrators in their agencies.
Some counselors move into research, consulting, or college teaching or go into
private or group practice. Some may choose to pursue a doctoral degree to improve
their chances for advancement.
1.4.6 Counsellor and Values

Each of us comes to the counselling encounter with a complex and hard won set
of values. Both client and counsellor will hold certain principles to do with
interpersonal conduct. Not only that, but counsellor and client actually have
different value systems. It is important to note that anyone’s value system is
likely to contain inherent contradictions, that is the contradictions which if
exposed can result in high levels of anxiety and the need to grow. Inevitably the
counselling encounter will be dealing with the client’s inability to decide between
possible causes of action and this will mean that they will need to explore, and if
necessary, modify their own value system.
This in turn means that if the counsellor is to be at all helpful she must be able to
enter the world of the client’s value system so that she is able to understand
potential sources of conflict. It is imperative that the Counselor is able to do this
non judgmentally, that is, she needs to be able to entertain her own “disbeliefs”
and, to the extent that she is able, to either model or suggest alternatives which
will be effective as well as minimally disruptive.
If the counsellor has a sense of missionary zeal, or a desire to impose a set of
beliefs other than those inherent in the skills listed above, she is likely to, at best,
be ineffective and at worst highly destructive to the well being of her client. In
relation to the notion that counselling is simply effective communication it should
be noted that highly skilled communicators are often in the business of persuasion,
such as for example Adolf Hitler was and so are sales people, politicians, and
media representatives.
Effective counselling implies that the inherent values of tolerance, acceptance
and respect for the individual often do not ensure effective communication.
What we can say is that effective communicators are able to use many of the
basic skills of counselling in order to “get their message across”, but this has
nothing to do with the value or otherwise of the message itself.
Both communication and counselling call upon knowledge, including an
understanding of action based techniques, to promote constructive interpersonal
dynamics. But this knowledge can be also used quite destructively. For clients,
who are usually at their most vulnerable when attending counselling, it is
imperative that counselors use their skills in a way that protects the fragile client
from further “abuse” through misuse of authority and status. Effective counselors
hold ethical values that effective communicators often do not have.
17
Introduction
1) What educational qualification you need to become a counselor?
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2) Why license is mandatory for a counselor?
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3) Explain why does a counselor need to be aware of his value system?
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1.5 LET US SUM UP

In this unit you learned about the concept of counseling and characteristics of an
effective counsellor. An effective counsellor does require more than effective
communication skills. Counselling is definitely a discipline of its own. It is our
belief that one can not be an effective counsellor without being an effective
communicator. However, effective counselor goes beyond effective communication.
Effective counselors have a strong knowledge base, an awareness of their own
human vulnerability, a desire to continue searching and awareness that they are
often dealing with vulnerable and easily influenced people. They are trained and
many training and refresher programmes are organised for them so that they are
in touch with the latest trends and their skills and knowledge are updated.
Counsellors can be responsible for their clients’ emotional life and death, which
is indeed a very heavy burden to shoulder and one which is taken up consciously
and willingly. If this is not the case then it is possible the counsellor may be just
an effective communicator.
1.6 UNIT END QUESTIONS

1) Differentiate counseling and guidance.
18 2) Explain the concept of counselor in counseling profession.
3) Discuss the various characteristics of an effective counselor and compare Introduction to Counseling
the same with that of guidance personnel. Counselor
4) How does the values of a counselor influence the counseling client
relationship?
5) What are the certification and license requirement for a counselor?
6) Give a note on Rehbailitation Council of India and its role in licensing
counselors.
1.7 SUGGESTED READINGS

Corey, G. (2008). Theory and Practice of Counseling and Psychotherapy. USA:
The Thompson Brooks.
Narayana Rao (2008). Counseling and Guidance. New Delhi: Tata Mc-Graw
Hill.
Nelson-Jones, R. (2002). Basic Counselling Skills: A Helper’s Manual. Sage

Publications Ltd.
Samuel T. Gladding (2009). Counseling: A Comprehensive Profession. Pearson

Education.
19
Introduction
UNIT 2 PROCESS OF COUNSELLING
Structure
2.0 Introduction
2.1 Objectives
2.2 The Process of Counseling
2.2.1 Counseling Process
2.2.2 Steps in Counseling Process
2.2.3 Stages of Counseling Process
2.2.4 Counselling Process Followed by Counselors
2.2.5 Procedure in the Counseling Process
2.2.6 Developing a Relationship
2.2.7 Working in a Relationship
2.2.8 Terminating a Relationship
2.3 Factors Influencing Counseling Process
2.3.1 Structure
2.3.2 Initiative
2.3.3 Setting
2.3.4 Client Qualities
2.3.5 Counsellor’s Qualities
2.4 Let Us Sum Up
2.0 INTRODUCTION
This unit deals with the counseling process. It starts the definition of the counseling
process, what it is and the typical features of the counseling process. This is
followed by steps in counseling process and the typical processes followed by
counselors in this process. Then we discuss the procedures involved in the
counseling process and how developing a relationship is important in this process.
Then we describe the working of the counselor and the client within the
relationship and then we present the termination of this relationship when the
counseling process reaches its goal. The next section deals with the factors
influencing counseling process which includes in it the structure, initiative to be
taken by the client, the setting in which the counsellign process takes place, the
client’s and the counsellor’s qualities.
2.1 OBJECTIVES
After completing this unit, you will be able to:
• Define the process of counseling;
• Elucidate the steps/stages involved in the process of counseling;
• Describe the key components involved in the different stages of counseling;
• Discuss the steps involved in the termination process of counseling; and
20 • Explain important factors influencing the counseling process.
Process of Counseling
2.2 THE PROCESS OF COUNSELLING
In process of counseling, the goal is established by the client. He is encouraged
and assisted by the counselor to be as specific about the goal as possible. The
more specific the goal, the easier the process. Since humans are generally
considered to be goal oriented, the more specific the goal, the more likely the
client and the counsellor will keep themselves on the path to that goal. The client
narrates their experiences and problems and thus create a focus on their fear
and their goal in order to assist their mind to assist them. It is also of value to the
counselor to guide them in identifying their fears and apprehensions. In the process
of identifying the fear the counselor offers some alternatives while attempting to
avoid interfering in the clients decision.
Some of the fears are:
• a fear of abandonment,
• a fear of rejection,
• a fear of not being enough
2.2.1 Counseling Process

Counseling can help client learn to make better decisions. It can help improve
personal skills, develop greater confidence in the person’s academic or work
performance, define career directions and acquire a keener awareness and
appreciation of the client’s needs and those of other people. With counseling,
clients can improve their communication with a special person, establish more
meaningful relationships, or cope more effectively with feelings of depression
or anxiety. Any personal, academic, or career concern may be explored in
counseling.
During counseling, the client will be helped to clarify feelings and needs. The
client and the counselor will work together to define realistic goals and explore
available options. As the client discovers ways to make changes, he will be
better able to direct his choices. Counseling is an active process, both during
sessions and outside of counseling, as the client implements new skills and
insights. Depending upon the intensity of concern(s), and level of involvement
in making needed changes, clients are generally able to resolve difficulties in
four to eight counseling sessions.
The client’s personal commitment to helping him or herself is crucial to an

effective counseling process. Counselors can help the clients only if they are
willing to receive help, attend scheduled sessions, and engage in new ways of
thinking and acting outside of the counseling setting.
Counselling is a process with a beginning, a middle and an end, where the

counsellor facilitates an individual to consider the aspects of their life they wish
to change.
The whole idea is to enable the client to explore a difficulty or distress which
they may be experiencing, assisted by the counsellor whose main role is to
facilitate the client to make his or her own decisions on how to proceed. It is not
an environment where the counsellor will say what has to be done or even give
advice. However, through this process the counsellor will endeavour to guide
21
Introduction the client from feeling a victim of circumstances to feeling that they have more
control over their life.
There are different models of counselling, differing routes or tools to enable the
client to change. Transactional Analysis (TA) is a model for understanding
personality, relationships and communication. In TA counselling, people talk
about their Parent, Adult and Child. These are distinctive parts of us all, available
and necessary for living as a whole, integrated person. TA holds that everyone
has intrinsic dignity and worth; they are ‘OK’. Everyone has the capacity to
think. There is a commitment to change, to making decisions and taking personal
responsibility for personal outcome.
Clarifying the problem and the desired change encourages the person to decide
how they wish to be. Often unpacking one problem may reveal its connection to
another. When people start the process of counselling they begin to experience
the recurring patterns in their lives, to identify their negative feelings and how
they play games and thereby limit themselves. A decision to make positive change
is a further step. Someone may know what their goal is, but they have to decide
to take positive action to achieve that goal.
The Counsellor offers support and facilitation on the basis that the client has
decided what he or she feels.
2.2.2 Steps in Counseling Process

The basic steps of counselling involve people in:
• gaining recognition for their skills and experience
• being confronted, from a caring position, by the ways they used to discount
themselves and others
• re-experiencing, in the present, any relevant events from the past. This can
help them to obtain emotional release from feelings or beliefs to which they
may be clinging, that are stopping them from meeting their immediate needs.
Emphasis is given to feelings and thoughts, as stimuli for action and change.
Support, challenge and practice are essential to enable all these steps to be
achieved.
Counselling may comprise a few sessions, or it may take longer, but it does not
go on for ever. In the end, the clients are helped to find the tools to enable them
to think, feel and behave in the way they desire.
2.2.3 Stages of Counselling Process

Effective leaders use the counseling process. It consists of four stages:
• Identify the need for counseling.
• Prepare for counseling.
• Conduct counseling.
• Follow up.
Counselling is a process that focuses on enhancing the psychological well being
of the client, such that the client is then able to reach their full potential. This is
22
achieved by the counsellor facilitating the client’s personal growth, development, Process of Counseling
and self understanding, which in turn empowers the client to adopt more
constructive life practices.
Counselling may be helpful in a number of ways. It can enable the client to

develop a clearer understanding of his or her concerns and help the client acquire
new skills to better manage personal and educational issues. The counsellor can
offer a different perspective and help the client to think of creative solutions to
problems. For the client, sharing his thoughts and feelings with someone not
personally involved in his life can be most helpful.
The counsellor treats all the information that the clients share as confidential
material. The counsellors are involved in case consultations and supervision for
the purposes of best practice. These meetings involve discussion of clients
concerns with the aim of formulating the best possible assessment and intervention
plan. Where possible, the identifying personal information is removed from the
discussion.
2.2.4 Counselling Process Followed by Counsellors

The counselling process will depend on the individual counsellor, the individual
client and the specific issue. However, there is a general counselling process that
the counsellors will follow:
1) Background information collection
2) Identification of core issues
3) Case formulation
4) Goal setting for the therapeutic process
5) Implementation of intervention
6) Evaluation of intervention
7) Closure
Prior to the initial interview, reception staff will ask the client to complete a
personal data sheet. During the initial interview, the counsellor will discuss the
client’s concerns with him and explore with him the alternative services if
indicated. By the end of the initial interview the client and the counsellor may
decide on one of the following options:
• no further counselling is required at this time, if during the initial interview
the client has been able to clarify his concerns and plan and appropriate
course of action.
• further appointments are needed to continue to explore the issues before
reaching a decision. A second appointment will be made with the client
either by the counsellor or by reception.
• alternative services are appropriate and the counsellor will assist the client
to identify specific resources to consider and pursue.
Counsellors work from differing theoretical approaches. Different counsellors
will place varying levels of emphasis on behaviour, on thinking and/or on
emotional aspects. All counsellors have the central goal to assist the client in
increasing his or her sense of well being.
23
Introduction Change does not happen quickly for most of us. The length of treatment depends
on a number of variables. Variables include:
• the severity of the problem,
• the motivation of the client,
• the type of problem and
• the age of the client.
• The more focused and limited the problem being addressed, the shorter
treatment can be.
• The more the treatment addresses healing emotional injuries, the longer it is
likely to take.
If the client feels dissatisfied with any aspect of the Counselling Services, they
are encouraged to discuss their concerns with the Senior Counsellor.
2.2.5 Procedure in the Counseling Process

1) Establish a safe, trusting environment
2) Help the person put their concern into words.
3) Active listening: find out the client’s agenda
a) paraphrase, summarize, reflect, interpret
b) focus on feelings, not events
4) Transform problem statements into goal statements.
5) Explore possible approaches to goal
6) Help person choose one way towards goal
7) Make a contract to fulfill the plan (or to take the next step)
8) Summarize what has occurred, clarify, get verification
9) Get feedback and confirmation
In general, a counsellor will listen to the client without butting in or imposing
their own values and beliefs on him or her. They will give the client the needed
space to explore their thoughts, feelings, or behaviour, whatever they are. People
can find it helpful just to have their concerns taken seriously.
The counsellor may also employ a variety of techniques to help the clients
understand their feelings. For instance, the counsellor may ask questions designed
to reflect back to the clients their thought processes and to help them make
sense of their feelings. The client thus might explore and implement changes in
the way he or she does things, and then can go on to enhance his life or his
relationship.
Counselling is a process guided by theory. Process can refer to what the counselor
does with the client as well as how change occurs within the client. The process
of counseling develops in definable stages with recognisable transitions. There
is a natural progression that takes place within the context of the helping
relationship. This process enables the counselor and the client to build a
relationship, assess the situation, set goals and come up with a plan to bring
about the desired results. This progression is known as the counseling process.
24
The process of counseling is dynamic in nature. The effectiveness of counseling Process of Counseling
ultimately depends upon how the process of counseling happens. It can be said
to start with rapport establishment, then progress through problem identification,
goal setting, intervention and then finally follow up.
Broadly, three major stages in the process can be described as follows:

1) Developing a relationship
2) Working in a relationship and
3) Terminating a relationship
Each stage has its own universal qualities and problems associated with it.
Counselors must be aware of the problems involved in the process of counseling.
Now let us discuss each stage in the process of counselling.
2.2.6 Developing a Relationship

Building a relationship, the first stage in the process of counselling, is a continuous
process. It begins by having the counsellor win the battle for structure and client
win the battle for initiative. In such situations both parties are winners. The client
wins by becoming more informed about the nature of counselling and learning
what to expect. The counsellor wins by creating an atmosphere where the client
is comfortable about sharing thoughts and feelings.
In order to develop positive helping relationships with the client, the counsellor
has to connect with them. This can only happen when they are made to feel like
the counsellor genuinely care about the clients well being and that the counsellor
understands why the clients are coming and the causes thereof. It is about behaving
and demonstrating the core conditions of genuineness, respect and empathy. To
develop solid relationships, the counsellor needs to create a safe environment
where they will feel comfortable enough to open up and talk to the counselor
about anything that is on their minds. The counsellor also needs to help them
see that despite their circumstances they have strengths.
Early stages of the counselling relationship afford the chance to build counsellor
understanding of client and issues faced. The counsellor is advised to use listening
skills and attend to non verbal communication. The counsellor should not be
judgmental in his decisions and jump to conclusions immediately. Certain tasks
to be taken care of by the counsellors are:
• Laying foundations for trust

• Establishing the structure and form the relationship will take
• Informed consent process
• Articulating roles of counselor and client and developing a collaborative
working alliance
• The “getting to know you” phase is the most critical stage of the relationship.
The counselor should work on the following things during this stage:
1) Developing Rapport and Building Trust
2) Create core conditions necessary for counselling
25
Introduction 1) Developing Rapport and Building Trust
i) Predictability and consistency

During the first stage of the relationship, it is critical to be both predictable
and consistent. If the counsellor schedules an appointment to meet the client
at a certain time, it’s important to keep it. It is understandable that at times
things come up and appointments cannot be kept. Consistency is the key to
speed up the trust building process.
ii) Testing
Young people generally do not trust adults. As a result, they use testing as a
coping or defense mechanism to determine whether they can trust the
counsellor. They will test to see if the counsellor really cares about them. A
client might test the counsellor by not reaching for a scheduled meeting to
see how the counsellor will react.
iii) Establish confidentiality

During the first stage of the relationship, it is important to establish
confidentiality with one’s client. This helps in developing trust. The
counsellor should let the client know that whatever he or she wants to share
with the counsellor will remain confidential, as long as (and it’s important
to stress this point) what the client tells the counsellor is not going to harm
the client or someone else. It’s helpful to stress this up front, within the first
few meetings with the client. Later on if the counsellor needs to break the
confidence because the information the client shared was going to harm
him or her or someone else, the client will not feel betrayed.
iv) Goal setting (transitions into Stage 2)

It is helpful during Stage 1 to take the time to set at least one achievable
goal together for the relationship. What do the client and counsellor want
to get out of this relationship? It is also good to help the client set personal
goals. Sometimes the client does not know how to set goals, and this will
provide them with the opportunity to set goals and work toward achieving
them.
2) Core Conditions Necessary for Successful Counselling
Rogers (1957) originally proposed core conditions needed in building a

relationship:
i) Empathetic understanding: Empathy promotes rapport and relationship.
ii) Unconditional positive regard: Considering Client as person of worth,
and is separate from actions.
iii) Congruence: Showing Genuine self in client interaction
Carkuff (1969) adds to these…
i) Respect: It strengthens the focus.
ii) Confrontation: It promotes realistic and accurate view.
iii) Immediacy: Consideration of problem with Here and Now attitude.
26
iv) Concreteness: Paying attention on what is practical in the process. Process of Counseling
v) Self disclosure: Promoting positive perception and appropriate focus in

counseling relationship.
2.2.7 Working in a Relationship

The successful outcome of any counselling process depends on a working alliance
between counsellor and the client. This occurs after clients and counsellors have
established a relationship and explored possible goals towards which to work.
Once trust has been established, the relationship moves into Stage 2. These phases
are facilitated by mutual interaction between the individuals involved. The
counsellor can help the client by appropriate leads, challenges to perception,
multi focused responding, accurate empathy, self disclosure, immediacy,
confrontation, contacts and rehearsal.
i) Changing Perceptions
Clients often come to counsellor as a last resort when they think that situation is
not only serious but hopeless. Counsellors can help clients change their distorted
or unrealistic perceptions by offering them an opportunity to explore thoughts
within a safe, accepting and in a non judgmental atmosphere. Perceptions
commonly change through the process of reframing which offers the client another
probable and positive viewpoint of what a situation is or why an event might
have happened.
ii) Leading
Changing client’s perceptions requires a high degree of persuasive skill and some
direction from the counselor. Such input is known as leading.
iii) Accurate Empathy

Use of empathy is one of the most vital elements in the counseling. Empathy is
the counsellor’s ability to experience the client’s world as if it were your own
without ever using the quality.
Two Components of Empathy are:

a) Empathic rapport. This refers to accurately sensing and being able to see
the client’s world the way they do.
b) Communicative attunement. This refers to verbally sharing one’s

understanding with the client.
There are two types of Empathy:

1) Primary Empathy. The ability to respond in such a way that is apparent to
both client and counsellor that the counsellor has understood the client’s
major themes.
2) Advanced empathy. It is a process of helping a client explore themes, issues
and emotions new to his or her awareness.
iv) Self Disclosure
Self disclosure is an important way to let clients know the counsellor as a person.
Self disclosure at a moderate level is seen more positively by clients than
27
Introduction disclosure at a high or low level (Edwards & Murdock, 1994). In moderation, it
is helpful for the counsellor to disclose facts about himself, if it serves the needs
of the session / client.
Self disclosure takes the following forms:

• The counsellor’s own problems
• Facts about the counsellor’s role
• The counsellor’s reactions to the client (feedback)
• The counsellor’s reactions to the counselor-client relationship
v) Positive Regard
Client revelations must be protected from counsellor’s “personal reactions,”
especially rejection or disdain. The counsellors should express appreciation of
the client as a unique and worthwhile person and embrace the client’s ethnic self
as well as other experiences that have shaped the client’s worldview.
vi) Responding Styles

Counselling is often perceived as just focusing on feelings but it is not true.
While counselling helps people work through feelings, how one responds and
communicates with others will affect how the counsellor responds to the client.
There are different Responding Styles of the clients;
1) Affective Responding. This focuses on feelings;
2) Behavioural Responding. This focuses on actions and behaviours;
3) Cognitive Response. This focusses on thoughts and cognitions. The
counsellor will balance these throughout the session with a client.
vii) Immediacy
This involves a counselor’s understanding and communicating of what is going
on between the counsellor and client within the helping relationship.
There are 2 types of immediacy
1) Relationship immediacy. (Between client & counsellor); 2)
2) “Here & Now” immediacy focuses on some particular event in the session.
viii) Humor
Humor can have a positive effect on the counselling process when used properly.
It must be used with sensitivity and timing. It does not demean and is supportive.
A session is not a time to try out a new joke heard at lunch.
ix) Confrontation
This is not skill at putting the client down for doing something wrong. This is an
invitation to the client to look more closely at behaviour that is not working or
interfering with growth, change, or healthy functioning.
x) Transference and Counter-transference

A concept as old as Freud, transference and counter-transference are issues that
affect all forms of counselling, guidance, and psychotherapy.
28
Transference: This is the client’s projection of past or present feelings, attitudes, Process of Counseling
or desires onto the counsellor. It can be direct or indirect and will cause the client
to react to the counselor as they would in the past or present relationship.
Counter-transference: This is the counsellor’s projected emotional reaction to

or behaviour towards the client. It can take on many forms, from a desire to please
the client, to wanting to develop a social or sexual relationship with the client.
When this happens, supervision or counseling for the counsellor is called for.
2.2.8 Terminating a Relationship

Termination is an important, though often misunderstood phase of counselling.
This is often ignored or taken for granted. Yet successful termination is vital for
the well being of client as well as counsellor. Termination is the end of the
professional relationship with the client when the session goals have been met.
It is a phase of counselling that can determine the success of all previous phases
and must be handled skillfully. A formal termination serves three functions:
• Counselling is finished and it is time for the client to face their life challenges.
• Changes which have taken place have generalised into the normal behaviour
of the client.
• The client has matured and thinks and acts more effectively and
independently.
Timing of Termination
There is no one answer when termination is to take place. Questions the counselor
may wish to ask concerning termination include:
• Have clients achieved behavioural, cognitive, or affective goals?
• Can clients concretely show where they have made progress in what they
wanted to accomplish?
• Is the counselling relationship helpful?
• Has the context of the initial counselling arrangements changed?
Resistance to Termination
Clients and Counsellors may not want counseling to end. In many cases this
may be the result of feelings about the loss and grief or insecurities of losing the
relationship. For clients, this is something to process. For counsellors, this is an
issue for supervision.
Premature Termination
Client
Many clients may end counselling before all goals are completed. This can be
seen by not making appointments, resisting new appointments etc. It is a good
idea to try and schedule a termination/review session with the client so closure
may take place. At this time a referral may be in order.
Counsellors
At times, counsellors have to end counselling prematurely. Whatever the reason
for the termination, a summary session is in order and referrals are made, if
appropriate, to another counsellor. 29
Introduction Referrals
At times, a counsellor needs to make a referral. When this is done, specific
issues need to be addressed with the client.
Reasons for the referrals
Note specific behaviours or actions which brought the need for a referral.
Have the names of several other counsellors ready for referral.
It is important to remember that the counselor cannot follow up with the new
counsellor to see if the client followed through (Confidentiality issue).
Follow Up
At times, a follow-up may be scheduled for various reasons including evaluation,
research, or checking with client. It needs to be scheduled so as to not take the
responsibility of change away from the client.

1) List out the things to be taken care of during the first stage of developing
a relationship.
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2) Describe the different core conditions necessary for successful counselling.
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3) Describe the different responding styles of the client.
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30
4) Discuss the different issues related to terminating a relationship.
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5) When does premature termination occur? What are the things to be
kept in mind during premature termination.
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2.3 FACTORS INFLUENCING COUNSELLING

PROCESS
The counselling process is influenced by several factors. The counselor need to
know these so that he can help it becto make the counseling time a productive
one both for the client and counsellor. The major factors which influence the
counselling process are as follows.
2.3.1 Structure
Structure in counselling is defined as the “joint understanding between the
counsellor and client regarding the characteristics, conditions, procedures, and
parameters of counselling” (Day & Sparacio, 1980, p.246). It helps in clarify the
counsellor client relationship and give it direction. It protects the rights, roles
and obligations of both counsellors and clients and ensure the success of
counselling.
Structure gives form to what the formal process will look like. Practical guidelines
are part of building structure. They include time limit of the session, action limits
for the prevention of destructive behaviour, role limits and procedural limits.
Counselling moves forward when client and counsellor know the boundaries of
the relationship and what is expected.
Structure is provided throughout all stages of counselling but is especially

important at the beginning. Its importance is most obvious when the client arrives
for counselling with unrealistic expectations or with no idea what to expect.
Counsellors need to stay flexible and continually negotiate the nature of structure
with their clients.
31
Introduction 2.3.2 Initiative
Initiative can be thought of as the motivation to change. Majority of the clients
who visit the counsellors are reluctant to some degree. Such clients lack initiative.
Some counsellors become impatient, irritated and insensitive and may ultimately
give up trying to work with such clients. Many counsellors end up blaming either
themselves or their clients. A role reversal exercise can help the counsellor to
understand the mental state of the involuntary, reluctant and resistant client.
A reluctant client is one who has been referred by the third party and is frequently
unmotivated to seek help. They do not wish to be in counselling. Many reluctant
clients terminate counselling pre maturely and report dissatisfaction with the
process.
A resistant client is one who is unwilling or opposed to change. Such an individual

may actively seek counselling but does not wish to go through the pain that
change demands.
There are several ways in which counsellors can help clients to win the battle
for initiative and achieve success in counselling. One way is to anticipate the
anger, frustration and defensiveness that some clients display. A second way is
to show acceptance, patience, and understanding as well as non judgmental
attitude. A third way is to use persuasion and the fourth way is through
confrontation.
2.3.3 Setting
Counselling can happen anywhere, but some physical settings promote the process
better than others. Among the most important factors that help or hurt the process
is the place where the counselling occurs. The room should be comfortable and
attractive with soft lighting, quiet colors, an absence of clutter, and harmonious
and comfortable furniture. The professional generally works in a place that
provides Privacy, Confidentiality, Quiet and Comfort. When working with a
client, youthe counselor must want to send a message that he is listening. This
can be done by being attentive both verbally and nonverbally. A distance of 30 to
39 inches is the average range of comfort between counsellor and clients of both
genders.
In addition to the above arrangements the counsellors should not be interrupted

during sessions. The counsellor should keep in mind the SOLER technique.
SOLER is an acronym which serves to remind the counselors how to listen:
S: Face the client squarely; that is, adopt a posture that indicates involvement.
O: Adopt an open posture. Sit with both feet on the ground to begin with and
with your hands folded, one over the other.
L: As you face your client, lean toward him or her. Be aware of their space
needs.
E: Maintain eye contact. Looking away or down suggests that you are bored or
ashamed of what the client is saying. Looking at the person suggests that
you are interested and concerned.
R: As the counselor incorporates these skills into the attending listening skills,
relax.
32
2.3.4 Client Qualities Process of Counseling
Counselling relationship starts with first impressions. The way the counsellor
and the client perceive one another is vital to the establishment of a productive
relationship. Counsellors generally like to work with clients who are most like
them. They are influenced by the physical characteristics of one’s best work to
all clients.
The client: Clients come in all shapes and sizes, personality characteristics, and
degree of attractiveness. The most successful candidates are said to be YAVIS:
Young, Attractive, Verbal, Intelligent, and Successful (Schofield, 1964). Less
successful clients are seen as HOUND: Homely, Old, Unintelligent, Nonverbal,
and Disadvantaged; or DUD: Dumb, Unintelligent and Disadvantaged (Allen,
1977).
A counsellor must consider a client’s body gestures, eye contact, facial expressions
and vocal quality to be as important as verbal communication. Cultural
background of the client should keep in mind while evaluating the non verbal
communication.
2.3.5 Counsellors Qualities

The personal and professional qualities are very important in building up
relationship with the client. Okun (1992) lists five important characteristics that
counsellors must possess:
• Self awareness,
• Honesty,
• Congruence,
• Ability to communicate, and
• Knowledge.
Clients depending on their culture initially like to work with counsellors who
are perceived as Experts, Attractive and Trustworthy. Expertness is the degree to
which a counsellor is perceived as knowledgeable and informed about his or her
specialty. Attractiveness is a function of perceived similarity between a client
and a counsellor. Counsellors can make themselves attractive by speaking in
clear, simple sentences and offering appropriate self disclosure. Trustworthiness
is related to the sincerity and consistency of the counsellor. The counsellor is
genuinely concerned about the client and shows it over time by establishing a
close relationship with the client.

1) Describe the importance of providing structure to the counselling
process.
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............................................................................................................... 33
Introduction
2) Describe the different aspects related to the setting of counselling.
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2.4 LET US SUM UP

The process of counselling develops in definable stages with recognisable
transitions. There is a natural progression that takes place within the context of
the helping relationship. There are certain important factors that influence the
counselling process. The major are: Structure, Initiative, Setting, Client Qualities,
and Counselor Qualities. The process of counselling occurs in stages like,
developing a relationship, working in a relationship, terminating a relationship.
The counsellor has to keep certain tasks in mind such as laying foundations for
trust, establishing the structure and form the relationship will take, in its first
stage of building relationship. Empathetic understanding, Unconditional positive
regard and Congruence are certain core conditions which are mandatory for
successful counselling. The last phase includes termination which is the end of
the professional relationship with the client when the session goals have been
met. It is a phase of counselling that can determine the success of all previous
phases and must be handled skillfully. Counselling can not be considered complete
and successful without the follow-up procedure.

1) Differentiate between a reluctant and a resistant client.
2) What is SOLER technique?
3) List qualities of a client needed for successful counselling relationship.
4) What is transference and counter transference?
5) Explain Empathy and its components.
6) Discuss the significance of termination in counselling relationship.

Corey, G. (2008): Theory and Practice of Counseling and Psychotherapy. USA:
Welfel & Peterson (2004): The Counseling Process: a Multi-theoretical

Integrative Approach. Thomson/Brooks/Cole.
Narayana Rao (2008): Counseling and Guidance. New Delhi: Tata Mc-Graw
Hill.
Samuel T. Gladding (2009): Counseling: A Comprehensive Profession. Pearson

34 Education.
UNIT 3 THEORETICAL APPROACHES TO
COUNSELING
Structure
3.0 Introduction
3.1 Objectives
3.2 Psychoanalytic and Adlerian Approach
3.2.1 Psychoanalytic Approach
3.2.2 The Phenomenological (Adlerian) Approach
3.3 Person-Centered, Existential and Gestalt Approaches
3.3.1 Person-Centered Approach
3.3.2 Existential Approach
3.3.3 Gestalt Approach
3.4 Rational Emotive Therapy and Transactional Analysis
3.4.1 Rational Emotive Therapy
3.4.2 Transactional Analysis
3.5 Behavioural Approach
3.6 Reality Therapy
3.7 Let Us Sum Up
3.0 INTRODUCTION
In this unit we will be dealing with theoretical approaches to counseling. We
start with psychoanalytic and Adlerian Approach, and put forward the view of
human nature within which the concepts of psychoanalytical theory such as the
id, ego and super ego are presented. Then we take up the role of counselor in
psychoanalytical approach the goals and techniques in which we present the
free association, dream analysis, analysis of transference and interpretation. Then
we take up the phenomenological approach that is of Adler and discuss the theory
ion terms of counseling. We consider the view of human nature in this theory,
the role of counselor, goals of the phenomenological approach and the techniques
thereof. This is followed by person centered, Existential and Gestalt Approaches
and here woo we consider the view of human nature and indicate how it is
differently viewed as compared to the psychoanalytical theory. We then consider
the role of counsellor in person centered approach the goals and techniques in
the same. The next section deals with rational emotive therapy and transactional
analysis and how these are used in counseling. Finally we take up the behavioural
approach, its principles, goals and techniques. Then we take up the reality therapy
and discuss how counselors use the same.
3.1 OBJECTIVES
• Discuss the need of theoretical approaches to counseling;
35
Introduction • Define psychoanalytic approach to counseling;
• Differentiate between cognitive and behavioural approach to counseling;
• Explain the views of human nature proposed by different approaches;
• Distinguish the role of a counselor in different counseling techniques; and
• Explain the techniques used in different theoretical approaches.
3.2 PSYCHOANALYTIC AND ADLERIAN

APPROACH
There are many theoretical models of psychology and counselling. Some are
best utilised for particular situations and needs. Often, an eclectic approach, or
the utilisation of several approaches is best for the resolution of
problems. Effective counselors scrutinise all theories and match them to personal
beliefs about the nature of people and change. Since the 1950s, psychologists
have adopted a number of diverse approaches to understanding human nature
and behaviour. Most counselling approaches fall within four broad theoretical
categories: psychoanalytic, affective, cognitive and behavioural. In addition to
these, there are Cognitive Behavioural approaches also which are gaining
importance in recent years.
Different approaches exist because there are different ways of explaining the
phenomena, for example, emotions can be explained in terms of the thoughts
associated with them or the physiological changes they produce. Psychologists
try to explain psychological phenomena from a range of different perspectives,
and so use different approaches.
3.2.1 Psychoanalytic Approach

This approach developed by Sigmund Freud in the early 1900s, involves analysing
the root causes of behaviour and feelings by exploring the unconscious mind
and the conscious mind’s relation to it. Psychoanalysis can take on a variety of
forms, varying from practitioner to practitioner. Psychoanalytical and
psychodynamic therapies are based on an individual’s unconscious thoughts and
perceptions that have developed throughout their childhood, and how these affect
their current behaviour and thoughts.
Psychoanalysis focuses on an individual’s unconscious, deep rooted thoughts

that often stem from childhood. Through free association, dreams or fantasies,
clients can learn how to interpret deeply buried memories or experiences that
may be causing them distress.
i) View of Human Nature

The Freudian view of human nature is dynamic. According to him, human nature
could be explained in terms of a conscious mind, a sub conscious and an
unconscious mind. The conscious mind is attuned to the events in the present, to
an awareness of the outside world. The subconscious mind is an area between
the conscious and unconscious mind which contains aspects of both. Within the
subconscious are hidden memories or forgotten experiences that can be
remembered if a person is given the proper cues. Finally beneath the subconscious
mind is the unconscious mind, the most powerful and least understood part of
36
the personality. The instinctual, repressed and powerful forces of the personality Theoretical Approaches to
Counseling
exist in the unconscious.
ii) Id, Ego and Super Ego

Id is a concept equivalent to a demanding child and it is ruled by the pleasure
principle. It refers to the raw, unorganised, inherited part of the personality. Its
main goal is to reduce tension created by our primitive drives such as hunger,
sex, aggression and irrational impulses.
Ego is a concept analogous to a traffic policeman and it is ruled by the reality
principle. Ego’s job is to meet the needs of the id, while taking into consideration
the reality of the situation. The ego is sometimes called “the executive” of an
individual’s personality. It is responsible for the higher cognitive functions such
as intelligence, thoughtfulness and learning.
Superego is the third concept which can be equaled to that of a judge and it is
ruled by the moral principle. Superego represents the rights and wrongs of the
society. It has two subparts: the conscience and the ego-ideal. The conscience
prevents us from doing morally wrong or bad things. The ego ideal is that part of
the superego that includes the rules and standards for good behaviours. These
behaviours include those that are approved of by parental and other authority
figures. Obeying these rules leads to feelings of pride, value, and accomplishment.
The ego ideal motivates the person to do what is morally proper. The superego
helps to control the id impulses, making them less selfish and more morally
correct.
iii) Ego-Defense Mechanisms

Ego-defense mechanisms are normal behaviours which operate on an unconscious
level and tend to deny or distort reality. They help the individual to cope up with
anxiety and prevent the ego from being overwhelmed. They have adaptive value
if they do not become a style of life to avoid facing reality. Some of the major
defense mechanisms described by psychoanalysts are the following:
1) Repression: It is the withdrawal of an unwanted idea, affect, or desire from
consciousness by pushing it down, or repressing it, into the unconscious
part of the mind.
2) Reaction formation: It is the fixation of an idea, affect, or desire in
consciousness that is opposite to a feared unconscious impulse.
3) Projection: It is a form of defense in which unwanted feelings are displaced
onto another person.
4) Regression: When confronted by stressful events, people sometimes abandon
coping strategies and revert to patterns of behaviour used earlier in development.
5) Sublimation: It is the diversion or deflection of instinctual drives, usually
sexual ones, into non-instinctual channels. It allows us to act out unacceptable
impulses by converting these behaviours into a more acceptable form.
6) Denial: It is used to describe situations in which people seem unable to face
reality or admit an obvious truth.
7) Rationalisation: It is the substitution of a safe and reasonable explanation
for the true, but threatening cause of behaviour.
37
Introduction 8) Displacement: Displacement involves taking out our frustrations, feelings
and impulses on people or objects that are less threatening.
9) Intellectualisation: It allows us to avoid thinking about the stressful,
emotional aspect of the situation and instead focuses only on the intellectual
component.
iv) Role of a Counselor

Counselors who practice psychoanalysis play the role of experts. They encourage
their clients to talk about whatever comes in their mind, especially childhood
experiences. After a few face to face interactions such an environment is created,
often have the client lie down while the analyst remains out of view, in which the
client feels free to express difficult thoughts. The role of the analyst is to let the
clients gain insight by reliving and working through the unresolved past
experiences that come into focus during sessions. The development of transference
is encouraged to help clients deal realistically with unconscious material.
Psychoanalytic counselors also use diagnostic labels to classify clients and help
develop appropriate plans for them.
v) Goals
The goal of psychoanalysis varies according to the client, but they focus mainly
on personal adjustment, usually inducing a reorganisation of internal forces within
the person. In most cases, a primary goal is to help the client become more aware
of the unconscious aspects of his or her personality, which include repressed
memories and painful wishes. A second major goal is to help a client work through
a developmental stage, not resolved in primary goal. If accomplished, clients
become unstuck and are able to live more productively. A final goal is helping
clients cope with the demands of the society in which they live. Psychoanalysis
stresses environmental adjustment, especially in the areas of work and intimacy.
vi) Techniques
Free Association: Client reports immediately without censoring any feelings or
thoughts. The client is encouraged to relax and freely recall childhood memories
or emotional experiences. In this way, unconscious material enters the conscious
mind, and the counselor interprets it. At times clients resist free association by
blocking their thoughts or denying their importance. Psychoanalysts make the
most of these moments by attempting to help clients work through their resistance.
Dream Analysis: Dream analysis is considered the first scientific approach to the
study of dreams. In this clients report dreams to counselor on regular basis. Freud
believed that dreams were a main avenue to understanding the unconscious.
Counselor uses the “royal road to the unconscious” to bring unconscious material
to light. Clients are encouraged to remember dreams. The counselor analyse two
aspects; The Manifest Content (obvious meaning), and the Latent Content (hidden
but true meaning).
Analysis of Transference: Transference is the client’s response to a counselor as
if the counselor were some significant figure in the client’s past, usually a parent
figure. This allows the client to experience feelings that would otherwise be
inaccessible. The counselor encourages this transference and interprets positive
or negative feelings expressed. Analysis of transference allows the client to achieve
insight into the influence of the past. Counter-transference: It is the reaction of
38 the counselor towards the client that may interfere with objectivity.
Interpretation: Interpretation should consider part of all above mentioned Theoretical Approaches to
Counseling
techniques. When interpreting, the counselor helps the client understanding the
meaning of the past and present personal events. It consists of explanations and
analysis of a client’s thoughts, feelings and actions. Counselor points out, explains,
and teaches the meanings of whatever is revealed. Counselors must carefully
time the use of interpretation.
3.2.2 The Phenomenological (Adlerian) Approach

Alfred Adler attempts to view the world from the client’s subjective frame of
reference e.g. how life is in reality is less important than how the individual
believes life to be. The basic premise is that human beings are always “becoming,”
that we’re always moving toward the future, and our concerns are geared toward
our subjective goals rather than an objective past. We are constantly aiming
towards what Adler calls superiority. When we have unrealistic or unattainable
goals, this can lead to self-defeating behaviours and discouragement which may
foster neurosis, psychosis, substance abuse, criminal behaviour, or suicide.

He emphasised that it is not the childhood experiences that are crucial but it is
our present interpretation of these events. He thought that people are primarily
motivated by social interest. It is Adler’s most significant and distinctive concept
which refers to an individual’s attitude toward and awareness of being a part of
the human community. He measured mental health by the degree to which we
successfully share with others and are concerned with their welfare. He explained
how happiness and success are largely related to social connectedness.
Another major component of his theory is that people strive to become successful.
Each person strives for growth and has a need for wholeness. If this need is
fulfilled, the person develops a superiority complex otherwise the person can
develop inferiority complex. His theory places considerable emphasis on birth
order and sibling relationships. Adler’s explained five psychological positions:
Oldest child receives more attention, spoiled, center of attention.
Second of only two behaves as if in a race, often opposite to first child.
Middle often feels squeezed out.
Youngest is being considered as the baby.
Only - does not learn to share or cooperate with other children, learns to deal
with adults.
ii) Role of Counselor
Adlerian counselors function primarily as diagnosticians, teachers and models
in equalitarian relationships they establish with their clients. They try to assess
why clients are oriented to a certain way of thinking and behaving. The counselor
makes an assessment by gathering information on the family constellation and
client’s earliest memories. The counselor then shares interpretations, impressions,
opinions and feelings with clients. The client is encouraged to examine and change
a faulty life style by developing social interest.
39
Introduction iii) Goals
The goals of Adlerian counseling revolve around helping people develop healthy
life styles. One of the major goals is to develop social interest. The four major
goals of the therapeutic process:
• Establishment and maintenance of an egalitarian counseling relationship.
• Analysis of a client’s life style.
• Interpretation of client’s life style in such a way that [promotes insight].
• Re-orientation and re-education of the client with accompanying behaviour
change.
iv) Techniques
To establish above mentioned goals and to accomplish behaviour change,
counselors use following techniques:
1) Confrontation: The counselor challenges clients to consider their own private

logic. When clients examine this logic, they often realise they can change it
and their behaviour.
2) Asking the question: The counselor asks, “what would be different if you
were well?’ The question is often asked during the initial interview, but it is
appropriate any time.
3) Encouragement: Counselors encourage their clients by stating their beliefs
that behaviour change is possible. It is the key to make productive life style
changes.
4) Acting “as if”: Clients are instructed to act as if they are the persons they
want to be.
5) Task Setting: Clients initially set short term range, attainable goals and
eventually work up to long term and realistic objectives.
6) Catching oneself: Clients learn to become aware of self destructive
behaviours or thoughts. At first counselor may help in this process, but
eventually this responsibility is taken over by clients.
7) Push Button: Clients are encouraged to realise that they have choices about
what stimuli in their lives they pay attention to. The technique is like pushing
the button because clients can choose to remember negative or positive
experiences.

1) Differentiate between id, ego and superego.
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Theoretical Approaches to
2) Describe the different defense mechanisms. Counseling
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3) Explain the different types of goals in psychoanalysis.
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4) How does Adlerian approach view human nature?
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5) Describe the importance of birth order and sibling relationship in
Adlerian theory.
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3.3 PERSON-CENTERED, EXISTENTIAL AND

GESTALT APPROACHES
3.3.1 Person Centered Approach
Person-Centered approach, founded by Carl Rogers in the 1940’s, is based on
the belief that people have the capacity and the right to move toward self-
actualisation. This approach views people as rational, forward-moving, and
realistic beings. He contended that negative, antisocial emotions are the result of
frustrated basic impulses.This approach views the client as their own best authority
on their own experience, and the client is fully capable of fulfilling their own
potential for growth.
41
Introduction i) View of Human Nature
Rogers believed that people are essentially good. Humans are characteristically
positive, forward- moving, constructive, realistic and trustworthy. Each of us
has the innate ability to reach our full potential. As infants we are born with it,
but because of early experiences, we may lose our connection to it. The self
concept we develop in response to our early experiences may tend to alienate us
from our true self. In this theory there is no such thing as mental illness. It is just
a matter of being disconnected from our self-potential. This approach is often
considered the most optimistic approach to human potential.
Rogers views the individual from a phenomenological perspective, that is

according to him the important aspect is the person’s perception of reality rather
than an event itself. His ideas are often referred to as “Self Theory”. The self is
an out growth of what a person experiences, and an awareness of self helps a
person differentiate him or herself from others.
ii) Role of a Counselor

The counselor’s role is a holistic one. He or she sets up and promotes a climate
in which the client is free and is encouraged to explore all aspects of self. The
counselor strives to develop a greater degree of independence and integration
for individuals in their surroundings and the people in their lives. Clients are
prepared to be open to the experience of counseling, to have trust in themselves,
to evaluate themselves internally, and pursue a willingness towards continued
growth. Clients will experience this technique differently depending on
perceptions of both the past and the possibilities of future events. Exploring a
wider range of beliefs and feelings help clients in this process. It helps clients to
better appreciate who they are and what they are capable of accomplishing.
iii) Goals
The goals of person centered counseling considers the client as a person, not his
or her problem. Rogers emphasises that people need to be assisted in learning
how to cope with situations. The client moves towards the goals of realisation,
fulfillment, autonomy, self determination, and perfection by becoming more
realistic in their perceptions. The aim is to make them more confident, more self
directed, more positively valued by themselves and less likely to be upset by
stress. They should be healthier, integrated, and well functioning persons in their
personality structure.
iv) Techniques
The counselor as a person is vital to person centered counseling. Counsellors
display openness, empathic understanding, independence, spontaneity,
acceptance, mutual respect and intimacy. They encourage clients to work toward
achieving these same conditions as ultimate counselling goals. The primary
techniques are the counsellor’s attitudes toward people in the following:
1) Unconditional positive regard: It means that the counsellor accepts the
client unconditionally and non judgmentally. The client is free to explore
all thoughts and feelings, positive or negative, without danger of rejection
or condemnation. Crucially, the client is free to explore and to express without
having to do anything in particular or meet any particular standards of
behaviour to ‘earn’ positive regard from the counsellor.
42
2) Empathic understanding: It means that the counsellor accurately Theoretical Approaches to
Counseling
understands the client’s thoughts, feelings, and meanings from the client’s
own perspective. When the counsellor perceives what the world is like from
the client’s point of view, it demonstrates not only that that view has value,
but also that the client is being accepted.
3) Congruence: It means that the counsellor is authentic and genuine and
transparent to the client. There is no air of authority or hidden knowledge,
and the client does not have to speculate about what the counsellor is ‘really
like’.
Rogers mentioned the following six core conditions for personality change:
• Two persons are in psychological contact.
• The client is in a state of incongruence.
• The counsellor is congruent and involved in the relationship.
• The counsellor experiences unconditional positive regard for the client.
• The counsellor experiences understanding of the client’s frame of reference.
• The communication of empathic and positive regard is achieved.
Methods that help promote the counselor client relationship include:
• Active and passive listening
• Reflection of thoughts and feelings
• Clarification
• Summarizing
• Confrontation of contradictions
• General or open leads that help client self exploration.
3.3.2 Existential Approach

Existential approach can be described as a philosophical approach that is not
designed to cure people but instead helps the client reflect and search for value
and meaning in life. Existentialism understands the human to be challenged by
the reality of temporary existence, and the view that life has no inherent meaning
and that the meaning had to be constructed. Authentic human beings are those
who could face existential futility and yet still go on to construct a meaningful
life.
The existential perspective was introduced into the US by Rollo May. He believed
that individuals can only be understood in terms of their subjective sense of self.
May was concerned with people’s loss of faith in values. If we lose our
commitment to a set of values we will feel lonely and empty. Life will be
meaningless. Viktor Frankl, a famous existentialist, believed that the prime motive
of human behaviour is the “will to meaning”. In order to find a meaning in our
troubled existence we need to discover meaning through values and we discover
our values through work, through love for others and through confrontation with
our own suffering.

According to the existentialists, human beings form their lives by the choices
they make. They focus on the freedom of choice and the action that goes with it. 43
Introduction We have no existence apart from the world. Being in the world is man’s existence.
The basic issue in life is that life inevitably ends in death. Thus we experience
angst or anguish because of our awareness of death’s inevitability. According to
Frankl (1962), the meaning of life always changes but it never ceases to be. We
can discover life’s meaning in three ways:
• By doing a deed. That is, by achieving or accomplishing something.
• By experiencing a value. As for instance experience the value of work of
nature, culture or love.
• By Suffering. That is, finding a proper attitude towards unalterable fate.
ii) Role of a Counsellor
Existential counsellors are focused on helping the client achieve and expand
their self awareness. It is assumed that once self awareness is achieved the client
can examine new ways of dealing with problems and accept the responsibility of
choosing. The role of the counsellor is to facilitate the client’s own encounter
with himself or herself, to work alongside him in exploring and understanding
better his values, assumptions and ideals. The counsellor is concerned about
what matters most to the client and to avoid imposing her own judgments, and to
help the client to elaborate on his own perspective.
The counsellor’s responsibility is to be aware of his or her own biases and

prejudices. The counsellors’ goal is to understand the client’s meaning rather
than their own and recognising the client’s assumptions and underlying life
themes. The counsellor must be sensitive to and help the client explore his
weaknesses, limitations and responsibilities as well as his strengths, opportunities
and freedoms.
iii) Goals
The goal of this technique is not to cure people of disorders, not to simply get rid
of symptoms. Rather it is to help them become aware of what they are doing and
encourage them to act, make life changing decisions etc. It is aimed at helping
people get out of their rigid roles and see more clearly the ways in which they
have been leading a narrow and restricted existence. The specific goals of
existential counselling are:
• To enable people to become more truthful with themselves.
• To help the clients to reflect upon and understand their existence.
• To increase self awareness and authentic living.
• To take responsibility for decisions.
• To encourage clients to find their own meanings and truths.
• To help people examine roots of some of their anxieties and learn how to
better cope with them.
• To get the person to believe to experience life and to live more fully in each
moment
iv) Techniques
Existential therapy is not considered as a system of highly developed techniques.
Subjective understanding of clients is primary and techniques are secondary. It
44
is not technique oriented. The interventions are based on philosophical views Theoretical Approaches to
Counseling
about the nature of human existence. It is free to draw techniques from other
orientations. The use of counsellor’s self is the core of therapy. It is commonly
integrated within other frameworks.
The most effective and powerful technique counsellors have is the relationship
with the client. They also make use of confrontation. Existential counsellors
borrow some techniques such as imagery exercises, awareness exercises goal
setting activities etc., from other models.
3.3.3 Gestalt Approach

Gestalt approach is an integrative orientation in that it focuses on whatever is in
the client’s awareness. This term was first used as the title of a book, written by
Fritz Perls, et.al (1951), “ Gestalt,” a German word meaning “whole” . It operates
as a therapy by keeping the person in what is known as the here and now. In this
approach, feelings, thoughts, body sensations and actions are all used as a guide
to understanding what is central for the client in each moment. The centrality of
whatever is in the client’s awareness is an ideal way to understand the world of
the client. Unresolved conflicts are worked out in the counseling session as if
they are happening in that moment. An emphasis is placed on personal
responsibility for one’s own well being.

Human nature is rooted in existential philosophy, phenomenology, and field
theory. Individuals have the capacity to self regulate in their environment. Gestalt
counsellors believe that human beings work for wholeness and completeness in
life. Self actualising tendency emerges through interaction in environment. Each
person tries to integrate self into healthy, unified whole. Overdependence on
intellectual experience and inability to resolve unfinished business causes
problems, such as the client may lose contact with environment, or become over
involved, may encounter unfinished business, or become fragmented.
ii) Role of a Counselor

Gestalt counsellor can help their client to both work through and move beyond
their painful emotional blocks. By following their client’s ongoing process, with
special attention to both the therapeutic relationship and the client’s style of
interrupting that process, the counsellor uses appropriate techniques. The
counsellor must pay attention to clients’ awareness, to clients’ body language,
nonverbal language, and inconsistence between verbal and nonverbal message
(e.g., anger and smile). The counselors must create atmosphere that promotes
growth. The counselor is exciting, energetic, fully human and personally involved.
iii) Goals
The main goal is to increase the client’s awareness of “what is.” Awareness
includes knowing the environment, knowing oneself, accepting oneself, and being
able to make contact. Stay with their awareness, unfinished business will emerge.
Change occurs through a heightened awareness of what the client is experiencing
moment to moment. The approach stresses present awareness and the quality of
contact between the individual and the environment.
45
Introduction Four Major Principles of Gestalt Therapy are:
Holism interested in the whole person emphasis on integration thoughts, feelings,
behaviours, body, & dreams.
Field Theory organism must be seen in its environment or its context as part of a
constantly changing filed-relational, in flux, interrelated and in process
Figure Formation Process how individual moment to moment organises

environment:
1) Background=undifferentiated field or ground
2) Figure=Emerging focus of attention
3) Organismic self-regulation =-restore equilibrium or contribute to growth
and change
iv) Techniques
Some of the most innovative techniques ever developed are found in Gestalt
therapy. These techniques take two forms:
i) Exercise and
ii) Experiments.
Exercises are readymade techniques such as enactment of fantasies, role playing,
psychodrama, dream work, empty chair, confrontation such as what and how,
making the rounds, exaggeration.
Experiments on the other hand are activities and grow out of the interaction
between counsellor and clients. They are not planned. The experiments are to
assist clients self awareness of what they are doing and how they are doing it.
Gestalt experiments include the following:
• Internal dialogue exercise,
• Making the rounds,
• Reversal technique,
• Rehearsal exercise,
• Exaggeration exercise,
• Staying with the feelings.

1) Discuss the role of counselor in the person-centred approach.
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46
2) Describe the goals of counseling in existential approach. Counseling
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3) Explain the major principles of Gestalt therapy.
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3.4 RATIONAL EMOTIVE THERAPY AND

TRANSACTIONAL ANALYSIS
3.4.1 Rational Emotive Therapy
Albert Ellis started Cognitive Behaviour Therapy in 1955. This technique assumes
that cognitions, emotions, and behaviours interact and have a reciprocal cause
and effect relationship. It is very directive and concerned as much with thinking
as with feeling. It also teaches that our emotions stem mainly from our beliefs,
evaluations, interpretations, and reactions to life situations. It is an educational
process in which clients learn to identify and dispute irrational beliefs that are
maintained by self indoctrination and replace ineffective ways of thinking with
effective and rational cognitions.

RET assumes that we all are born with a potential for both rational and irrational
thinking. There is a biological and cultural tendency to think crookedly and to
needlessly disturb ourselves. Humans are self talking, self evaluating and self
sustaining. We develop emotional and behavioural problems when we mistake
simple preferences (love, approval, success) for dire needs. There is a tendency
to invent disturbing beliefs and keep ourselves disturbed through our self talk.
Humans have the capacity to change their cognitive, emotive, and behavioural
processes.

Counsellors are active and direct in this approach. They act as instructors who
teach and correct client’s cognitions. Therefore they must listen carefully for
illogical and faulty statements from the clients and challenge their beliefs. The
counsellor focusses on the thoughts and beliefs of the client trying to identify
those, which create problems. Ellis identifies several characteristics desirable
for counsellors.
47
Introduction They need to be:
• bright,
• knowledgeable,
• empathetic,
• persistent, and
• scientific.
iii) Goals
The primary goal of RET is to focus on helping people realise that they can live
more rational and productive lives and to change the way clients think by using
their automatic thoughts to reach the core schemata and begin to introduce the
idea of schema restructuring. Another goal of RET is to help people change self
defeating habits of thought or behaviour. One way of teaching them through
ABC of RET
A = existence of fact, event, behaviour, attitude of individual.
B = person’s belief
C = emotional & behavioural consequence or reaction of individual
D = disputing intervention-challenge beliefs
E = effective philosophy after disputing
F = new set of feelings
Human beings are largely responsible for creating their own emotional reactions
and disturbances. Goal is to show people how to change irrational beliefs that
directly “cause” disturbed emotional consequences.
A B C
(Activating Event) (Belief) (Consequence – Emotional
and Behavioural)
D E F
(Disputing (Effect – An (New
Intervention) Effective Feeling)
Philosophy is
Developed)
iv) Techniques
RET encompasses a number of diverse techniques. Two primary ones are teaching
and disputing. In the first few sessions, counsellors teach their clients the anatomy
of an emotion, that feelings are a result of thoughts, not events and that self talk
influences emotion. Disputing thoughts take one of three forms: cognitive,
imaginal and behavioural.
Cognitive disputation involves the use of direct questions, logical reasoning,

and persuasion. It also uses syllogisms, that is a deductive form of reasoning.
48
Imaginal disputation depends on the client’s ability to imagine and explore a Theoretical Approaches to
Counseling
technique known as rational emotive imagery (REI).
Behavioural disputation involves behaving in a way that is opposite of the client’s

usual way. Two other powerful techniques are confrontation and encouragement.
3.4.2 Transactional Analysis

Transactional analysis is another cognitive theory formulated by Eric Berne in
the early 1960s. He believed that the majority of our life experiences are recorded
in our subconscious minds in an unaltered fashion and become a part of the way
we behave. The behaviour is subconsciously designed to get reactions and
determine how others feel about us. It is a method of dealing with behavioural
disorders and can be used to manage classroom behaviour if we understand that
children’s acceptable and unacceptable behaviour is designed to ascertain how
others feel about them. He believed that there were three states of mind in all
humans, no matter how old they were, called the ego states.
Berne believed that a lot of people get stuck in one ego state more than the other
two and that this may be due to early childhood experiences. His theory was that
in childhood we have a life position assigned to us, because of the experiences
we have from birth onwards. He thinks there are four possible life positions:
I’m not OK, You’re OK;

I’m not OK, You’re not OK;
I’m OK, You’re not OK;
I’m OK, You’re OK.
i) Views of Human Nature

Transactional analysis is an optimistic theory based on the assumption that people
can change despite an unfortunate events of the past. It focuses on four methods
of understanding and predicting human behaviour:
• Structural analysis: understanding what is happening within the person.
• Transactional analysis: describing what happens between two or more people
• Game analysis – understanding transactions that lead to bad feelings
• Script analysis – understand a person’s life plan
The counsellor initially plays the role of a teacher. The counsellor helps the
client obtain the tools necessary for change in the present. Counsellors work
contractually on solving “here and now” problems and focuses on creating
productive problem solving behaviours. Using transactional analysis, counsellors
establish an egalitarian, safe and mutually respectful working relationship with
their clients. This working relationship provides tools which the clients can
utilise in their day to day functions to improve the quality of their lives.
iii) Goals
The primary goal of TA focuses on helping clients transform themselves from
“frogs” into “princes and princesses”.
49
Introduction Others goals are:
• to learn the language and concepts underlying Transactional analysis,
• to learn analyse relationships with one another in terms of TA, and
• to develop our ability to engage in straight, effective communication with
one another on a daily basis.
iv) Techniques
TA has initiated a number of techniques for helping clients to reach their goals.
The most common are structural analysis, transactional analysis, game analysis
and script analysis. Other techniques include: Treatment Contract, Interrogation,
Specification, Confrontation, Explanation, Illustration, Confirmation,
Interpretation and Crystallisation.

1) Describe the assumptions of Rational Emotive Therapy about human
nature.
...............................................................................................................
...............................................................................................................
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...............................................................................................................
...............................................................................................................
2) Explain the A B C D E F model of Rational Emotive Therapy.
...............................................................................................................
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3) Describe the four life positions as mentioned in transactional analysis.
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3.5 BEHAVIOURAL APPROACH

This approach is based on the premise that primary learning comes from
experience and applies learning principles to the elimination of unwanted
behaviours. The initial concern is to help the client analyse behaviour, define
problems, and select goals. Behavioural Therapy is effective for individuals who
50
require treatment for some sort of behaviour change, such as addictions, phobias Theoretical Approaches to
Counseling
and anxiety disorders. It concentrates on the ‘here and now’ without focusing on
the past to find a reason for the behaviour. The behavioural approach says that
people behave in the way that their environment has taught them to behave, e.g.,
through rewards and punishments, modeling, etc. So this approach attempts to
change the way the environment reinforces particular behaviour and works at
applying learning principles to help people to learn new behaviours by behavioural
experiments, role playing, assertiveness training, and self management training.
Four Aspects of Behaviour Therapy

1) Classical Conditioning
In classical conditioning certain respondent behaviours, such as knee jerks and
salivation, are elicited from a passive organism.
2) Operant Conditioning
It focuses on actions that operate on the environment to produce consequences.
If the environmental change brought about by the behaviour is reinforcing, the
chances are strengthened that the behaviour will occur again. If the environmental
changes produce no reinforcement, the chances are lessened that the behaviour
will recur.
3) Social Learning Approach

It gives prominence to the reciprocal interactions between an individual’s
behaviour and the environment.
4) Cognitive Behaviour Therapy

It emphasises cognitive processes and private events (such as client’s self-talk)
as mediators of behaviour change.

As the behaviourist views human nature, humans are neither good nor bad but
are living organisms capable of experiencing a variety of behaviours. Their
personality is composed of traits. The behaviourist believes that people can
conceptualise and control their behaviour and have the ability to learn new
behaviours. In addition, people can influence the behaviour of others as well as
be influenced by the behaviour of others. Behaviourists concentrate on behavioural
processes as they are closely associated with overt behaviour and believe that all
behaviour is learned, whether it is adaptive or maladaptive. They also believe
that learning and development occur in one of the three ways:
• respondent learning,
• operant conditioning and
• social modeling.
A counsellor may take one of the several roles, depending on his or her behavioural
orientation. The counsellor functions as a consultant, teacher, advisor and
facilitator. The behaviour counsellor tries to help the individual to learn new and
more adaptable behaviours and to unlearn old non adaptable behaviours. The
behaviour counsellor focuses attention on the individual’s ongoing behaviours
51
Introduction and their consequences in his own environment. He tries to restructure the
environment so that more adaptable patterns of behaviour can be learned and
non adaptable patterns of behaviour can be unlearned. An effective behavioural
counsellor operates from a broader perspective and involves the client in every
phase of counselling.
iii) Goals
Basically behavioural counsellors want to help clients make good adjustments
to life circumstances and achieve personal and professional objectives. A major
step is to reach mutually agreed upon goals. Blackham and Silberman(1971)
suggests four steps in this process:
1) Defining the problem

The clients are asked to specify when, where, how and with whom the
problem arises.
2) Take a developmental history

Knowledge about how the client has handled past circumstances.
3) Establish specific goals

Counselors help clients break down goals into small, achievable goals.
4) Determine the best method for change

Helping the client to reach desired goal by choosing the appropriate method.
Continuous assessment of the effectiveness of method is must.
iv) Techniques
General behavioural techniques are applicable to all behaviour theories, although
a given technique may applicable to a particular approach at a given time in a
specific circumstance.
Systematic desensitisation: This is a technique used specifically with phobias.

It helps the client to pair relaxation with previously feared stimuli.
Aversive therapy: It is almost the opposite of systematic desensitisation and

has the client pair some aversive stimuli (e.g., nausea, pain, disturbing images,
etc.) with some behaviour that he/she is having difficulty giving up. For example,
a person trying to quit drinking might take a drug that makes her nauseous
whenever she drinks alcohol. Both systematic desensitisation and aversive therapy
make use of classical conditioning learning principles—learning that occurs when
things get paired together. Systematic desensitisation “teaches” the client a new
thing by pairing relaxation with something they fear whereas Aversive therapy
“teaches” a new thing by pairing a bad experience with some behaviour they
want to eliminate.
Behaviour Modification programs: These approaches try to increase positive

behaviour and decrease negative behaviour by using reinforcements and
punishments in the most effective ways based on learning principles. The
counselor will try to help the parents identify in what ways the undesired behaviour
is being reinforced and eliminate that reinforcement and help them develop ways
to reinforce desired behaviour.
52
Use of Reinforcers: Reinforcers are those events which increase the probability Theoretical Approaches to
Counseling
of occurrence of a desired behaviour in the future by applying consequences that
depend on the behaviour in question.
Positive Reinforcement: The administration of positive consequences to workers
who perform desired behaviours- Pay, promotions, interesting work, praise,
awards.
Negative Reinforcement: The removal of negative consequences when workers
perform desired behaviours-Nagging, complaining.
Punishment: Administering negative consequences to undesirable behaviours
in an effort to decrease the probability that the behaviour will occur again in the
future.
Shaping: It is a process in which undifferentiated operant behaviours are gradually
changed into a desired behaviour pattern by the reinforcement of success
approximations, so that the behaviour gets closer and closer to the target behaviour.
Extinction: When pairing of conditioned and unconditional stimulus stops then
association weakens and conditioned response becomes less frequent till it
disappears.
Generalisation: Conditioned response occurs in response to stimuli which are
similar to the conditioned stimulus.
Discrimination: Conditioned response does not occur to all possible similar
stimuli-learned difference between stimuli
The cognitive behavioural approach examines the patient’s beliefs and behaviours.
Individuals hold beliefs about themselves and relationships that affect behaviour.
Negative beliefs lead to maladaptive behaviours. By examining and challenging
these beliefs with new information, subsequent new behaviours can change. This
approach also examines behaviours directly so that new, more adaptive behaviours
can be developed. This approach is especially beneficial for changing habits,
learned behavioural patterns, phobias, and many forms of depression.
3.6 REALITY THERAPY

Counselling approach developed by psychiatrist William Glasser helps people
gain control over their lives by self-evaluating their behaviour, then choosing
behaviour that meets their needs effectively and responsibly. It is based on choice
theory that how we deal with unsatisfying relationships. Clients choose their
behaviours to cope with unsatisfying relationships (depressing, obsessing, and
worrying). We often mistakenly choose misery in our best attempt to meet our
needs. We act responsibly when we meet our needs without keeping others from
meeting their needs. Two basic needs which are important are:
1) To love and to be loved, and
2) To feel worth.
William Glasser’s Reality technique focuses on consciousness that human beings
operate on a conscious level and that they are not driven by unconscious forces
53
Introduction or instincts. A second belief about human nature is that there is a health or growth
force within everyone. The force manifests at two levels, viz. (i) physical and
(ii) psychological.
Physical needs or survival needs like food, water, shelter etc. are automatically
controlled by the body. The four primary psychological needs are:
• Belonging – the need for friends, family and love;
• Power – the need for self esteem, recognition and competition;
• Freedom – the need to make choices and decisions; and
• Fun – the need to play, laughter, learning and recreation.
Behaviour is purposeful because it is destined to close the gap between what we
want and what we perceive we are getting. All behaviour has four components:
Acting, Thinking, Feeling, and Physiology

The counselor basically serves as a teacher and model, accepting the client in a
warm and involved way while focusing the client on the control if displayed
thoughts and actions. The counsellor assists the client in dealing with present
and establishes satisfying relationship. The counsellor is a role model of a human
who knows what life is all about and is also one who is successful in dealing
with life and not afraid to discuss any subject with their clients, teaches them to
behave in more effective ways and helps client look for better choices.
iii) Goals
1) The primary goal of reality technique is to make their clients psychologically
strong and rational. They must learn to be responsible for their own behaviour
that affects themselves and others.
2) The second goal is to help clients in knowing what they want in life. It is
vital to know the goals of life if we want to act responsibly.
3) Other goals are to help clients to get connected or reconnected with people
they have chosen to place in their quality world;
4) To teach clients choice theory and to teach client to behave in more effective
ways.
iv) Technique
Reality therapy is an action oriented technique. Some of its more effective and
active techniques are:
• teaching,
• employing,
• humor,
• confrontation,
• role playing,
• involvement and
• contracts.
54
It uses the WDEP system (Given in the box). Theoretical Approaches to
Counseling
W. Wants: What do you want to be and do?
D. Doing and Direction: What are you doing? Where do you want to go?
E. Evaluation: Does your present behaviour have a reasonable chance of
getting you what you want?
P: Planning – “SAMIC”- Simple, Attainable, Measurable, Immediate
and Controlled.
There are eight steps in reality therapy that strategically incorporates its goals
and techniques and these are given below:
1) Develop a relationship with client. (Involvement).
2) Focus on behaviour. Ask “what are you doing”?
3) Client evaluates his/her behaviour. Ask “is your behaviour helping you or
getting you what you want”?
4) If not, make a plan to change your behaviour.
5) Get a commitment to carry out plan. Perhaps sign contract.
6) Accept no excuses when plan is not carried out. Simply remind client of
plan. Perhaps revise plan.
7) Do not punish. Clients who fail already have a failure identity. Punishment
does no good.
8) Never give up.

1) Discuss the role of counselor in behaviour therapy.
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2) How does reality therapy view human nature?
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3) Explain the technique of reality therapy.
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55
Introduction
3.7 LET US SUM UP
There are many theoretical models of psychology and counseling. Most
counseling approaches fall within four broad theoretical categories:
psychoanalytic, affective, cognitive and behavioural. The Freudian view of human
nature is dynamic. According to him, human nature could be explained in terms
of a conscious mind, a sub conscious and an unconscious mind whereas Adler
focuses on our present interpretation of the events. He thought that people are
primarily motivated by social interest. Existentialism understands the human to
be challenged by the reality of temporary existence, and the view that life has no
inherent meaning; meaning had to be constructed.
The person centered approach views the client as their own best authority on
their own experience, and the client is fully capable of fulfilling their own potential
for growth. In Gestalt approach, feelings, thoughts, body sensations and actions
are all used as a guide to understand client behaviour in each moment. The
centrality of whatever is in the client’s awareness is an ideal way to understand
the world of the client.
The behaviour approach is based on the premise that primary learning comes from
experience and applies learning principles to the elimination of unwanted
behaviours. Reality approach is based on choice theory that how we deal with
unsatisfying relationships. Clients choose their behaviours to cope with unsatisfying
relationships. Each theory has its own benefits and limitation. The counselor should
use an integrative approach depending upon the problem of the client.

1) Define psychoanalytic approach and its view on human nature.
2) Describe the different techniques of psychoanalysis.
2) Explain Adler’s perspective.
3) Discuss the goals and techniques involved in behaviour approach to counselling.
4) What is Transactional Analysis? Explain the role of counsellor in this technique?
5) Describe the techniques involved in Person Centered Approach.
6) Describe the important features of Existential therapy.
7) How do counselors use Rational Emotive therapyapporach.

The Thompson Brooks
Hill
Samuel T. Gladding (2004): Counseling Theories: Essential Concepts and
Applications. Publisher: Prentice Hall
Baruth & Robinson (1987): An Introduction to the Counseling Profession.
Prentice-Hall
56
UNIT 4 ETHICS IN COUNSELING Counseling
Structure
4.0 Introduction
4.1 Objectives
4.2 What are the Ethics?
4.2.1 Reasons for Ethical Codes
4.3 Ethical Principles of Counseling
4.4 Professional Codes of Ethics
4.4.1 ACA Code of Ethics: Purpose
4.5 The ACA Eight Main Sections
4.5.1 Section A: The Counseling Relationship
4.5.2 Section B: Confidentiality, Privileged Communication and Privacy
4.5.3 Section C: Professional Responsibility
4.5.4 Section D: Relationships with Other Professionals
4.5.5 Section E: Evaluation, Assessment, and Interpretation
4.5.6 Section F: Supervision, Training, and Teaching
4.5.7 Section G: Research and Publication
4.5.8 Section H: Resolving Ethical Issues
4.6 Let Us Sum Up
4.0 INTRODUCTION
In this unit we will be dealing with ethical issues in counseling. First we define
what are Ethics and why there is a need for ethical code. This is followed by
ethical Principles of Counseling and in this we elucidate the principles of ethics
in counseling. Then we take up professional codes of ethics and then almost
reproduce the American counseling Association’s ethical principles and codes,
widely used and as defined in their 8 different sections. The ethics are felated to
the relationship between the counselor and the client, in regard to confidentiality,
professional responsibility, relationship with other professionals and ethics as
related to evaluation etc. The next section deals with ethical issues related to
supervision, training and teaching, research and publication.
4.1 OBJECTIVES
• Discuss the concept of ethics;
• Explain the need for ethical issues;
• Describe Kitchener’s main principles;
• Explain purpose of ACA Code of Ethics; and
• Discuss main sections of American Counseling Association.
57
Introduction
4.2 WHAT ARE THE ETHICS?
Counseling is not a value free or neutral activity rather it is a profession based on
values which are orienting beliefs about what is good and how that good should
be achieved. On the basis of the values, counselors and clients take directions in
the counseling process and make decisions. Counselors are guided in their
thoughts and actions by moral values, professional and personal ethics, and legal
precedents and procedures. Counselors who are not aware of their values, ethics
and legal responsibilities as well as those of clients they can cause harm to their
clients despite their good intentions. It is, therefore, vital for counselors to have
knowledge of professional counseling guidelines. Ethical counselors display care
and wisdom in their practice.
The term is often used synonymously with morality, in some case the two terms
overlap. Both deal with what is good and bad or study of human conduct and
values. Yet each has a different meaning.
Kitchener (1986): Ethics involves “making decisions of a moral nature about

people and their interaction in the society”.
Van Hoose (1985): Ethics is generally defined as a philosophical discipline that

is concerned with human conduct and moral decision making.
Ethics are normative in nature and focus on principles and standards that govern
relationship between counselors and clients.
Morality, on the other hand, involves judgment and evaluation of action. It is

associated with such words as good, bad, right, wrong, ought and should (Brandt,
1959).
4.2.1 Reasons for Ethical Codes

Ethical standards exist for many reasons. They are designed to provide some
guidelines for the professional behaviour of members. One of the primary reasons
is that “without a code of established ethics, a group of people with similar
interests can not be considered a professional organisation” (Allen, 1986). Van
Hoose and Kottler(1985) offer three reasons for the existence if ethical codes:
Ethical standards protect the profession from the government. They allow the
profession to regulate itself and function autonomously.
Ethical standards help control internal disagreement and bickering, thus promoting
stability within the profession.
Ethical standards protect practitioners from the public. Especially in malpractice

cases. If professionals behave according to ethics, the behaviour is judged to be
in compliance with the standards.
In addition, these provide clients with some protection from incompetent

counselors.
Certain other reasons are:

1) Ensuring competent professional behaviour
58
2) Responsibility to public trust Ethics in Counseling
3) Professionals monitor their own and other members’ professional behaviour

4) Controversies over the development of ethical codes
5) Ethical dilemmas
6) Character and virtue
7) ACA Ethics code
8) Aspirations and Guidelines
9) Standards
4.3 ETHICAL PRINCIPLES OF COUNSELING

Kitchener (1984) has identified five moral principles which often help to clarify
the issues involved in a given situation. The five principles are: autonomy, justice,
beneficence, non-maleficence.
1) Being trustworthy (fidelity): It involves the notions of loyalty, faithfulness,

and honoring commitments. Being trustworthy is regarded as fundamental
to understanding and resolving ethical issues. Practitioners who adopt this
principle: act in accordance with the trust placed in them; strive to ensure
that clients’ expectations are ones that have reasonable prospects of being
met; honor their agreements and promises; regard confidentiality as an
obligation arising from the client’s trust; restrict any disclosure of confidential
information about clients to furthering the purposes for which it was
originally disclosed.
2) Autonomy: The essence of this principle is allowing an individual the

freedom of choice and action. This principle emphasises the importance of
developing a client’s ability to be self-directing within therapy and all aspects
of life. It addresses the responsibility of the counselor to encourage clients,
when appropriate, to make their own decisions and to act on their own
values. There are two important considerations in encouraging clients to be
autonomous. First, helping the client to understand how their decisions and
their values may or may not be received within the context of the society in
which they live, and how they may impinge on the rights of others. The
second consideration is related to the client’s ability to make sound and
rational decisions. The principle of autonomy opposes the manipulation of
clients against their will, even for beneficial social ends.
3) Beneficence: The principle of beneficence means acting in the best interests

of the client based on professional assessment. Beneficence reflects the
counselor’s responsibility to contribute to the welfare of the client. Simply
stated it means to do good, to be proactive and also to prevent harm when
possible (Forester-Miller & Rubenstein, 1992). It directs attention to working
strictly within one’s limits of competence and providing services on the
basis of adequate training or experience. There is an obligation to use regular
and on-going supervision to enhance the quality of the services provided
and to commit to updating practice by continuing professional development.
An obligation to act in the best interests of a client may become paramount
when working with clients whose capacity for autonomy is diminished
59
Introduction because of immaturity, lack of understanding, extreme distress, serious
disturbance or other significant personal constraints.
4) Non maleficence: Nonmaleficence is the concept of not causing harm to

others. Often explained as “above all do no harm”, this principle is considered
by some to be the most critical of all the principles, even though theoretically
they are all of equal weight (Kitchener, 1984; Rosenbaum, 1982; Stadler,
1986). This principle reflects both the idea of not inflicting intentional harm,
and not engaging in actions that risk harming others (Forester-Miller &
Rubenstein, 1992). Non-maleficence involves avoiding sexual, financial,
and emotional or any other form of client exploitation; avoiding
incompetence or malpractice; not providing services when unfit to do so
due to illness, personal circumstances or intoxication. The practitioner has
an ethical responsibility to strive to mitigate any harm caused to a client
even when the harm is unavoidable or unintended.
5) Justice: The principle of justice requires being just and fair to all clients
and respecting their human rights and dignity. Justice does not mean treating
all individuals the same. Kitchener (1984) points out that the formal meaning
of justice is “treating equals equally and unequals unequally but in proportion
to their relevant differences” (p.49). It directs attention to considering
conscientiously any legal requirements and obligations, and remaining alert
to potential conflicts between legal and ethical obligations. Practitioners
have a duty to strive to ensure a fair provision of counselling and
psychotherapy services, accessible and appropriate to the needs of potential
clients. If an individual is to be treated differently, the counselor needs to be
able to offer a rationale that explains the necessity and appropriateness of
treating this individual differently.

1) Differentiate between ethics and morality.
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2) Explain the importance of having ethical code.
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60
Ethics in Counseling
3) What are the different ethical principles of counseling?
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4.4 PROFESSIONAL CODES OF ETHICS

A professional code of ethics is a set of standards of conduct based upon on
agreed on set of values by which professionals in a given occupation such as
counseling or psychology.
The American Counseling Association (ACA) is a nonprofit professional and

educational organisation dedicated to the growth and enhancement of the
counseling profession. Founded in 1952, ACA is the world’s largest association
representing professional counselors in various practice settings. ACA is
instrumental in setting professional and ethical standards for the counseling
profession. The Association has also made considerable strides in accreditation,
licensure, and national certification.
In ACA, ethical standards are arranged under topical section headings. There are
five main purposes and eight major sections of standards.
4.4.1 ACA Code of Ethics: Purpose

The ACA Code of Ethics serves five main purposes:
i) The Code enables the association to clarify to current and future members,
and to those served by members, the nature of the ethical responsibilities
held in common by its members.
ii) The Code helps support the mission of the association.
iii) The Code establishes principles that define ethical behaviour and best
practices of association members.
iv) The Code serves as an ethical guide designed to assist members in
constructing a professional course of action that best serves those utilising
counseling services and best promotes the values of the counseling
profession.
v) The Code serves as the basis for processing of ethical complaints and
inquiries initiated against members of the association.
Rehabilitation Council of India Code of Ethics for Counsellors

RCI Code of Ethics Adopted July 17, 2001 Revised March 28, 2006
Introduction
The standards contained in this Code of Ethics are statements of ethical principles
having broad applicability to members and registrants of RCI. However, the
61
Introduction enumeration of particular duties and the proscription of certain conduct do not
negate the existence of other obligations logically flowing from such principles.
Conduct deemed unethical may be construed to include lesser offenses, such as
aiding and abetting.
Members and registrants of RCI should also recognise that their profession and
their practice may be governed by various laws and regulations regarding
professional registration and the conduct of trade. It is their responsibility,
therefore, to be familiar with those laws and regulations and to conduct themselves
accordingly.
General Obligations Members and registrants shall maintain and further their
knowledge of the science and profession of roofing, waterproofing, and the
building envelope, and shall maintain the highest possible standard of professional
judgment and conduct.
Obligations to the Public

Members and registrants should uphold the letter and spirit of the ethical standards
governing their professional affairs and should consider the full impact of their
actions on the community at large.
Thus, a member or registrant shall: i). Engage only in accurate, appropriate and
truthful promotion of his/her practice; ii) Be respectful of the rights of others in
obtaining professional work or employment; and iii) Make only accurate, truthful
and appropriate statements or claims about his/her professional qualifications,
experiences or performance.
Obligations to the Client

Members and registrants shall conduct themselves in a fashion which brings
credit to themselves, their employers and their profession. In addition to upholding
the behavioural standards described above, a member or registrant:
i) Shall preserve the confidence of his/her client or employer and serve each
in a professional and competent manner.
ii) Shall exercise unprejudiced and unbiased judgment and conduct when
performing all professional services;
iii) Shall practice only in his/her area of competence;
iv) Shall decline any activity or employment, avoid any significant financial or
other interest, and decline any contribution if it would reasonably appear
that such activity, employment, interest, or contribution could compromise
his or her professional judgment or conduct, or prevent him/her from serving
the best interest of his/her client or employer, without making full disclosure
to the client and obtaining the client’s consent thereto;
v) Shall neither offer nor make any payment or gift to any public official, private
client or industry representative with the intent of influencing that person’s
judgment or decision in connection with an existing or prospective project
in which the member/registrant is interested; and
vi) May contribute his services or anything of value to those endeavors which
the member deems worthy. Further, a member or registrant has the right to
participate in the political process and to contribute time and money to
62 political campaigns.
Obligations to the Profession and Building Industry Ethics in Counseling
Members and registrants shall:

i) Recognise the value and contributions of others engaged in the design and
construction process, and refrain from making false statements about the
work of others, and shall not maliciously injure or attempt to injure the
prospects, practice, or employment position of others; and
ii) Encourage professional education and research, as well as the development
and dissemination of information relating to the design and construction of
roofing, waterproofing, and building envelope systems.
Further, the following practices are not in themselves unethical, unprofessional,
or contrary to any policy of RCI, and RCI members and registrants are free to
decide for themselves whether to engage in any of these practices:
i) Submitting competitive bids or price quotations, including in circumstances
where price is the sole or principle consideration in the selection of a
consultant;
ii) Providing discounts; or
iii) Providing free services.
4.5 THE ACA EIGHT MAIN SECTIONS

Section A: The Counseling Relationship
Section B: Confidentiality, Privileged Communication, and Privacy
Section C: Professional Responsibility
Section D: Relationships with Other Professionals
Section E: Evaluation, Assessment, and Interpretation
Section F: Supervision, Training, and Teaching
Section G: Research and Publication
Section H: Resolving Ethical Issues
Each section of the ACA Code of Ethics begins with an Introduction. The
introductions to each section discuss what counselors should aspire to with regard
to ethical behaviour and responsibility. The Introduction helps set the tone for
that particular section and provides a starting point that invites reflection on the
ethical mandates contained in each part of the ACA Code of Ethics. When
counselors are faced with ethical dilemmas that are difficult to resolve, they are
expected to engage in a carefully considered ethical decision-making process.
Reasonable differences of opinion can and do exist among counselors with respect
to the ways in which values, ethical principles, and ethical standards would be
applied when they conflict. While there is no specific ethical decision-making
model that is most effective, counselors are expected to be familiar with a credible
model of decision making that can bear public scrutiny and its application.
Through a chosen ethical decision-making process and evaluation of the context
of the situation, counselors are empowered to make decisions that help expand
the capacity of people to grow and develop.
63
Introduction ACA (1995) reproduced below:
4.5.1 Section A: The Counseling Relationship
Counselors encourage client growth and development in ways that foster the
interest and welfare of clients and promote formation of healthy relationships.
Counselors actively attempt to understand the diverse cultural backgrounds of
the clients they serve. Counselors also explore their own cultural identities and
how these affect their values and beliefs about the counseling process. Counselors
are encouraged to contribute to society by devoting a portion of their professional
activity to services for which there is little or no financial return.
A.1) Welfare of Those Served by Counselors
A.1.a) Primary Responsibility
A.1.b) Records
A.1.c) Counseling Plans
A.1.d) Support Network Involvement
A.1.e) Employment Needs
A.2) Informed Consent in the Counseling Relationship
A.2.a) Informed Consent
A.2.b) Types of Information
A.2.c) Developmental and Cultural
A.2.d) Inability to Give Consent
A.3 Clients Served by Others
A.4 Avoiding Harm and Imposing Values
A.4.a) Avoiding Harm
A.4.b) Personal Values
A.5) Roles and Relationships with Clients
A.5.a) Current Clients
A.5.b) Former Clients
A.5.c) Nonprofessional Interactions or Relationships
A.5.d) Potentially Beneficial
A.5.e) Role Changes in the Professional Relationship
A.6) Roles and Relationships at Individual, Group, Institutional, and
Societal Levels
A.6.a) Advocacy
A.6.b) Confidentiality and Advocacy
A.7) Multiple Clients
A.8) Group Work
A.8.a) Screening
A.8.b) Protecting Clients
64
A.9) End-of-Life Care for Terminally Ill Clients Ethics in Counseling
A.9.a) Quality of Care

A.9.b) Counselor Competence, Choice, and Referral
A.9.c) Confidentiality
A.10) Fees and Bartering

A.10.a) Accepting Fees from Agency Clients
A.10.b) Establishing Fees
A.10.c) Nonpayment of Fees
A.10.d) Bartering
A.10.e) Receiving Gifts
A.11) Termination and Referral

A.11.a) Abandonment Prohibited
A.11.b) Inability to Assist Clients
A.11.c) Appropriate Termination
A.11.d) Appropriate Transfer of Services
A.12) Technology Applications

A.12.a) Benefits and Limitations
A.12.b) Technology-Assisted Services
A.12.c) Inappropriate Services
A.12.d) Access
A.12.e) Laws and Statutes
A.12.f) Assistance
A.12.g) Technology and Informed Consent
A.12.h) Sites on the World Wide Web
ACA made several additions to this section in 2005. In the 1995 ethical code,
there was an emphasis on the need to avoid any type of non professional
relationship with clients , but in 2005 code speaks of potentially beneficial
interaction between counselors and clients. This goes beyond the traditional
professional counseling relationship. Another change is in regard to the boundary
issues related to having sexual or romantic relationships with ex clients for 2-5
years. Now this ex clients includes one’s family members, romantic partners etc.
A siginificant addition is in regard to guidance to counselors serving terminally
ill clients. It directs the counselors to take measures that enable clients to obtain
high quality end of life care; to exercise the highest degree of self determination
possible, to be given every opportunity to engage in informed decision making
regarding their end of life care; to receive complete and adequate assessment
regarding their ability to make competent rational decision on their own behalf
from a professionakl experienced in end of life care practice.
65
Introduction 4.5.2 Section B: Confidentiality, Privileged Communication,
and Privacy
Introduction
Counselors recognise that trust is a cornerstone of the counseling relationship.
Counselors aspire to earn the trust of clients by creating an ongoing partnership,
establishing and upholding appropriate boundaries, and maintaining
confidentiality. Counselors communicate the parameters of confidentiality in a
culturally competent manner.
B.1) Respecting Client Rights
B.1.a) Multicultural/Diversity Considerations
B.1.b) Respect for Privacy
B.1.c) Respect for Confidentiality
B.1.d) Explanation of Limitations
B.2) Exceptions
B.2.a) Danger and Legal Requirements
B.2.b) Contagious, Life-Threatening Diseases
B.2.c) Court-Ordered Disclosure
B.2.d) Minimal Disclosure
B.3) Information Shared With Others
B.3.a) Subordinates
B.3.b) Treatment Teams
B.3.c) Confidential Settings
B.3.d) Third-Party Payers
B.3.e) Transmitting Confidential Information
B.3.f) Deceased Clients
B.4) Groups and Families
B.4.a) Group Work
B.4.b) Couples and Family
B.5) Clients Lacking Capacity to Give Informed Consent
B.5.a) Responsibility to Clients
B.5.b) Responsibility to Parents and Legal Guardians
B.5.c) Release of Confidential Information
B.6) Records
B.6.a) Confidentiality of Records
B.6.b) Permission to Record
B.6.c) Permission to Observe
B.6.d) Client Access
B.6.e) Assistance with Records
66
B.6.f) Disclosure or Transfer Ethics in Counseling
B.6.g) Storage and Disposal after Termination

B.6.h) Reasonable Precautions
B.7) Research and Training
B.7.a) Institutional Approval
B.7.b) Adherence to Guidelines
B.7.c) Confidentiality of Information Obtained in Research
B.7.d) Disclosure of Research Information
B.7.e) Agreement for Identification
B.8) Consultation
B.8.a) Agreements
B.8.b) Respect for Privacy
B.8.c) Disclosure of Confidential Information
One major change in section B is an increased discussion of privacy and
confidentiality when working with clients who are minors or adults who cannot
give informed consent. Standardss B.5.a,b and c outline the need for counselors
to protect the confidentiality of such clients and to include clients in all decisions.
Counsellors are expected to work to establish as appropriate collaborative
relationships with parents / guardians to best serve clients. There is a significant
change related to family counseling. Standard B.2.b (family counseling) of 1995
stated that information about one family member cannot be disclosed to another
member without permission. In 2005 code, (couples and family counseling)
Ethics requires the counselors to clearly define who is considered the “client”
and discuss expectations and limitations of confidentiality. They have to seek
agreement and then document in writing the agreement involving all members
in the counseling and preserve the confidentiality of information known.
4.5.3 Section C: Professional Responsibility

Introduction
Counselors aspire to open, honest, and accurate communication in dealing with
the public and other professionals. They practice in a non-discriminatory manner
within the boundaries of professional and personal competence and have a
responsibility to abide by the ACA Code of Ethics. Counselors actively participate
in local, state, and national associations that foster the development and
improvement of counseling.
Counselors advocate promoting change at the individual, group, institutional,

and societal levels that improves the quality of life for individuals and groups
and remove potential barriers to the provision or access of appropriate services
being offered.
Counselors have a responsibility to the public to engage in counseling practices

that are based on rigorous research methodologies. In addition, counselors engage
in self-care activities to maintain and promote their emotional, physical, mental,
and spiritual well-being to best meet their professional responsibilities.
67
Introduction C.1) Knowledge of Standards
C.2) Professional Competence
C.2.a) Boundaries of Competence
C.2.b) New Specialty Areas of Practice
C.2.c) Qualified for Employment
C.2.d) Monitor Effectiveness
C.2.e) Consultation on Ethical Obligations
C.2.f) Continuing Education
C.2.g) Impairment
C.2.h) Counselor Incapacitation or Termination of Practice
C.3) Advertising and Soliciting Clients
C.3.a) Accurate Advertising
C.3.b) Testimonials
C.3.c) Statements by Others
C.3.d) Recruiting Through Employment
C.3.e) Products and Training Advertisements
C.3.f) Promoting to Those Served
C.4) Professional Qualifications
C.4.a) Accurate Representation
C.4.b) Credentials
C.4.c) Educational Degrees
C.4.d) Implying Doctoral-Level Competence
C.4.e) Program Accreditation Status
C.4.f) Professional Membership
C.5) Nondiscrimination
C.6) Public Responsibility
C.6.a) Sexual Harassment
C.6.b) Reports to Third Parties
C.6.c) Media Presentations
C.6.d) Exploitation of Others
C.6.e) Scientific Bases for Treatment Modalities
C.7) Responsibility to Other Professionals
C.7.a) Personal Public Statements
2005 modification states that in addition to counselors being responsible to seek
assistance for problems that reach the level of professional impairment, the
counselors are now ethically obligated to assist colleagues or supervisors in
recognising their own professional impairment and provide consultation and
assistance when warranted. Another addition is to c.6.e. that is scientific bases
68
for treatment modalities. 1995 code directed the counsllors to monitor their Ethics in Counseling
effectiveness, but did not speak of their responsibility to base techniques and
treatment plans on theory and empirical or scientific results. The 2005
modification requires that the counselors define the techniques and procedures
and explain the potential risks and ethical considerations of using such techniques
and procedures and take steps to protect clients from possible harm.
4.5.4 Section D: Relationships with Other Professionals

Introduction
Professional counselors recognise that the quality of their interactions with
colleagues can influence the quality of services provided to clients.
They work to become knowledgeable about colleagues within and outside the
field of counseling. Counselors develop positive working relationships and
systems of communication with colleagues to enhance services to clients.
D.1) Relationships with Colleagues, Employers, and Employees
D.1.a) Different Approaches
D.1.b) Forming Relationships
D.1.c) Interdisciplinary Teamwork
D.1.d) Confidentiality
D.1.e) Establishing Professional and Ethical Obligations
D.1.f) Personnel Selection and Assignment
D.1.g) Employer Policies
D.1.h) Negative Conditions
D.1.i) Protection from Punitive Action
D.2) Consultation
D.2.a) Consultant Competency
D.2.b) Understanding Consultees
D.2.c) Consultant Goals
D.2.d) Informed Consent in Consultation
2005 modifications: Counsellors actross work settings are part of interdisciplinary
teams. There are several new standards that address responsibilities to develop
and strengthen relationships with colleagures from other disciplines to best serve
clients (standard D.1.b) The 2005 modification requires the counselors to keep
the focus on the well being of clients by drawing on the perspectives, values and
experiences of the counslling progession and those of colleagues from other
disciplines and to clarify professional roles, parameters of confidentiality and
ethical obligations of the team and its members.
4.5.5 Section E: Evaluation, Assessment and Interpretation

Introduction
Counselors use assessment instruments as one component of the counseling
process, taking into account the client personal and cultural context. Counselors
69
Introduction promote the well-being of individual clients or groups of clients by developing
and using appropriate educational, psychological, and career assessment
instruments.
E.1) General
E.1.a) Assessment
E.1.b) Client Welfare
E.2) Competence to Use and Interpret Assessment Instruments
E.2.a) Limits of Competence
E.2.b) Appropriate Use
E.2.c) Decisions Based on Results
E.3) Informed Consent in Assessment
E.3.a) Explanation to Clients
E.3.b) Recipients of Results
E.4) Release of Data to Qualified Professionals
E.5) Diagnosis of Mental Disorders
E.5.a) Proper Diagnosis
E.5.b) Cultural Sensitivity
E.5.c) Historical and Social Prejudices in the Diagnosis of Pathology
E.5.d) Refraining From Diagnosis
E.6) Instrument Selection
E.6.a) Appropriateness of Instruments
E.6.b) Referral Information
E.6.c) Culturally Diverse Populations
E.7) Conditions of Assessment Administration
E.7.a) Administration Conditions
E.7.b) Technological Administration
E.7.c) Unsupervised Assessments
E.7.d) Disclosure of Favorable Conditions
E.8) Multicultural Issues/ Diversity in Assessment
E.9) Scoring and Interpretation of Assessments
E.9.a) Reporting
E.9.b) Research Instruments
E.9.c) Assessment Services
E.10) Assessment Security
E.11) Obsolete Assessments and Outdated Results
E.12) Assessment Construction
E.13) Forensic Evaluation: Evaluation for Legal Proceedings
70
E.13.a) Primary Obligations Ethics in Counseling
E.13.b) Consent for Evaluation

E.13.c) Client Evaluation Prohibited
E.13.d) Avoid Potentially Harmful Relationships
2005 modifications: One noteworthy change in this section is the terminology
used. The word tests used in 1995 code has been replaced with the word
assessment which has a broader and more holistic meaning. In E 13.a and in
E.13.d. the counselors are required to understand their primary obligations when
conducting forensic evaluations, how these obligations differ from those involved
in counseling and their responsibility to explain to the clients. The new standards
also prohibit counselors from conducting forensic evaluations with clients they
are counseling or have counseled so as to avoid potentially harmful professional
or personal relationships with family members, romantic partners and close friends
of individuals they are evaluating or have evaluated in the past. (Standard
E 13.d)
4.5.6 Section F: Supervision, Training and Teaching

Introduction
Counselors aspire to foster meaningful and respectful professional relationships
and to maintain appropriate boundaries with supervisees and students. Counselors
have theoretical and pedagogical foundations for their work and aim to be fair,
accurate, and honest in their assessments of counselors-in-training.
F.1) Counselor Supervision and Client Welfare
F.1.a) Client Welfare
F.1.b) Counselor Credentials
F.1.c) Informed Consent and Client Rights
F.2) Counselor Supervision Competence
F.2.a) Supervisor Preparation
F.2.b) Multicultural Issues/Diversity in Supervision
F.3) Supervisory Relationships
F.3.a) Relationship Boundaries with Supervisees
F.3.b) Sexual Relationships
F.3.c) Sexual Harassment
F.3.d) Close Relatives and Friends
F.3.e) Potentially Beneficial Relationships
F.4) Supervisor Responsibilities
F.4.a) Informed Consent for Supervision
F.4.b) Emergencies and Absences
F.4.c) Standards for Supervisees
F.4.d) Termination of the Supervisory Relationship
F.5) Counseling Supervision Evaluation, Remediation, and Endorsement
F.5.a) Evaluation
71
Introduction F.5.b) Limitations
F.5.c) Counseling for Supervisees
F.5.d) Endorsement
F.6) Responsibilities of Counselor Educators
F.6.a) Counselor Educators
F.6.b) Infusing Multicultural Issues/ Diversity
F.6.c) Integration of Study and Practice
F.6.d) Teaching Ethics
F.6.e) Peer Relationships
F.6.f) Innovative Theories and Techniques
F.6.g) Field Placements
F.6.h) Professional Disclosure
F.7) Student Welfare
F.7.a) Orientation
F.7.b) Self-Growth Experiences
F.8) Student Responsibilities
F.8.a) Standards for Students
F.8.b) Impairment
F.9) Evaluation and Remediation of Students
F.9.a) Evaluation
F.9.b) Limitations
F.9.c) Counseling for Students
F. 10) Roles and Relationships between Counselor, Educators and Students
F.10.a) Sexual or Romantic Relationships
F.10.b) Sexual Harassment
F.10.c) Relationships with Former Students
F.10.d) Nonprofessional Relationships
F.10.e) Counseling Services
F.10.f) Potentially Beneficial Relationships
F.11) Multicultural/Diversity Competence in Counselor, Education and
Training Programs
F.11.a) Faculty Diversity
F.11.b) Student Diversity
F.11.c) Multicultural/Diversity Competence
2005 modifications: This section has been reorganised since 1995 and greatly
expanded in terms of noting ethical obligations of counselors who supervise
counseling students, trainees and staff. This section F focussesn on counselor
supervision and client welfare across settings, informed consent in the supervisory
72
relationship. It also deals with competence of counseling supervisors, supervisor Ethics in Counseling
responsibilities and potentially harmful or beneficial relationships between
supervisors and supervisees. It also deals with the relationship between faculty
members and students, students welfare and orientation, self growth experiences,
impairment of counseling students and supervisees. It also presentsthe requirement
of ethical evaluation of the performance of supervisees and students and
endorsement of supervisees and students.
4.5.7 Section G: Research and Publication

Introduction
Counselors who conduct research are encouraged to contribute to the knowledge
base of the profession and promote a clearer understanding of the conditions
that lead to a healthy and more just society. Counselors support efforts of
researchers by participating fully and willingly whenever possible. Counselors
minimize bias and respect diversity in designing and implementing research
programs.
G.1) Research Responsibilities
G.1.a) Use of Human Research Participants
G.1.b) Deviation from Standard Practice
G.1.c) Independent Researchers
G.1.d) Precautions to Avoid Injury
G.1.e) Principal Researcher Responsibility
G.1.f) Minimal Interference
G.1.g) Multicultural/Diversity
G.2) Rights of Research Participants
G.2.a) Informed Consent in Research
G.2.b) Deception
G.2.c) Student/Supervisee Participation
G.2.d) Client Participation
G.2.e) Confidentiality of Information
G.2.f) Persons Not Capable of Giving Informed Consent
G.2.g) Commitments to Participants
G.2.h) Explanations after Data Collection
G.2.i) Informing Sponsors
G.2.j) Disposal of Research
G.3) Relationships with Research Participants
G.3.a) Non professional Relationships
G.3.b) Relationships with Research Participants
G.3.c) Sexual Harassment and Research Participants
G.3.d) Potentially Beneficial Interactions
73
Introduction G.4) Reporting Results
G.4.a) Accurate Results
G.4.b) Obligation to Report Unfavorable Results
G.4.c) Reporting Errors
G.4.d) Identity of Participants
G.4.e) Replication Studies
G.5) Publication
G.5.a) Recognising Contributions
G.5.b) Plagiarism
G.5.c) Review/Republication of Data or Ideas
G.5.d) Contributors
G.5.e) Agreement of Contributors
G.5.f) Student Research
G.5.g) Duplicate Submission
G.5.h) Professional Review
2005 modifications: The term research subjects has been replaced by the terms
research participants. According to new standards G.1.c. the independent
researchers have an ethical obligation to consult with researchers who are familiar
with Institutional Review Board requirements in order to provide appropriate
safeguards for research participants. This section also deals with issues related
to publication. The new standards specifically state that the counselors do not
plagiarise the work of others. The professional review has also been expanded in
the new code.
4.5.8 Section H: Resolving Ethical Issues

Introduction
Counselors behave in a legal, ethical, and moral manner in the conduct of their
professional work. They are aware that client protection and trust in the profession
depend on a high level of professional conduct. They hold other counselors to
the same standards and re willing to take appropriate action to ensure that these
standards are upheld.
Counselors strive to resolve ethical dilemmas with direct and open communication
among all parties involved and seek consultation with colleagues and supervisors
when necessary. Counselors incorporate ethical practice into their daily
professional work. They engage in ongoing professional development regarding
current topics in ethical and legal issues in counseling.
H.1) Standards and the Law
H.1.a) Knowledge
H.1.b) Conflicts Between Ethics and Laws
H.2) Suspected Violations
H.2.a) Ethical Behaviour Expected
74
H.2.b) Informal Resolution Ethics in Counseling
H.2.c) Reporting Ethical Violations

H.2.d) Consultation
H.2.e) Organisational Conflicts
H.2.f) Unwarranted Complaints
H.2.g) Unfair Discrimination against Complainants and Respondents
H.3) Cooperation with Ethics Committees
2005 modifications: The 2005 code provides greater clarity to counselors about
ways to address potential conflicts between ethical guidelines and legal
requirements. Standard H.1.b. notes that in such situations counselors make
known their commitment to the code of ethics and take steps to resolve the
conflict. If the conflict cannot be resolved by such means, counselors may adhere
to the requirements of law, regulations or other governing legal authority. Another
change in this section is the expanded list of potential agencies and organisations
to which information regarding suspected or documented ethical violations may
be reported to include “state or national certification bodies, state licensing boards
or appropriate institutional authorities. (standard H.2.c.) Finally there is a new
standard (H.2.g) that protects the rights of ACA members who have made or
been the subject of an ethics complaint.
4.6 LET US SUM UP

The challenge of working ethically means that counselors will inevitably
encounter situations where there are competing obligations. Counselors are having
code of ethics to guide them in the practice of helping others. Counselors generally
consult ethical standards of ACA when they face ethical dilemmas. In making
ethical decisions, counselors rely on personal values as well as ethical standards.
They also consult with professional colleagues. It is imperative that counselors
become well informed regarding ethics for their as well as their client’s welfare.
Counselors should have academic and working knowledge of ethics.
These ethics are intended to be of assistance in such circumstances by directing

attention to the variety of ethical factors that may need to be taken into
consideration and to alternative ways of approaching ethics that may prove more
useful. No statement of ethics can totally alleviate the difficulty of making
professional judgments in circumstances that may be constantly changing and
full of uncertainties. By accepting this statement of ethics, members of the
American Counseling Association are committing themselves to engaging with
the challenge of striving to be ethical, even when doing so involves making
difficult decisions or acting courageously.

1) Define Ethics.
2) Discuss the ethical principles of counseling.
3) What are the purposes of ACA code of ethics?
4) Explain Section C of ACA.
75
Introduction 5) Explain the meaning of Beneficence and Nonmaleficence.
6) What are professional codes of ethics?

Hill.
Tim Bond (2000): Standards and Ethics for Counselling in Action. SAGE
Publication
Samuel T. Gladding (2009): Counseling: A Comprehensive Profession. Publisher:

Pearson/Merrill Prentice Hall.
76
UNIT 1 PSYCHOANALYSIS,
PSYCHODYNAMIC AND
PSYCHOTHERAPY
Structure
1.0 Introduction
1.1 Objectives
1.2 Psychotherapy
1.2.1 Essentials of Psychotherapy
1.3 Psychoanalysis
1.3.1 Phases in the Evolution of Psychoanalysis
1.3.2 Brief History of Psychoanalysis
1.3.3 The Work of a Psychoanalyst
1.3.4 Goals of Psychoanalysis
1.4 Techniques in Psychoanalysis
1.4.1 Maintaining the Analytical Framework
1.4.2 Free Association
1.4.3 Dream Analysis
1.4.4 Interpretation
1.4.5 Analysis and Interpretation of Resistance
1.4.6 Analysis of Transference
1.4.7 Counter Transference
1.5 Psychodynamic Therapies
1.5.1 Freudian School
1.5.2 Ego Psychology
1.5.3 Object Relations Psychology
1.5.4 Self Psychology
1.6 Differences between Psychodynamic Therapy and Psychoanalysis
1.7 Let Us Sum Up
1.0 INTRODUCTION
In this unit we will be dealing with psychotherapy, psychoanalysis and other related
therapies. It provides a detailed account of psychoanalysis and presents the
component factors in the same. We then discuss the essentials of Psychotherapy
and point out its importance. Then we take up psychoanalysis and as the first step
we elucidate the evolution of psychoanalysis and then follow it up by presenting
a history of psychoanalysis. Then we take up the functions of a psychoanalyst and
detail the same. This is followed by the goals of psychoanalysis and the techniques
of psychoanalysis. The next section deals with the psychodynamic therapies and
their significance. Then we point out the differences between Psychodynamic
Therapy and Psychoanalysis
5
Counselling: Models and
Approaches 1.1 OBJECTIVES
• Discuss the concept of psychotherapy;
• Define psychoanalysis;
• Describe the goals of psychoanalysis;
• Identify the difference between psychodynamic therapy and psychoanalysis;
and
• Explain the techniques like dream analysis and free association used by the
psychotherapist.
1.2 PSYCHOTHERAPY
Psychotherapy consists of the whole range of psychologically based treatments
by which trained practitioners help people who have psychological problems.
Sometimes it is used in more restricted way. It refers to forms of treatment in
which a psychotherapist and a client tackle client’s problem through talking.
Traditionally it focuses on serious problems associated with intra psychic, internal,
and personal issues and conflicts. Characteristically, it emphasises the following
issues:
• The past more than the present
• Insight more than change
• The detachment of the therapist
• The therapist’s role as an expert
Psychotherapy is a systematic interaction between a therapist and a client that
brings psychological principles to bear on influencing the client’s thoughts, feelings,
or behaviour to help that client overcome abnormal behaviour or adjust to problems
in living. The interaction is between two or more individuals where one of them,
called client or patient, is seeking help for a problem and the other participant,
called therapist, provides necessary therapeutic help. The interaction is usually
mediated by verbal means although facial expressions, bodily gestures and
movement are also used. It usually involves a long term relationship that focuses
on reconstructive change. Psychotherapies are procedures in which persons with
mental disorders interact with a trained psychotherapist who helps them change
certain behaviours, thoughts, or emotions so that they feel and function in a better
way. It helps the patients to manage their symptoms better and function at their
best in everyday life. It consists of a series of techniques for treating mental health,
emotional and some psychiatric disorders and helps the individuals understand
what helps them feel positive or anxious, as well as accepting their strong and
weak points.
1.2.1 Essentials of Psychotherapy

i) Systematic Interaction: Psychotherapy is a systematic interaction between
a client and a therapist. The therapist structures the therapy process based
upon a theoretical viewpoint and an understanding of the client’s cultural
and social background.
6
ii) Psychological Principles: Psychotherapy is based on psychological theory Psychoanalysis,
Psychodynamic and
and research in various areas such as personality, learning and abnormal Psychotherapy
behaviour.
iii) Thoughts, feelings and behaviours: Psychotherapy influences clients’
thoughts, feelings and behaviour.
iv) Psychological Disorders, adjustment problems and personal growth:
While psychotherapy is often used with people who have psychological
disorders, it can also be used to help people with adjustment (loss of spouse,
shyness) and personal growth.
Psychotherapy or talk therapy is currently used by psychologists and other
professionals in different forms. It uses varied range of procedures and can be
conducted with individuals as well as with groups. There are many different therapy
styles and techniques including Psychodynamic Psychotherapy, Cognitive
Behavioural Therapy (CBT), Group Therapy, and Couples Therapy. The unique
elements of psychotherapy are that it varies according to different theoretical
perspectives. The first organised system of psychotherapy which has a considerable
influence in the field of Psychology was Psychoanalysis by Sigmund Freud.
1.3 PSYCHOANALYSIS
Psychoanalysis is a very significant perspective in the field of psychology. It is a
method of analysing psychic phenomena and treating emotional disorders that
involves treatment sessions during which the client or the patient is encouraged to
talk freely about personal experiences and especially about early childhood and
dreams. Psychoanalysis is both a theory of mental functioning and a specific type
of psychological treatment philosophy. It is generally known as a theory of human
behaviour.
It has three applications:
i) a method of investigation of the mind;
ii) a systematised set of theories about human behaviour;
iii) a method of treatment of psychological or emotional illness.
Psychoanalysis was first devised in Vienna in the 1890s by Sigmund Freud. It
involves analysing the root causes of behaviour and feelings by exploring the
unconscious mind and the conscious mind’s relation to it. It focuses on an
individual’s unconscious, deep-rooted thoughts that often stem from childhood.
Freud believed that Id, Ego and Super-Ego are three major parts of personality
which represent desire, reason and conscience.
He was of the opinion that the root cause of all mental disorders is repressed
desired in the unconscious mind.
This repression occurs due to non acceptance of Id impulses to ego or superego.

These urges persist in the unconscious and individuals devote a considerable time
to have a check on them and to keep them out of conscious part of the personality.
People often use defense mechanisms to protect the ego from feeling of anxiety
generated by these inner conflicts.
7
Counselling: Models and 1.3.1 Phases in the Evolution of Psychoanalysis
Approaches
Freud (1914b, 1927) described three phases in the evolution of Psychoanalysis.
The first phase

During first phase of psychoanalysis, Freud found that the central aspect of human
mind was unconscious thoughts that could be accessed through dreams, fantasies,
jokes, slip of tongues, hypnosis, free association, and so on.
The second phase

In the second phase, Freud discarded hypnosis and emphasised on free association.
He found that clients voluntarily permitted the emergence of unconscious materials
in free association. As Freud always wanted a unique theory so he developed his
own specific techniques like Dream Analysis, Free Association and so on.
Third phase
During the third phase, he elaborated his dream analysis technique and described
primary and secondary processes. Primary processes are governed by Id, the
pleasure principle and are illogical. They can be found in dreams, poetry, myth
and magic. Psychosis is the ultimate form of this process.
Secondary processes are governed by logic and are associated with the ego and
reality principle.
At the end of the third phase of Psychoanalysis, other analysts such as Jung(1875-
1961), Adler(1870-1937), Horney(1885-1952), Sullivan(1892-1949) and Erikson
(1902-1992) modified Freud’s psychoanalysis.
1.3.2 Brief History of Psychoanalysis

Psychoanalysis has also its roots in hypnosis. The first contributor was Franz
Mesmer, who is known for inducing a mental state called Mesmerism. He has
presented the idea of animal magnetism. He used magnets for the treatment of
paralysis, later he claimed that he could treat paralysis without magnets by directing
his own magnetic fluid to the patient’s body.
Liebault and Bernheim introduced Mesmerism in the Nancy school, France. Jean
Martin Charcot was a French Neurologist who used hypnosis to treat hysterical
patients. In 1885 Charcot introduced Freud to hypnosis. Freud began developing
his own theory of psychoanalysis under Charcot’s influence. Josef Breuer
introduced Freud to Cathartic method of treatment of hysteria.
Freud emphasised on unconscious drives. He used the term Psychoanalysis in

three distinct ways: Firstly, it is a theory which describes the structure of the
mind, the development of the personality, and psychopathology; secondly it is
used as a technique to treat psychological difficulties; and thirdly it is a method of
scientific investigation based on a clinical observation called case study.
Anna Freud (1895-1982) was especially instrumental in carrying on her father’s

tradition, particularly in her pioneering work on defense mechanisms.
Carl Jung, viewed by Freud as his heir apparent, separated away from Freud’s
inner circle. He had serious differences with Freud’s theory of drives. He agreed
8 with the importance of the unconscious but condemned Freud for his
overemphasising the sexual and aggressive drives. Jung emphasised on collective Psychoanalysis,
Psychodynamic and
unconscious which was consistent with Freud’s primitive universal fantasies. He Psychotherapy
laid emphasis on cultural symbols and believed that humans inherited a desire for
higher religious fulfillment and self development.
Alfred Adler was the first disciple of Freud to disagree with the master. He
developed individual psychology and emphasised on societal pressures which
shape the personality and believed that behaviour is motivated by need to be
superior.
Karen Horney disagreed with Freud’s premise that women have penis envy rather
felt that men on the other hand envied women. She believed that the basic anxiety
results from disturbances in parent child relationships and in attempting to deal
with basic anxiety, individuals develop a characteristic social orientation
(dependent, submissive, inflated self concept, avoidant etc.).
Erik Erikson agreed with Freud that development occurred in stages but emphasised
social as opposed to sexual development. He described that development occurs
across the lifespan and believed that ego is relatively powerful part of personality
that functions to establish and maintain a sense of identity (ego psychology).
Carl Rogers Client Centered therapy’s core focus is on analyst’s patient, empathetic,
uncritical and receptive approach.
Otto Rank, a devoted follower of Freud, rejected theories of Oedipus complex.
He related all neurotic anxieties to birth trauma. The central part of his theory was
separation anxiety and believed that all forms of separation reactivated the primal
anxiety of birth trauma.
Sándor Ferenczi, a close colleague of Freud’s, is known as one of the most daring
experimenters of the early psychoanalysts. He anticipated the humanistic movement
in psychotherapy by emphasising that the analyst could not be a mere detached
observer. He felt that the analyst must have an attitude of genuine caring in order
to assist the patient’s healing caused by past abuse and the analyst cannot be in the
position of an authority because it creates a hierarchal relationship between the
analyst and client.
He experimented with a technique called “mutual analysis,” where he and the

patient would take turns lying on the couch and free-associating but this technique
did not work out.
Melanie Klein’s work is an extension of Freud’s work, but also a transformation

of Freud’s original insights through her unique interpretive perspectives. Klein
was also profoundly influenced by Sandor Ferenczi, her own psychoanalyst.
Working with children, Klein felt she had observed processes in pre-Oedipal
children that were very similar to oedipal conflicts in older children. Throughout
her career, she attempted to theoretically justify these observations.
In turn, Klein and her followers applied her practice and theory to work with
psychotic adult patients. Klein’s technique, in all cases, involved a method of
using “deep” interpretations which she felt communicated directly to the
unconscious of the client, thus by-passing ego defenses. The term “object relations”
ultimately derived from Klein, since she felt that the infant introjects the ‘whole’
other with the onset of the depressive position during the ontogenesis of the self.
9
Counselling: Models and As a therapy, psychoanalysis is based on the concept that individuals are unaware
Approaches
of the many factors that cause their behaviour and emotions. These unconscious
factors have the potential to produce unhappiness, which in turn is expressed
through a score of distinguishable symptoms, including disturbing personality
traits, difficulty in relating to others, or disturbances in self-esteem or general
disposition (American Psychoanalytic Association, 1998).
1.3.3 The Work of a Psychoanalyst

• The psychoanalyst basically helps the person to tell his or her story by
establishing a solid working alliance with the client.
• He gathers background information and history and then selects the problem
or issue to be worked on.
• He tries to explore the precipitating events and deals with resistance shown
by client.
• He then collaborates with the client to form a diagnosis and treatment plan
and increase the client’s awareness regarding defensiveness.
• The psychoanalytic process helps in exploring the client’s transference and
monitors the therapist’s counter transference.
• Psychoanalyst helps in examining how the past is impacting the present.
• The psychoanalyst helps the client to behave more effectively.
• He provides feedback and confronts discrepancies, negotiates with the client
regarding homework assignments.
• The psychoanalyst reminds the client of the termination date and end therapy
as agreed upon with the client.
• The psychoanalyst schedules follow-up too as needed.
1.3.4 Goal of Psychoanalysis

The goal of psychoanalysis varies according to the client, but they focus mainly
on personal adjustment, usually inducing a reorganisation of internal forces within
the person.
The primary goal in most cases is to help client in achieving insight which can
consciously make them aware of the psychodynamics that underlie their problems.
This awareness helps the clients to make adjustment to their current life situations.
People repeatedly encounter and deal with repressed emotions, motives and
conflicts.
The second major goal is to help client work through a developmental stage, not
resolved in primary goal. If accomplished, clients become unstuck and are able to
live more productively.
The final goal is to help clients cope with the demands of the society in which
they live.
The goal of psychoanalysis is to enable the person to deal with the unconscious
urges in a realistic and mature manner. But the question arises how to penetrate
10 the unconscious mind.
The ways to penetrate take on a variety of forms varying from practitioner to Psychoanalysis,
Psychodynamic and
practitioner. Freud suggested certain methods to achieve the aim or goal of Psychotherapy
psychoanalysis. Some of these methods include the following:
• Free association
• dreams or fantasies
clients can learn how to interpret deeply buried memories or experiences that may
be causing them distress.
1.4 TECHNIQUES IN PSYCHOANALYSIS

The six basic techniques of psychoanalytic therapy are:
1) Maintaining the Analytic Framework,
2) Free Association,
3) Dream Analysis,
4) Interpretation,
5) Analysis of Resistance,
6) Analysis of Transference.
Each of the above is being discussed in detail below
1.4.1 Maintaining the Analytic Framework

This refers to a whole range of procedural and stylistic factors such as the analyst’s
relative anonymity, the regularity and consistency of meetings and in time
conclusion of the sessions. The psychoanalytic process stresses upon to maintain
a particular framework to accomplish the therapy’s goal. The consistent framework
itself works as a therapeutic factor.
1.4.2 Free Association

Freud and subsequent psychoanalysts widely used this technique as they considered
that it provides important clues to the workings of the unconscious mind. They
believed that mental events are meaningfully associated with one another and
those clues to the contents of the unconscious can be found in the ongoing stream
of thoughts, memories, images and feelings that we experience. It consists of the
individual lying on a couch in a partly darkened room producing an uncensored,
non-calculated account of what they are thinking and feeling during the session.
The nature of responses made during a free association session indicate the concerns
and preoccupations of a person’s unconscious as there is no censorship by the
conscious mind, the Ego. Client reports immediately without censoring any feelings
or thoughts. The client is encouraged to relax and freely recall childhood memories
or emotional experiences. In this way, unconscious material enters the conscious
mind, and the counselor interprets it. At times clients resist free association by
blocking their thoughts or denying their importance. Psychoanalysts make the
most of these moments by attempting to help clients work through their resistance.
1.4.3 Dream Analysis

Dream analysis is a particular tool of the psychoanalytic school of thought proposed
by Freud and Jung, and is considered as the first scientific approach to the study 11
Counselling: Models and of dreams. It gives an important set of clues to the unconscious mind, because
Approaches
dreaming is thought to express levels of unconscious wish fulfillment expressive
of the individual’s deepest conflicts and desires.
Freud was of the opinion that we can give expressions to our desires and impulses
that we are unable to express during our waking hours because they are
unacceptable by the society. Thus we can gratify illicit sexual desires and thoughts
which we generally repress during the day. In this clients report dreams to counselor
on regular basis.
Freud believed that dreams were a main avenue to understanding the unconscious.
He reported that in this way he gained important insight into the causes of client’s
problems. But Freud did not provide any specific and clear rule to interpret dreams
and there was no way of determining whether that interpretation is right or wrong.
Counselor uses the free association and other techniques to the bring unconscious
material to the conscious. Clients are encouraged to remember dreams. The
counselor analyses two aspects, viz., the manifest content and the other latent
content.
1.4.4 Interpretation
Interpretation should consider part of all above mentioned techniques. It consists
of the analyst’s pointing out, explaining and teaching the client the meanings of
behaviour that is manifested in dreams, free associations, and resistances. When
interpreting, the counselor helps the client to understand the meaning of the past
and present personal events.
Interpretation is grounded in therapist’s assessment of the client’s personality and

of the factors in the client’s past that contributed to his difficulties. Counselor
points out, explains, and teaches the meanings of whatever is revealed. The therapist
must be guided by a sense of client’s readiness to consider it and it should be well
timed.
Counselors must carefully time the use of interpretation for better understanding
of unconscious influences and impulses. A general rule is that interpretation should
be presented when the phenomena to be interpreted is close to conscious awareness.
Another rule is that interpretation should always start from the surface and go
only as deep as the client is able to go. Also it is best to point out a resistance
before interpreting the conflict that lies beneath it.
1.4.5 Analysis and Interpretation of Resistance

Anything which works against the progress of therapy and prevents the client to
produce unconscious material is called Resistance. The client shows reluctance
to bring unconscious material at the level of awareness. Freud viewed resistance
as an unconscious dynamic that people used to defend against the anxiety and
pain that would arise if they become aware of their repressed feelings. Resistance
is a defense against anxiety that prevents clients and therapist from succeeding in
their effort to gain insight into the dynamics of the unconscious. The therapist
must respect the resistance of clients and assist them in working therapeutically
with their defenses. If the therapist handles it properly It can be the most valuable
12
tool to understand the client.
1.4.6 Analysis of Transference Psychoanalysis,
Psychodynamic and
Psychotherapy
Freud discovered and developed this psychoanalytic concept of transference which
later on developed by many other analysts and professionals. The concept
developed out of the inappropriate ending of a treatment. It is the client’s response
to a counselor as if the counselor were some significant figure in the client’s past,
usually a parent figure. Transference is a displacement of attitudes and feelings
originally experienced in relationships with persons onto the analyst in the long
past history of the patient.
It is a universal phenomenon. Patients are not aware at a conscious level of the

displacement that has taken place. This allows the client to experience feelings
that would otherwise be inaccessible. This is ambivalent in nature which can be
positive (affectionate) as well as negative (hostile) towards the analyst. In positive
transference, the patient has confidence in the doctor. If intense, the patient may
over-idealise the doctor or develop sexual feelings toward the doctor. In negative
transference, the patient may become resentful or angry toward the doctor if the
patient’s desires and expectations are not realised. This may lead to noncompliance
Counter transference.
These phenomena increase emotionality and may thus alter judgment and behaviour
in patients’ relationships with their therapist (trans-ference) and therapist’
relationships with their patients (counter-transference).
1.4.7 Counter Transference

This is an analyst’s feelings that are thought to be related to what the patient is
projecting onto the psychoanalyst. In this, feelings about a client and the reaction
of the counselor towards the client who reminds the doctor of a close friend or
relative may interfere with objectivity. The counselor encourages this transference
and interprets positive or negative feelings expressed. Analysis of transference
allows the client to achieve insight into the influence of the past. Analytically
oriented therapists consider transference as the core of the therapeutic process as
it aims in achieving awareness and personality change. It allows the clients to
achieve insight into the influence of past on their present functioning and enables
clients to work through old conflicts that are keeping them fixated and retarding
their emotional growth. Through appropriate interpretation, clients become aware
of their long standing inappropriate behaviours and gradually change some of
them.
1.5 PSYCHODYNAMIC THERAPIES

Historically, psychodynamic therapies are based on the principles of psychoanalytic
theory that mental disorders stem primarily from the kind of hidden conflicts first
described by Freud. The term Psychoanalytic and psychodynamic have been used
synonymously. Psychodynamic therapy or Psychoanalytic Psychotherapy is a
general name for therapeutic approaches which try to get the patient to bring to
the surface their true feelings, so that they can experience them and understand
them. These therapies assume that the mental disorders occur because something
has gone seriously wrong in the balance between these inner forces. These therapies
assert that a person’s behaviour is affected by his or her unconscious mind and
past experiences. Both psychotherapeutic approaches derive from a set of principles
13
Counselling: Models and derived from psychoanalysis. Among these principles are the dynamic unconscious,
Approaches
transference, counter transference, resistance and psychic determinism.
Several different approaches to brief psychodynamic psychotherapy have evolved

from psychoanalytic theory and have been clinically applied to a wide range of
psychological disorders. There is a body of research that generally supports the
efficacy of these approaches. Psychodynamic therapy is the oldest of the modern
therapies. (Freud’s psychoanalysis is a specific form and subset of psychodynamic
therapy.) As such, it is based in a highly developed and multifaceted theory of
human development and interaction.
There are four major schools of psychoanalytic theory, each of which has influenced
psychodynamic therapy. The four schools are:
• Freudian,
• Ego Psychology,
• Object Relations, and
• Self Psychology.
1.5.1 Freudian School

Freudian psychology is based on the theories first formulated by Sigmund Freud.
It is sometimes referred to as the drive or structural model. The essence of Freud’s
theory is that sexual and aggressive energies originating in the id or unconscious
are modulated by the ego, which is a set of functions that moderates between the
id and external reality. Defence mechanisms are constructions of the ego that
operate to minimize pain and to maintain psychic equilibrium. The superego,
formed during latency between age 5 and puberty, operates to control id drives
through guilt.
1.5.2 Ego Psychology

Ego Psychology derives from Freudian psychology. It focuses upon enhancing
and maintaining ego function in accordance with the demands of reality. Heinz
Hartmann, the father of Ego Psychology, studied the ways in which the ego
organises itself, adapts, and deploys ID drives. Ego Psychology stresses the
individual’s capacity for defence, adaptation, and reality testing. Heinz Hartmann-
leader of ego therapy. It focuses on the ego’s workings in creating defenses rather
than focusing on the underlying id content. It engages the patient with less emphasis
on uncovering hidden secrets but more on psychic structure-i.e. the relationships
between the id, the ego, and superego (Mitchell and Black-1995)
1.5.3 Object Relations Psychology

Object Relations psychology was first articulated Melanie Klein, W.R.D. Fairbairn,
D.W. Winnicott, and Harry Guntrip. According to this theory, human beings are
always shaped in relation to the significant others surrounding them. Our struggles
and goals in life focus on maintaining relations with others, while at the same
time differentiating ourselves from others. The internal representations of self
and others acquired in childhood are later played out in adult relations. Individuals
repeat old object relationships in an effort to master them and become freed from
them.
14
1.5.4 Self Psychology Psychoanalysis,
Psychodynamic and
Psychotherapy
Self Psychology, founded by Heinz Kohut, observed that the self refers to a person’s
perception of his experience of his self, including the presence or lack of a sense
of self-esteem. The self is perceived in relation to the establishment of boundaries
and the differentiations of self from others (or the lack of boundaries and
differentiations). Self Psychology emphasises empathy which is used to describe
an intra-psychic process in the therapist by which an understanding of the patient,
particularly an emotional understanding, a capacity to feel what the other is feeling,
is enhanced.
Each of the four schools of psychoanalytic theory presents discrete theories of

personality formation, psychopathology formation, and change; techniques by
which to conduct therapy; and indications and contraindications for therapy.
Like Psychoanalysis, Psychodynamic Psychotherapy uses the basic assumption

that everyone has an unconscious mind and that feelings held in the unconscious
mind are often too painful to be faced. Thus we come up with defenses to protect
us knowing about these painful feelings. Psychodynamic therapy assumes that
these defenses have gone wrong and are causing more harm than good. It tries to
unravel them, as once again, it is assumed that once you are aware of what is
really going on in your mind the feelings will not be as painful. Several forms of
therapy are based on these assumptions, but the most famous is Psychoanalysis
developed by Freud.
1.6 DIFFERENCE BETWEEN PSYCHODYNAMIC

THERAPY AND PSYCHOANALYSIS
Although similar to Psychoanalysis as it was derived from a similar background,
Psychodynamic therapy is distinguished from psychoanalysis in several particulars,
including the fact that psychodynamic therapy need not include all analytic
techniques and is not conducted by psychoanalytically trained analysts. It tends to
differ in the following ways:
Psychoanalysis
Focuses on repressed childhood conflicts, Id content, Ego activity.
• Brings conflict to conscious awareness to overcome neurosis.
• All adult problems can be traced back to childhood
• An Interaction of ego, superego, and id.
• Tends to affect a lot more of your personality.
• Conducted more frequently over a longer period of time.
Psychodynamic
• Less emphasis on sexual and aggressive drives.
• Less emphasis on unconscious information.
• More emphasis on past relationships.
• Offshoot of the psychoanalytic school.
• Interpretation is main tool.
• Mediator, a conscience and a devil. 15
Counselling: Models and • Has more specific goal e.g. sorting out a phobia.
Approaches
• Conducted over a shorter period of time with less frequency than
psychoanalysis
1.7 LET US SUM UP

Psychotherapy is procedures in which persons with psychological problems and
mental disorders interact with a trained psychotherapist who helps them change
certain behaviours, thoughts and emotions so that they feel and function better.
The outcome of psychotherapy depends upon the client, the therapist and the
techniques used by the therapist. Many forms of psychotherapy exist, ranging
from the techniques used by Freud through modern techniques base on learning
and cognitions.
Psychoanalysis is a form of psychotherapy focuses on helping individuals gain

insight into their hidden inner conflicts and repressed wishes. The goal of Freudian
psychoanalysis is to achieve insight into the unconscious dynamics that underlie
their behaviour disorders so that they can deal adaptively with their current
environment. The chief means for promoting insight is the interpretation of the
client’s free associations, dream content, resistance and transference reactions.
Psychodynamic therapists view maladaptive behaviours as symptoms of an
underlying conflict that needs to be resolved if behaviour is to be changed.

1) What is Psychotherapy? What are its essentials?
2) What is Psychoanalysis? Discuss the phases in its evolution.
3) Discuss the role of Dream analysis in Psychoanalysis.
4) Explain the techniques used by Psychoanalysts.
5) What are Psychodynamic therapies? How are they different from
Psychoanalysis?
6) Discuss the schools of psychoanalysis which have influenced Psychodynamics.

Anthony Bateman, Dennis Brown and Jonathan Pedder (2010): Introduction to
Psychotherapy: An Outline of Psychodynamic Principles and Practice. Publisher:
Routledge
Sigmund Freud (2007): The Origin and Development of Psychoanalysis.
References
Corey, G. (2008): Theory and Practice of Counseling and Psychotherapy. The
Thompson Brooks
Marty Sapp (2009): Psychodynamic, Affective, and Behavioural Theories to
Psychotherapy. Charles C Thomas – Publisher LTD.
Samuel T. Gladding (2009): Counseling: A Comprehensive Profession. Publisher:
Pearson Education.
Jane Milton, Caroline Polmear and Julia Fabricius (2004): A Short Introduction
16 to Psychoanalysis. SAGE Publishing Ltd.
Psychoanalysis,
UNIT 2 BEHAVIOURAL THERAPY, Psychodynamic and
Psychotherapy
COGNITIVE BEHAVIOUR
THERAPY AND APPROACHES TO
COUNSELLING
Structure
2.0 Introduction
2.1 Objectives
2.2 Behaviour Therapy
2.2.1 History
2.2.2 Systematic Desensitisation
2.2.3 Exposure: An extinction Approach
2.2.4 Aversion Therapy
2.2.5 Operant Conditioning Treatments
2.3 Cognitive Behavioural Therapy (CBT)
2.3.1 Brief History
2.3.2 ABC Model of CBT
2.3.3 Goals of CBT
2.3.4 Techniques/ Principles Used in CBT
2.3.5 Levels of Cognition
2.3.6 Techniques Used in CBT
2.3.7 Hierarchical Structure of A-B-C
2.4 Let Us Sum Up
2.0 INTRODUCTION
This unit deals with behaviour therapy cognitive behaviour therapy and related
issues. We start with Behaviour Therapy, how it started and with what purpose
and proceed to give some of the techniques related to behaviour therapy. The
techniques such as systematic desensitisation, exposure, flooding, and aversion
therapy are all discussed in this unit. Then we take up operant conditioning
techniques under which we discuss the positive reinforcement, participant modeling
and assertiveness training etc. This is then followed by cognitive behaviour therapy
in which we discuss its history, present the ABC model of CBT and describe the
techniques of CBT in detail. We then present the hierarchical structure of ABC
model of cognitive behaviour therapy and elucidate the principles underlying
cognitive therapies.
2.1 OBJECTIVES
• Define behaviour therapy;
• Describe classical conditioning procedures in behaviour therapy; 17
Counselling: Models and • Explain cognitive-behavioural therapy (CBT) and its principles;
Approaches
• Describe A-B-C Model of CBT;
• Identify the difference between behaviour therapy and cognitive-behavioural
therapy (CBT); and
• Explain the techniques involved in CBT.
2.2 BEHAVIOUR THERAPY

Behavioural psychology, or behaviourism, arose in the early 20th century in reaction
to the method of introspection that dominated psychology at the time. John B.
Watson, the father of behaviourism, had initially studied animal psychology. In
the 1960s, behaviour approaches emerged as a dramatic departure from the
assumptions and methods that characterised psychoanalytic and humanistic
therapies. They argued that psychology should concern itself only with publicly
observable phenomena i.e., overt behaviour. According to Behaviouristic thinking,
as mental content is not publicly observable, thus it cannot be subjected to rigorous
scientific inquiry.
The new practitioners of behaviour therapy denied the importance of inner

dynamics, instead they insisted that
1) maladaptive behaviours are not merely symptoms of underlying problems
but rather are problems;
2) problem behaviours are learned on the same ways normal behaviours are;
and
3) maladaptive behaviours can be unlearned by applying principles derived from
research on classical conditioning, operant conditioning and modeling.
Consequently, behaviourists developed a focus on overt behaviours and their
environmental influences.
Behaviour therapy involves changing the behaviour of clients to reduce dysfunction

and to improve quality of life. Behaviour therapy includes a methodology, referred
to as behaviour analysis, for the strategic selection of behaviours to change, and
a technology to bring about behaviour change, such as modifying antecedents or
consequences or giving instructions. Behaviour therapy represents clinical
applications of the principles developed in learning theory.
2.2.1 History
Around 1920s, the application of learning principles to the treatment of behavioural
disorders began to appear, but it had little effect on the mainstream of psychiatry
and clinical psychology. Behaviour therapy emerged as a systematic and
comprehensive approach to psychiatric (behavioural) disorders in 1960s. Joseph
Wolpe and his colleagues used pavlovian techniques to produce and eliminate
neuroses in cats. From this research, Wolpe developed systematic desensitisation.
At about the same time, Eysenck and Shapiro stressed the importance of an
experimental approach in understanding and treating individual patients, using
modern learning theory. A Harvard psychologist B. F. Skinner also inspired the
origin of behaviour therapy. Skinner’s students began to apply his operant
conditioning technology, developed in animal conditioning laboratories, to human
18 beings in clinical settings.
Classical conditioning procedures have been used in two major ways. Behavioural Therapy,
Cognitive Behaviour Therapy
i) First, they have been used to reduce or de condition anxiety responses. and Approaches to Counselling
ii) Second, they have been used in attempts to condition aversive stimuli.
His most commonly used classical conditioning procedures are:
• Systematic Desensitisation,
• Exposure therapy, and
• Aversion therapy.
Let us take up each of these and discuss.
2.2.2 Systematic Desensitisation

In 1958 Joseph Wolpe introduced Systematic Desensitisation, This is actually
learning based treatment for anxiety disorders. Wolpe viewed anxiety as a classical
conditioned response. His goal was to eliminate anxiety by using a procedure
called Counterconditioning. In this, a new response that is incompatible with
anxiety is produced. For example relaxed state which is incompatible with anxiety
state. This relaxed state is conditioned to the anxiety arousing conditioned stimulus
(CS), like for instance fear of a closed room or fear of heights etc.
It is based on the behavioural principle of Counterconditioning, whereby a person

overcomes maladaptive anxiety elicited by a situation or an object by approaching
the feared situation gradually, in a psychophysiological state that inhibits anxiety.
In systematic desensitisation, patients attain a state of complete relaxation and are

then exposed to the stimulus that elicits the anxiety response.
The negative reaction of anxiety is inhibited by the relaxed state, a process called
reciprocal inhibition.
Instead of using actual situations or objects that elicit fear, patients and therapists
prepare a graded list or hierarchy of anxiety provoking scenes associated with a
patient’s fears. The learned relaxation state and the anxiety provoking scenes are
systematically paired in treatment. Thus, systematic desensitisation consists of
three steps:
• Hierarchy construction
• Relaxation training
• Desensitisation of the fear evoking stimulus.
Step 1: Hierarchy Construction
When constructing a hierarchy, clinicians determine all the conditions that elicit
anxiety, and then patients create a hierarchy list of 10 to 12 scenes that produce
anxiety and these are then put in order of increasing anxiety. In the box below is
given an example of a hierarchy construction used in the systematic desensitisation
treatment of a Test Anxious College Student.
19
Approaches Scene: Hierarchy of Anxiety Arousing Scenes
Hearing about someone else who has a test (Least anxiety provoking)
Instructor announcing that a test will be given in three weeks
Instructor reminding class that there will be a test in two weeks
Overhearing classmates talk about studying for the test, which will occur in
one week
Instructor reminding class of what it will be tested on in two days
Leaving class the day before exam
Studying the night before test
Getting up morning of the test
Walking toward the building where the exam will be given
Walking into the exam room
Instructor walking into the room with the test
Tests being distributed
Reading the test questions
Watching others finishing the test
Seeing a question I can not answer
Instructor waiting for me to finish the test (High anxiety provoking)
Step 2: Relaxation Training

Relaxation training can help people control their physiological responses in
stressful situations. These techniques produce physiological effects opposite to
those of anxiety, that is slow heart rate, increased peripheral blood flow, and
neuromuscular stability.
A variety of relaxation methods have been developed. Most methods use

progressive relaxation, also known as somatic relaxation training, developed by
the psychiatrist Edmund Jacobson.
It provides a means of voluntarily reducing or preventing high level of arousal.

Patients relax major muscle groups in a fixed order, beginning with the small
muscle groups of the feet and working towards shoulders, neck, face and head
etc. Moving from lowest extremities to the head is called cephalcaudal. Ofcourse
one can also start with head muscles, face muscles and move down to neck etc.
and then on to the extremities.
Some clinicians use hypnosis to facilitate relaxation or use tape-recorded exercise

to allow patients to practice relaxation on their own.
Mental imagery is a relaxation method in which patients are instructed to imagine

themselves in a place associated with pleasant relaxed memories.
Such images allow patients to enter a relaxed state or experience. The physiological
changes that take place during relaxation are the opposite of those induced by the
stress responses that are part of many emotions.
Muscle tension, respiration rate, heart rate, blood pressure, and skin conductance
decrease. Relaxation increases respiratory heart rate variability, which is an index
20 of parasympathetic tone. In the box below relaxation step by step are given
Behavioural Therapy,
With its focus on full, cleansing breaths, deep breathing is a simple, yet Cognitive Behaviour Therapy
powerful, relaxation technique. It’s easy to learn, can be practiced almost and Approaches to Counselling
anywhere, and provides a quick way to get your stress levels in check. Deep
breathing is the cornerstone of many other relaxation practices, too, and can
be combined with other relaxing elements such as aromatherapy and music.
All you really need is a few minutes and a place to stretch out.
How to practice deep breathing

The key to deep breathing is to breathe deeply from the abdomen, getting as
much fresh air as possible in your lungs. When you take deep breaths from
the abdomen, rather than shallow breaths from your upper chest, you inhale
more oxygen. The more oxygen you get, the less tense, short of breath, and
anxious you feel. So the next time you feel stressed, take a minute to slow
down and breathe deeply:
• Sit comfortably with your back straight. Put one hand on your chest and
the other on your stomach.
• Breathe in through your nose. The hand on your stomach should rise. The
hand on your chest should move very little.
• Exhale through your mouth, pushing out as much air as you can while
contracting your abdominal muscles. The hand on your stomach should
move in as you exhale, but your other hand should move very little.
• Continue to breathe in through your nose and out through your mouth.
Try to inhale enough so that your lower abdomen rises and falls. Count
slowly as you exhale.
If you have a hard time breathing from your abdomen while sitting up, try
lying on the floor. Put a small book on your stomach, and try to breathe so
that the book rises as you inhale and falls as you exhale.
Progressive muscle relaxation for stress relief
Progressive muscle relaxation is another effective and widely used strategy
for stress relief. It involves a two-step process in which you systematically
tense and relax different muscle groups in the body.
With regular practice, progressive muscle relaxation gives you an intimate

familiarity with what tension—as well as complete relaxation—feels like in
different parts of the body. This awareness helps you spot and counteract the
first signs of the muscular tension that accompanies stress. And as your body
relaxes, so will your mind. You can combine deep breathing with progressive
muscle relaxation for an additional level of relief from stress.
Progressive Muscle Relaxation Sequence
• Right foot
• Left foot
• Right calf
• Left calf
• Right thigh
21
Approaches • Left thigh
• Hips and buttocks
• Stomach
• Chest
• Back
• Right arm and hand
• Left arm and hand
• Neck and shoulders
• Face
Most progressive muscle relaxation practitioners start at the feet and work their
way up to the face. For a sequence of muscle groups to follow, see the box to the
right:
• Loosen your clothing, take off your shoes, and get comfortable.
• Take a few minutes to relax, breathing in and out in slow, deep breaths.
• When you’re relaxed and ready to start, shift your attention to your
right foot. Take a moment to focus on the way it feels.
• Slowly tense the muscles in your right foot, squeezing as tightly as you
can. Hold for a count of 10.
• Relax your right foot. Focus on the tension flowing away and the way
your foot feels as it becomes limp and loose.
• Stay in this relaxed state for a moment, breathing deeply and slowly.
• When you’re ready, shift your attention to your left foot. Follow the
same sequence of muscle tension and release.
• Move slowly up through your body — legs, abdomen, back, neck, face
— contracting and relaxing the muscle groups as you go.
Step 3: Desensitisation of the Anxiety Provoking Stimulus

In the final step, called desensitisation, the patient proceeds systematically through
the list from the least, to the most, anxiety provoking scene while in a deeply
relaxed state. In fact they vividly imagine the situation as is given in the list and as
they imagine and as they are in the relaxed state, the scene even if evokes anxiety
the anxiety does not bother the individual. In case it does, then the patient is made
to relax once again all the more and the same scene is imagined, until the anxiety
is no more evoked when visualising the concerned anxiety provoking situation.
Once the patient is totally relaxed even under the anxiety provoking situation, the
patient is asked to move to the next item in the list that is anxiety provoking. The
same process as above is repeated until the situation no more evokes anxiety.
Then the patient moves on to the third item in the list and so on. The rate at which
the clients progress through the list is determined by their responses to the stimuli.
When patients can vividly imagine the most anxiety provoking scene of the
hierarchy with equanimity, they experience little anxiety in the corresponding
real life situation.
22
2.2.3 Exposure: An Extinction Approach Behavioural Therapy,
and Approaches to Counselling
From a behavioural point of view, phobias and other fears result from classically
conditioned emotional responses. The conditioning experience is assumed to
involve a pairing of the phobic object (fear of heights let us say) with an aversive
unconditioned stimulus (UCS). For example, if a person has a fear of heights,
then put him at a height (UCS) where he has no way to come down except with
the help of a ladder that you may provide him later. As a result, the phobic stimulus
(Height) becomes a conditioned stimulus (CS) that elicits the conditioned response
(CR) of anxiety. Continuously staying exposed to the aversive stimulus (heights)
in course of time brings down the anxiety and the extremenegative reaction. As
this process of exposure is repeated again and again, the patient does not react
negatively or with fear when exposed to heights.
Thus, according to this formulation, the most direct way to reduce the fear is
through a process of classical extinction of the anxiety response. The client may
be exposed to real life stimuli or asked to imagine scenes involving the stimuli.
These stimuli will evoke considerable anxiety, but the anxiety will be extinguished
in time if the person remains in the presence of the fear evoking stimulus (heights)
and the UCS (anxiety) does not occur.
Some critics of exposure treatment are concerned that the intense anxiety evoked
by the treatment may worsen the problem or cause clients to flee from the treatment.
But experimental research has proved this technique a very effective treatment
for extinguishing anxiety in both animals and humans.
Advances in computer technology have made it possible to present environmental

cues in Virtual Reality (VR) for exposure treatment. Virtual reality involves the
use of computer technology to create highly realistic virtual environments that
stimulate virtual actual experience so vividly that they evoke many of the same
reactions that a comparable real world environment would. Beneficial effects have
been reported with virtual reality exposure of patients with height phobia, fear of
flying, spider phobia, and claustrophobia. Much experimental work is being done
in the field.
2.2.4 Aversion Therapy

For some clients, the therapeutic goal is not to reduce anxiety but actually to
condition anxiety to a particular stimulus that triggers deviant behaviour. In aversion
therapy, the therapist pairs a stimulus (drinking alcohol) that is attractive to the
client (the CS) with a noxious UCS (vomiting due to an injection given immediately
before taking alcohol) in an attempt to condition an aversion to the CS (alcohol).
When a noxious stimulus (vomiting as punishment) is presented immediately
after a specific behavioural response, theoretically, the response is eventually
inhibited and extinguished. Many types of noxious stimuli are used which include
for instance, electric shocks, substances that induce vomiting, corporal punishment,
and social disapproval. The negative stimulus is paired with the behaviour, which
is thereby suppressed. The unwanted behaviour may disappear after a series of
such sequences. Aversion therapy has been used for alcohol abuse, paraphilias
(child molesters), and other behaviours with impulsive or compulsive qualities,
but this therapy is controversial for many reasons. For example, punishment does
not always lead to the expected decreased response and can sometimes be positively
reinforcing. 23
Counselling: Models and 2.2.5 Operant Conditioning Treatments
Approaches
The term behaviour modification refers to treatment techniques that apply operant
conditioning procedures in an attempt to increase or decrease a specific behaviour
like positive reinforcement, extinction, negative reinforcement, or punishment.
i) Positive Reinforcement: When a behavioural response is followed by a

generally rewarding event, such as food, avoidance of pain, or praise, it tends
to be strengthened and to occur more frequently than before the reward. This
principle has been applied in a variety of situations. In the inpatient hospital
wards, patients with mental disorder receive a reward for performing a desired
behaviour, such as tokens that they can use to purchase luxury items or certain
privileges. The process, known as token economy, has successfully altered
undesirable behaviours to desirable behaviours.
ii) Flooding: Flooding, sometimes called implosion, is similar to graded

exposure in that it involves exposing the patient to the feared object in vivo;
however, there is no hierarchy. It is based on the premise that escaping from
an anxiety provoking experience reinforces the anxiety through conditioning.
Thus, clinicians can extinguish the anxiety and prevent the conditioned
avoidance behaviour by not allowing patients to escape the situation.
In a variant, called imaginal flooding, the feared object or situation is
confronted only in the imagination, not in real life.
Many patients refuse flooding because of the psychological discomfort
involved.
It is also contraindicated when intense anxiety would be hazardous to a patient
(e.g., those with heart disease or fragile psychological adaptation). The
technique works best with specific phobias.
iii) Participant Modeling: In participant modeling, patients learn a new

behaviour by imitation, primarily by observation, without having to perform
the behaviour until they feel ready. Learning by watching others’ behaviour
is also called Observational learning.
Just as irrational fears can be acquired by learning, they can be unlearned by

observing a fearless model confront the feared object. The technique has
been useful with phobic children who are placed with other children of their
own age and sex who approach the feared object or situation.
With adults, a therapist may describe the feared activity in a calm manner
that a patient can identify.
Or, the therapist may act out the process of mastering the feared activity with
a patient.
Sometimes, a hierarchy of activities is established, with the least anxiety

provoking activity being dealt with first. The participant modeling technique
has been used successfully with agoraphobia by having a therapist accompany
a patient into the feared situation. In a variant of the procedure, called
behaviour rehearsal, real life problems are acted out under a therapist’s
observation or direction.
24
iv) Assertiveness Training: Assertive behaviour enables a person to act in his Behavioural Therapy,
or her own best interest, to stand up for herself or himself without undue and Approaches to Counselling
anxiety, to express honest feelings comfortably, and to exercise personal rights
without denying the rights of others.
Two types of situations frequently call for assertive behaviours:
• setting limits on pushy friends or relatives and
• commercial situations, such as countering a sales pitch or being persistent
when returning defective merchandise.
Early assertiveness training programs tended to define specific behaviours
as assertive or nonassertive.
v) Social Skills Training: Social skills training have been found to be efficacious
for depression and schizophrenics. These training programs cover skills in
the following areas:
• conversation,
• conflict management,
• assertiveness,
• community living,
• friendship and dating,
• work and vocation, and
• medication management.
Each of these skills has several components. For example, assertiveness skills
include the following:
• making requests,
• refusing requests,
• making complaints,
• responding to complaints,
• expressing unpleasant feelings,
• asking for information,
• making apologies,
• expressing fear, and
• refusing alcohol and street drugs.
Each component involves specific steps.
2.3 COGNITIVE BEHAVIOURAL THERAPY (CBT)

In 1960s, Cognitive revolution in Psychology occurred and by 1970 many
behaviour therapists influenced by it began to call it Cognitive Behavioural therapy.
Cognitive behavioural therapy (CBT) is an amalgam of two therapies: cognitive
therapy (CT) and behavioural therapy. The term “cognitive behavioural therapy”
is a very general term for a classification of therapies with similarities.
2.3.1 Brief History
CBT is a form of psychotherapy that emphasises the important role of thinking in
how we feel and what we do. It does not exist as a distinct therapeutic technique.
Beck and Ellis are two names associated with Cognitive Behavioural Therapy. 25
Counselling: Models and Albert Ellis’s system, originated in the early 1950s, developed Rational Emotive
Approaches
Therapy (RET), the first discrete therapeutic approach to CBT. Aaron T. Beck,
inspired by Albert Ellis, developed cognitive therapy in the 1960s.
Ellis developed and popularised the ABC model of emotions, and later modified
the model to the A-B-C-D-E approach.
In the 1990’s Ellis renamed his approach Rational Emotive Behaviour Therapy.
Behavioural therapy focuses on a person’s actions and aims to change unhealthy
behaviour patterns.
In the 1960’s, Aaron Beck, M.D. developed his approach called Cognitive Therapy.
CT focuses on a person’s thoughts and beliefs, and how they influence a person’s
mood and actions, and aims to change a person’s thinking to be more adaptive
and healthy. Aaron Beck proposed the basic principles of CBT which can be applied
to variety of psychiatric and medical problems. It focuses on identifying and
changing maladaptive patterns of information processing and related behaviours.
CBT methods are rooted in a psychological understanding of symptoms. It shares
three fundamental propositions:
1) Cognitive activity affects behaviour
2) Cognitive activity may be altered and monitored
3) Desired behaviour change may be effective through cognitive change
Beck’s approach became known for its effective treatment of depression.
Cognitive behavioural approach is based on the assumption that anxiety,
depression, and negative emotions develop from maladaptive thought processes.
2.3.2 ABC Model of CBT

This model records a sequence of events in terms of:
A – Activating Event (described as a ‘Trigger’)
B – Beliefs (e.g. the thoughts that occur when the Activating Event happens)
C – Consequences ( how you feel and behave when you have those Beliefs )
This ABC technique of irrational belief has proven as the major tool in cognitive
therapy. The main aim of this technique is to focus around the causes that develop
irrational belief and has to be recorded during the therapy.
Behaviour
Fig.1: Basic Cognitive Behaviour Model

Source: From Wright JH. Basco MR. Thase ME: Learning Cognitive-Behaviour Therapy: An
26 Illustrated Guide. Washington. DC. American Psychiatric Publishing. 2006, p 5
CBT helps a person focus on his or her current problems and how to solve them. Behavioural Therapy,
Both patient and therapist need to be actively involved in this process. The therapist and Approaches to Counselling
helps the patient learn how to identify distorted or unhelpful thinking patterns,
recognise and change inaccurate beliefs, relate to others in more positive ways,
and change behaviours accordingly. There are several approaches to cognitive
behavioural therapy, including the following:
1) Rational Emotive Behaviour Therapy,

2) Rational Behaviour Therapy,
3) Rational Living Therapy,
4) Cognitive Therapy, and
5) Dialectic Behaviour Therapy.
2.3.3 Goals of CBT

CBT focuses on A Here and Now orientation.
The goals of CBT are:
• To challenge the thoughts about a particular situation by identifying the
cognitive traps
• To help the patient to identify less threatening alternative and
• To test out these alternatives in the real world.
• It also aims to leave clients at the completion of therapy with the freedom to
choose their emotions, behaviours and lifestyle (within physical, social and
economic restraints).
• To Finally effect profound and lasting change in the underlying belief system
of the client, rather than simply eliminating the presenting symptoms.
• To make the client equipped with self help techniques that enable coping in
the longterm future
2.3.4 Techniques/Principles of CBT

CBT is based on several principles. These are:
• It is brief and time-limited
• It is structured, directive, and problem-oriented
• It is based on the cognitive-behavioural model of emotional disorders.
• It is a collaborative effort between the CBT practitioner and the client seeking
treatment and requires a sound therapeutic relationship. They work together
to try to understand the person’s difficulties and what may be contributing to
them.
• The sessions of CBT are typically one hour in length.
• The clients are guided to discover new ways of thinking for themselves with
specific questions.
• It is often based on an education model.
27
Counselling: Models and • It relies on the inductive method, a scientific approach using logic and
Approaches
reasoning.
• It uses between-session practice as a central feature (for people to put into
practice what they have learned). New behaviours are initially tested in safe
situations (for example, the practitioner’s office).
• It focuses on the present. The past cannot be changed, but the way we think
about the past can be changed
2.3.5 Levels of Cognition

Three major levels of cognition, relevant to the practice of CBT, were identified
by Beck and his colleagues. These are (i) Full consciousness, (ii) Automatic
Thoughts, and (iii) Schemas.
i) Consciousness is a state in which rational decisions are made with full
awareness.
ii) Automatic thoughts are more autonomous, often private cognitions that flow
rapidly in the stream of everyday thinking and may not be carefully assessed
for accuracy or relevance.
iii) Schemas, the deepest level of cognition, are fundamental rules for information
processing which are shaped by developmental influences and other life
experiences. Schemas that play a major role in regulating self worth and
behavioural coping strategies are a frequent target of CBT.
Examples of automatic thoughts and maladaptive schemas
Autiomatic Thoughts Maladaptive schemas

I should be doing better in life I must be perfect to be accepted
I have let him / her down I am a fake
I always keep messing things up If I choose to do something, I must
succeed.
I cannot handle it I am unlovable
It is too much for me No matter what I do, I won’t succeed
I don’t have much of a future The world is too frightening for me
Things are out of control Others cannot be trusted
I feel like giving up I must always be in control
I will never be able to get this done I am stupid
Something bad is sure to happen Other people will take advantage of me.
(Source: Wright e.t all (2011))
2.3.6 Techniques Used in CBT

The CBT techniques, described below, are useful in eradicating certain problems
in a time bound manner which stem from maladaptive thoughts and behaviours.
The techniques are given in the following section:
28
i) Cognitive Rehearsal: In this technique, the therapist asks the patient to recall Behavioural Therapy,
a problematic situation of the past. The therapist and patient both work together and Approaches to Counselling
to find out the solution to the problem.
ii) Validity Testing: This is one of the first cognitive therapy techniques. Every
disorder or disease must have supporting evidence and the therapist asks the
patient, to defend his feelings, thoughts and beliefs, with objective evidence.
The faulty nature or invalidity of the beliefs of the patient is exposed if he is
unable to produce any kind of objective evidence.
iii) Writing in a diary / Journal: It is the practice of maintaining a diary to

keep an account of the situations that arise in day to day life. This is a detailed
diary, which notes every emotion, thought and belief. The therapist and the
patient, later, collectively assess the diary/ journal, to analyse how they actually
affect the behaviour of the individual..
iv) Guided Discovery: The purpose of this technique is to enable the patient
realise his cognitive distortions. The patient becomes aware of his cognitive
distortions through a series of questions and answers.
v) Systematic Positive Reinforcement: Cognition can be changed over a period

of time, by positive encouragements and small rewards. It is one of the
cognitive behavioural therapy techniques in which positive behaviours of a
person are rewarded with a positive reinforcement.
A reward system is established for the reinforcement of certain positive

behaviours. Just like positive reinforcement, withholding the reinforcement
is also equally important. It helps in eradicating a maladaptive behaviour.
vi) Aversive Conditioning: This technique makes use of dissuasion for lessening
the appeal of a maladaptive behaviour. The patient is exposed to an unpleasant
stimulus while engaging him in a particular behaviour or thought for which
he has to be treated, thus, the unpleasant stimulus gets associated with such
thoughts/behaviours and then the patient exhibits an aversive behaviour
towards them.
vii) Modeling: In Modeling, the patient makes use of the behaviour of the therapist
as a model in order to solve his/her problems. The therapist performs role
playing exercises which are aimed at responding in an appropriate way to
overcome difficult situations.
viii) Homework: The therapist gives a set of assignments to patients as homework.

The patient take notes during the session, reviews the audiotapes of a particular
session or reads article/books that are related to the therapy.
2.3.7 Hierarchical Structure of A-B-C

People experience events in their life. These events lead to assumptions (right or
wrong) being made about that event. Once the assumption has been made, it gets
placed into our subconscious mind. This assumption then generates beliefs or
conclusions. These beliefs can either be true/accurate or false/inaccurate.
From these beliefs comes our thinking and self talk. From our thinking and self
talk comes our feelings and emotions. Finally, our feelings and emotions give rise
29
Counselling: Models and to our behaviour and actions. The following diagram displays the way in which
Approaches
one wrong assumption can give birth to many beliefs, which in turn gives birth to
many more self talk, emotional and behavioural issues.
Looking at this hierarchy structure, true change, that is life long and effective, can
only happen if the core assumptions are uncovered and dealt with. The assumption
is the base level which determines everything else in the hierarchy. If change was
attempted by only addressing the behavioural level, sooner or later the emotions
and self talk would cause that change to be negated. Will power can not override
the internal feelings below the behavioural level. If change was attempted at the
emotions and feelings level, then changed behaviour will follow, but at some
point internal self talk, beliefs and assumptions will be too much to bear and
cause the emotions then actions to revert back.
Thus Cognitive therapy involves getting down to the beliefs level.

Down at this level, lasting change can begin to occur.
Change in the belief system results in change in all the levels above it.
The only problem is that the underlying assumption that caused the false belief
and then conflict is still lurking.
It means that if the assumption itself is incorrect/wrong/false, then it will generate
other false beliefs.
What can occur in therapy then is that false belief upon false belief are traced,
faced and replaced, but there always seems to be more.
30
The ONLY way to achieve true freedom from the shackles is to uncover the core Behavioural Therapy,
assumption at the base level. and Approaches to Counselling
Once you find this and confront it, the false beliefs take care of themselves and no
new ones are created, your self talk changes, your emotions and feelings turn
positive and your actions follow suit.
2.4 LET US SUM UP

Behaviour therapy has been used successfully for a variety of disorders and can
be easily taught. It requires less time than other therapies and is less expensive to
administer. Although useful for circumscribed behavioural symptoms, the method
cannot be used to treat global areas of dysfunction (e.g., neurotic conflicts,
personality disorders).
Controversy continues between behaviourists and psychoanalysts, which is

epitomised by Eysenck’s statement: “Learning theory regards neurotic symptoms
as simply learned habits; there is no neurosis underlying the symptoms, but merely
the symptom itself. Get rid of the symptom and you have eliminated the neurosis.”
Analytically-oriented theorists have criticized behaviour therapy by noting that

simple symptom removal can lead to symptom substitution: When symptoms are
not viewed as consequences of inner conflicts and the core cause of the symptoms
is not addressed or altered, the result is the production of new symptoms. Whether
this occurs remains open to question, however.
Whereas CBT is based on the concept that mental disorders are associated with
characteristic alterations in cognitive and behavioural functioning and that this
pathology can be modified with pragmatic problem-focused techniques. CBT is
well established as a treatment for depression, anxiety disorders, and eating
disorders. There is growing evidence that it can play an effective role in the clinical
management of a large range of other disorders, including schizophrenia, bipolar
disorder, and axis II conditions.

1) What is Behaviour Therapy? Give a brief outline of its history.
2) What is modeling, and how it can be used in treating psychological problems?
3) Writ a note on Exposure as an extinction approach.
4) Construct a hierarchy of fear arousing situation of any animal.
5) Define CBT and discuss the levels of cognitions.
6) According to CBT, What is the primary cause of mental disorders?
7) Explain the hierarchical structure of A-B-C model of CBT.

David W., Helen K., Joan K. (2007): An Introduction to Cognitive Behaviour
Therapy: Skills and Applications. SAGE Publishers
31
Counselling: Models and John P. Foreyt, Diana P. Rathjen(1978): Cognitive Behaviour Therapy: Research
Approaches
and Application. Publisher: Plenum Press.
Judith S. Beck (1995). Cognitive Therapy: basics and beyond. New York, Guilford
References
Judith S. Beck (1995). Cognitive Therapy: basics and beyond.
Marty Sapp (2009): Psychodynamic, Affective, and Behavioural Theories to
Psychotherapy. Charles C Thomas – Publisher LTD.
Wright JH, Basco MR, Thase ME (2006): Learning Cognitive-Behaviour Therapy:
An Illustrated Guide. Washington, DC, American Psychiatric Press,
32
Behavioural Therapy,
UNIT 3 DRAMA AND ART THERAPY IN Cognitive Behaviour Therapy
and Approaches to Counselling
COUNSELING
Structure
3.0 Introduction
3.1 Objectives
3.2 Drama Therapy
3.2.1 Five Stage Theory
3.2.2 Drama Therapy Techniques
3.2.3 Applications of Drama Therapy
3.3 Art Therapy
3.3.1 Basic Approaches
3.3.2 Steps in Art Therapy
3.3.3 Art Therapy Techniques
3.4 Let Us Sum Up
3.0 INTRODUCTION
Counseling is both an art and a science. It is scientific in its development of
theoretical approaches to working with individuals and groups. It is artistic in the
way in which it uses timing and emphasis to implement certain methods with
particular individuals. For effective counseling, art and science must work together
for the welfare of client as well as counselor. Artistic methods and therapies can
be important and useful for the growth of counseling profession because it may
promote new insight. The creative arts have a significant contribution to make to
counseling theory and practice. Creative arts refers to art forms including visual
representations like painting, drawing and sculpture, literary expressions, drama
and music, that help the individuals become more aware of themselves or others.
In counseling, creative arts are defined as arts that are employed in therapeutic
settings to help facilitate relationships between counselors and clients. Various
art forms have been employed in counseling. The most widely used are: Visual
Art, Psychodrama, Poetry, Dance and Music. This unit will discuss art and drama
therapy.
3.1 OBJECTIVES
• Discuss the concept of drama therapy;
• Define art therapy;
• Explain the steps involved in the process of art therapy;
• Describe five stage theory; and
• Explain art and drama therapy techniques.
33
Approaches 3.2 DRAMA THERAPY
Drama therapy is defined by the National Association for Drama Therapy as “the
systematic and intentional use of drama/theater processes, products, and
associations to achieve the therapeutic goals of symptom relief, emotional and
physical integration and personal growth.”
The word ‘drama’ comes from ancient Greek and means quite literally “things
done” (Harrison, 1913).
Drama therapy uses action techniques, particularly role play, drama games,
improvisation, puppetry, masks, and theatrical performance, in the service of
behaviour change and personal growth.
It is an active approach that helps the client tell his or her story to solve a problem,
achieve a catharsis, extend the depth and breadth of inner experience, understand
the meaning of images, and strengthen the ability to observe personal roles while
increasing flexibility between roles.
The result is an active, experiential process that draws on the person’s capacity
for play, utilising it as a central means of accessing and expressing feelings, gaining
insight, practicing successful approaches to difficult situations. It has its roots in
religion, theatre, education, social action, and mental health/therapy
Early humans began to make art that is, paintings, sculpture, music, dance, and
drama about 45,000 years ago. The origins of the arts and religion seem to be
intertwined because the arts naturally provided effective symbolic ways to express
abstract religious ideas. Dance and drama, in particular, were extremely useful in
rites to create sympathetic and contagious magic as well as to embody myths and
rituals.
The first written theoretical account of drama therapy can be found in connection
with Greek theatre. In his Poetics, Aristotle says the function of tragedy is to
induce catharsis which is a release of deep feelings (specifically pity and fear) to
purge the senses and the souls of the spectators (Aristotle, trans. 1954). According
to Aristotle, the purpose of drama is not primarily for education or entertainment,
but to release harmful emotions in an individual which in turn will lead to harmony
and healing to the individual as well as in the community (Boal, 1985).
Drama therapy applies techniques from theatre to the process of psychotherapeutic

healing. It emerged as a field in the late 1970’s from hospitals and community
programs where it was first used with clients to produce plays and later was
integrated with improvisation and process drama methods. The focus in drama
therapy is on helping individuals grow and heal by taking on and practicing new
roles. While much drama therapy aims at helping people who are in therapy, drama
therapists have extended their applications beyond clinical contexts to enrich the
lives of at risk individuals, to prevent problems, and to enhance wellness of healthy
people. Many of the skills for such extensions require a measure of training
psychological training as well as a strong basis in theatre.
Just as psychotherapy treats people who have difficulties with their thoughts,
emotions and behaviour, drama therapy uses drama processes (games,
improvisation, storytelling, role play) and products (puppets, masks, plays/
34
performances) to help people understand their thoughts and emotions better or to Drama and Art Therapy in
Counselling
improve their behaviour.
The drama therapist is trained in four general areas:
i) drama/theatre,
ii) general and abnormal psychology,
iii) psychotherapy, and
iv) drama therapy.
The drama therapist’s role is to facilitate the client’s experience in a way that
keeps the client emotionally and physically safe while the client benefits from the
dramatic process. Depending on the goals and needs of the client, the drama
therapist chooses a method that will achieve the desired combination of
understanding, emotional release, and learning of new behaviour.
Some methods, such as drama games, improvisation, role play, developmental
transformations, sociodrama and psychodrama are very process oriented and
unscripted. The work is done within the therapy session and not presented to an
audience.
Other methods, such as Playback Theatre, Theatre of the Oppressed, and the
performance of plays are more formal and presentational, involving an audience.
Puppets, masks, and rituals can be used as part of performance or as process
techniques within a therapy session.
Certain techniques like drama games, role play, etc. involve fictional work. The
client pretends to be a character different from him or herself. This can expand
the client’s role repertoire.
Other techniques, such as Psychodrama, Therapeutic Spiral Model, Playback
Theatre, Theatre of the Oppressed and autobiographical performances, allow the
client to explore his or her life directly. Clients need to have good ego strength to
be able to do this kind of non-fiction work because it requires an honest, searching
look at oneself.
3.2.1 Five Stage Theory

Renee Emunah (1994) has identified five stages through which most drama therapy
groups progress. Her five stage theory parallels established wisdom from group
dynamics on how successful groups form and grow.
1) The first stage is Dramatic Play where the group gets to know each other and
the therapist through playing together develop trust, group cohesion, and
basic relationship skills.
2) The second stage is the Scene Work Stage where they continue playing. The
focus remains on developing dramatic skills which they will need as they
continue in treatment. As they grow older and begin school, they are
encouraged to develop their abstract reasoning skills and use them in their
learning.
3) Stage Three focuses on Role Play, exploring issues through fictional means.
Perhaps the group acts out a generic family conflict or a familiar character
from a fairy tale or legend that goes through a crisis or challenge shared by
group members. When the group is ready, they can move on to the next stage. 35
Counselling: Models and 4) Stage Four: Culminating Enactments, where personal issues are acted out
Approaches
directly through psychodrama or autobiographical performance.
5) The final stage is Dramatic Ritual, which usually involves closure to the
work of the group. This might be the sharing of a public performance that
has been created by the group or the sharing of a private ritual within the
group
3.2.2 Drama Therapy Techniques

Drama therapy techniques differ from therapist to therapist or from session to
session, but certain concepts are common to all forms.
1) Use of Metaphor: The first is the use of metaphor through action. Behaviours,
problems, and emotions can be represented metaphorically, allowing for
symbolic understanding. An emotion can be represented with a metaphorical
image: anger displayed as a volcano, an exploding bomb, or a smoldering
fire. These images can be dramatised which allow the client to gain more
insight into the qualities of the emotion and how it functions positively or
negatively in his/her life.
2) Concrete embodiment: This technique allows the abstract to become concrete
through the client’s body. Embodiment allows clients to “experience” or “re-
experience” in order to learn, to practice new behaviours, or to experiment
with how to change old behaviours. Playing a role quite different from oneself
often feels more comfortable than playing oneself directly.
3) Dramatic Projection: This technique is akin to concrete embodiment and

employs metaphor. It is the ability to take an idea or an emotion that is within
the client and project it outside to be shown or acted out in the drama therapy
session.
4) A client’s difficulty asking for help (an internal problem) can be dramatised
in a scene with other members of the group, with puppets, or through masks,
so the problem becomes an external problem which can be seen, played with,
and shared by the therapist and the group.
5) Creation of transitional space: The creation of Transitional Space is an

important component in many therapeutic and learning environments, but it
is essential in drama therapy. Transitional space is the imaginary world that
is created when we play or imagine together in a safe, trusting situation.
6) It is a timeless space in which anything we can imagine can exist. It is created

jointly by the therapist and the clients playing together and believing in the
possibility that anything can happen.
7) Incorporating other Arts: Drama therapy is like a crossroad, where all the
arts come together and are allowed to work together. Drama therapists use
music, movement, song, dance, poetry, writing, drawing, sculpture, mask
making, puppetry, and other arts with their drama therapy activities. Drama
therapists are required to have training in the other creative arts therapies and
why many drama therapists have credentials in one of the other arts therapy
modalities.
36
3.2.3 Applications of Drama Therapy Drama and Art Therapy in
Counselling
Drama therapy is primarily conducted in groups, but can be used in individual,
couples, or family counseling. It can be found in a wide variety of settings with
many different kinds of clients. Any kind of therapy group that uses talk therapy
can use drama therapy. For some groups, the action methods of drama therapy are
more effective. Drama therapy ignores the excuses and denial, getting right to the
behaviour.
Other types of groups for instance, nonverbal clients or children who are not good
candidates for verbal therapy can often participate successfully in drama because
they can not verbalize rather show how they feel. It is practiced in clinical settings,
residential settings, correctional facilities, educational situations, corporations and
businesses, community action settings, and social and recreational centers.
3.3 ART THERAPY

Art therapy is a modality emerged from the interacting of art, creativity and
psychotherapy. It uses art media to express internal images, feelings, thoughts
and sensations in a concrete form. It provides the opportunity for non verbal
expression and communication, which can assist in improving the client’s
functional abilities and resolving emotional issues. The use of art as therapy implies
that the creative process can be a means both of reconciling emotional conflicts
and of fostering self awareness and personal growth.
The use of art can be traced all throughout history, from prehistoric eras to the
present, but art therapy first received significant attention due to the theories of
Freud and Jung (Wadeson, 1980). These psychologists believed in the importance
of symbolism, which is very prominent in art forms.
Art therapy has continued to evolve and became a recognised profession in the
1960’s. According to Wadeson (1980), “the creation of the American Journal of
Art Therapy and the establishment of the American Art Therapy Association”
were responsible for art therapy’s rise to a recognised profession and therapeutic
intervention.
Art therapy is based on the idea that the creative process of art making is healing
and life enhancing and is a form of nonverbal communication of thoughts and
feelings (American Art Therapy Association, 1996). It is the therapeutic use of art
making, within a professional relationship, by people who experience illness,
trauma, or challenges in living, and by people who seek personal development.
Through creating art and reflecting on the art products and processes, people can
increase awareness of self and others, cope with symptoms, stress, and traumatic
experiences; enhance cognitive abilities; and enjoy the life affirming pleasures of
making art. It is used to encourage personal growth, increase self understanding,
and to assist in emotional reparation and has been employed in a variety of settings
with children, adults, families and groups.
It is a modality that can help individuals of all ages create meaning and achieve
insight, find relief from overwhelming emotions, resolve conflict and problems,
enrich daily life and achieve an increased sense of well-being (Malchiodi, 1998).
37
Counselling: Models and Art therapy is a mental health profession that uses the creative process of art
Approaches
making to improve and enhance the physical, mental and emotional well being of
individuals of all ages. It is based on the belief that the creative process involved
in artistic self-expression helps people to resolve conflicts and problems, develop
interpersonal skills, manage behaviour, reduce stress, increase self-esteem and
self-awareness, and achieve insight.
Art therapy integrates the fields of human development, visual art (drawing,
painting, sculpture, and other art forms), and the creative process with models of
counseling and psychotherapy. It is used with children, adolescents, adults, groups,
and families to assess and treat anxiety, depression, and other mental and emotional
problems; physical, cognitive, and neurological problems; and psychosocial
difficulties related to medical illness. Art therapy programs are found in a number
of settings including hospitals, clinics, public and community agencies, educational
institutions, businesses, and private practices.
Art therapists are master’s level professionals who hold a degree in art therapy or
a related field. Educational requirements or syllabus include theories of art therapy,
counseling, and psychotherapy, ethics and standards of practice, assessment and
evaluation, individual, group, and family techniques, human and creative
development, multicultural issues research methods, and practicum experiences
in clinical, community, and/or other settings. Art therapists are skilled in the
application of a variety of art modalities (drawing, painting, sculpture, and other
media) for assessment and treatment. Art therapy combines traditional
psychotherapeutic theories and techniques with an understanding of the
psychological aspects of the creative process, especially the affective properties
of the different art materials.
3.3.1 Basic Approaches

There are two basic ways in which an art therapist can approach the idea of art
therapy. The first is to be process intensive. In this approach the art therapist, uses
art as a means to help his/her patient(s) to discover something about him or herself.
Art is used as a catharsis, an emotional journey to which self-actualisation and
discovery are the end result. Edith Kramer was the first person to champion this
school of thought. Kramer emphasised the healing qualities of art making, and
was concerned with artistic quality.
The second approach is not to be so concerned with the process of making the art,
but with what the person is consciously or unconsciously expressing through their
art. Margaret Naumburg believed that this was the best way to utilise art therapy.
In this way, the art therapist uses art as a window into the subconscious of the
patient, and from there can attempt to figure out the underlying problems that the
patient may be suffering from. It can be risky to look into art too closely, but in the
case of children, who may not have the words to express how they are feeling; it
is very beneficial to use art as a mode of expression.
3.3.2 Steps in Art Therapy

1) Assessment: Assessment often comes at the beginning of art therapy, and
usually happens during the first session that the therapist has with the client.
Assessment is used by the therapist to find out what the client is going through,
and to gain any other information that he or she may wish to find out about
38
the client. It is important to be very up-front at this time with the client, being Drama and Art Therapy in
Counselling
very clear that the session is not treatment oriented, but is for assessment
purposes. Assessment at the beginning of therapy is an important first step
because it is at this point that the therapist will decide if art therapy is a good
option for the client or if it would be a waste of time.
2) Treatment in the Beginning: During the first session, the first thing for the
therapist is to establish a good rapport with the client because it allows for
the development of trust in the relationship. It is also essential for the art
therapist to better grasp the framework from which the client is operating.
After establishing a rapport with the client and getting a grasp on the client’s
vantage point, the art therapist can introduce art therapy to the client by giving
back-round information about art therapy, and answering any questions that
the client may have. At this point, the therapist may suggest doing some
artwork.
This first piece of art that the client creates is a very important one because it
sets the tone for the rest of the session. Because many people have art anxiety
in these beginning sessions, it is important that the therapist makes the client
feel as comfortable as possible. This could be done by saying to the client
that they should not worry about artistic accomplishment, but rather self-
expression. Another important aspect of this first artistic work is the reaction
of the therapist to it.
After this first session, it is important for the art therapist to begin developing
treatment goals, as well as to reflect on what initial reactions the therapist
may have after the first meeting.
3) Mid-phase of treatment: It is hard to know when the treatment has moved

from the beginning portion to the mid phase but there are a couple of key
differences which are given below:
• when the trust between the client and therapist has been established,
and
• the focus of the sessions becomes more goal oriented, that do mark the
mid-phase.
In the mid phase of treatment the therapist first establishes direction and
boundaries, both personal and professional. There are many different
techniques that are used in art therapy and knowing which one to use at what
time is one of the art therapist’s toughest jobs. Because each case is unique
and each client is different, the art therapist must custom fit the art therapy
for each individual client.
4) Termination: The termination of art therapy is initiated abruptly and clearly.

Either the art therapist or the client can initiate the termination of the art
therapy. Termination is generally decided upon when the therapist or the client
realises that the therapy is finite. It is a very important part of the therapy
process. The way in which therapy is brought to a close is crucial to the
outcome of the treatment. If termination is handled incorrectly, the client or
patient may regress as the end of therapy approaches.
39
Counselling: Models and The therapist should prepare the patient well in advance. This can be done by
Approaches
bringing up the issue of termination, focusing on its importance and discussing
and interpreting feelings and behaviours due to the pending ending of the sessions.
This is a difficult tightrope for the therapist to walk because focusing on the end
often brings to mind other separations that client may have suffered.
When nearing the end of the therapy, the client and therapist should begin relooking
at the art that the client has created throughout the sessions and talking about the
progress that the client has made. It is also a good idea to use art in these last few
sessions to help express feeling about the termination of the therapy sessions. The
therapist often will join the client on these works of art.
The termination of the art therapy brings up a very practical question as well,
what should be done with the art that the client created during the course of the
sessions? This is a tricky question, but ultimately it is one that should be answered
by the client. They could keep the art as a form of remembrance to the journey
they went through, or give it to the therapist to show the importance of the
therapeutic bond that they reached.
These are of course not the only two options that the client has, but two of the
most common ones.
3.3.3 Art Therapy Techniques

The following are some techniques that art therapists use:
1) Exploration Tasks: An exploration task can be quite liberating. The goal is
to encourage the patient/client to let go of conscious thoughts and controls,
and to have them express themselves as freely and spontaneously as possible.
In this way, exploration tasks are very much akin to verbal free associations.
Exploration tasks are generally used in the beginning sessions of art therapy.
Some examples of exploration tasks are:
a) Scribble Technique /Automatic Drawing

In this, the patient/client is asked to relax and begin to make draw free lines
or scribbles on paper. In some cases the patient/client will be instructed not
to remove his or her pen from the paper until the exercise is over. Automatic
drawing provides an excellent way for the patient/client to let down their
guards and thus is a good starting point for therapy.
b) Free Drawing
In free drawing all the choices are up to the patient/client. The patient/client
is told to express him or herself freely, and not to worry about planning the
picture. This technique is useful because the images that the patient/client
creates are often mirrors into the person’s present problems, strengths and
weaknesses. Often at the end of free drawing, the patient/client is asked to
share and explain what they drew about.
c) Drawing Completion
In the drawing completion technique, a patient/client is given one or more
pieces of paper that already have a few lines or simple shapes on them. These
shapes or lines act as a starting point for the art therapy artist, and they are to
40
be incorporated into a larger picture. Because of the wide individual responses
to the same stimuli, this is an excellent technique for a group discussion Drama and Art Therapy in
Counselling
topic. Kinget developed this approach for therapeutic purposes.
2) Rapport-Building: Rapport-building exercises are used in both individual

and group art therapy settings. The basic idea behind rapport building exercises
is to reduce the amount of isolation that the patients/clients may feel while
they are creating their art. This includes isolation from the other patients/
clients in the group, and the distance they feel between themselves and the
therapist. Some examples of Rapport-Building are:
a) Conversational Drawing
In conversational drawing, the group is broken up into pairs. The two people
who are assigned to work together are seated across from one another. The
only way of communication is with shapes, colours and lines. In this way, the
pair is not only communicating, but sharing at the same time. This is a good
way from patients to get to know one another a little better.
b) Painting Completion by the Group

In painting completion by the group, each member of the group is asked to
name one thing, an object, feeling or event, and then depict it. From here,
one or more of the group members begin adding to the collage, trying to
improve upon what is already there. This technique better enables people to
become aware of how it feels when they make something and have someone
else “put upon you anything they want to.” The patients/clients are encouraged
to share what they are feeling about someone else adding to their work.
c) Painting with an Observer

In painting with an observer, one member of a pair tells the other one whatever
comes to into his or her minds as he or she watches the other one paint. The
painter can respond to what the other one is saying as he or she sees fit during
their painting. This exercise promotes discussion of feelings of dependency
and autonomy, as well as acceptance issues.
3) Expression of Inner Feelings: These techniques are designed to help the

patient/client get in touch with inner feelings, desires and fantasies and to
make visual representations of them. This is done in the hope that the patient
will become increasingly aware of him or herself. The therapist will then
attempt to help the patient/client deal with these feelings, and move in a
direction toward a solution. An example of expression of inner feelings
technique is called “three wishes”.
a) Three Wishes
In the three wishes technique, the patient or client is asked to paint or portray
three or more wishes. Responses tend to be of desires for things, personal
security and so on. Responses to this exercise reflect maturity level, degree
of egocentricity and so on. Discussion that follows this exercise focuses on
the strength of the wish and whether or not these goals/wishes are attainable.
4) Self Perception: The self perception technique is aimed at moving a client

toward a more complete awareness of personal needs and body image. Some
examples of this technique are as follows:
41
Counselling: Models and Immediate States -Here the patient/client selects one or more of statements
Approaches
“I am”, “I feel”, “I have”, or “I do” to paint about.
a) Self-Portraits
Self-portraits can vary from being realistic, done with or without a mirror to
abstract. A variation of this technique is to give a time limit to the painter,
such as one minute. In this way, the artist is forced to quickly decide what
important feature about themselves they wish to draw.
b) Draw Yourself as an Animal

Here the patient/client is asked to draw themselves as any kind of animal, or
as the animal that they see themselves as most similar to. This is a good
group building technique because the discussions are usually funny as well
as revealing.
5) Interpersonal Relations: The interpersonal relations technique is designed

to make the patient/client more aware of others, and how others may perceive
him or her. Some examples of this technique are as follows:
a) Portraits of Groups Members

Here group members are asked to depict each other. This exercise helps group
members to more fully clarify their feelings toward each other.
b) Group Mural
Here the group works cooperatively on a large project. The choice in subject
matter and materials may be left to the group or predetermined by the therapist.
This exercise promotes cooperation, group unity, fitting in individually to a
larger whole and self expression in a larger group setting.
6) The Individual’s Place in the World: This technique is designed to help

the patient/client to see where he or she fits into the world, and hopefully
accept and deal with this realisation. Some examples of this technique are as
follows:
a) House-Tree-Person
Here the patient/client is asked to depict a house, tree and a person in one
picture. The patient/client is faced with the task of how to relate the human
figure to the other two common environmental features.
b) Collage and Assemblage

Here the patient/client is allowed to create a personal world out of any
materials that he or she may desire. The therapist may predetermine themes,
or the patient/client may work until themes begin to appear by themselves.
It is important to keep in mind that although there are many techniques available
to the art therapist and all of them are valid, no one technique should dominate.
This is because the techniques discussed here are only loose guidelines that the
art therapist should take into consideration. More important than these guidelines
are that the approaches that the art therapist chooses to take are well designed and
thought out to meet the specific demands and needs of the individual or group.
42
Drama and Art Therapy in
3.4 LET US SUM UP Counselling
Art and Drama therapies have benefited all areas of health care system. According
to the American Art Therapy Association, Inc.’s professional definition of Art
Therapy, Art Therapy is a human service profession that utilises art media, images,
the creative art process and patient/client responses to the created products as
reflections of an individual’s development, abilities, personality, interests, concerns
and conflicts. Defining art therapy is a daunting task because it is an evolving
science, and because it is hard to come up with a definition that fully encompasses
what art therapy is, but it doesn’t mean that it is any less beneficial as a form of
therapy. Art therapy is not just a stepping stone to a verbal exchange, and should
not be treated in this way. The art therapist should be very careful of over or under
reliance on the verbal amplifications of the art by the client or patient.
One of the great advantages of art therapy is it fosters use of both sides of the
brain. The nonverbal art expression is primarily a right brain process; the writing
is coming from the left-brain language centers.
Drama therapy is the systematic and intentional use of drama and theatre processes
to achieve the therapeutic goals of symptom relief and personal growth. It is an
active, experiential approach that facilitates the client’s ability to solve problems,
set goals, express feelings appropriately, achieve catharsis, improve interpersonal
skills and relationships, and strengthen the ability to perform personal life roles.
It increases flexibility between roles. Dance therapy is proving especially beneficial
for the elderly to increase their range of mobility.

1) What is art therapy?
2) Define drama therapy.
3) Explain the steps used in art therapy.
4) What is rapport building?
5) Illustrate with examples the exploration technique of art therapy.
6) Discuss Renee Emunah’s stages in drama therapy.
7) What do you mean by Dramatic projection?

Judith A. Rubin (2001): Approaches to Art Therapy: Theory and Technique.
Publisher: Bruner- Routledge
Dorothy M. Langley (2006): An Introduction to Drama Therapy. SAGE
Publications Ltd.
References
David R. Johnson, Renée E. (2009): Current Approaches in Drama Therapy.
Charles E. Thomas –Publisher Ltd.
Judith A. Rubin (1998): Art Therapy: an Introduction. Publisher: Bruner- Routledge
Sue Jennings (1997): Drama therapy: Theory and Practice 3, Volume 3 Publisher:
Routledge.
Robert J. Landy (1994): Drama Therapy: Concepts, Theories, and Practices. 43
Approaches UNIT 4 OTHER THERAPIES (PERSONS
CENTER COUNSELING AND
SOLUTION FOCUS COUNSELING)
Structure
4.0 Introduction
4.1 Objectives
4.2 Person Centered Counselling
4.2.1 Basic Assumptions of Person Centered Counselling
4.2.2 Core Conditions
4.2.3 Process of Therapy
4.2.4 Techniques Used In Person Centered Therapy
4.3 Solution Focused Counseling
4.3.1 Basic Assumptions
4.3.2 Therapeutic Process
4.3.3 Therapeutic Goals of Solution Focused Brief Therapy (SFBT)
4.3.4 Steps in Solution Focused Brief Therapy
4.3.5 Solution Focused Tasks
4.3.6 Solution Focused Techniques
4.4 Different Questioning Techniques
4.4.1 The Miracle Questions (MQ)
4.4.2 Scaling Questions
4.4.3 Exception Seeking Questions
4.4.4 Coping Questions
4.4.5 Problem Free Talk
4.5 Let Us Sum Up
4.0 INTRODUCTION
In this unit we will be dealing with person centered counseling and solution focused
therapy. We start with person centered counselling in which we discuss the basic
assumptions of person centered counseling followed by the core conditions needed
for person centered counseling. Then we give a detailed account of the counseling
process of person centered counseling. Then we elucidate the many techniques
that are part of person centered counseling. This is followed by a detailed account
of solution focused counselling . Here we put forward the basic assumptions of
solution focused counseling, followed by the therapeutic process involved in the
same. The next section presents the therapeutic goals of solution focused therapy
and the various steps involved in the therapeutic process. The section also talks
about the various tasks of solution focused therapy and the various techniques in
carrying out the therapy. This therapy has certain typical questioning techniques
which are then presented that involves miracle questioning, scaling question,
coping question etc.
44
Other Therapies (Persons
4.1 OBJECTIVES Center Counselling and Solution
Focus Counselling)
• Define person center counseling;
• Discuss the core conditions needed for person center counseling;
• Explain the assumptions and techniques of person center counseling;
• Describe the assumptions and therapeutic process in solution focus counseling;
• Identify the therapeutic goals of solution focus counseling; and
• Explain the techniques used in solution focus counseling.
4.2 PERSON CENTERED COUNSELLING

Person centered counseling, formerly known as client centered counseling and
nondirective counseling, is a treatment approach developed by Carl Rogers in the
1940s. It has provided the basis for many more recent counseling approaches.
The principle of person centered counseling is the idea that if the counselor can
provide clients with a genuine relationship in which they feel understood, accepted,
and valued, their self esteem will be enhanced and they will increasingly be able
to draw on their own resources to help themselves. This humanistic approach
views each person as unique and able to strive towards self actualisation and
achievement of his or her full potential. This model has certain qualities:
1) Person oriented.
2) Advocates a holistic view of people as well as a belief in the human potential.
3) Emphasises the person’s experience, perceptions, agenda, and goals.
4) Promotes a therapeutic alliance in which the counselor communicates
empathy, acceptance, genuineness and congruence.
5) Focuses on life long development, self esteem, self awareness, and self
actualisation.
6) Emphasises feelings and emotions.
7) Encourages concreteness and specificity as well as exploration.
4.2.1 Basic Assumptions of Person Centered Counseling

The basic assumptions of person centered counseling are as follows:
1) Human beings are growth oriented and tend towards self actualisation. This
natural process of development towards higher stages of moral, emotional
and behaviour evolution can be facilitated by professional helpers who are
able to stimulate the inherent capacity for progress in clients who are
temporarily faltering.
2) Every individual exists in a continually changing world of experience of

which he is the center (Rogers, 1951). This proposition emphasises the central
importance of the individual and the subjective nature of personal experience.
3) An important vehicle for change is the therapeutic relationship that exudes

qualities of trust, openness, acceptance, permissiveness and warmth. The
45
Counselling: Models and degree to which the counselor is able to create this nurturing atmosphere will
Approaches
influence the client’s possibility for growth.
4) The legitimate focus of counseling content is on affect and the exploration of
feelings. Both interpersonal relationships and self- conception may be
improved by becoming aware of feelings about oneself and others by learning
to express these emotions in sensitive and self enhancing ways.
5) The universal goals of counseling are to help people to be more free,
intentional, ethical, and human. This means that time is spent in sessions
helping clients to examine their values and personal characteristics so that
that may become more humane and caring in their relationship with self and
others.
6) The client has the primary responsibility for the course of treatment. Thus a
goal is shared by the client and the counselor; they both share a mutual
understanding of the client’s world.
7) Human beings are intrinsically good and trustworthy. They will intrinsically
move, in a deliberate way, towards goals that are satisfying and socially
responsible. Irresponsible or socially undesirable behaviour emerges from
defensiveness that alienates human beings from their own nature.
4.2.2 Core Conditions

Carl Rogers has considered three main core conditions that are essential for
effective counseling. These are:
1) Unconditional Positive Regard: This means that the counselor accepts the
client unconditionally and non-judgmentally. The client is free to explore all
thoughts and feelings, positive or negative, without fear of rejection. The
therapist must show a positive approval of how they are feeling. It helps in
building up or restoring the client’s unconditional positive self regard (Iberg,
1996). The client is free to explore and to express without having to do
anything in particular or meet any particular standards of behaviour to ‘earn’
positive regard from the counselor.
2) Congruence: Congruence or genuineness, involves letting the other person
know “where you are” emotionally (Rogers, 1980). It means that the counselor
is authentic and genuine, and transparent to the client. There is no air of
authority or hidden knowledge, and the client does not have to speculate
about what the counselor is ‘really like’. Congruence can be either positive
or negative, and the therapist must express their feelings to be as genuine as
possible. it is so important for the therapist to become congruent with their
client so that a trusting relationship can be created in which the client can let
the therapist into their lives. It is very crucial factor in establishing trust.
3) Empathy: Rogers defines empathy as “to sense the clients private world as
if it were your own, but without ever losing the “as if” quality” (Rogers,
1992). Empathic understanding means that the counselor accurately
understands the client’s thoughts, feelings, and meanings from the client’s
own perspective. When the counselor perceives what the world is like from
the client’s point of view, it not only views its value, but also accepts the
client as it is. A good counselor needs to show empathy during therapy, to be
able to understand and accurately be aware of the problems that the client is
46
conveying.
4.2.3 Process of Therapy Other Therapies (Persons
Center Counselling and Solution
Focus Counselling)
Rogerian counseling involves the counselor’s entry into the person’s unique
phenomenological world. Phenomenological world means it is the study of the
development of human consciousness and self awareness as a preface to philosophy
or a part of philosophical world. In mirroring this world, the counselor does not
disagree or point out contradictions. Neither does the counsellor attempts to delve
into the unconscious. Rogers describes counseling as a process of freeing a person
and removing obstacles so that normal growth and development can proceed and
the person can become more independent and self directed.
During counseling, the client can move from rigidly self perceiving to fluidity.
Certain conditions are necessary for this process. A ‘growth promoting climate’
requires the counselor to be congruent, have unconditional positive regard for the
person as well as show empathic understanding. Congruence on the part of the
counselor refers to the counsellor’s ability to be completely genuine whatever the
self of the moment. The counsellor is not expected to be a completely congruent
person all the time, as such perfection is impossible.
The client and the counsellor will work towards the outcome, the product. But
there is also something else going on, that is the process of counseling which
affects the healing. This is the time the client spends with his counsellor, and
during the period the process takes place and between the client and counsellor
many issues are sorted out. The message that the client should be getting from
this safe stranger in this secure place is an assurance that the client is worth taking
seriously, and that the concerns of the client are real ones.
Here the therapist sees the strength in the client, and is optimistic about the client’s
future when the latter does not believe that he or she has any future. And yet the
client believes that the counsellor is sincere and has some insights. So the client
begins to realise that he is able to see in the therapist someone he or she dimly
recognises from way back before the client was so worried about. In other words
the client is a little more confident, a little surer of the direction in which he or she
is proceeding.
Rogers believed that the most important factor in successful therapy was not the
therapist’s skill or training, but rather his or her attitude. Three interrelated attitudes
on the part of the therapist are central to the success of person centered therapy:
(i) congruence (ii) unconditional positive regard and (iii) empathy. Congruence
refers to the therapist’s openness and genuineness. In other words, the willingness
of the therapist to relate to clients without hiding behind a professional facade.
Therapists who function in this way have all their feelings available to them in
therapy sessions and may share significant emotional reactions with their clients.
Congruence does not mean, however, that therapists disclose their own personal
problems to clients in therapy sessions or shift the focus of therapy to themselves
in any other way.
Unconditional positive regard means that the therapist accepts the client totally
for who he or she is without evaluating or censoring, and without disapproving of
particular feelings, actions, or characteristics. The therapist communicates this
attitude to the client by a willingness to listen without interrupting, judging, or
giving advice. This attitude of positive regard creates a nonthreatening context in
47
Counselling: Models and which the client feels free to explore and share painful, hostile, defensive, or
Approaches
abnormal feelings without worrying about personal rejection by the therapist.
The third necessary component of a therapist’s attitude is empathy (“accurate

empathetic understanding”). The therapist tries to appreciate the client’s situation
from the client’s point of view, showing an emotional understanding of and
sensitivity to the client’s feelings throughout the therapy session. In other systems
of therapy, empathy with the client would be considered a preliminary step to
enabling the therapeutic work to proceed; but in person-centered therapy, it actually
constitutes a major portion of the therapeutic work itself.
A primary way of conveying this empathy is by active listening that shows careful
and perceptive attention to what the client is saying. In addition to standard
techniques, such as eye contact, that are common to any good listener, person-
centered therapists employ a special method called reflection, which consists of
paraphrasing and/or summarising what a client has just said.
This technique shows that the therapist is listening carefully and accurately, and
gives clients an added opportunity to examine their own thoughts and feelings as
they hear them repeated by another person. Generally, clients respond by elaborating
further on the thoughts they have just expressed.
According to Rogers, when these three attitudes (congruence, unconditional

positive regard, and empathy) are conveyed by a therapist, clients can freely express
themselves without having to worry about what the therapist thinks of them. The
therapist does not attempt to change the client’s thinking in any way.
Even negative expressions are validated as legitimate experiences. Because of

this nondirective approach, clients can explore the issues that are most important
to them—not those considered important by the therapist. Based on the principle
of self-actualisation, this undirected, uncensored self exploration allows clients
to eventually recognise alternative ways of thinking that will promote personal
growth. The therapist merely facilitates self actualisation by providing a climate
in which clients can freely engage in focused, in-depth self-exploration.
Thus the process of therapy is:
1) Client’s communications about externals and not self
2) Client describes feelings but not recognise or “own” them personally
3) Client talks about self as an object in terms of past experiences
4) Client experiences feelings in present-just describes them with distrust and fear
5) Client experiences and expresses feelings freely in present-feelings bubble up
6) Client accepts own feelings in immediacy and richness
7) Client trusts new experiences and relates to others openly and freely
4.2.4 Techniques Used in Person Centered Therapy

It is not technique-oriented. This approach is simply to restate what the client just
said or the technique of reflection of feelings. The therapeutic relationship is the
primary agent of growth in the client. Therapist’s presence is being completely
engaged in the relationship with clients. The best source of knowledge about the
client is the individual client. Caring confrontations can be beneficial. The general
48
techniques used in this therapy are:
1) Listening: Active listening involves summarising the person’s emotions back Other Therapies (Persons
to them, asking questions to help them express what they feel or believe or Focus Counselling)
asking questions to achieve a better understanding of what they are saying.
The feeling of being valued as a human being creates the sense of safe space
for their deeper internal explorations. In listening the counselor:
• Invites the client to describe his/her reasons for coming to talk.
• Allow the client time to respond – this behaviour is called as attending
or active listening.
• Helps create true intimacy between the counselor and the client – trust,
comfortable with each other.
• Tells the client that you are interested in him/ her, wants to listen to him,
and will try to understand both the spoken and the unspoken message in
the communication.
2) Accepting
• The counselor accepts the client unconditionally for who he/she is-
Unconditional Positive regard.
• Being professional, the counselor is not prejudice towards the client.
3) Respecting
• The counselor respects the client’s view of his/her life.
• Helps the client towards a greater degree of independence and integration
of the individual with respect towards his/her multicultural background.
4) Understanding
• The counselor understands the client’s feeling sensitively and accurately.
• Empathetic understanding help the counselor sense client’s feeling as if
they were his/her own without becoming lost in those feelings.
Empathetic understanding helps the counselor to reflect the client’s
experiences.
5) Responding
• The counselor responds to the client’s story.
• Also responds to seek clarification about the client’s feelings and
thoughts.
• Respond by giving advices and suggestions that can help for the client’s
personal growth.
Roger’s Person Centered Counseling technique has certain strengths. It is a
Phenomenological approach which focuses on empathy, unconditional positive
regard and acceptance. It helps in increasing self-understanding. It is very genuine
and reflective. But it has certain weaknesses too. In this technique, client is not
challenged and not all clients are able to find their own answers. It is too simple
and undirected. As such it has no interventions/techniques. Despite its limitations,
still it has been used widely as it focuses on inner and subjective experience.
49
Approaches 4.3 SOLUTION FOCUSSED COUNSELING
Solution focused Counseling developed by Steve De Shazer, Insoo Berg, Eve
Lipchek and Michele Weiner-Davis, is post Modern approach that emphasises
the client’s strengths and focuses on solutions. It is also known as Solution focused
brief therapy (SFBT) or Brief Therapy (BT). The emphasis of SFBT is to focus on
what is working in client’s lives in contrast to the traditional models of therapy
that tend to be problem- focused. These therapists assist clients in paying attention
to the exceptions to their problem patterns. They promote hope by helping client
discovering exceptions, times when the problem is less intrusive in their lives
(Metcalf, 2001). SFBT looks at the positive side of problems and what works. It
believes that all people are free to make choices.
It is a competency based model, which minimizes emphasis on past failings and

problems, and instead focuses on clients’ strengths and previous successes. There
is a focus on working from the client’s understandings of her/his concern/situation
and what the client might want different. Differing from skill-building and
behaviour therapy interventions, this model assumes that solution behaviours
already exist for clients. Clients’ solutions are not necessarily directly related to
any identified problem by either the client or the therapist. It can be used in a
variety of settings with a variety of problems.
Solution-focussed therapy focuses on people’s strength, competence, and

possibilities instead of their deficits, weaknesses and limitations (O’Hanlon &
Weiner Davis 1989).
The solution focussed approach builds upon clients’ resources. It aims to help
clients achieve their preferred outcomes by evoking and co-constructing solutions
to their problems (O’Connell, 2001).
Solution Focussed Brief Therapy differs from traditional treatment in that

traditional treatment focuses on exploring problematic feelings, cognitions,
behaviours, and/or interaction, providing interpretations, confrontation, and client
education (Corey, 1985). In contrast, SFBT helps clients develop a desired vision
of the future wherein the problem is solved, and explore and amplify related client
exceptions, strengths, and resources to co-construct a client-specific pathway to
making the vision a reality. Thus each client finds his or her own way to a solution
based on his or her emerging definitions of goals, strategies, strengths, and
resources.
4.3.1 Basic Assumptions

Different therapists have described assumptions in different ways:
Walter and Peller (1992, 2000) described SFT as a model that explains how
people change and how they can reach their goals. They gave following basic
assumptions:
• Individuals who come to therapy do have the capability of behaving effectively,

even though this effectiveness may be temporarily blocked by negative
cognitions. Problem focused thinking prevents people from recognising
effective ways they have dealt with problems.
50
• There are advantages to a positive focus on solutions and on the future. If Other Therapies (Persons
clients can reorient themselves in the direction of their strengths using solution Focus Counselling)
talk. There is a good chance that a therapy can be brief.
• There are exceptions to every problem. By talking these exceptions, clients
can get control over what had seemed to be an insurmountable problem. The
climate of these exceptions allows the possibility of creating solutions. Rapid
changes are possible when clients identify exceptions to their problems.
• Clients often present only one side of themselves. This therapy invites clients
to examine another side of the story they are presenting.
• Small changes pave the way for larger changes. Small changes are all that are
needed to resolve problems that clients bring to therapy.
• Clients want to change, have the capacity to change and are doing their best
to make changes happen. Therapist should adopt a cooperative stance with
clients rather than devising strategies to control resistive patterns. With
therapist’s cooperation, resistance does not occur.
• Clients can be trusted in their intentions to solve their problems. There are
no right solutions to specific problems that can be applied to all people. Each
individual is unique and so, too is each solution.
O’Hanlon & Weiner Davis (1989): They provided several powerful assumptions
as the foundation of solution-focused therapy:
• Individuals who come to therapy have strengths, resources, and the ability to
resolve the challenges they face in life.
• Change is always possible and is always happening.
• The counselor’s job is to help clients identify the change that is happening
and to help them bring about even more change.
• Most problems do not require a great deal of gathering of historical information
to resolve them.
• The resolution of a problem does not require knowing what caused it.
• Small changes lead to more changes.
• With rare exceptions, clients are the most qualified people to identify the
goal of therapy. (Exceptions include illegal goals [e.g., child abuse] and clearly
unrealistic goals.)
• Change and problem resolution can happen quickly.
• There’s always more than one way to look at a situation
General Assumptions
• Clients are their own experts who know what is best for them.
• The therapist accepts the client’s view of reality.
• Therapy is collaborative and cooperative.
• Uses the resources available to the client.
51
Counselling: Models and • Goals are specific, behavioural and obtainable.
Approaches
• Problems are reframed in a more positive way.
• Focus on what is right and what is working.
• Goals are always set in positive terms.
• People are highly susceptible and dependent.
• Don’t ask a client to do something that he or she has not succeeded at before.
• Avoid analysing the problem.
• Be a survivor not a victim.
4.3.2 Therapeutic Process

Solution focused brief therapy (SFBT). “What SFBT does is that instead of
digging somewhere deep it mainly focuses on client strengths and resiliencies
examining previous solutions and exceptions to the problem, and then, through a
series of interventions, encouraging clients to do more of those behaviours”. In
this case it is important what are the effective therapeutic principles implemented
in SFBT. It is important to mention that principle is ‘ a set of rules that guides the
therapy’, than a technique is ‘a specific procedure to get a specific result’. So
principles are something what will be followed during all the therapy than technique
is something used to achieve a well defined goal at a certain time. These might be
distinguished as the main principles of Solution Focused Therapy:
Principle 1: Start where the client is, or adapt to the stage in which the client
finds himself
There can be three different types of people who end up in front of the ones
offering professional health:
• A Complainant – a person who does not have a clear request for help (a
drinking housewife who says that no way she can cope without drinking as
long as her husband works long hours and she has to take care of home on
her own)
• A Visitor – the one sent to seek for help by the doctors, friends, relatives
• A Buyer – a person who actively seeks for help on his own (contacts a therapist
about the drinking problems on his own and not influenced by anyone)
In scientific literature these mentioned types of people seeking for help can also
be defined as three stages which change during the process of relationship between
the therapist and the client. It is very important that therapist would correctly
identify at what stage is the person seeking for help than he first contacts him. In
this case therapist can use correct principles to move a client along the stages and
get the result more effective. A client can very easily turn from a Visitor to
Complainant and then a Buyer.
Principle 2: Use and enhance the client’s competence

Every person has abilities and coping strategies prior to any therapeutic
intervention. Therefore, the therapeutic process should consist of bringing forward
52 and implementing solutions that are already present in clients and their systems.
Therapy works better if the solution suggested by the therapist is based on the Other Therapies (Persons
natural healing processes of the patient, in this way all the best competences of Focus Counselling)
the client can be used.
Principle 3: Defining clear goals and obtaining the client’s collaboration

Solution focused approach gives a very important meaning to the clear definition
of the goal which a person coping with various problems should achieve. Client
needs to define the goal using the details and concrete examples regarding how
his life should be rather than how he has been coping with this problem or is at the
certain stage of the therapy.
Principle 4: Change client’s perception and experience

Promoting corrective emotional experience is another basic principle in SFBT.
Corrective emotional experience refers to ‘exposing the patient under
more favourable circumstances to emotional situation which he could not handle
in the past under less favorable circumstances ‘(Alexander, French & al., 1946).
Nowadays this principle is considered as an efficient. It is described as an ability
to create experiences where the client has the opportunity to learn something new
is an essential ingredient in brief therapy.
Principle 5: Solution oriented language

Solution focused approach helps the clients to discover their own solutions and
expects the therapist to adopt a trusting and respectful attitude. In the solution
focused therapy it is very important that a therapist adopts the language of the
patient: words, intonation, speed of talking and reflex. This, firstly, will build the
trust and secondly, will help to communicate. In solution focused approach therapy
the one who knows the solution is patient himself, just a therapist needs to help
out while bringing that solution to the day light, while being supportive and
respectful. There should not be any confrontation, denials, only the suggestions
and alternatives.
Principle 6: Restore and enhance hope and positive expectation

Hope and positive expectation have a strong influence on final outcome of any
therapy. Solution focused approach in therapy seeks of the ways to enhance hope,
as a willing to improve into the healing process. Positive expectations in solution
focused approach is something that stimulates the patient to focus more on the
healing process.
To sum up: solution focused approach in therapy is a process during which the
clear goals are defined by the patient and a therapist is the one trying to engage the
best of patient’s skills and competences in order to achieve these goals. Also This
is the kind of therapy which focuses only on the positive factors: hope, healing,
improvement, goals and dismisses the negative things: problems and fails. In this
case therapist is like a silent advisor who never is to persuasive and instead of
telling the patient what to do only suggests alternatives in the way patient thinks
it was actually his idea.
Solution focused counseling assumes a collaborative approach with clients in

contrast to the educative stance that is associated with most traditional models of
therapy. If clients are involved in the process from beginning to end, the therapy
will be successful. Collaborative and cooperative relationships are more important
53
Counselling: Models and than hierarchical relationship in therapy. Walter & Peller described four steps that
Approaches
characterise the process of SFBT:
1) Find out what clients want rather than searching for what they do not want.
2) Do not look for pathology and do not attempt to reduce it by giving them a
diagnostic label. Instead look for what clients are doing that is already working
and encourage them to continue in that direction.
3) If what clients are doing is not working encourage them to experiment
something different.
Principle 4: Keep therapy brief by approaching each session as if it were the
last and only session.
SFBT is an approach that focuses on how clients change, rather than one which
focuses on diagnosing and treating problems. As such, it uses a language of change.
The signature questions used in solution-focused interviews are intended to set
up a therapeutic process where in practitioners listen for and absorb clients’ words
and meanings, then formulate and ask the next question by connecting to clients’
key words and phrases. Therapists then continue to listen and absorb as clients
again answer from their frames of reference, and once again formulate and ask
the next question by similarly connecting to the client’s responses. It is through
this continuing process of listening, absorbing, connecting, and client responding
that practitioners and clients together co-construct new and altered meanings that
build toward solutions.
4.3.3 Therapeutic Goals of SFBT

The solution focused therapist believes that people have the ability to define
meaningful goals and that they have the resources required to solve their problems.
Each client is unique and constructs unique goals for better future. The therapists
focus on small, realistic and achievable changes that can lead to additional positive
outcomes. Modest goals are viewed as the beginning of the change. SBF therapists
use similar words, pace and tone in the same language as of the clients. Clients
must feel that their concerns are heard and understood before they can formulate
meaningful personal goals. Walter and Peller (1992) emphasised the importance
of assisting the clients in creating their well defined goals that are:
1) Stated positively ion the client’s language;
2) Are process or action oriented;
3) are structured in here and now;
4) are attainable, concrete and specific;
5) are controlled by the client.
O’Hanlon & Weiner- Davis (2003) offers several forms of goals: Changing the
viewing of a situation or a frame of reference, changing the doing of problematic
situation, and tapping client strength and resources.
4.3.4 Steps in SFBT

The structure of solution building differs greatly from traditional approaches to
problem solving as can be seen in brief description of steps involved (De Jing &
54
Berg, 2008):
1) Clients are given opportunity to describe their problems. The therapist listens Other Therapies (Persons
respectfully and carefully as clients answer the therapist’s question, “How Focus Counselling)
can I be useful to you”?
2) The therapist works with clients in developing well- formed goals as possible.
The question is posed, “What will be different in your life when your problems
are solved”?
3) The therapist asks clients about those times when they were problem free.
Clients are assisted in exploring these exceptions, with special emphasis on
what they did to make these events happen.
4) At the end of each solution building conversation, the therapist offers clients
summary feedback, provides encouragement and suggests what clients might
observe or do before the next session to further solve their problem.
5) The therapist and the client evaluate the progress being made in reaching
satisfactory solutions by using a rating scale. Clients are asked what needs to
be done before they see their problem as being solved and also what their
next step will be.
4.3.5 Solution Focused Tasks

Molnar and de Shazer (1987) discussed a list of five tasks and corresponding
rationales. These tasks represent a simple attempt to realise the objectives of
solution-focused counseling.
Task 1: The client is told and asked, “Between now and the next time, I would
like you to observe, so that you can tell me next time, about those times when you
are able to make it (the goal) happen.”
Rationale: This task is given if the client is able to construct a problem and goal,
and identify and amplify exceptions.
like you to pay attention to and make note of what you do when you are able to
effectively cope with or deal with the problem.”
Rationale: This task is given if the client is able to construct a problem and goal
and identify exceptions, but is unable to amplify exceptions.
like you to observe, so that you can tell me next time, what happens in your life
(relationship, family, work situation) that you want to continue to have happen.”
Rationale: This task is given if the client is able to construct a problem and goal,
and potential exceptions, but is unable to identify exceptions.
Task 4: The client is told and asked, “Try to avoid making any drastic changes. If
anything, think about what you will be doing differently when things are improved.”
Rationale: This task is given if the client is able to construct a problem, but is
unable to construct a goal.
Task 5: The client is told and asked, “The situation is very volatile. Between now
and the next time, attempt to think about why the situation is not worse.”
Rationale: This task is given if the client is in severe crisis. 55
Counselling: Models and 4.3.6 Solution Focused Techniques
Approaches
1) Mapping the Influences of the Problem: This technique, developed by
Michael White, refers to a line of questioning aimed at helping the client
understand how the problem has influenced his or her life. When mapping
the influences of the problem, counselors ask how the problem has affected
various aspects of the client’s life, including relationships, work, and daily
functioning, e.g. in the problem of depression, the counselor might ask the
client to identify ways in which depression has affected aspects of their life.
The purpose of this technique is to use the influences as a basis from which
to later identify exceptions.
2) Scaling: In this clients are asked to rate their subjective experiences, such as
how they feel, how they deal with their problems, and so forth on a scale
from 0 to 10. Molnar and de Shazer (1987) developed a reverse scale which
can be effective Scaling techniques are useful for clients who find it difficult
to discern exceptions and notice differences. The therapist asks the clients to
keep a written record of their ratings. Then, review the ratings with your
client, and focus on the client’s best days and highlight the other information
that was recorded as these are exceptions that can be amplified.
3) Journaling: Journaling, also known as the structured log, is a useful exercise

for clients who are unable to identify exceptions or unable to develop goals
at all. The client might be asked to keep track of times when the problem
does not happen or when the goal happens. The client is asked to describe in
detail what they did, how they coped, what was different, and so forth. The
structured log often leads to helping the client identify exceptions and set
more attainable and realistic goals.
4) What is Better?: De Shazer (1994) proposed a simple question that

counselors can use during follow-up sessions aimed at identifying exceptions:
“What’s better? Starting off the next session with the variations in question
like “What’s better?” or “What’s new?” or “What’s up?” or “What do you
want to talk about?” can get you and the client in a solution- focused direction
from the start. These types of questions might help in identifying exceptions
that were missed in prior sessions or raise new problems and exceptions.
5) The Surprise Task: When working with couples and families, the surprise
task can serve to identify positive outcomes that might otherwise not have
been produced in counseling. In this task, one family member is instructed to
surprise another family member on two occasions. The other family member
is instructed to observe for times when the other surprises them.
6) Strategic Eclecticism: Solution focussed counseling allows for the

compatible application of diverse theories and techniques within its own
clinical theory. Eclecticism can be understood in terms of a strategic approach.
The term strategic refers to an effort on the part of counselors to tailor
conceptualisations and interventions to account for the uniqueness of each
client, thereby facilitating the change process in an effective manner and
often in a brief period of time.
56
Other Therapies (Persons
4.4 DIFFERENT QUESTIONING TECHNIQUES Center Counselling and Solution
Focus Counselling)
4.4.1 The Miracle Question (MQ)
This is powerful in generating the first small steps of ‘solution states’ by helping
clients to describe small and realistic steps they can take as soon as the next day
involves asking the client to imagine how their future would look in an ideal
world, with particular attention to the absence of the problem that brought them
to therapy in the first place.
4.4.2 Scaling Questions

These are used to monitor change in the client, who rates their position on a scale,
usually ranging from one (the worst scenario) to ten (the best scenario). Scaling
questions (SQ) can be used when there is not enough time to use the Miracle
Question. It is used in many ways, including with children and clients who are not
verbal or who have impaired verbal skills. Careful exploration enables clients to
identify resources that enable movement along the scale towards their rating of a
better future.
4.4.3 Exception Seeking Questions

These assume that there are always times when the problem is less acute, and
investigate what enables this to be so. The client can then use this knowledge to
improve their situation and gain confidence in their own autonomy.
4.4.4 Coping Questions

These are used to elicit examples of times when the client coped with even the
direst of situations, so that a problem-focused narrative can be challenged and
transformed into a more positive and solution focused alternative. This question
is a powerful reminder that all clients engage in many useful things even in times
of overwhelming difficulties. Coping questions such as, “How have you managed
to carry on?”; “How have you managed to prevent things from becoming worse?”
open up a different way of looking at client’s resiliency and determination.
4.4.5 Problem-Free Talk

This focuses on areas outside of the problem and enables both therapist and client
to establish an atmosphere in which the strengths and positive qualities of the
latter is emphasised and drawn upon to help improve other areas of life e.g. Hobbies
and social activities.
4.5 LET US SUM UP

Rogers has developed a person centered approach to create an environment at
which clients are able to hash out their problems in a self directed way. The therapist
is merely a listener, there to make the client feel that what they are feeling is
ordinary. Rogers states it, “people are essentially trustworthy, that they have a
vast potential for understanding themselves and resolving their own problems
without direct intervention on the therapists part, and that they are capable of self
directed growth.
57
Counselling: Models and Brief solution-focused counseling (BSFC) offers great promise to practitioners
Approaches
seeking an efficient and research-supported approach to school problems and the
young people who experience them. The BSFC approach presented in this article
is derived from four decades of psychotherapy outcome research on the essential
ingredients or “common factors” of therapeutic change—client, relationship, hope,
and model-technique factors. Outcome research can be translated into practical
strategies for resolving problems including the “ambassador approach” to client–
practitioner relationships, the strategic use of language, and the emphasis on client
strengths and resources.

1) Define Person Centered Counseling.
2) What do you understand by Congruence?
3) Describe the general techniques involved in Person Centered Counseling.
4) What is Solution-Focused Brief Therapy? Write down its steps.
5) Describe O’Hanlon & Weiner Davis basic assumptions.
6) Explain mapping the Influences technique of SFBT. Also discuss different
questioning techniques.

Gerald Corey (2009): Theory and Practice of Counseling and Psychotherapy.
Publisher: Thompson Brooks.
Mearns, D and Thorne, B (2000): Person-Centred Therapy Today.Sage
Publications.
Rogers, Carl R. (1983): On Becoming a Person: a Therapist’s View of
Psychotherapy. Boston: Houghton Mifflin.
References
Gerald Corey (2009): Theory and Practice of Counseling and Psychotherapy.
Publisher: Thompson Brooks.
Jeffrey A. Kottler & David S. Shepard (2008): Introduction to Counseling: Voices
from the Field. Publisher: Thompson Brooks.
Mearns, D. & Thorne, B. (1998): Person-Centered Counselling in Action. Sage
Publications
58
HIV/AIDS Counselling
UNIT 1 HIV/AIDS COUNSELLING
Structure
1.0 Introduction
1.1 Objectives
1.2 What is HIV/AIDS
1.2.1 How does it Transmit
1.2.2 Signs and Symptoms of HIV/AIDS
1.3 Diagnosis of HIV/AIDS
1.4 Misconceptions
1.5 Prevalence of HIV/AIDS in Asian Countries
1.6 Aims of HIV/AIDS Counselling
1.6.1 Prevention of HIV Transmission
1.6.1.1 General Awareness
1.6.1.2 Counselling the HIV Affected Persons
1.6.2 Counselling the AIDS Patients and Family
1.7 Let Us Sum Up
1.0 INTRODUCTION
AIDS stands for Acquired Immune Deficiency Syndrome, a disorder in which
immune system is gradually weakened and eventually disabled by the Human
Immunodeficiency Virus (HIV).
HIV testing and counseling services are a gateway to HIV prevention, care and
treatment. The benefits of the knowledge of HIV status include the following;
1) At the individual level: Enhanced ability to reduce the risk of acquiring or
transmitting HIV; access to HIV care, treatment and support; and protection
of unborn infants.
2) At the community level: A wider knowledge of HIV status and its links to
interventions can lead to a reduction in denial, stigma and discrimination
and to collective responsibility and action.
3) At the population level: Knowledge of HIV epidemiological trends can
influence the policy environment, normalize HIV/AIDS and reduce stigma
and discrimination.
In the communities that have been longest and hardest hit by the epidemic, an
increasing number of people with HIV are becoming ill and need care, treatment
and support. However, most people with HIV are unaware of their HIV status.
Scaling up HIV testing and counseling services is a critical step for scaling up a
range of interventions in HIV/AIDS prevention, care, treatment and support.
In September 2003, WHO made a call to action for a target of providing access
to ARV treatment for three million people in resource-limited settings by 2005
5
Type of Counselling and of working towards universal access. This requires that many more millions
of people be tested for HIV and counseled in order to identify those who can
benefit from immediate access to treatment, and to prevention and support
services. Indeed, the increased availability of ARV treatment is likely to generate
a dramatically increased demand for HIV testing and counseling.
In June 2006, a number of documents relating to the policy and provision of HIV
testing and counseling to infants and children were added to the toolkit. They
include a selection of documents covering policies, child’s rights and strategic
frameworks, child-focused counseling, consent, confidentiality and disclosure,
clinical diagnosis and laboratory issues, monitoring and evaluation and case
studies.
WHO and UNAIDS released in May 2007, the Guidance to Provider-initiated

HIV Testing and Counseling in Health Facilities, which articulates
recommendations developed over the course of a year-long consultation with
many different stakeholders. This guidance which builds on previous policy
positions of both WHO and UNAIDS encourages health care providers to
routinely recommend HIV testing and counseling to all patients who present
with conditions that suggest underlying HIV infection.
HIV/AIDS is one of the most serious diseases. However, since the modes of
transmission are well known, awareness is the best method to reduce the
occurrence of this disease. At present prevention is the only way to handle this
crisis which has become a global menace.
1.1 OBJECTIVES
At the end of the unit, you will be able to:
• Know the meaning of HIV and AIDS;
• Understand how does HIV and AIDS occur;
• Recognise the sign and symptoms of HIV/AIDS;
• Aware of the myths and facts about HIV/AIDS;
• Explain the diagnosis of HIV;
• Describe the aims of HIV counseling; and
• Understand the importance of prevention of HIV.
1.2 WHAT IS HIV/AIDS?

HIV is a virus, which cause impairment to the immune system in the humans.
HIV stands for Human Immunodeficiency Virus. These belong to the family of
virus called retrovirus. This looks like a sunflower in a full bloom which is
thousand times smaller than the thickness of hair.
AIDS stands for Acquired Immuno Deficiency Syndrome. HIV is the virus that
causes AIDS.
Redfield, Wright and Tramont explain AIDS as –
A-Acquired means which is taken from some body else and there is no genetic
6 inheritance
ID- Immune deficiency that is, the immune system becomes so weak and HIV/AIDS Counselling
inadequate that the body is unable to fight against the disease
S- Syndrome when group of diseases or symptoms are present and a person is
unable to cope with it.
The HIV attacks our immune system which is our body’s “security force” to
fight off infections. Once the HIV enters the body, it weakens the body’s immune
system. HIV mostly infects T-cells, also known as CD4+ cells, or T-helper cells.
These cells are white blood cells that activate the immune system to fight disease.
Once inside the cell, HIV starts producing millions of little viruses, which
eventually kill the cell and then go out to infect other cells. With the breakdown
of the immune system the body becomes susceptible to numerous infections.
These are called “opportunistic infections” because they take advantage of the
body’s weakened defenses. Thus HIV virus itself does not cause death. It is the
opportunistic infections that cause death. AIDS is the condition where many
opportunistic infections take hold of the body.
When the person is infected with HIV, s/he may remain asymptomatic for several
years; that is, s/he does not suffer from any illnesses as a result of lower immunity.
It may develop into AIDS after a number of years. People with HIV may not
know that they have the virus, but can pass on the virus to others.
1.2.1 How does it Transmit?

There are three main modes of transmission:
1) Unprotected sex: Engaging in unprotected/unsafe sex,i.e. not using condome
or any other barrier devices leads to the risk of HIV infection. In fact,
heterosexual transmission is the route by which most people with AIDS
have become infected with HIV worldwide. A significant portion of HIV
infection among women in the World is acquired through heterosexual
contact. HIV can be found in the blood, semen, pre-seminal fluid, or vaginal
fluid of a person infected with the virus.
2) Blood exposures: Various blood exposures that carry risks of HIV
transmission include injections (intramuscular, subcutaneous, intravenous),
blood tests, infusions, dental care, surgery, other medical procedures,
tattooing, piercing, shaving, manicures, and pedicures (when cuts occur),
and needle-stick accidents. Sharing of syringes, needles or injecting
equipments carry high risks of HIV infection.
HIV can also be transmitted through other body fluids such as semen, vaginal
fluid, breast milk, cerebrospinal fluid (which surrounds the brain and the
spinal cord), synovial fluid (which surrounds bone joints) and amniotic fluid
(which surrounds a fetus). Though HIV is also present in other body fluids
such as saliva and sweat, it is present in such low quantities that transmission
through these routes is impossible.
Thus, HIV is not spread through these body fluids:
• Sweat
• Tears
• Saliva (spit)
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Type of Counselling 3) Mother to baby transmission: HIV can be transmitted through an infected
pregnant woman to her baby during pregnancy or delivery, as well as through
breast feeding.
Thus, transmission of HIV most often occurs through unprotected sex, through
the transfer of contaminated blood from one infected person to another, through
infected pregnant women.
However, HIV is not transmitted through casual contacts like hugging, kissing
(between people with no significant dental problems), dancing, sharing food or
drinks, sharing exercise equipment, using a shower, bath, or bed used by an
HIV+ person , insect bites.
The counselor must be clear of the fact that no matter how a person became
infected, they are facing a serious and life threatening disease. Therefore the
counselor must have an objective and empathetic attitude towards the HIV affected
person. Counselor must take each case separately and must make a preparation
for the counseling program to help the patient.
1.2.2 Signs and Symptoms of HIV/AIDS

Most people with HIV are asymptomatic for eight to ten years although it only
takes three to ten weeks for the body to initially respond to infection by the HIV
virus by producing antibodies. The progression of HIV in the body is:
• HIV infection: Entry of virus in the body through any of routes
• Window period: Few weeks to few months
• Silent infection: No symptoms seen for five to eight years.
The ‘window period’ is a term used to describe the period of time between HIV
infection and the production of antibodies. During this time, an antibody test
may give a ‘false negative’ result, which means the test will be negative, even
though a person is infected with HIV. To avoid false negative results, antibody
tests are recommended three months after potential exposure to HIV infection.
A negative test at three months will almost always mean a person is not infected
with HIV. If an individual’s test is still negative at six months, and they have not
been at risk of HIV infection in the meantime, it means they are not infected
with HIV.
It is very important to note that if a person is infected with HIV, they can still
transmit the virus to others during the window period.
HIV may lead to AIDS. The symptoms of AIDS vary widely depending on the
specific constellation of disease, that one develops (Cunningham&Selwyn, 2005).
Unfortunately, the world wide prevalence of this deadly disease continues to
increase at an alarming rate so the counselor must be aware of the following
symptom which can be classified into major and minor.
The major symptoms are as following:
1) Chronic or recurring diarrhea
2) Unexplained low grade fever more than a month’s duration
3) Dry cough
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4) Fatigue HIV/AIDS Counselling
5) Progressive dementia
6) Progressive involuntary weight loss of 10% of the known body weight
7) Recurrent respiratory infections with poor response to microbial
The minor symptoms are as following:
1) Oral thrush
2) Recurrent or multi dermatomes Herpes Zoster recurrent skin infection
3) Severe seborrhea dermatitis
4) Pneumonia
NACO Guidelines
Below is given the NACO (National AIDS Control Organization) guidelines for
Case Definition of AIDS in India.
Case definition for AIDS in India was revised in October, 1999. The new case
definition is as follows:
I) Case Definition of AIDS in Children (up to 12 years of age)

1) The positive tests for HIV infection by ERS (ELISA/RAPID/SIMPLE)
in children above 18 months or confirmed maternal HIV infection for
children less than 18 months.
AND
2) Presence of at least two major and two minor signs in the absence of
known causes of immuno-suppression.
Major Signs
a) Loss of weight or failure to thrive which is not known to be due to
medical causes other than
HIV infection.
b) Chronic diarrhea (intermittent or continuous) > 1 month duration.
c) Prolonged fever (intermittent or continuous) > 1 month duration.
Minor Signs
a) Repeat common infections (e.g. Pneunonitis, ottitis, pharyngitis etc.)
b) Generalised lymphadenopathy
c) Oropharyngeal candidiasis
d) Persistent cough for more than 1month

e) Disseminated maculo - papular dermatosis
II) Case Definition of AIDS in adults (for persons above 12 years of age)
1) Two positive tests for HIV infection by ERS test (ELISA/RAPID/
SIMPLE)
AND
2) Any one of the following criteria:
9
Type of Counselling a) Significant weight loss (> 10% of body weight) within last one month/
Cachexia (not known to be due to a condition other than HIV infection).
AND
Chronic diarrhea (intermittent or continuous) > 1 month duration or
prolonged fever (intermittent or continuous) > 1 month duration
b) Tuberculosis: Extensive pulmonary, disseminated, miliary, extra-
pulmonary tuberculosis.
c) Neurological impairment preventing independent daily activities, not
known to be due to the conditions unrelated to HIV infection (e.g.
trauma)
d) Candidasis of the oesophagus (diagnosable by oral candidiasis with
odynophagia)
e) Clinically diagnosed life -threatening or recurrent episodes of
pneumonia, with or without etiological confirmation
f) Kaposi Sarcoma
g) Other conditions:
• Cryptococcal meningitis
• Neuro Toxoplasmasis
• CMV retinitis
• Pencillium marneffei
• Recurrent Herpes Zoster or multi-dermatomal herpes infection

1) What is HIV?
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2) Differentiate between HIV and AIDS.
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3) How can a baby be affected by HIV?
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4) What is a window period?
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1.3 DIAGNOSIS OF HIV/AIDS

HIV test involves detecting antibodies of the virus or the genetic material (DNA
or RNA) of HIV in the blood or other sample. If this is present the person is
called HIV positive.
After the original infection, it takes between 2 weeks and 6 months for antibodies
to HIV to appear in the blood. The period between becoming infected with HIV
and the point at which antibodies to HIV can be detected in the blood is called
the seroconversion or “window” period. During this period, an HIV-infected
person can still spread the disease, even though a test will not detect any antibodies
in his or her blood.
Several tests can find antibodies or genetic material (RNA) to the HIV virus.
These tests include:
• Enzyme-linked immunosorbent assay (ELISA): This test is usually the
first one used to detect infection with HIV. If antibodies to HIV are present
(positive), the test is usually repeated to confirm the diagnosis. If ELISA is
negative, other tests are not usually needed. This test has a low chance of
having a false result after the first few weeks that a person is infected.
• Western blot: This test is more difficult than the ELISA to perform, but it is
done to confirm the results of two positive ELISA tests.
• Polymerase chain reaction (PCR): This test finds either the RNA of the
HIV virus or the HIV DNA in white blood cells infected with the virus. PCR
testing is not done as frequently as antibody testing, because it requires
technical skill and expensive equipment. This test may be done in the days
or weeks after exposure to the virus. Genetic material may be found even if
other tests are negative for the virus. The PCR test is very useful to find a
very recent infection, determine if an HIV infection is present when antibody
test results were uncertain, and screen blood or organs for HIV before
donation.
Testing is often done at 6 weeks, 3 months, and 6 months after exposure to find
out if a person is infected with HIV.
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Type of Counselling
1.4 MISCONCEPTIONS
Misconception about AIDS is wide spread. A great many people have unrealistic
fears that AIDS can be readily transmitted through casual contact with infected
person. These people worry unnecessary about contracting AIDS from a
handshake, a sneeze, or from a utensil.
Many young heterosexuals who are sexually active with a variety of partners
foolishly downplay their risk for HIV, naively assuming that they are safe as
long as they avoid IV drugs use and sexual relation with gay or bisexual men.
They generally underestimate the probability that there sexual partners may have
previously used IV drugs or unprotected sex with an infected individual.
People generally think that AIDS is usually accompanied by discernible

symptoms, their prospective sexual partners who carry HIV virus will carry telltale
signs of illness. However, having AIDS and being infected with HIV are not the
same thing, and HIV carriers often remain healthy and symptom -free for many
years after they are infected. Hence there is a crucial need to create public
awareness and educate them about AIDS.
Below are given some of the myths bout the AIDS and the facts.
Myth: Having HIV means you have AIDS
Fact: Human immunodeficiency virus (HIV) is a virus that destroys the body’s
CD4 immune cells, which help fight disease. With the right medications, you
can have HIV for years or decades without HIV progressing to AIDS. AIDS
(acquired immunodeficiency syndrome) is diagnosed when you have HIV as
well as certain opportunistic infections or your CD4 cell count drops below 200.
Myth: HIV/AIDS can be acquired through casual contact

Fact: HIV/AIDS cannot be acquired through hugging , using the same towel, or
sharing the same glass or utensil. However, the risk of infection comes form
having unprotected sex, sharing needles, or getting a tattoo from unsterilized
equipment.
Myth: An HIV infected person has just a few years to live

Fact: Everyone with HIV experiences it differently. Some people may develop
AIDS within a few months as the virus quickly weakens their immune system.
Many others can live for decades with HIV and have a normal life expectancy.
You can help prevent HIV from progressing to AIDS by seeing your doctor
regularly and following your doctor’s recommendations.
Myth: HIV always shows off through its symptoms

Fact: Some people don’t show any signs of HIV for years after being infected.
Many can have some symptoms within 10 days to a few weeks after infection.
These first symptoms are similar to the flu or mononucleosis and may include
fever, fatigue, rash, and sore throat. They usually disappear after a few weeks
and you may not have symptoms again for several years. The only way to tell
you have HIV is to get tested.
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Myth: HIV can be cured HIV/AIDS Counselling
Fact: There is no cure for HIV, but treatment can keep virus levels low and help
maintain the immune system. Some drugs interfere with proteins HIV needs to
copy itself; others block the virus from entering or inserting its genetic material
into your immune cells. Your doctor will consider your general health, the health
of your immune system, and the amount of virus in your body to decide when to
start treatment.
Myth: HIV cannot affect me and my family

Fact: Anyone can get HIV – men, women and children. Many people are silent
carriers of HIV; even they themselves are unaware of this. HIV gets spread through
unsafe sex, infected syringes and blood and from infected mothers.
Myth: Sex is safe when both partners have HIV

Fact: Just because you and your partner both have HIV, doesn’t mean you should
forget about protection when you have sex. Using a condom or other latex barrier
can help protect you from other sexually transmitted diseases as well as other
strains of HIV, which may be resistant to anti-HIV medication. Even if you are
being treated and feel well you can still infect others.
Myth: You cannot have a baby if you are HIVpositive

Fact: Infected mothers can indeed pass HIV to their babies during pregnancy or
delivery. However, you can lower the risk by working with your doctor and
getting the appropriate care and medication. Pregnant women with HIV can take
medications to treat their infection and to protect their babies against the virus.
1.5 PREVALENCE OF HIV/AIDS IN ASIAN

COUNTRIES
Statistics reported the rise in incidence of HIV/AIDS in the Asian Countries by
the surveys done by various international organizations (UN, UNICEF, etc.) after
the late 80’s. Facts rate that around 31000 children below the age of 15 are
surviving with HIV/AIDS in the Asian countries in east and the pacific with
11000 newly infected in the year 2007 and the number could exceed around
25000 in 2015.
According to global action for children (NGO):
• Approximately 2.2 million children are affected form HIV/AIDS world wide.
• Largest number of HIV/AIDS orphans in the world.
• 2/3 of the India’s cases are reported in the 6 of 28 states e.g. Maharashtra,
AP, Manipur, Karnataka TN, Nagaland.
The figures above suggest the need for awareness regarding HIV/AIDS and taking
preventive measures through counseling and large scale awareness generation
program and by conducting workshops for the teenagers. Women are biologically
and socially more prone to HIV infection than men, the low status of women in
society inhibits their ability to protect themselves from HIV infection coming
either from their husbands or other sex partners.
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Type of Counselling
1) Describe the diagnostic tests for HIV/AIDS.
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2) Mention the various misconceptions about HIV/AIDS.
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1.6 AIMS OF HIV/AIDS COUNSELING

Counseling in HIV and AIDS has become a core element in a holistic model of
health care, in which psychological issues are recognised as integral to patient
management. It concentrates specifically on emotional and social issues related
to possible or actual infection with HIV and to AIDS. With the consent of the
client, counselling can be extended to spouses, sex partners and relatives (family-
level counselling, based on the concept of shared confidentiality). HIV counselling
has as its objectives both prevention and care (UNAIDS Technical Update,
Geneva, 1997).
HIV and AIDS counseling can have two general aims:
1) Prevention of HIV transmission
2) Provision of counselling services to the AIDS patients and their family
1.6.1 Prevention of HIV Transmission

It is vital that HIV counseling should have these dual aims because the spread of
HIV can be prevented by changes in behaviour. One to one prevention counseling
has a particular contribution in that it enables frank discussion of sensitive aspects
of a patient’s life—such discussion may be hampered in other settings by the
patient’s concern for confidentiality or anxiety about a judgmental response.
Also, when patients know that they have HIV infection or disease, they may
suffer great psychosocial and psychological stresses through a fear of rejection,
social stigma, disease progression, and the uncertainties associated with future
management of HIV.
Good clinical management requires that such issues be managed with consistency
and professionalism, and counseling can minimize both morbidity and reduce
its occurrence. All counselors in this field should have formal counseling training
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and receive regular clinical supervision as part of adherence to good standards HIV/AIDS Counselling
of clinical practice.
Thus prevention will include in the first place, creating awareness among the
public about the HIV/AIDS. Then, after a person is infected with HIV, prevention
can focus on providing counselling to the person on how to live his life being a
HIV carrier.
1.6.1.1 General Awareness

A public awareness is the need of the hour to control the spread of this serious
infection and disease which has physical, social, emotional and occupational
implications. The behavioural changes that minimize the risk of developing AIDS
are fairly straight forward, although making the changes is often more easier
said than done ( Coastes and Collins ). The more sexual partners a person has,
the higher the risk that he or she will be exposed to the HIV virus. Thus, people
can reduce their risk by following the practice of safe sex and being careful in
matters of blood transmission, use of syringes etc.
Counselling can aim at the following points to spread the awareness about HIV/
AIDS:
• Determining whether the lifestyle of an individual places him or her at risk
• Behaviour that put people at risk for AIDS /HIV
• Working with an individual so that he or she understands the risks
• Helping to identify the meanings of high risk behaviour
• Information about myths and facts for HIV/AIDS
• How AIDS/HIV is transmitted
• Civic right issues related to HIV/AIDS
• Prevention and treatment for HIV/AIDS
1.6.1.2 Counselling to HIV Affected Persons
Diagnosis of HIV infection brings with it profound social, emotional and medical
consequences. The adjustment to HIV infection involves constant stress
management in family life and work place. The counselor need to be very sensitive
about the feelings of the patients’ and should have empathic and positive attitude
towards AIDS patients. A good rapport must be made which will help in breaking
the diagnostic news of HIV in a positive way. The counselor must discuss and
remove the misunderstandings about HIV transmission.
Victims of HIV usually believe that nothing can be done now. These people have
to be helped by developing a strong self- image, to cope with the hard ship of life
without taking recourse to faulty methods of finding happiness or depression.
Counseling should be given to prevent further deterioration or onset of full blown
AIDS, so as to remain healthy and live longer, by taking good personal care in
terms of food, medicines etc.
People are likely to be distressed when informed that they are HIV positive. The
primary challenges that they face are a changed new life style they have to follow
such as accepting the possibility of shortened life span; coping with stigmas
attached to the illness; reactions of others; coping with the personal relationships,
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Type of Counselling adopting methods to remain emotionally healthy; initiating changes in behaviour
to prevent HIV transmission. Therefore behavioural and psychological services
are an integral part of health care for HIV infected people.
Whenever a person comes for HIV testing, there should be a pre test and post
test counseling.
Patients may present for testing for any number of reasons, ranging from a
generalised anxiety about health to the presence of HIV related physical
symptoms. For patients at minimal risk of HIV infection, pre-test discussion
provides a valuable opportunity for health education and for safer sex messages
to be made relevant to the individual. For patients who are at risk of HIV infection,
pre-test discussion is an essential part of post-test management. These patients
may be particularly appropriate to refer for specialist counseling expertise.
The following are some of the points which the counselor may cover in the pre
test and post test discussion with the person who has come for HIV testing.
Pretest discussion checklist:
• What is the HIV antibody test (including seroconversion)
• The difference between HIV and AIDS
• The window period for HIV testing
• Medical advantages of knowing HIV status and treatment options
• Transmission of HIV
• High risk sexual behaviour
• High risk injecting drug practices
• Safer sex and risk reduction
• Safer injecting drug use
• If the client were positive how would the client cope: personal resources,
support network of friends/partner/family?
• Who to tell about the test and the result
• Partner notification issues
• HIV status of regular partner: is partner aware of patient testing?
• Confidentiality
• Does client need more time to consider?
• Is further counseling indicated?
• How the results of the test are obtained (in person from the counselor)
Post-test counseling
HIV results should be given in a simple and straightforward manner in person.
For HIV negative patients this may be a time where the information about risk
reduction can be “heard” and further reinforced. With some patients it may be
appropriate to consider referral for further work on personal strategies to reduce
risks—for example one to one or group interventions.
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Many reactions to an HIV positive diagnosis are part of the normal and expected HIV/AIDS Counselling
range of responses to news of a chronic, potentially life threatening medical
condition. Many patients adjust extremely well with minimal intervention. Some
will exhibit prolonged periods of distress, hostility, or other behaviours which
are difficult to manage in a clinical setting. It should be noted that serious
psychological maladjustment may indicate pre-existing morbidity and will require
psychological/psychiatric assessment and treatment. Depressed patients should
always be assessed for suicidal ideation.
Effective management requires allowing time for the shock of the news to sink
in; there may be a period of emotional “ventilation”, including overt distress.
The counselor should provide an assurance of strict confidentiality and rehearse,
over time, the solutions to practical problems such as who to tell, what needs to
be said, discussion around safer sex practices and adherence to drug therapies.
Clear information about medical and counseling follow up should be given.
Counseling may be of help for the patient’s partner and other family members.
Coping procedures rehearsed at the pre-test discussion stage will need to be

reviewed in the context of the here and now; what plans does the patient have for
today, who can they be with this evening? Direct questions should be answered
but the focus is on plans for the immediate few days, when further review by the
counselor should then take place. Practical arrangements including medical follow
up should be written down. Overloading the patient with information about HIV
should be avoided at this stage. Sometimes this may happen because of the health
professional’s own anxiety rather than the patient’s needs. Counseling support
should be available to the patient in the weeks and months following the positive
test results.
Coping Strategies give below may be suggested:
• Using counseling
• Problem solving
• Participation in discussions about treatment
• Using social and family networks
• Use of alternative therapies, for example relaxation techniques, massage
• Exploring individual potential for control over manageable issues
• Disclosure of HIV status and using support options
The following are the different psychological responses to a HIV positive
test result.
Shock is seen in terms of diagnosis, recognition of mortality, loss of hope for the
future etc.
Fear and anxiety is a common feature which is seen in terms of uncertain
prognosis, effects of medication and treatment/treatment failure , isolation and
abandonment and social/sexual rejection, infecting others and being infected by
them, partner’s reaction etc.
Depression is seen in adjustment to living with a chronic viral condition, absence
of a cure, limits imposed by possible ill health, possible social, occupational,
and sexual rejection if treatment fails etc.
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Type of Counselling Anger and frustration is expressed over becoming infected, having to adopt
new and involuntary health/lifestyle restrictions, incorporating demanding drug
regimens, and possible side effects.
Guilt is the result of interpreting HIV as a punishment; for example, for being
gay or using drugs, over anxiety caused to partner/family.
Counseling patients and partners together:

Counseling can also be offered to patients and their partner together. This should
only take place with the patient’s explicit consent, but it may be important for
the following reasons:
• Adjustments to sexual behaviour and other lifestyle issues can be discussed
and explained clearly to both.
• If the patient’s partner is HIV negative (i.e. a serodiscordant couple) particular
care and attention must be paid to emotional and sexual consequences in the
relationship.
• Misconceptions about HIV transmission can be addressed and information
on safe sex given.
• The partner’s and the patient’s psychological responses to the diagnoses or
result, such as anxiety or depression, can be explained and placed in a
manageable perspective.
• There may be particular issues for couples who have children or who are
hoping to have children or where the woman is pregnant.
Partners and family members sometimes have greater difficulty in coming to
terms with the knowledge of HIV infection than the patients do themselves.
Individual counseling support is often required to manage this, particularly role
changes within the relationship, and other adjustment issues that may lead to
difficulties. This is part of a holistic approach to the patient’s overall health care.
In many cases the need for follow up counseling may be episodic and this seems
appropriate given the long term nature of HIV infection and the different
challenges a patient may be faced with. The number of counseling sessions
required during any of these periods largely depends on the individual presentation
of the patient and the clinical judgment of the counselor.
1.6.2 Counselling the AIDS Patients and Family

AIDS is the final stage of HIV infection process, typically manifested about 7-
10 years after the original infection (Carey & Vanable, 2003). With onset of
AIDS, one is left virtually defenseless against a host of opportunistic infectious
agents. The stages of AIDS/HIV and its treatment are divided into three parts
where the counselor should be very vigilant.
The first stage is known as asymptomatic stage, second is known as symptomatic

stage and third is known as end of life stage.
1) Asymptomatic stage: At this stage the counselor must remember to treat
the patient on food and nutrition, support, treatment with antiretroviral drugs
prevention of onward transmission.
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2) Symptomatic stage: At this stage the counselor must remember to help the HIV/AIDS Counselling
patient on management of nutritional effects; treatment of HIV related
infections, medical care and psychological support.
3) End of the life stage: In this stage, the counselor’s role is very important
because the counselor not only helps the patient but the family also. As the
patient and family is under depression and grief. The counselor should make
the patient emotionally strong for the truth (death) and prepare him for death
by which, he/she not only enables the family to accept the fact of life but
also help the patient to live the remaining life to the fullest.
AIDS cannot be cured. The only way out is the prevention. Various treatments
are given to the AIDS patient to fight with the infections. The antiretroviral
treatment has been found to be useful. However, patient adherence is an important
factor in the efficacy of drug regimens. The presence of side effects can often
make patients feel more unwell and some may be unable to cope with the side
effects. Counseling may be an important tool in determining a realistic assessment
of individual adherence and in supporting the complex adjustment to a daily
routine of medication.
It is very crucial to provide support to those affected directly and indirectly by

HIV. Hence, individual, relationship, family counseling and support groups are
of great help to enable the patient and his/her family to adjust and cope up with
the various aspects and issues of life.

1) How will you provide counselling to a HIV affected person?
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2) Explain the different psychological responses to a HIV positive test
result.
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3) Discuss the importance of counselling patients and partners together.
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1.7 LET US SUM UP
In this unit you learned about the HIV/AIDS and understood the serious threat it
poses to our society. However, if we can spread the awareness, it can be prevented
well. Counsellors need to play an important role in creating awareness through
writing, role plays, film, talks, lectures, campaign i.e. educative programs about
AIDS/HIV. You learned the different ways of transmission of HIV and the signs
and symptoms of HIV/AIDS. The various myths prevalent on HIV were described.
Finally the need and importance of HIV/AIDS counselling is discussed. This is
crucial in terms of making the patient as well as the family members cope up
with life changing disease. Even with the significant medical advances in patient
management, counseling remains an integral part of the management of patients
with HIV, and their partners and family.
“HIV testing and counseling services are a gateway to HIV prevention, care
and treatment”.

1) Describe the different modes of transmission of HIV.
2) What are the different signs and symptoms of HIV/AIDS?
3) Explain the myths and facts related to HIV/AIDS.
4) Discuss the role of counselling in the prevention of HIV/AIDS.
5) Discuss the various ways in which an awareness programme can be
developed.

Counselling and HIV/AIDS: UNAIDS Technical Update (UNAIDS Best Practice
Collection: Technical Update). Geneva: UNAIDS, November, 1997.
NACO Facts and figures: HIV estimates – 2003. Available at:

www.nacoonline.org/facts_hivestimates.htm
NACO Monthly updates on AIDS (31st July, 2005). Available at: http://
www.nacoonline.org/facts_reportjuly.htm
India-Canada Collaborative HIV/AIDS Project (ICHAP): ‘Community-based

HIV prevalence study in ICHAP demonstration project area, key findings’,
Bangalore: ICHAP, 2004.
Tamil Nadu State AIDS Control Society: Activities of TANSACS. Chennai:

TANSACS, 2005.
20
UNIT 2 EDUCATIONAL AND VOCATIONAL
COUNSELLING
Structure
2.0 Introduction
2.1 Objectives
2.2 Meaning of Educational and Vocational Counselling
2.2.1 Educational, Vocational and School Counselors
2.3 Need for Educational and Vocational Counselling
2.4 Scope of Educational and Vocational Counselling
2.5 Educational Counselling
2.6 Vocational Counselling
2.7 Let Us Sum Up
2.0 INTRODUCTION
Most people have dreams about what they would like to be when they grow up.
Sometimes these dreams or images start at a very early age. Or, as it often happens,
a person may finish high school and still not really know what they want for a career.
Everyone is different. We all are special and unique. You have your own skills
and abilities, strengths and weaknesses, likes and dislikes – about what you want
to do with your life. This is reflected in the choices you make, decisions you take
and plans you make for your life with regard to the educational and vocational
aspects. However, sometimes you may not be very clear about what you want in
your life. You may not even be aware of your strengths and limitations, interests
and abilities. In the absence of these, you may make a wrong decision or
inappropriate educational and vocational choice.
Working toward a career involves a process. It is like taking a journey to a certain

destination. You just don’t arrive at a destination automatically. It takes planning
and time before you get there. There can be many stops or the plan may change
along the way. It takes planning, time, and effort to make proper educational and
vocational planning. Counselling plays a crucial role to help you make appropriate
educational choices keeping in mind your abilities and interests and arrive at a
suitable career choice. Hence it is important to understand the concept, meaning
and nature of educational and vocational counseling.
2.1 OBJECTIVES
• Understand the meaning of educational and vocational counseling;
• Explain the need for educational and vocational counseling; and
• Identify the goals of educational and vocational counseling. 21
Type of Counselling
2.2 MEANING OF EDUCATIONAL AND
VOCATIONAL COUNSELING
Counselors work in diverse community settings designed to provide a variety of
counseling, rehabilitation, and support services. Their duties vary greatly,
depending on their specialty, which is determined by the setting in which they
work and the population they serve. Although the specific setting may have an
implied scope of practice, counselors frequently are challenged with children,
adolescents, adults, or families that have multiple issues, such as mental health
disorders and addiction, disability and employment needs, school problems or
career counseling needs, and trauma. Counselors must recognise these issues in
order to provide their clients with appropriate counseling and support.
School counselors help students evaluate their abilities, interests, talents, and
personalities to develop realistic academic and career goals. Counselors use
interviews, counseling sessions, interest and aptitude assessment tests, and other
methods to evaluate and counsel students. They also operate career information
centers and career education programs. Often, counselors work with students
who have academic and social development problems or other special needs.
Educational counseling helps the individual with problems related to education.

It is basically concerned with helping the students in choosing/selecting
appropriate courses of study. The counselor takes into account the aptitude,
interest, abilities and specific background of the student to provide educational
counseling.
Vocational counseling aims at helping the person select a proper vocation and
prepare for it. Deciding on a career/vocation is crucial as it involves lots of time,
effort and money. Entering into a career which turns out to be inappropriate for
the person will lead to job dissatisfaction, unhappiness and maladjustment in
work life. All these will affect negatively the personal life of the individual.
Hence deciding on a vocation is very important task. Vocational counseling
facilitates this decision by providing appropriate counseling to the individual.
Placement counseling is an important part of vocational counseling. The counselor
makes the individual aware about his abilities, aptitude, attitude and interests;
and helps him in a proper placement suitable to his abilities and from which he
derives job satisfaction.
Thus the goals of educational and vocational counseling can be described as

follows:
• Explore, analyse and develop the factors constituting their self-concept
(interests, personal qualities and characteristics, values, skills etc.).
• Explore, evaluate, process and classify information and alternative education
and vocation pathways with respect both to their needs and choices and to
labour market requirements.
• Integrate information about education and vocation/career with information
derived from self-observation so that they develop to decision-making
capabilities both with respect to their orientation in education and choices in
occupation(s) befitting their particular psychosocial make up.
• Create and implement own education and vocation plans.
22
Ultimately, the individuals will be able to make the correct choices with respect Educational and Vocational
Counselling
to their future occupation/vocation through educational and vocational
counseling.
2.2.1 Educational, Vocational and School Counselors

Educational and vocational counseling is provided by the school counselors,
educational counselors, vocational counselors and career counselors. They provide
individuals and groups with career, personal, social and educational counseling.
The counselor needs to take into account the personal social aspect of the
individual in order to provide educational and vocational counseling.
A school counselor is a counselor and an educator who works in elementary,

middle, and high schools to provide academic, career, college access, and personal/
social competencies to K-12 students. The interventions used include
developmental school counseling, curriculum lessons and annual planning for
every student, and group and individual counseling. School counselors assist
students of all levels, from elementary school to postsecondary education. They
advocate for students and work with other individuals and organisations to
promote the academic, career, personal, and social development of children and
youth.
Elementary School Counselors provide individual, small-group and classroom

guidance services to students. Counselors observe children during classroom
and play activities and confer with their teachers and parents to evaluate the
children’s strengths, problems, or special needs. In conjunction with teachers
and administrators, they make sure that the curriculum addresses both the
academic and the developmental needs of students. Elementary school counselors
do less vocational and academic counseling than high school counselors do.
High School Counselors counsel students regarding subjects/courses to choose

at the senior secondary/college level, admission requirements, entrance exams,
financial aid, training/technical schools, and apprenticeship programs. They help
students develop job search skills, such as resume writing and interviewing
techniques. College career planning and placement counselors assist students/
alumni with career development and job-searching techniques.
School counselors at all levels help students to understand and deal with social,
behavioural, and personal problems. These counselors emphasise preventive and
developmental counseling to enhance students’ personal, social, and academic
growth and to provide students with the life skills needed to deal with problems
before they worsen. Counselors provide special services, including alcohol and
drug prevention programs and conflict resolution classes. They also try to identify
cases of domestic abuse and other family problems that can affect a student’s
personal development and thereby affecting his career development.
Counselors interact with students individually, in small groups, or as an entire

class. They consult and collaborate with parents, teachers, school administrators,
school psychologists, medical professionals, and social workers to develop and
implement strategies to help students succeed.
Vocational Counselors also called employment counselors or career counselors,

usually provide career counseling outside the school setting. Their chief focus is
23
Type of Counselling helping individuals with career decisions. Vocational counselors explore and
evaluate the client’s education, training, work history, interests, skills, and
personality traits. They may arrange for aptitude and achievement tests to help
the client make career decisions. They also work with individuals to develop
their job-search skills and assist clients in locating and applying for jobs. In
addition, career counselors provide support to people experiencing job loss, job
stress, or other career transition issues.
Rehabilitation Counselors also provide vocational counseling to persons with

disabilities.
They help people deal with the personal, social, and vocational effects of
disabilities. They counsel people with both physical and emotional disabilities
resulting from birth defects, illness or disease, accidents, or other causes. They
evaluate the strengths and limitations of individuals, provide personal, educational
and vocational counseling, offer case management support, and arrange for
medical care, vocational training, and job placement. Rehabilitation counselors
interview both individuals with disabilities and their families, evaluate school
and medical reports, and confer with physicians, psychologists, employers, and
physical, occupational, and speech therapists to determine the capabilities and
skills of the individual. They develop individual rehabilitation programs by
conferring with the client. These programs often include training to help
individuals develop job skills, become employed, and provide opportunities for
community integration. Rehabilitation counselors are trained to recognise and
to help lessen environmental and attitudinal barriers. Such help may include
providing education, and advocacy services to individuals, families, employers,
and others in the community. Rehabilitation counselors work toward increasing
the person’s capacity to live independently by facilitating and coordinating with
other service providers.
2.3 NEED FOR EDUCATIONAL AND

VOCATIONAL COUNSELING
The modern day has thrown numerous challenges. In this era of internet and
global competition, going for relevant and suitable educational and vocational
options has become a crucial decision. There are a plethora of choices available
in the vocational market. In addition there is the pressure and expectation from
the parents as well as the peer group. The society also has an influence on the
types of courses and vocations chosen. In the process the individual – his abilities,
interests, aptitude and values – are lost sight of. In this scenario counseling and
consultancy services have become the need of the hour.
With many options in the field of education there has always been felt a need to
have a professional guidance which could provide the right direction to a student.
The issues relating to career opportunity are one of the most important concerns
of a young mind. Education in India in earlier times in the decades of 60s, 70s
and 80s used to be mostly detached from career and job opportunities. There
was also lack of organised guidance except possibly from parents and senior
family members. Therefore, we see a large number of cases where type of job
and basic qualification a person possesses are totally divorced. This sometimes
has raised serious concern about the utility of education. However, during last
decade things have started changing dramatically. Today’s youth are
24
more focused, knowledgeable, inquisitive, and ambitious. One of the strengths Educational and Vocational
Counselling
of India as a country is existence of a huge working force whose median age is
in 20s. This very demographic profile has created a significant opportunity as
well as concern for all. This is significant as this strong and huge workforce can
change the destiny of the country. But at the same time the large manpower can
itself lead to disastrous consequence if not channelised properly. It may lead to
rising unemployment rate, waste of precious human resource, increase in crimes
and antisocial activities, depression and other mental health problems. We have
the world’s largest population with one of the highest number of young people
but majority of them are without right skills needed for modern jobs. The people
living in rural places also have inadequate resources, knowledge and skills
rendering them not fit for the growing challenges of the job market.
Hence there is a great need to equip the vast majority of our young people
with right vocational skills. Developing the right work attitude and work values,
providing training in right skills, promoting entrepreneurial spirit in huge urban
and rural young population who come out of the schools / colleges (10th &
12th standard) is a major challenge. It is in this context that the concept
of educational and vocational counseling is increasingly assuming more
importance. Educational and vocational counseling in an organised manner is
relatively a new phenomenon in India. One requires huge exposure to the world
as a whole to be an effective counselor. Besides being a person with substantial
understanding on a global scale of the economy, educational fields, emerging
areas of opportunity, and a good psychologist, a good counselor is one who has
execution ability of:
a) Aligning a student’s career goals and objectives with available economic
opportunities not only in India but on a global basis,
b) Assessing basic competencies / skill sets of a student and aligning them
with job functions and / or higher education in the right field,
c) Suggesting the most important field of study or career suitable for a candidate
considering all facts of the case.
There is nothing right or wrong in an absolute context in the parlance of
counseling. Counseling is nothing but an expert opinion given to a particular
student in response to his / her query on a specific question (career or education
related). The student needs to consider the option carefully, weigh pros and
cons, discuss with family members and then take final decision. If necessary, the
student should approach counselor with another round of queries.
2.4 SCOPE OF EDUCATIONAL AND VOCATIONAL

COUNSELLING
Counseling refers to a specialised assistance provided to the students in the area
of educational and vocational counseling. It is a continuous and comprehensive
process of helping students to become more efficient, adjusted and realise their
true potential. In this process the educational and vocational counseling largely
derives from personal counseling also. The counselor provides assistance in a
variety of fields like employment, education, scholarships and other financial
assistance, social life and personal adjustment. The students are helped to choose
courses/training programmes, develop efficient study skills and get necessary
25
Type of Counselling remedial assistance in educational related matters. The counselor also helps the
students in pre-employment activities, job placement services and successful
adjustment to the work situation and work colleagues in the field of vocational
counseling.
Broadly educational and vocational counseling activities target individuals who

are:
• about to make a choice with respect to their education and vocation,
• in search of new fields of study/training,
• already employed but dissatisfied with their current occupation, hence in
search of new areas of training and professional development,
• unemployed or have lost their jobs for whatever reason and wish to resume
employment, and
• the marginalised sections of the society and need proper educational and
vocational counseling to realise their potential and establish themselves in
the society.

1) What do you mean by educational counseling?
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2) Describe the meaning of vocational counseling
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3) Who is a vocational counselor?
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26
Educational and Vocational
4) Why will a student need educational counseling? Counselling
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5) Describe the scope of educational and vocational counseling.
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2.5 EDUCATIONAL COUNSELING

Education is not only about teaching, but also about learning. Education is
“Learning to Know, Learning to Do, Learning to be and Learning to Live
Together.” It should aim at expanding the mental horizons and broaden the outlook
of the students through training in cooperation, consideration, team spirit and
service. Education should help channelise the youthful energies towards creativity
and self actualisation. Counseling plays a very significant role in fulfilling these
goals of education. Education counseling aims at making learning a joyful
experience for the children. It helps them understand their abilities and personality
dispositions so that they can perform at their best in the school.
Education has become an indispensable part of modern day life in view of the
rising competitive market and the complexities of the present day world. In the
present scenario, education only can ensure a bright future for our children.
However, education itself has become so much complex and demanding that
counseling has become a necessity in order to successfully adjust to the
requirements of the educational setting, realise one’s goals and aspirations and
achieve them.
Educational counselors make use of the psychological principles of learning,

remembering, motivation and emotion to understand and explain different
problems faced by the students with regard to learning, remembering, adjusting
to the teaching-learning situation and the curriculum load. As Rao (1991) points
out, education, viewed in the context of its counseling function, is concerned
with the kind of activities, which if implemented, would best accomplish the
educational goal of harmonious individual growth. The purpose of education is
to make the person competent. Educational counseling by helping the students
how to learn and developing an understanding of themselves enables them to
adjust with the academic pressure and promotes the academic development of
the students.
27
Type of Counselling Educational counseling can broadly comprise of the following three sub-areas
(Rao, 1991).
a) appraisal of the strengths and weaknesses of the student through
administering objective tests, talking to the teachers; and then discussing
these with the student in the light of his choices, interests and aspirations.
This helps provide a proper choice of courses and co-curricular activities
leading to successful adjustment to the educational setting.
b) identifying the strengths and weaknesses of the study skills and providing
the necessary remedial services. Study skills and practices followed by the
students is crucial to their scholastic achievement. Many students fail because
of their faulty or inappropriate study skills. Improvement of these will benefit
the students tremendously in their academic success.
c) resolving personal problems and improving inter-personal relations, leading
to better mental health and thereby helping the student to achieve academic
success. The relationship of the student with the teachers and the peer group
is vital as it affects the mental health of the student. If the student is anxious,
worried, feels inferior, withdrawn, harassed and prejudiced against, then it
adversely affects his scholastic progress. Hence the educational counselor
needs to take care of these issues while addressing the educational concerns
of the student.
The objectives/goals of educational counseling at the elementary stage (std. I to
VIII), secondary (Std. IX & X) and senior secondary stage (Std. XI &XII) are
mentioned described as follows.
i) Elementary Stage
Counseling elementary school children is critical in the sense that this sets the
stage for a positive or negative attitude of the child towards the school and
academic activities. The goal of counseling at this stage is to make the transition
from home to school a smooth experience for the child and learning a joyful
exercise for the child. The major goal of counseling
Here is to help the child in making proper adjustment to the school situation.
Counseling elementary school children involves helping them with their learning
problems, and providing them with an engaging and enjoyable learning experience
at the school. It also involves helping them to adjust with the teacher and peers.
The following can be mentioned as the aims of counseling at the elementary
stage.
• adjustment of students to the school
• improvement of teacher-student relationship
• acquisition of effective study habits and practices
• developing student potential
• inculcating basic academic skills
• improving test taking skills
ii) Secondary Stage
This stage marks a transition from childhood to adolescence. With the onset of
adolescence, there comes the accompanied physical and physiological changes,
28
leading to an identity crisis. There is a need for greater independence from the Educational and Vocational
Counselling
parents and at the same time dependence on the peer group. The adolescents
have their individualistic ideas,interests and emotions, and they desire recognition
and acceptance and encouragement of these.During this stage, students face
many academic and social pressures which creates stress in them. In this context,
the goals of counseling lies in expressing warmth, understanding and friendliness
towards the adolescents and the counselor tries to help the adolescent gain insight
into his problems, and develop appropriate attitudes, interests and goals.
Mentioned below are a few of the goals of counseling at the secondary stage.
• Development of proper academic skills
• Assisting in academic achievement
• Improving test taking skills
• Developing critical thinking skills
• Improve the decision making capacity of students
iii) Senior Secondary Stage
Students at the senior secondary stage are in their late adolescence stage/phase.
They are progressing towards adulthood, but are not yet adults. They are in a
crucial stage of life where it is high time for them to think consciously about
their further educational pland and vocational avenues. They need to take concrete
steps to decide and pursue their educational and vocational plans.
The goals of counseling at this stage are as follows:
• helping the student to obtain, organise and apply academic information from
a variety of sources
• develop positive interest in learning through involvement in active and
practical learning
• helping the student to make further educational planning taking into account
his abilities, aptitude, interests and attitudes.
• Helping to develop critical thinking and decision making skills
• Assisting student to make successful school-to-work or school-to-higher
studies transition.
2.6 VOCATIONAL COUNSELING

The choice of a vocation is one of the crucial decisions in one’s life. It determines
the type of people one would work with, the nature of the environment in which
one would work and the type of work one is going to do. All these should
commensurate with the type of person one is, i.e., the abilities, interests,
aspirations, attitudes and the values one has and the particular situation and family
environment one has. Hence a career should be chosen with utmost care, thought
and planning. However, it is often found that this crucial decision is taken very
lightly and not enough consideration and planning is given to it. Since it has a
significant repercussion on the future life affecting one’s own and his family’s
happiness, vocational counseling is the need of the hour. Vocational counseling
should be an integral part of the total educational process.
29
Type of Counselling There are a number of theories of vocational development which explains how
does vocational choices and preferences develop in an individual. For example,
Ginzberg suggests three stages: fantasy, tentative and the realistic stages in
vocational choice. First, the individual makes choice at the fantasy level that is
he wishes to be an artist or space scientist without taking into account the reality.
At the tentative stage the person thinks about certain vocations on a tentative
basis, but at the realistic stage he takes a decision based on his real abilities,
aptitude, interest etc. A vocational counselor should know about the different
theories of vocational development in order to provide better and comprehensive
counseling to the individual.
Vocational guidance and counseling is a process of assisting the individual to

choose an occupation, prepare for it enter in it and progress in it. It is primarily
concerned with assisting the individual in acquiring an increased maturity for
making vocational choices, helping the individual make decisions involved in
planning a future and building a career. The problem is not solved once for all
when an individual makes a choice. Counseling is required further also in terms
of helping the person to adjust in the work place and deriving job satisfaction.
So the process of vocational guidance is a life long process. It is a continuous
process of effecting satisfactory vocational adjustment.
In the early days of vocational counseling, the counselor’s function was chiefly
that of supplying information on training programs, or providing guidance leading
to specific employment. More recently the recognition that psychological and
social factors affect the choice of a vocation as well as the adjustment to it, and
that personal and emotional problems often interfere with vocational planning,
made it mandatory that the counselor be concerned with personality development,
the counselor also must learn to understand and evaluate the student’s
psychological adjustment level. Out of these new concepts, a different role for
the vocational counselor emerged.
Vocational counseling today has become a process in which the experienced and
trained person assists an individual:
1) to understand himself and his opportunities,
2) to make appropriate adjustments and decisions in light of his understanding,
3) to accept the responsibility for his choice,
4) to follow a course of action in harmony with his choice.
Some other goals of vocational counseling can be listed as follows:
• Helping student in reaching optimal development: A student at secondary
level has interest in reading about and in investigating various occupations.
School can do a lot to develop this interest e.g. a boy shows interest in
mechanics. Simple machine may be given to him, which he may open, and
put the parts together. He may be interested in getting knowledge of the
underlying principals used in the machine .Information about the mechanical
processes may be passed on to him by taking him to the factory and work
shops. Interests, which have a vocational values, should thus be encouraged
in all possible ways.
• Helping student learn effective decision-making skills: One can be
30 expected to learn decision-making skills only when one has complete
information about his own capacities and weaknesses and also the information Educational and Vocational
Counselling
of vocational field of his choice. Skill in making a decision comes through
following certain steps. He should learn to withhold a decision until he has
examined all aspects of situation, that is, he must consider his own abilities
and the world of work around him. He must arrive at a complete knowledge
of the occupational fields of his choice through his own efforts. He should
be able to reject all advice and information offered to him by his superiors
and come to his own decision. The counselor’s responsibility is to enable
the student in this decision making.
• Helping student in selecting maturely and objectively a vocation: Once

the student is able to decide independently what occupation he/she should
follow, they can benefit from the assistance given to them for selecting the
best vocation. The counselor helps the student in choosing the career/vocation
according to the interest, qualification etc.
Vocational counseling is often mistaken with vocational guidance. The latter is

concerned largely with providing occupational or career information to the
students. It consists of collection, classification, filing and dissemination of
occupational information by use of several media of communication such as
bulletin board, career corner, career pamphlets, films, documentaries, individual
and group discussions. Vocational counseling is closely related to these functions.
However, vocational counseling is basically more concerned with the vocational
development of an individual. The main focus in vocational counseling is the
student or the client. It is concerned with the discovery of his potentialities,
interests and attitudes such that he is helped to actualise himself in the pursuit of
his vocation. Vocational counseling uses several techniques of client appraisal
and assessment and assists the individual in his self actualisation.

1) Describe the three sub-areas of educational counseling.
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2) Discuss the importance of educational counseling at the elementary
stage.
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31
Type of Counselling
3) Differentiate between vocational counseling and vocational guidance.
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2.7 LET US SUM UP

In this unit you learned about two important types of counseling, that is,
educational counseling and vocational counseling. Although these two can be
treated as separate types of counseling, both are interdependent and overlap.
Educational considerations have implications for vocational development and
vocational counseling derives largely from the attitudes, values and interests
acquired through the educational process. The meaning and scope of educational
and vocational counseling were described. The present unit developed an
understanding in you about the importance of educational and vocational
counseling in the challenging and competitive environment prevalent in the
current education arena and career field.

1) Discuss the goals of educational and vocational counseling.
2) Discuss the importance of educational counseling in the present day school context.
3) Describe the roles and functions of a school counselor.
4) Explain the need for educational and vocational counseling.

Aggarwal, J. C. (1991). Educational, Vocational Guidance and Counseling. New
Delhi: Doabai House.
Bhatnagar, R. P., & Seema, R. (2003). Guidance and Counselling in Education
and Psychology. Meerut: R.Lal Book Depot.
Indu, D. (1983). The Basic Essentials of Counseling. New Delhi: Sterling
Publishers Private Ltd.
Kochhar, S. K. (1984). Guidance and Counseling in Colleges and Universities.
New Delhi: Sterling Publishing Pvt.Ltd.
Madhusudan, M. (1983). Educational and Vocational Guidance. Sambalpur:
Saha Publishers & Distributors.
Narayan S. Rao (1991). Counseling and Guidance. New Delhi:Tata McGraw-
Hill.
Sharma, N. R. (1989). Educational and Vocational Guidance. Agra: Vinod Pustak
Mandir.
Sharma, R. N. (2008). Vocational Guidance and Counseling. Delhi: Surjeet
32 Publications.
Educational and Vocational
UNIT 3 CHILD PROTECTION AND CHILD Counselling
RIGHTS COUNSELLING
Structure
3.0 Introduction
3.1 Objectives
3.2 Child Rights in India
3.3 Who is a Child?
3.4 What are Children’s Rights?
3.4.1 Right to Survival
3.4.2 Right to Protection
3.4.3 Right to Participation
3.4.4 Right to Development
3.5 What is Child Protection?
3.5.1 Difference between Child Rights and Child Protection
3.6 Child Rights Counseling
3.6.1 Vulnerable Child
3.6.1.1 Child Abuse
3.6.1.2 Street Children
3.6.1.3 Disability in Children
3.6.1.4 Drug Abuse
3.7 Let Us Sum Up
3.0 INTRODUCTION
India has made tremendous progress with regard to different aspects of
development. It has taken large strides in addressing issues like child education,
health and development. However, child protection has remained largely
unaddressed.
India is home to almost 19 percent of the world’s children. More than one third
of the country’s population, around 440 million, is below 18 years. According to
one assumption 40 percent of these children are in need of care and protection,
which indicates the extent of the problem. In a country like India with its
multicultural, multi-ethnic and multi-religious population, the problems of
socially marginalised and economically backward groups are immense. Within
such groups the most vulnerable section is always the children. (Study on Child
Abuse: India 2007 by Ministry of Women and Child Development, Government
of India, 2007). In this context protection of the child and ensuring the rights of
the children will not only protect the child, but also provide him/her opportunities
to achieve all round growth and development.
Traditionally in India, the responsibility of care and protection of children has

been with families and communities. However, this very same situation also has
made the children vulnerable to many kinds of neglect, abuse and exploitation; 33
Type of Counselling in the process violating the child’s rights. Our society is yet to become fully
aware and understand the rights of the children. When we talk about the various
rights of the children, then the gaps in child protection become obvious.
Let us see the following statistics reported by the Ministry of Women and Child
Development, India.
2.5 million Children die in India every year, accounting for one in five deaths in
the world, with girls being 50% more likely to die. One out of 16 children die
before they attain one year of age, and one out of 11 die before they attain five
years of age. India accounts for 35% of the developing world’s low birth weight
babies and 40% of child malnutrition in developing countries, one of the highest
levels in the world. Although India’s neo-natal mortality rate declined in the
1990s from 69 per 1000 live births in 1980 to 53 per 1000 live births in 1990, it
remained static, dropping only four points from 48 to 44 per 1000 live births
between 1995 and 2000.
The 2001 Census data and other studies illustrate the terrible impact of sex
selection in India over the last few decades. The child sex ratio (0-6 years) declined
from 945 girls to 1000 boys in 1991 to 927 in the 2001 Census. Around 80% of
the total 577 districts in the country registered a decline in the child sex ratio
between 1991 and 2001. About 35% of the districts registered child sex ratios
below the national average of 927 females per 1000 males. In the 1991 Census,
there was only one district with a sex ratio below 850, but in the 2001 Census,
there were 49 such districts.
India has the second highest national total of persons living with HIV/AIDS
after the Republic of South Africa. According to National Aids Control
Organization (NACO), there were an estimated 0.55 lakh HIV infected 0-14
year old children in India in 2003. UNAIDS, however, puts this figure at 0.16
million children.
According to the 2001 Census report, amongst all persons living with disabilities,
35.9% were children and young adults in the 0-19 age group. Three out of five
children in the age group of 0-9 years have been reported to be visually impaired.
Movement disability has the highest proportion (33.2%) in the age group of 10-
19 years. This is largely true of mental disability also.
Source: Ministry of Women and Child Development (2007): Working Group
Report on Women and Children for the Eleventh Five Year Plan (2007-2012)
This shows the extent to which our children face neglect, discrimination and
exploitation in our society. This also reflects our lack of knowledge and
understanding of the rights of our children. Violations of the child’s right to
protection take place in every country and are massive, under-recognized and
under-reported barriers to child survival and development, in addition to being
human rights violations. Adopting rights based approach with regard to children
at various administrative and policy levels will help generate awareness and
observation of these rights for the benefit of our children.
3.1 OBJECTIVES
• Know the status of child rights in India;
34
• Define a ‘child’; Child Protection and Child
Rights Counselling
• Describe the different rights of the children;
• Understand the concept of child protection;
• Differentiate between child rights and child protection;
• Understand violation of child rights in its various forms; and
• Describe the importance of providing counseling to children whose rights
are violated.
3.2 CHILD RIGHTS IN INDIA

India is a party to the UN declaration on the Rights of the Child 1959. Accordingly,
it adopted a National Policy on Children in 1974. The policy reaffirmed the
constitutional provisions for adequate services to children, both before and after
birth and through the period of growth to ensure their full physical, mental and
social development. It has also developed appropriate monitoring procedures to
assess progress in implementing the Convention, involving various stake holders
in the society.
In order to ensure child rights practices and in response to India’s commitment

to UN declaration to this effect, the government of India set up a National
Commission for Protection of Child Rights (NCPCR). The Commission is a
statutory body notified under an Act of the Parliament on December 29, 2006.
Besides the chairperson, it will have six members from the fields of child health,
education, childcare and development, juvenile justice, children with disabilities,
elimination of child labour, child psychology or sociology and laws relating to
children.
The National Commission for Protection of Child Rights emphasises the principle
of universality and inviolability of child rights and recognizes the tone of urgency
in all the child related policies of the country. For the Commission, protection of
all children in the 0 to 18 years age group is of equal importance. Policies define
priority actions for the most vulnerable children. This includes focus on regions
that are backward or on communities or children under certain circumstances.
The NCPCR believes that while addressing only some children, there could be a
fallacy of exclusion of many vulnerable children who may not fall under the
defined or targeted categories. In its translation into practice, the task of reaching
out to all children gets compromised and a societal tolerance of violation of
child rights continues. Therefore, it considers that it is only in building a larger
atmosphere in favour of protection of children’s rights, that children who are
targeted become visible and gain confidence to access their entitlements.
India is also a signatory to the World Declaration on the Survival, Protection and
Development of Children. In pursuance of the commitment made at the World
Summit, the Department of Women and Child Development under the Ministry
of Human Resources Development has formulated a National Plan of Action for
Children. Most of the recommendations of the World Summit Action Plan are
reflected in India’s National Plan of Action-keeping in mind the needs, rights
and aspirations of 300 million children in the country. The priority areas in the
Plan are health, nutrition, education, water, sanitation and environment. The Plan
gives special consideration to children in difficult circumstances and aims at
35
Type of Counselling providing a framework, for actualisation of the objectives of the Convention in
the Indian context.
3.3 WHO IS A ‘CHILD’?

According to international law, a child means every human being below the age
of 18 years. This is a universally accepted definition of a child and comes from
the United Nations Convention on the Rights of the Child (UNCRC), an
international legal instrument accepted and ratified by most of the countries.
India has always recognised the category of persons below the age of 18 years as
distinct legal entity. That is precisely why people can vote or get a driving license
or enter into legal contracts only when they attain the age of 18 years. Marriage
of a girl below the age of 18 years and a boy below 21 years is restrained under
the Child Marriage Restraint Act, 1929. Moreover, after ratifying the UNCRC in
1992, India changed its law on juvenile justice to ensure that every person below
the age of 18 years, who is in need of care and protection, is entitled to receive it
from the State.
According to psychologists, a child is a person, not a sub person, and the parents
have right and responsibility to take care of them. As a child (minor), by law,
children do not have autonomy or the right to make decisions on their own for
themselves in any known jurisdiction of the world. Instead their adult caregivers,
including their parents, teachers and others, are vested with that authority,
depending on the circumstances. Some believe that this state of affairs gives
children insufficient control over their own lives and causes them to be vulnerable.
What makes a person a ‘child’ is the person’s ‘age.’ Even if a person under the
age of 18 years is married and has children of her/his own, she/he is recognized
as a child according to international standards.
3.4 WHAT ARE CHILDREN’S RIGHTS?

Children’s rights are the rights of special protection and care afforded to the
young including their right to association with both of biological parents, their
identity as well as the basic needs for food, universal state-paid education and
health care. Interpretations of children’s rights range from allowing children the
capacity for autonomous action to the enforcement of children being physically,
mentally and emotionally free from abuse.
A right is as an agreement or contract established between the persons who hold

a right (often referred to as the “rights-holders”) and the persons or institutions
which then have obligations and responsibilities in relation to the realisation of
that right (often referred to as the “duty-bearers”.) Child rights are specialised
human rights that apply to all human beings below the age of 18.
According to the United Nations Convention on Rights of Child (UNCRC),

Child Rights are minimum entitlements and freedoms that should be afforded to
all persons below the age of 18 regardless of race, color, gender, language, religion,
opinions, origins, wealth, birth status or ability and therefore apply to all people
everywhere. The purpose of the UNCRC is to outline the basic human rights that
should be accorded to children. The following four broad categories of rights
cover all civil, political, social, economic and cultural rights of every child.
36
3.4.1 Right to Survival Child Protection and Child
Rights Counselling
A child’s right to survival begins before a child is born. According to Government
of India, a child’s life begins after twenty weeks of conception. Hence the right
to survival is inclusive of the child’s right to be born, right to nutrition, health &
care, shelter and clothing and the right to live with dignity.
3.4.2 Right to Protection

This includes right to protection from abuse, exploitation and neglect. A child
has the right to be protected from neglect, exploitation and abuse at home and
outside the home. Every child has a right to lead a well protected and secure life
away from neglect.
3.4.3 Right to Participation

A child has the right to participate in any decision-making that involves him/her
directly or indirectly. There are varying degrees of participation as per the age
and maturity of the child. Right to participation also includes right to expression,
right to information and right to Name and Nationality.
Every child has a right to know his basic rights and his position in the society.
High incidence of illiteracy and ignorance among the deprived and
underprivileged children, however, prevents them from having access to
information about them and their society. Every child also has a right to identify
himself with the nation, but a vast majority of underprivileged children in India
are treated like commodities and exported to other countries as labor or prostitutes.
3.4.4 Right to Development

Children have the right to all forms of development - Emotional, Mental and
Physical. Emotional development is fulfilled by proper care and love of a support
system, mental development through education and learning and physical
development through recreation, play and nutrition. Thus right to education and
right to recreation are two important rights of children.
The Constitution of India guarantees all children certain rights, which have been
specially included for them. These include:
• Right to free and compulsory elementary education for all children in the 6-
14 year age group (Article 21 A).
• Right to be protected from any hazardous employment till the age of 14

years (Article 24)
• Right to be protected from being abused and forced by economic necessity

to enter occupations unsuited to their age or strength (Article 39(e)).
• Right to equal opportunities and facilities to develop in a healthy manner

and in conditions of freedom and dignity and guaranteed protection of
childhood and youth against exploitation and against moral and material
abandonment (Article 39 (f)).
Besides these they also have the following rights as equal citizens of India, just
as any other adult male or female:
37
Type of Counselling • Right to equality (Article 14).
• Right against discrimination (Article 15).
• Right to personal liberty and due process of law (Article 21).
• Right to being protected from being trafficked and forced into bonded labour
(Article 23).
• Right of weaker sections of the people to be protected from social injustice
and all forms of exploitation (Article 46).
3.5 WHAT IS CHILD PROTECTION?

UNICEF considers child protection as the prevention of or responding to the
incidence of abuse, exploitation, violence and neglect of children. This includes
commercial sexual exploitation, trafficking, child labour and harmful traditional
practices, such as female genital mutilation/cutting and child marriage. Protection
also allows children to have access to their other rights of survival, development,
growth and participation. UNICEF maintains that when child protection fails or
is absent, children have a higher risk of death, poor physical and mental health,
HIV/AIDS infection, educational problems, displacement, homelessness,
vagrancy and poor parenting skills later in life.
According to the Integrated Child Protection Scheme (ICPS), protection is about

keeping children safe from a risk or perceived risk to their lives or childhood. It
is about recognising that children are vulnerable and hence reducing their
vulnerability by protecting them from harm and harmful situations. Child
protection is about ensuring that children have a security net to depend on and if
they happen to fall through the holes in the system, the system has the
responsibility to provide the child with the necessary care and rehabilitation to
bring them back into the safety net.
Research, documentation and interventions by government and the civil society

groups in the past have clearly brought forth some of the following child protection
issues that deserve special attention: 1) Gender Discrimination, 2) Caste
discrimination, 3) Disability, 4) Female foeticide, 5) Infanticide, 6) Domestic
violence, 7) Child sexual abuse, 8) Child marriage, 9) Child labor, 10) Child
prostitution, 11) Child trafficking, 12) Child sacrifice, 13) Corporal Punishment
in schools, 14) Examination Pressure and Student Suicides, 15) Natural disasters,
16) War and conflict, 17) HIV/AIDS.
3.5.1 Difference between Child Rights and Child Protection

It is important to understand the difference between these two concepts. Child
rights are a set of principles or ideals. They are entitlements and some of them
are justifiable in a court of law, but they are not tangible. Protection is one of
these rights. But Child Protection is more than a right. It is a framework or
system by which the rights of a child can be exercised. The framework consists
of various duty bearers such as the departments of the government, police, school,
civil society, who all have roles to play to ensure that a child’s rights are met; and
in the case that a child’s rights are violated that the violator be brought to justice
and care be provided to the child. Child protection is not only treatment, but
should also be preventive. Risk management needs to take place to reduce the
risk of violation of child rights in any given circumstance or space.
38
Child protection is hence the means through which all other rights of a child can Child Protection and Child
Rights Counselling
be upheld. For example a child has a right to live a normal childhood in a family
environment. The child protection framework need to first take steps to ensure
families are able to survive by providing them health, education, and food for
free or at minimal cost. The next step is to address the needs of children who
have fallen through the cracks such as destitute, abandoned, and orphan children.
The framework includes the mechanisms to relocate these children into caring
families either through adoption or foster care and provide these children with
access to health and education services. Hence the framework is not a single
ministry or single government body; it is the interlinking functions of all ministries
and sectors.

1) What is NCPCR?
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2) Define a ‘Child’.
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3) Explain the Right to Participation.
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4) Describe the rights of children mentioned in the constitution of India.
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39
Type of Counselling
5) Differentiate between child protection and child rights.
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3. 6 CHILD RIGHTS COUNSELING

3.6.1 Vulnerable Child
A “vulnerable child” means a child who is unable to protect himself or herself.
This includes a child who is dependent on others for sustenance and protection.
A vulnerable child is defenseless; exposed to behaviour, conditions or
circumstances that he or she is powerless to manage; and is susceptible and
accessible to a threatening parent or caregiver. Vulnerability is judged according
to physical and emotional development, ability to communicate needs, mobility,
size and dependence.
All children due to their age are considered to be at risk for exploitation, abuse,
violence and neglect. But vulnerability cannot be defined simply by age. Though
age is one component, vulnerability is also measured by the child’s capability
for self-protection. The question that arises is, are children capable of protecting
themselves. Can children provide for their basic needs, defend against a dangerous
situation or even recognize a dangerous situation.
A child’s vulnerability comes from various factors that hinder a child’s ability to
function and grow normally. The following factors further compound children’s
vulnerability:
i) Age within age: Younger children, especially those below the age of six,
are much more dependent on the protection system.
ii) Physical disabilities and mental disabilities: Children become more

vulnerable to abuse and neglect if they are suffering from any physical or
mental disability.
iii) Powerlessness: comes of the situations and people that surround the children.
If a child is given the power by the state, family or community to participate
and fulfill their own rights and responsibilities they are less vulnerable.
iv) Defenselessness: comes from the lack of protection provided by the state or
parents or community. If there is no child abuse law than how is a child
suppose to defend himself/herself against abuse.
v) Passivity: due to situation or treatment of the child. For example a child

who is enslaved or oppressed does not have the ability to seek help or
protection.
vi) Invisible: Children who the system doesn’t even recognize are highly
40 vulnerable.
The Integrated Child Protection (ICPS) defines vulnerability in two categories: Child Protection and Child
Rights Counselling
1) Children in need of care and protection
2) Children in conflict with law
A child in need of care and protection is defined as a child who:
Doesn’t have a home or shelter and no means to obtain such an abode
Resides with a person(s) who has threatened to harm them and is likely to carry
out that threat, harmed other children and hence is likely to kill, abuse or neglect
the child.
Is mentally or physically handicapped, or has an illness, terminal or incurable

disease and has no one to provide and care for him/her.
Has a parent or guardian deemed unfit or unable to take care of the child.
Is an orphan, has no family to take care of him/her, or is a runaway or missing

child whose parents cannot be located after a reasonable search period.
Is being or is likely to be sexual, mentally, emotionally or physically abused,

tortured or exploited.
Is being trafficked or abusing drug substances.
Is being abused for unthinkable gains or illegal activities.
Is a victim of arm conflict, civil unrest or a natural disaster
Children in Conflict With Law are juveniles who have allegedly committed a
crime under the Indian Penal Code.
The ICPS also recognises a third category of children: Child in contact with law.
These children are victims of or witnesses to crimes. ICPS lastly outlines that
vulnerable children groups also include but are not limited to the following:
“children of potentially vulnerable families and families at risk, children of socially
excluded groups like migrant families, families living in extreme poverty,
scheduled castes, scheduled tribes and other backward classes, families subjected
to or affected by discrimination, minorities, children affected by HIV/AIDS,
orphans, child drug abusers, children of substance abusers, child beggars,
trafficked or sexually exploited children, children of prisoners, and street and
working children.”
Thus vulnerable children are those who are susceptible to abuse, exploitation,
and neglect. Child protection is derived out of the duty to respond to the needs of
vulnerable groups of children.
Let us now discuss the following groups of vulnerable children whose rights are
violated and providing counseling to them.
3.6.1.1 Child Abuse

The growing complexities and challenges of life coupled with changes in the
socio-economic conditions of people have played a major role in increasing the
vulnerability of children to various forms of abuse. Child abuse is a violation of
the basic human rights of a child. It is a state of emotional, physical, economic
and sexual maltreatment meted out to a person below the age of eighteen.
41
Type of Counselling According to the World Health Organization (WHO), “Child abuse or
maltreatment constitutes all forms of physical and/or emotional ill-treatment,
sexual abuse, neglect or negligent treatment or commercial or other exploitation,
resulting in actual or potential harm to the child’s health, survival, development
or dignity in the context of a relationship of responsibility, trust or power.’’
Thus child abuse is the physical, sexual, emotional mistreatment, or neglect of

children. Child abuse has serious physical and psycho-social consequences which
adversely affect the health and overall well-being of a child.
Child abuse has many forms: physical, emotional, sexual, neglect, and
exploitation. Any of these that are potentially or actually harmful to a child’s
health, survival, dignity and development are abuse.
Physical abuse is when a child has been physically harmed by kicking, punching,
beating, biting, hitting, stabbing, burning or otherwise harming the child.
Emotional abuse is also known as verbal abuse, mental abuse, and psychological
maltreatment. It can be seen as a failure to provide a supportive environment
and primary attachment figure for a child so that they may develop a full and
healthy range of emotional abilities. Emotional abuse consists of acts such as
insulting, rebuking, restricting movement, threatening, scaring, discriminating,
ridiculing, belittling, etc.
Sexual abuse is inappropriate sexual behaviour with a child. It is engaging a

child in any sexual activity that he/she does not understand or cannot give
informed consent for or is not physically, mentally or emotionally prepared for.
This includes using a child for pornography, sexual materials, prostitution and
unlawful sexual practices. To be considered ‘child abuse’, these acts have to be
committed by a person responsible for the care of a child (for example a baby-
sitter, a parent, or a daycare provider), or related to the child. If a stranger commits
these acts, it would be considered sexual assault and handled solely by the police
and criminal courts.
Neglect is the failure to provide for the child’s basic needs. Neglect can be
Physical: not providing adequate food, clothing or shelter; Medical: lack of
appropriate medical and mental health care; Educational: failure to provide
appropriate schooling or take care of special educational needs; Psychological:
lack of any emotional support and love, not attending to the child’s emotional
and psychological needs.
Counseling for Child Abuse

The problem of child abuse and human rights violations is one of the most critical
matters on the international human rights agenda. In the Indian context,
understanding and acceptance of child rights as primary inviolable rights is still
to catch up. Counseling to such children can be provided in the following ways.
Using Props: Hugging a doll or favorite stuffed animal or blanket is a way to
calm the fears and anxieties of the abused child. They dramatize trauma and
abuse by symbolically setting up fantasy worlds, using structured or unstructured
play situations, artwork, music, puppets, or clay. Their stories emerge as they set
up parallel worlds to their own, allowing the counselor to observe and hypothesize,
42
and begin to piece together an appropriate treatment plan.
In this safe setting, children can experience challenging emotions and traumas in Child Protection and Child
Rights Counselling
stages, allowing them also to find ways to adapt to these traumas and regain a
sense of control in their lives. As the relationship between counselor and child
matures, the child senses unconditional acceptance, and begins to build new
worlds, ones that offer hope and promise. The counselor addresses any
maladaptive behaviours that could put the child at risk for further abuse, and
even possibly future mental health issues.
Educating Caregivers: And once the counselor has a solid understanding of the
child’s issues and needs, then educating the child’s caregivers becomes imperative.
Counselors also support caregivers in implementing the treatment plan, which
takes many weeks or months, and involves many frustrations and setbacks –
even in the most loving and accepting environments. The counselor becomes a
teacher as well as therapist, advising the child and caregivers about the course of
recovery, which challenges both the child and caregiver at each major
developmental stage – from starting school, to the teen years, dating, self-
sufficiency, and parenting.
The child abuse counselor also conducts group sessions for abused children.
Young children, for example, benefit from participating in developmental play
groups. And children and youth who are sexually abused benefit from group
counseling, seeing that they are not alone, and processing their feelings of shame
and guilt with others who feel the same.
Victim’s of sexual abuse, depending on the child’s age, and the type and extent
of abuse, also benefit from different therapeutic techniques. These techniques,
ranging from psychotherapy to trauma-focused play therapy, and trauma-focused
cognitive-behavioural therapy, guide victims through processing the experience
to normalising reactions. The counselor works with the child to develop healthy
coping patterns while addressing associated conditions of depression, anxiety,
panic attacks and symptoms of post traumatic stress disorder.
Biofeedback, eye movement desensitisation, and relaxation techniques are also

tools that the counselor employs when working with sexually abused children
and youth. The therapist also counsels the family or individual family members
on adaptive strategies for overcoming abuse and developing healthy family
functioning.
3.6.1.2 Street Children

Street children are considered to be an urban problem. Children can be found in
railway stations, near temples and dargahs, in markets, under bridges, near bus
stops etc. Hence the definition of street is not in the literal sense, but refers to
those children without a stable home or shelter. There are three major categories
of street children:
a) children who live on the street with their families and often work on the
street. These may be children from migrated families, or temporarily migrated
and are likely to go back to their homes;
b) children who live on the street by themselves or in groups and have remote
access or contact with their families in the villages. Some children travel to
the cities for the day or periods of time to work and then return to their
villages; 43
Type of Counselling 3) children who have no ties with their families such as orphans, refugees and
runaways.
It is the second and third category of children who are most vulnerable as they
are easy victims of abuse, and inhuman treatment. They often engage in petty
theft or prostitution for economic survival. Children run away from their homes
for a variety of reasons. Some may have faced traumatic experiences in their
homes. Their parents may be abusive or have problems with alcoholism, poverty
and unemployment. Some children leave home drawn by the glamour of the big
cities.
“Children of the street” are homeless children who live and sleep on the streets
in urban areas. They are on their own and do not have any parental supervision
or care though some do live with other homeless adults. “Children on the street”
earn a livelihood from street such as street urchins and beggars. They return
home at night and have contact with their families. The distinction is an important
one because children of the street lack emotional and psychological support of a
family.
Counseling for Street Children

Street children have many problems related to substance use and sexual and
reproductive health including HIV/AIDS and other STDs. As different individual
and social factors contribute to these problems, a variety of responses are required.
For the most part, as a street educator the interventions you will be implementing
will focus on changing or influencing the life of the street child. However, to be
effective you will have to:
• Ensure that street children participate as key players in these interventions.
• Coordinate groups or individuals in the community who work with street

children.
• Ensure that services and resources are available to street children.
Interventions should also aim at providing information, building basic skills,

providing counseling, improving access to health services, creating a more
positive and safe environment and involving the street children themselves in
various activities.
Street children need various resources to meet their physical and emotional needs.
Resources can be internal (inside a person), e.g. intelligence, capacity to work
etc., or they can be external (outside the person i.e. in the environment), e.g.
schools, health services, community organisations and people who care. Even
though street children usually have many internal resources, they usually lack
external ones. Without these external resources, they may have a hard time
learning new skills that would help improve their lives. It may be more difficult
for them to develop healthy ideas and practices about substance use if they do
not have the benefit of resources such as street education and informational
campaigns. If they have fewer ways of coping with stress, they may fall back on
substances to relieve it. Your task involves identifying these resources and making
them available or accessible to street children.
44
The question of prevention or treatment of substance use and sexual and Child Protection and Child
Rights Counselling
reproductive health-problems and providing support to street children can be
approached at three levels:
1) Individual level (street children)
2) Local community level
3) Beyond the community
Life skills can enable the street children to:

Be assertive: e.g. the ability to state one’s dislike for sex or substance use clearly.
This skill helps street children to communicate their needs and to resist social
pressures.
Negotiate: the ability to discuss and get others to agree to what one wants. A
street child could negotiate to use a contraceptive method such as condoms during
sexual intercourse.
Think critically: street children can learn to assess potential risks in various
situations ahead of time, and think about why they engage in risk behaviour. A
street child who knows the problems that may arise from substance use and
realises that he or she uses substances as a way of making friends or coping with
stress may try to find other ways of addressing those needs and avoid getting
involved in using substances.
Develop self-awareness and self-esteem: increasing understanding of personal

strengths, interests, personal priorities and goals. This can decrease the attitude
of ‘just letting it happen’.
Make and build friendships: having real friends can be a source of support and
protection and may help street children resist pressure from adults who try to
exploit them.
Life skills are not applied in isolation, rather they depend on each other. For
example, to learn decision making, street children should be able to identify
their feelings about their situation and what they want out of life (self-awareness).
The learning and application of life skills also need to be closely linked to the
reality of the street children’s lives.
3.6.1.3 Disability in Children

Disability in children –physical as well as mental disability- leads to neglect and
abuse of children. The main causes of disability in children are:
• Communicable disease
• Infection in early childhood
• Early motherhood
• Nutritional deficiencies
• Insufficient or inaccessible health care services
• Inadequate sanitation
• Inter-family marriages
45
Type of Counselling There are many protection issues that also lead to disability. Children who are
trafficked, abused and sexually exploited are at risk for psychological effects as
well as physical problems. Other forms of violence against children can also
lead to a disability such as corporal punishment in schools, children living on
the streets, and purposefully created disabilities for begging. Children from poor
families face a double disability.
Disability is still functioning in the realm of social welfare instead of a rights

perspective. Teachers are not trained and schools don’t have the infrastructure to
deal with children with disabilities.
Treatment for Disability in Children

Comprehensive counseling interventions for children include individual and
group therapy, case management, rehabilitation counseling, and psychiatric
consultation with a family and child psychiatric physician. Individual consultation
for parents is also available to better prepare them to help their children, teens,
and transition age adolescents. Additional services are as follows:
i) Therapeutic Behavioural Services (TBS): TBS is available for children

with extreme needs who have required hospitalisation in the past couple of
years. These children may qualify for intensive behavioural treatment in the
home, school, or community. Significant parental consultation may also be
provided.
ii) Behavioural Life Coaching: Adolescents and transitional age young people
benefit from Behavioural Life Coaching, as it helps foster integration into
the community and the development of skills leading to independence within
the context of their diagnoses.
iii) Transitional Youth Program: These programmes help young people deal
with emerging developmental and psychological issues post-high school. It
fosters behavioural skill development for a smoother transition to community
life.
iv) Behavioural Consultation: This helps parents, supervisors at care homes

and others learn about using effective reward systems to teach young clients
how to achieve success in their home and community settings.
v) Family Support and Education: Monthly meetings can provide information

and much-needed support to parents or significant others, including care
workers who serve children with developmental disabilities who have mental
health needs.
3.6.1.4 Drug Abuse
“If current trends continue, 250 million children alive today will be killed by
tobacco.” - W.H.O.
The incidence of drug abuse among children and adolescents is higher than the
general population. This is notably because youth is a time for experimentation
and identity forming. In developed countries drug abuse among youth is generally
46
associated with particular youth subcultures and lifestyles. The use of tobacco is Child Protection and Child
Rights Counselling
a major concern amongst children. The use of certain drugs such as whitener,
alcohol, tobacco, hard and soft drugs is especially wide spread among street
children, working children and trafficked children.
Drug Addiction Treatment Methods

Drug addiction is a treatable disorder. Through treatment that is tailored to
individual needs, patients can learn to control their condition and live normal,
productive lives. Like people with diabetes or heart disease, people in treatment
for drug addiction learn behavioural changes and often take medications as part
of their treatment regimen.
Behavioural therapies can include counseling, psychotherapy, support groups,

or family therapy. Treatment medications offer help in suppressing the withdrawal
syndrome and drug craving and in blocking the effects of drugs.
The ultimate goal of all drug abuse treatment is to enable the patient to achieve
lasting abstinence, but the immediate goals are to reduce drug use, improve the
patient’s ability to function, and minimize the medical and social complications
of drug abuse.
Counseling plays an important role in this. Counseling techniques have been

shown to be most effective in bringing positive changes in addiction behaviours.
Counseling aims at the following: cognitive (understanding the problem and
solution), behavioural (making new habits more comfortable than the old
destructive habits), family systems (realising the dynamics formed in childhood
that affect adult actions; and involving family members to strengthen new response
patterns).
Positive reinforcement, comfortable social attachments within the new activities

and direction away from old cycles of abuse must be part of any therapy.
Alcoholics Anonymous and similar groups offer a place for self-examination,
mutual support and growth at the patient’s own pace. Success may lie in the
motivation and resolution of the patient to effect positive change.
Thus counseling can be provided to the abused children and their caregivers to
help them come out of the trauma, sufferings and anxieties. Treatment may include
psychotherapy, rehabilitation counseling, cognitive behaviour therapy, supportive
therapy, behaviour therapy, play therapy, and other modalities as necessary to
assist the individual in overcoming anxiety, fear and depression.
However, most important is that counseling can adopt a preventive approach

and create awareness and understanding regarding the rights of the children.
This will help protect the children so that they can develop in a healthy way.
Counseling strategies can aim at developing a protective environment for children
emphasising the importance of knowing, understanding, accepting and enforcing
legal standards in child protection. Further community-based approaches can be
used that promote and strengthen the capacity of families and communities to
address child protection issues.
47
Type of Counselling
1) What do you mean by a vulnerable child?
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2) Describe the categories of vulnerability by ICPS.
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3) Analyse the definition of child abuse given by WHO.
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4) Describe the counseling interventions for the disabled children.
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3.7 LET US SUM UP

In this unit you learned about the issues related to child rights and child protection.
The meaning of child rights and child protection was discussed. You also came
to understand the different forms of child rights violation. Building a protective
environment for children will help prevent and respond to this child rights
violation, abuse and exploitation. Counseling strategies to deal with all these
were described. A comprehensive approach to address the issue of child protection
and child rights should include the following: Strengthening government
commitment and capacity to fulfill children’s right to protection; promoting
the establishment and enforcement of adequate legislation; addressing harmful
48 attitudes, customs and practices; encouraging open discussion of child
protection issues that includes media and civil society partners; developing Child Protection and Child
Rights Counselling
children’s life skills, knowledge and participation; building capacity of
families and communities; providing essential services for prevention,
recovery and reintegration, including basic health, education and protection;
and establishing and implementing ongoing and effective monitoring and
reporting.

1) What do you mean by rights of children? Describe the different types of
rights of children.
2) Discuss the issue of child protection in the context of India.
3) Describe child abuse. Discuss the counseling techniques for such children.
4) What are the strategies of counseling you’ll adopt for street children?

Commonwealth Youth Programme Secretariat (1995) . Working with Young
People: A Guide Topreventing HIV/AIDS and STDs. London, Commonwealth
Youth Programme, United Nations Children’s Educational Fund.
Kadden R, Carroll K, et al. Cognitive behavioural coping skills therapy manual:

A clinical researchguide for therapists treating individuals with alcohol abuse
and dependence National Institute on Alcohol Abuse and Alcoholism. Project
MATCH Monograph Series. (Vol. 3. 1992).
Griffith, R. & Tengnah, C. (2007). Protecting Children: The role of the law 1.
Principles and key concepts. British Journal of Community Nursing, 12, 122-4,
126-8.
Howard J. (1995). Psychoactive Substance Use and Community Involvement in

Health. Draft. Geneva,World Health Organisation.
Jarvis T, Tebbutt J, et.al (1995). Treatment Approaches for Alcohol and Drug
Dependence. An Introductory Guide. Chichester, West Sussex: John Wiley &
Sons.
http://www.wcd.nic.in/childabuse.pdf
49
Type of Counselling
UNIT 4 ADDICTION/ANXIETY
COUNSELLING
Structure
4.0 Introduction
4.1 Objectives
4.2 Meaning of Anxiety Disorder
4.2.1 Symptoms of Anxiety Disorders
4.3 Alcohol and Drug Addiction
4.3.1 Meaning of Substance /Abuse
4.3.2 Addictive Behaviour
4.4 Developing an Addiction
4.4.1 The Hallmarks of Addiction
4.4.2 How Anxiety can Lead to Addiction
4.5 Symptoms of Addiction and Anxiety
4.6 Causes for the Addiction and Anxiety Abuse
4.6.1 Other Causes for Addiction/ Anxiety
4.7 Treatment for Addiction and Anxiety
4.7.1 Group Therapy and Counseling
4.7.2 Behaviour Counseling
4.7.3 Environmental Therapies
4.7.4 Supportive Psycho Therapy
4.7.5 Re-Educated Psycho Therapy
4.7.6 Self Control Brain Technique
4.7.7 Cognitive Behaviour Therapy
4.7.8 Individual Counseling
4.8 Let Us Sum Up
4.0 INTRODUCTION
Addiction and anxiety often go hand in hand. Depression may be the reason an
addict begins using drugs or alcohol or, it may develop as the addiction progresses.
Dual diagnosis of addiction and anxiety is, when a person has an addiction plus
a psychiatric illness such as anxiety, doctors say that they have a “dual diagnosis”.
The term is a reminder for the counselors, physicians, and other medical
professionals that this client has extra challenges on the road to recovery.
Depression and other psychiatric illnesses increase the risk of addiction. Of all
people who are diagnosed as having a psychiatric illness, roughly 29% are alcohol
or drug abusers. As many as 37% of people who abuse alcohol and 53% of
people who abuse drugs, have at least one serious mental illness. Depression,
already common in the general population, is even more common among
alcoholics and drug abusers.
50
Addiction/Anxiety
4.1 OBJECTIVES Counselling

• Understand the meaning of addiction / anxiety disorder;
• Describe the symptoms of addiction/anxiety;
• Explain the causes of addiction and anxiety disorder;
• Know the factors leading to development of addiction; and
• Discuss the various counseling techniques useful for addiction/anxiety.
4.2 MEANING OF ANXIETY DISORDER

Anxiety is a combination of both psychological and physiological symptoms
that can lead to stress, physical discomfort, persistent worrying and obsessing,
fear of social situations and other phobias, as well as panic attacks. People with
anxiety often experience an unpleasant feeling that is typically characterised as
uneasiness, apprehension, fear, or worry. Anxiety is experienced in numerous
forms, ranging from the concretely physical to the intensely emotional. A common
physical manifestation of anxiety is a panic attack, which is experienced as a
combination of a pounding heart, sweating, shaking, and a shortness of breath.
4.2.1 Symptoms of Anxiety Disorders

The symptoms of the anxiety disorders are as follows:
1) Feelings of nervousness and/or fear
2) Excessive or irrational worry
3) Panic attacks
4) An urge to avoid a situation, place or person
5) Paranoid thinking and behaviours
6) Intrusive and negative thoughts about self or others
7) Nausea
8) Dizziness
9) Depression, anger management, loneliness or despair
10) Problems with an important relationship.
11) Stress, anxiety or panic.
12) Communication issues
13) Life transitions like separation, divorce, career change, job loss, or a major illness.
14) Struggling with a mental illness like bipolar disorder or major depression.
15) Substance abuse or other addiction in yourself or someone you love.
16) Grief over the loss of a loved one, including a pet.
17) Caregiver stress.
18) Unresolved trauma.
19) Spiritual issues or crises of faith.
51
Type of Counselling
4.3 ALCOHOL AND DRUG ADDICTION
For thousands of years, human beings have taken mind-altering substances as a
way to alter their perceptions and play with their minds. Natural herbs,
manufactured drugs, and alcohol have all been used in this way. Many people
are able to take such substances only occasionally and without interference to
their relationships or general wellbeing. But there have also always been people
who have had difficulty moderating their use of drugs or alcohol, and it is these
people who may go on to suffer from addiction.
Drug addiction can be seen in the people who are non adjustable and not able to
cope-up with the problems to greater extent. In the 21th century the drug abuse
has increased in an enormous proportions and is becoming a serious problem of
the people of by which the survival of the society is in a threat too.
The drugs consumed by the people can vary in various forms, from taking of
direct drugs to indirect forms of the drug e.g. alcoholism poses a serious social
problem which involves teen age to old age people.
Today the use of drugs and even addiction have increased even at the school and
college level. So is the case of anxiety. In other words because of the anxiety
factors, use of drugs is rising; therefore today the importance of the role of the
teachers and the counselors has increased as they not only have to educate the
students, help to make wise choices but also to educate them, help them to know
about the substance abuse/drug addiction and the danger related to it.
Addiction may occur at any age but the onset is more during young adulthood
and the adolescent too (APA, American Psychological Association). The use of
drugs /substances in today’s youth may be because of anxiety, natural curiosity,
impact of westernization, peer pressure, to express their own indentify, by
experimentation and may be because of environmental and hereditary factors.
Other reason for being addicts may be that today more youth is becoming
unemployable and competition is increasing day by day, expectancy age is
increasing that is wellness of health, by which the retirement age is also increasing.
The increase in population is also one of the cause of frustration among the
youth and to release their frustration, stress, anxiety the youth is becoming drug
addicted to substances or drugs. The use of drugs is becoming the means of
escape from feelings of void and helplessness.
4.3.1 Meaning of Substance/Abuse

Substance abuse is the over indulgence and dependence on the drugs or other
chemicals leading to the effects that are detrimental to the individual’s physical,
mental health or the welfare of others (Mosby’s medical, nursing and allied health
dictionary, 1998)
Addictive behaviour is based on the pathological need for a substance or activity
may involve abuse of substance such as nicotine, alcohols etc.
The disorder is characterised by a continuous use of medication, psycho-active
substances; non -medically indicated drugs that result in failure to meet the social/
personal responsibilities such as work, family, interpersonal relation.
52
Two categories of drugs are commonly used, which the counselor must keep in Addiction/Anxiety
Counselling
mind which are the tranquilizers and sedatives. The counselor should also keep
in mind, the individual’s (client’s) lifestyle and personality as it also plays an
important role in the development of addictive disorder and are the central themes
in some type of treatment.
The most commonly used problem substances are the psycho-active drugs .The
psycho-active drugs are those drugs that directly affect mental functioning:
alcohol, nicotine, barbiturates, minor tranquilizers, amphetamines, heroin, and
marijuana.
4.3.2 Addictive Behaviour

Behaviour based on pathological needs for a substance or an activity is one of
the most pervasive and intransigent mental problems which our society is facing.
Therefore the need to treat them is also very important, so the counselor must
look into the diagnostic classification of addictives or psychoactive substance
related disorder which are divided into two major category—
1) Psychoactive substance including mental disorder, are those conditions which

involve in chronic problems that is organic impairment resulting from the
ingestion of psychoactive substances.
These conditions stem from toxicity in the brain due to vitamin deficiency.
2) Second category, focuses on the maladaptive behaviour resulting from regular
and consistent use of a substance and includes substance dependence disorder
and psychoactive substance abuse.
The classification of substance abuse disorder by DSM IV and ICD- 10 given by
WHO is divided into two categories –
a) Substance dependence disorder
b) Substance abuse disorder
Substance dependence is seen by marked physiological need for increasing
amount of drug or withdrawal symptoms, when the drugs are not available.
Increased drug use leads to increased physical dependence, and users may find
that they get sick if they do not take drug.
• Increased drug use leads to increased tolerance to the drug, and users may
find that they need to take more of the drug to get the same effect.
• Drug users may harm themselves or others while intoxicated (e.g. drinking
and driving) or by the actual act of drug taking (e.g. catching or passing on
an infectious disease such as AIDS or Hepatitis, through shared needle use).
• Drug addicts may resort to criminal activities such as theft or prostitution to
fund their drug taking, particularly if their drug addiction has forced them
to lose their job.
• Drug addicts may overdose, die of drug related disease or suicide.
53
Type of Counselling
1) What do you mean by anxiety disorder?
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2) Describe the symptoms of anxiety disorder.
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3) Define substance abuse.
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4.4 DEVELOPING AN ADDICTION

Addiction to drugs (including marijuana, heroin, cocaine, ICE or alcohol) rarely
happens instantaneously. The process of drug addiction is generally a slow one
which builds up over time. People might, initially, use drugs only in a recreational
way – they might use it to chill with some friends, make more of a dance party,
or as a way to enhance the experience of sex. Alternatively, people might start
using drugs initially for a specific purpose – a glass of wine after work to help
unwind from the day, some lines of coke to aid a student cramming for an exam.
Using drugs in a contained way might seem fairly harmless, and certainly some
people are able to use drugs sporadically or only in particular and limited
circumstances. But for many others, drug taking can become habitual,
desensitization leads to increased use, and the addiction takes hold.
Drug addicts typically spend a lot of time (and money) thinking about, purchasing
and taking drugs – the process of buying and taking drugs becomes the central
interest in their lives. Other pursuits and responsibilities, such as work, study,
friends and family, often fall by the wayside – jobs get lost, exams failed, and
relationships fail.
54
4.4.1 The Hallmarks of Addiction Addiction/Anxiety
Counselling
Addiction can be characterised as a state in which the person or their relatives
and friends come to experience their drug use as a hindrance to the quality of
their everyday life. This interference to one’s life may come in many forms; but
often involves an experience of depression or anxiety, for some people issues
with violence or loss of control, for others loss of good judgment or a loss of a
significant relationship. Counselors and psychologists have developed a number
of evidence based approaches for the treatment of addiction.
4.4.2 How Anxiety can Lead to Addiction

Some people use alcohol and illegal drugs to deal with the symptoms of anxiety.
Doctors call this “self-medicating”. The effects of alcohol or drugs can provide
temporary relief from feelings of sadness, guilt or worthlessness. When the effects
wear off, the bad feelings return. This cycle can lead to continuing use and eventual
addiction.
Another link involves the consequences of anxiety. Depressed people often

withdraw from social contacts and may even have trouble holding jobs. They
may find themselves spending more time alone, without a supportive social
network and turning to drugs or alcohol for comfort. It may even be easier to
spend time with others who abuse alcohol and drugs instead of pursuing healthier
relationships because social expectations may be lower.
Even for people who aren’t using alcohol or drugs to self-medicate and haven’t
lost their social connections, anxiety appears to increase the risk of addiction.
Many doctors think that whatever makes people vulnerable to anxiety also makes
them more likely to abuse alcohol or drugs. Someone without anxiety may be
able to try an illicit drug or drink alcohol regularly without any long-term
problems; for a depressed person, these same activities may be more likely to
lead to addiction.
4.5 SYMPTOMS OF ADDICTION AND ANXIETY

Symptoms of addiction and anxiety can be very similar. When anxiety is directly
connected to the drug or alcohol abuse and isn’t present independently, it’s not
considered a “dual diagnosis” but just a consequence of the addiction. For
example, several psychiatric problems are directly related to cocaine. Cocaine
abuse can lead to hallucinations, anxiety, sleep problems, sexual dysfunction
and a mood disorder that includes anxiety. However, once the person stops using
cocaine, the psychiatric problems generally get better. Amphetamines, heroin
and inhalants can all have similar effects.
In order to ensure prevention and effective counseling, a counselor should know
these varieties of drug that are been consumed by the people.
Symptoms of Addiction/Anxiety
Early recognition of the symptoms of addiction/anxiety increases chances for
successful treatment and favorable out come. The role of counselor is preventive,
remedial and educative.
Addiction/anxiety leads to changes in behaviour which can be seen in terms of
psychological and physiological conditions of individual. 55
Type of Counselling The symptoms can be described as follows:
• Sudden mood change
• Anger
• Irritation
• Low self esteem
• Loneliness
• Depression
• Lack of interest
• Change of priorities
• Personality changes
• Poor judgment
• Negative attitude
• Dishonesty
• Starts arguments
• Withdrawal symptoms
• Family relation problem
• Lacks intimate relationship
Certain physiological changes are also seen in the client such as,
• loss of memory
• Restlessness and fatigue
• Distortion in health
• Increase in heart rate
• Sweating
• Palpitation
• Confusion
• Irritation
• Weak immune system
• Chances of suffering major disease (Cancer, HIV AIDS)
• Difficulty in speaking

1) Anxiety leads to addiction. Explain.
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56
Addiction/Anxiety
2) Describe the symptoms of addiction/anxiety. Counselling
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4.6 CAUSES FOR THE ADDICTION AND ANXIETY

ABUSE
As addiction is a complex phenomenon it has various causes. The causes can
range from psychological to social, biological and cultural. The psychological
causes can be tension, anxiety, fear, stress, frustration etc. The social can be
friend circle, society, economic status, etc. The biological can be the heredity
factor, various diseases, etc. The cultural can be the traditional culture,
demographic condition, etc.
Some of the causes are listed below:
• Repressed desires
• Repeated failure and striving for success
• Mal-adjustment /adaption with the environment e.g. new surrounding, new
jobs/friends.
• Personal cause- the type of personality (type A/B), emotional instability.
• Too much of fear for examination, inability to prepare.
• Ineffective parenting e.g. lack nurturing and parental attachment, poor social
coping skills inappropriately aggressive and shy behaviour, neighborhood
conditions, negative attitude towards life.
4.6.1 Other Causes for Addiction/Anxiety

Why is it that some people seem prone to drug addiction, while others are not? It
seems that certain factors are predictors of addictive personalities:
1) Genetics: Vulnerability to some forms of drug addiction often seems to be
hereditary (this does not mean that if your parent was a drug addict, you
will be too). It simply means that you might be predisposed, genetically, to
addictive behaviour.
2) Childhood Abuse or Trauma: There is much evidence to suggest that
addiction has a great deal to do with childhood experiences, so if you were
subjected to abuse as a child (sexual, emotional or physical), or you
experienced neglect or some sort of trauma, or you were the child of addicted
parents, these are all indicators that you might be more susceptible to
developing a drug addiction in later life.
3) Mental Illness: There is some evidence to suggest that people who are
mentally ill or affected by other psychological issues (such as anxiety or
depression) may use drugs as a way to manage their condition.
57
Type of Counselling 4) Chronic Pain: Sufferers of chronic pain can become addicted to drugs as
they search out solutions to their constant pain.
While these factors might predispose people to becoming addicts, it is clear that
these are not essential criteria on which to develop an addiction. Drug addiction
affects people of all races, classes, backgrounds and cultures. Anyone can suffer
addiction, and all addicts are likely to suffer some kind of negative consequences
to their addiction.
4.7 TREATMENT FOR ADDICTION AND ANXIETY

Treatment on the psychological level by the counselor involves the personality
assessment which focuses on the client’s present mental state, the role of
personality and emotional stress in development of disorder within the client.
The assessment procedure involves the subjective, objective and projective use
of personality assessment of the client. By this the information regarding each
and every aspect of behaviour of the client in known to the counselor e.g.
information regarding occupation, family relations, education, marital and other
data concerning the client’s life situation is obtained.
When a person has both addiction and anxiety, one of the first steps in treatment
is to figure out which came first. That may be possible from the patient’s history.
The person may be able to describe depressed feelings that preceded the addiction.
Or, they may describe self-medicating with alcohol or drugs. Sometimes, it’s
necessary to help the person quit drinking or doing drugs first, and then evaluate
for anxiety.
If it’s clear that the anxiety is a consequence of the addiction, treating the addiction
is usually all that’s needed. If the anxiety is a separate issue, it must be addressed
as well. Treatment may include special counseling and antidepressant medicines.
The combination of addiction and anxiety can make it more difficult to recover.
When a person feels sad, hopeless or exhausted, battling an addiction is a special
challenge that may be difficult to face. However, knowing about the link between
addiction and anxiety, being aware that dual diagnosis is possible and seeking
treatment to address both issues can help make recovery possible.
The counselor should keep in mind the psychological treatment which aims at
alleviating the individual’s maladjusted behaviours and strive to bring about
personality change to foster more effective adjustment. The counseling techniques
which are used generally are as follows –
1) Group therapy
2) Behaviour therapy
3) Environmental interventions
4) Supportive psycho therapy
5) Re educated psycho therapy
6) Self control training technique
7) Cognitive behaviour therapy
8) Individual Counselling
58
4.7.1 Group Therapy and Counseling Addiction/Anxiety
Counselling
Group therapy and Counseling aims at releasing of emotions and perception
through sharing. The goal of group therapy is to modify attitude and behaviour
.It provides the clients with incentive and motivation to make changes by
themselves, because in anxiety/drug addiction group counseling may be used for
resolving problems which the individuals have developed. They have inadequate
understanding of one self, not aware of harmful effect of faulty habits, dealing
with rejection and abuse. Group psychotherapy is considered to be remedial,
supportive and reconstructive. The focus is on the conscious, unconscious and
subconscious aspect of personality of the people.
The selected group members should be of same age, same problem and having
same socio-economic status. The aim of group counseling is to make each member
take on responsibility to put forth his /her experience by sharing and listening.
The members are able to express their views and ideas.
In group counseling self help groups are formed by interested individuals that
come together, to deal with common problems, for example, smoking, alcoholism,
drugs etc. The counselor should keep in mind to generate community feeling
within the members which is one of the important parts of the healing process.
The steps and skills followed by a counselor, in group counseling are as follows:
1) planning the group
2) selection of members
3) stages of group process
1) Planning the group in counseling process comprises of following:
i) Purpose: The counselor first identifies and clarifies the purpose of
counseling, i.e. why group counseling is required for the addictives.
ii) Size: The counselor should look into the size i.e. number of clients.
The average group size should be of 5-7 members who are having same
problem.
iii) Length and frequency: The duration of session must be decided well
in advance looking into the severity of addiction, in the starting the
session should be of 45 minutes to 60 minutes and later can be adjusted
according to the need.
iv) Time for counseling: Time should be set well in advance by the
counselor looking into the mood of the clients.
v) Physical sitting: The group session is best conducted in a room or
open place with minimum noise, comfortable sitting arrangement in a
circle with good ambience.
2) Selection of members – While providing group counseling the selection of
group members is very important. This will depend on the addiction level
i.e. mild, moderate, and severe of the clients.
i) Level of commitment: Before counseling a good rapport must be
established among the members so that they know each other which
will facilitate their sharing of their problems.
59
Type of Counselling ii) Acceptance and trust: In order to develop trust, the counselor must
remember his/her role, so that clients will trust him and a positive
therapeutic force is seen in the group.
3) Stages of group process:
i) Beginning stage: starts in rehabilitation center .In the beginning of
counseling session the group may take rather longer couple of sessions
to develop trust for working in sharing environment.
ii) Working stage: This is the main stage of group discussion. At this
stage the problems are redefined and causes for addiction/anxiety is
known. Not only this, the group members try to find out solutions by
themselves with the help of counselor .Conscious efforts are made to
solve the problems. At times group situation can be very difficult for
alcoholics, who are, engrossed in denial of their own responsibilities
but at the same time, they also provide the opportunity to see new
possibilities for coping with circumstances that have led to their
difficulties.
iii) Closing stage: It is the stage where the members share what they have
learnt. The counselor summarizers the outcome. This stage takes 1-2
session, the bonding is seen amongst the group member and the
counselor. The counselor should note that if required the parents/
relatives/spouse/children must also be counselled.
Follow up: Follow up enables the group members to keep in touch. The counselor
should take the feed back so that follow up plans could be discussed before
termination.
4.7.2 Behaviour Counseling

Behaviour counseling/ therapy plays an important role in the treatment of
addictives .There are several sub type of behaviour therapy which are very
effective, e.g. aversion therapy which involves the presentation of aversive stimuli
with alcohol consumption in order to suppress drinking behaviour.
Anxiety level and other symptoms can be cured by various other behavioural
therapies such as token economy, positive reinforcement, systematic
desensitization, flooding etc. Not only this, exposure therapy is used for reduction
of anxiety, negative feeling, emotions etc. This exposure is usually done in gradual
manner under safe and control conditions in the presence of therapist. Training
and muscular relaxation given by Jacobson is one of the popular method for
effective anxiety management. Moreover yoga and meditation is also useful in
reducing anxiety/addiction.
Constructing an Anxiety Hierarchy

Systematic desensitization makes use of an anxiety hierarchy. It consists of listing
of all situation, events that evokes fear in the clients. The counselor must help
the clients to place them in rank order by arranging the items of hierarchy from
the least to the most anxiety provoking.This rating is called as the subjective
unit of distress (SUD). The client is asked to imagine each SUD in a relaxed
state which gradually helps the client to reduce his anxiety/addiction.
60
4.7.3 Environmental Therapies Addiction/Anxiety
Counselling
For counseling environmental interventions are also important, rightly stated by
Booth et al “Environment supports have shown to be an important component
to an alcoholic recovery.”
Therefore preventive interventions can provide skills and support to high risk
people to enhance level of protective factors and prevent drug abuse. The
prevention program should address all form of drug addiction whether legal
drug such as alcoholism, tobacco etc. and use of illegal drugs like heroin,
marijuana or inappropriate use of drug e.g. inhalants.
Preventive programs should be of long duration with repeated interventions.

These environmental interventions include peer discussion, role play,
advertisement, etc which helps the client to overcome the problems.
4.7.4 Supportive Psycho Therapy

The aim of supportive psychotherapy is to help the addictives suffering from
anxiety to feel more adequate in facing his/her problem more effectively and
confidently. This is inter-personal psychodynamic approach to treat the client,
where all efforts are made to make the individual more confident with the help
of counselor. The counselor tries to orient the client to increase clients’ awareness
related to the positive aspect of life. Luborsky’s (1984) Supportive/ expressive
psycho-analytically oriented therapy can be used by counselor in treating addictive
anxiety clients. It is based on the assumptions that a Core Conflictural
Relationship Theme (CCRT) is at the center of person’s problem. This
relationship theme develops from the early childhood experience, but the client
is unaware of it and its connection to childhood experiences. Therapy/counseling
is oriented towards increasing the client’s awareness of the theme. It is assumed
that the client will have better control over behaviour if he/she knows more
about what is going on at the level of unconscious. The transference relationship
is important that the CCRT will be lived out and enacted in relationship to the
counselor and the problem faced by the client will be resolved.
4.7.5 Re-Educated Psycho Therapy

Re- educated psychotherapy is one of the important therapy to treat the addictives/
anxiety. It helps the client to gain an insight into oneself and modify or change
the faulty assumptions and attitude paving the way to fundamental changes in
personality. It is also necessary to deal with the individual’s social environment
and his/her adjustment to it. In most of the cases, changes in family situation
help the client to make effective adjustment. According to Hoyt (1995) it is
precise and well time intervention technique.
4.7.6 Self Control Training Technique

Self control training technique (Miller Brown et al 1995) suggests that the goal
of the counselor/therapist is to reduce addictive intake without abstaining all
together. There is now even a computer based self control training program
available that has been shown to reduce alcohol intake (Hester 1997)
In addition to the above, some psychologists have designed various written

material, work book and exercises to help the client with specific problems.
61
Type of Counselling In this self help group mutual supporter can be seen online. Self help and mutual
support group can exchange written messages on specific topics.

CBT primarily focuses on helping the client to overcome unproductive thoughts
and belief’s and replace them with constructive ones. People suffering from
anxiety and addiction undergo change in their thought, behaviour, and emotions.
All these three play an important role in the functioning of an individual. Cognitive
behaviour therapy which focuses on the thought pattern proves an effective
intervention. The counselor may use the cognitive therapy by Aron Beck
(1950,1976), rational emotive behaviour therapy (REBT) by Alberst Ellis (1960),
stress inoculation training by Meichenbaun (1977). These approaches are based
on the premise that people experiencing negative emotions such as anger,
depression, anxiety etc. have negative belief about themselves and their future.
The counselor tries to alter these negative beliefs. The counselor makes the client
aware of their cognitive distortions, help the client to understand how these
distortions in perception and thinking are the result of anxiety, depression and
stress. The counselors also help the clients to bring about changes through
corrections to the distortions in perception and thinking. The counselor also helps
the clients to search for alternative solutions to the problem.
4.7.8 Individual Counseling

Individual counseling is an inner journey of self exploration that is focused on
one’s goals. It is a collaborative effort that will help the client to shift out of the
patterns that no longer serve them and steer them toward the life they desire.
Following are some of the aims:
1) Develop more fulfilling relationships
2) Heal past hurts and traumas
3) Manage anger, depression and anxiety
4) Cope more effectively with life changes
5) Increase self esteem
6) Feel more balanced and whole

1) Describe the role of genetics in contributing to the development of
addiction/anxiety.
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62
Addiction/Anxiety
2) How can cognitive behaviour therapy help in the treatment of addiction/ Counselling
anxiety?
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3) Explain Individual Counselling.
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4.8 LET US SUM UP

In this unit you learned about the meaning of anxiety disorders and substance
abuse. The symptoms of addiction/anxiety were also described. You also came
to know how is an addiction developed and the role of anxiety in the development
of an addiction. The various symptoms of addiction/anxiety were described in
detail. The different causes such as personal, biological, social, psychological
and cultural factors were also described as leading to addiction/anxiety disorder.
Finally you learned about the variety of counselling techniques and therapies to
deal with addiction/anxiety.

1) What do you mean by Addictive behaviour? How does one develop
addiction? Discuss.
2) Describe the causes of Addiction/Anxiety.
3) Critically discuss the effectiveness of group therapy in overcoming addiction/
anxiety.
4) Explain the importance of anxiety hierarchy in dealing with anxiety/addiction.
5) Describe the environmental therapies.

Diana Sanders (2003). Counselling for Anxiety Problems. Sage Publications NY
Veeraraghavan, V and Singh, Shalinig (2000) Treatment of Anxiety Disorders.

Sage Publications.
63
Depression
UNIT 1 DEPRESSION
Structure
1.0 Introduction
1.1 Objectives
1.2 Definition and Description of Depression
1.2.1 Signs and Symptoms of Depression – General Terms
1.2.2 Psychological Symptoms: Feelings, Thoughts and Behaviour
1.2.3 Physical or Somatic Symptoms
1.2.4 Criteria for Formal Diagnosis of Major Depression
1.2.5 Criteria for Dysthymic Disorder
1.2.6 Criteria for Bipolar I Disorder
1.2.7 Criteria for Bipolar II Disorder
1.2.8 Criteria for Cyclothymic Disorder
1.3 Seasonal Affective Disorder (SAD)
1.3.1 Typical Symptoms
1.4 Depressive Disorder (Unipolar Disorder)
1.4.1 Dysthymic Disorders
1.5 Causes of Depression
1.5.1 Genetic Factors
1.5.2 Psychological Factors
1.5.3 Psychoanalytic Theories
1.5.4 Interpersonal Theories
1.5.5 Cognitive Theories
1.5.6 Helplessness Theories
1.6 Treatment of Depression
1.6.1 Biologically Based Treatment
1.6.2 Psychodynamic Approach to Treatment of Depression
1.6.3 Interpersonal Psychotherapy
1.6.4 Behavioural Therapy
1.7 Let Us Sum Up
1.9 Glossary
1.0 INTRODUCTION
Most people at some point in their life experience at least some degree of low
mood or depression. It is generally felt as sadness that is a normal response to
painful circumstances such as financial losses, the break-up of a relationship or
losing a job. However, sometimes the depressed mood continues for a prolonged
period of weeks or months. At this stage a psychiatrist might diagnose a depressive
disorder.
Depression is a term used to describe a mood state in which the main symptoms
or features include prolonged feelings of sadness or emptiness and lack of interest 5
Counselling for Mental in previously enjoyed activities. This caused depressed people significant distress,
Disorders
since they lose motivation to participate fully in their lives. Depressed people
have difficulty spending time with other people and might lose contact with
friends and family, which could deprive them of essential support. They might
even lose their job because of poor work performance or attendance.
Depression can also result from medical conditions or other psychological

disorders. For example, people suffering from adrenal and thyroid dysfunction
display depressive symptoms due to their being either very over or underweight.
Similarly, agoraphobics might become depressed because their fear of being
vulnerable in public places makes it difficult for them to experience taking part
in social activities. This prevents them from having essential, healthy contact
with other people. In this unit we will be dealing with depression, define and
describe the symptoms, discuss the different types of depression, causes of
depression and then the treatment of this disorder.
1.1 OBJECTIVES
• Define depression;
• Describe the symptoms of depression;
• Explain the causes of depression;
• Elucidate the different types of depression; and
• Describe the various treatment interventions for Depression.
1.2 DEFINITION AND DESCRIPTION OF

DEPRESSION
Although depression is often thought of being in an extreme state of sadness,
there is a vast difference between clinical depression and sadness. Sadness is a
part of being human, a natural reaction to painful circumstances. All of us will
experience sadness at some point in our lives. Depression, however, is a physical
illness with many more symptoms than an unhappy mood.
The person with clinical depression finds that there is not always a logical reason
for his dark feelings. Exhortations from well meaning friends and family for him
to “snap out of it” provide only frustration, for he can no more “snap out of it”
than a diabetic can will his pancreas to produce more insulin.
Sadness is a transient feeling that passes as a person comes to term with his
troubles. Depression can linger for weeks, months or even years. The sad person
feels bad, but continues to cope with living. A person with clinical depression
may feel overwhelmed and hopeless.
To clarify the differences between normal sadness and depression, there are
specific, defined criteria for the diagnosis of major depression:
A person who suffers from a major depressive disorder must either have a
depressed mood or a loss of interest or pleasure in daily activities consistently
for at least a two week period. This mood must represent a change from the
6 person’s normal mood and impair his functioning in his daily life.
A depressed mood caused by substances such as drugs, alcohol, or medications Depression
is not considered a major depressive disorder, nor is one that is caused by a
general medical condition.
1.2.1 Signs and Symptoms of Depression – General Terms

• Loss of interest in formerly pleasurable activities
• Dissatisfaction with life
• Withdrawal from social activities
• Loss of energy
• Feeling useless or hopeless
• Irritability
• Great concern with health problems
• Sadness or crying
• Worry and/or self-criticism
• Difficulty concentrating and/or making decisions
• Loss of appetite and weight.
1.2.2 Psychological Symptoms: Feelings, Thoughts and

Behaviours
• Feeling sad, blue, depressed, or hopeless most of the day.
• Greatly reduced interest or pleasure in all or almost all activities; inability
to think of anything that would be enjoyable to do (health permitting)
• Feelings of excessive guilt or a feeling that one is a worthless person.
• Slowed or agitated movements (not in response to pain or discomfort)
• Recurrent thoughts of dying or of ending one’s own life, with or without a
specific plan.
1.2.3 Physical or Somatic Symptoms

• Significant, unintentional weight loss and decrease in appetite; or, less
commonly, weight gain and increased in appetite.
• Insomnia or excessive sleeping
• Fatigue and loss of energy
• A diminished ability to think, concentrate, or make decisions
• Physical symptoms of anxiety, including dry mouth, cramps, diarrhea, and
sweating, ideation, or suicide attempt or plan.

1) Define and describe depression.
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7
Counselling for Mental
Disorders 2) How is normal depression different from pathological depression?
...............................................................................................................
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3) Elucidate the signs and symptoms of depression in general.
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4) What are the psychological symptoms of depression?
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5) Enlist the physical or somatic symptoms of depression.
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1.2.4 Criteria for Formal Diagnosis of Major Depression

The following criteria are taken from the DSM-IV, the Diagnostic and Statistical
Manual of Mental Disorders 4th edition, published by the American Psychiatric
Association, 1994.
For your convenience, a general listing of signs and symptoms of depression,
the translated version, follows the formal diagnostic criteria, for ease in
interpreting the symptoms.
For a diagnosis of a major depression:
1) At least 5 of the following symptoms.
2) These symptoms must be present during the same 2 week period.
3) These symptoms must represent a change from a previous level of
8 functioning.
Depressed mood nearly every day during most of the day. Depression
• Marked diminished interest or pleasure in almost all activities.

• Significant weight loss (when not dieting), weight gain, or a change in
appetite.
• Insomnia or hypersomnia (excess sleep).
• Psychomotor agitation or psychomotor retardation.
• Fatigue or loss of energy.
• Feelings of worthlessness or inappropriate guilt.
• Impaired ability to concentrate or indecisiveness
• Recurrent thoughts of death, recurrent suicidal
• Someone who has major depressive disorder has experienced one or more
major depressive episodes without ever experiencing a manic or hypomanic
episode.
1) Major Depressive Episode: A major depressive episode is marked by either

depressed mood or a loss of interest or pleasure in almost all activities and
at least four additional symptoms from the following group.
• Marked weight loss or gain when not dieting, constant sleeping problems,
agitated or greatly slowed down behaviour, fatigue, inability to think
clearly, feelings of worthlessness, and frequent thoughts about death or
suicide. These symptoms must last at least 2 weeks and represent change
from the person’s usual functioning.
2) Recurrent Major depressive Disorder: At least half of the people who

experience a major depressive episode will later have a recurrence of major
depression. For many people, an initial episode of major depression will
develop over time into a recurrent illness.
3) Major Depressive Episode with psychotic Features: About 15% of people

with a major depression have some psychotic symptoms usually delusions.
The delusions typically include guilt (“It is my fault that she is ill”),
punishment (“Iam suffering because Iam a terrible person”) or poverty (“I
will go bankrupt and starve in my old age”). Sometimes, delusions do not
have depressive themes.
1.2.5 Criteria for Dysthymic Disorder

a) Depressed mood for most of the day, for more days than not, as indicated
either by subjective account or observation by others, for at least 2 years.
In children and adolescents, mood can be irritable and duration must be at
least one year.
b) Presence, while depressed, of two (or more) of the following:
1) Poor appetite or overeating
2) Insomnia or hypersomnia
3) Low energy or fatigue
4) Low self-esteem
9
Counselling for Mental 5) Poor concentration or difficulty making decisions
Disorders
6) Feelings of hopelessness
c) During the 2-year period (1 year for children or adolescents) of the
disturbance, the person has never been without the symptoms in Criteria A
and B for more than 2 months at a time.
d) No Major Depressive Episode has been present during the first 2 years of
the disturbance (1 year for children and adolescents); i.e., the disturbance is
not better accounted for by chronic Major Depressive Disorder, or Major
Depressive Disorder, In Partial Remission.
e) There has never been a Manic Episode, a Mixed Episode, or a Hypomanic
Episode, and criteria have never been met for Cyclothymic Disorder.
f) The disturbance does not occur exclusively during the course of a chronic
Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
g) The symptoms are not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition (e.g.,
hypothyroidism).
h) The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Most people who have a dysthymic disorder would tell that they have felt
depressed for many years, or for as long as they remember. Feeling depressed
seems normal to them. It has become a way of life. They feel helpless to change
their lives.
Dysthymic is defined as a condition characterised by mild and chronic depressive

symptoms. Periods of dysthymia have been found to last from 2 to 20 or more
years, with a median duration of about 5 years. About 3% of the general population
and about 30% of those seen at outpatient clinics can be classified as dysthymic.
Some researchers have criticized the DSM-IV criteria because they believe they
do not give enough emphasis to what these researchers consider the most
characteristic symptoms of dysthymia: the cognitive symptoms, including low
self-esteem, feelings of guilt or thinking about the past, and subjective feelings
of irritability or excessive anger.
Because the depressed mood is long-lasting, dysthymia has sometimes been

considered a personality disorder. However, most researchers include it in the
group of mood disorders and believe it is biologically related to depression.
Dysthymia and major depressive disorder have been found to have a high degree
of comorbidirty. This means that both types of mood disorders are likely to occur
in the same individual.
A person with dysthymic disorder develops symptoms of major depression

because the criteria for both diagnoses are met. This dual state occurs quite
frequently
Although dysthymia seems to make people more vulnerable to major depression,

dysthymia itself is different from major depression in terms of the ages at which
10
people are most likely to be affected. In major depression, rates increase in certain Depression
age groups, but in dysthymia, the rate is stable from about age 18 until at least
age 64
Dysthymic disorders tend to be chronic, persisting for long periods. In contrast,

periods of intense depression are usually described as time-limited, which means
that even without treatment the symptoms naturally tend to lessen over time.
1.2.6 Criteria for Bipolar I Disorder

(Most Recent Episode Unspecified)
a) Criteria, except for duration, are currently (or most recently) met for a Manic,
a Hypomanic, a Mixed, or a Major Depressive Episode.
b) There has previously been at least one Manic Episode or Mixed Episode.
c) The mood symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
d) The mood symptoms in Criteria A and B are not better accounted for by
Schizoaffective Disorder and are not superimposed on Schizophrenia,
SchizophreniformDisorder, Delusional Disorder, or Psychotic Disorder Not
Otherwise Specified.
e) The mood symptoms in Criteria A and B are not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a medication, or
other treatment) or a general medical condition (e.g., hyperthyroidism).
1.2.7 Criteria for Bipolar II Disorder

a) Presence (or history) of one or more Major Depressive Episodes.
b) Presence (or history) of at least one Hypomanic Episode.
c) There has never been a Manic Episode or a Mixed Episode.
d) The mood symptoms in Criteria A and B are not better accounted for by
Schizoaffective Disorder and are not superimposed on Schizophrenia
Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not
Otherwise Specified.
e) The symptoms cause clinically significant distress or impairment in social
1.2.8 Criteria for Cyclothymic Disorder

a) For at least 2 years, the presence of numerous periods with hypomanic
symptoms and numerous periods with depressive symptoms that do not
meet criteria for a Major Depressive Episode.
NOTE: In children and adolescents, the duration must be at least 1 year.
b) During the above 2-year period (1 year in children and adolescents), the
person has not been without the symptoms in Criterion A for more than 2
months at a time.
c) No Major Depressive Episode,Manic Episode, or Mixed Episode has been
present during the first 2 years of the disturbance.
11
Counselling for Mental d) The symptoms in Criterion A are not better accounted for by Schizoaffective
Disorders
Disorder and are not superimposed on Schizophrenia, Schizophreniform
Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise
Specified.
e) The symptoms are not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition (e.g.,
hyperthyroidism).
f) The symptoms cause clinically significant distress or impairment in social,

1) Delineate the criteria for formal diagnosis of major depression.
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2) What criteria to be followed to diagnose dysthymic disorder?
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3) What criteria do we use to diagnose Bipolar I Disorder?
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4) Describe the criteria to be used for Bipolar disorder II.
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12
Depression
5) Explain the criteria for diagnosing cyclothymic disorder.
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1.3 SEASONAL AFFECTIVE DISORDER (SAD)

Sometimes people can experience depression at particular times of the year,
especially in northern countries and typically in winter. This seasonal pattern to
the depression is called SAD. People with SAD are often treated with light therapy
(exposure to artificial lights that imitate daylight) to lift their depressive episode.
1.3.1 Typical Symptoms

The typical emotions experienced during depression include sadness, guilt and
despair. It is also common for a depressed person to experience irritability,
agitation and anxiety. People suffering from depression can feel less motivated
to participate in activities or interests they previously enjoyed. As the depression
becomes worse, they might not bother to eat or cook for themselves, stop going
to work or taking care of their appearance. Sometimes depression makes people
not want to live and they might contemplate, attempt or even commit suicide.
The effects of depression on a person’s thinking include indecisiveness, reduced

concentration and decreased speed of thought. People experiencing depression
often have negative ideas, including self-criticism, they feel that others do not
understand them or punishing them and they do not look forward to the future.
Depression can also cause changes in the sufferer’s psychomotor activity. The
changes can range from inactivity (psychomotor retardation), such as slowed
movements or lack of movement to restless activity (psychomotor agitation)
such as pacing up and down.
Depression causes a range of changes in physiological or body functioning such

as reduced or increased appetite, fatigue or excessive tiredness and loss of sex
drive. Sleep disturbance is very common and has been estimated to affect more
than 90% of depressed individuals. Depression can also cause shorter periods of
sleep and increasingly broken sleep.
DSM IV outlines the criteria for a major depressive episode and also for the
presence of a single episode of depression and recurrent episodes. For a major
depressive disorder to be considered recurrent, a period of two months must
separate each depressive episode.
13
Disorders 1.4 DEPRESSIVE DISORDERS (UNIPOLAR
DISORDERS)
1.4.1 Dysthymic Disorders
Most people who have a dysthymic disorder would tell that they have felt
depressed for many years, or for as long as they remember. Feeling depressed
seems normal to them. It has become a way of life. They feel helpless to change
their lives.
Dysthymic is defined as a condition characterised by mild and chronic depressive
symptoms. Periods of dysthymia have been found to last from 2 to 20 or more
years, with a median duration of about 5 years. About 3% of the general population
and about 30% of those seen at outpatient clinics can be classified as dysthymic.
Some researchers have criticized the DSM-IV criteria because they believe they
do not give enough emphasis to what these researchers consider the most
characteristic symptoms of dysthymia: the cognitive symptoms, including low
self-esteem, feelings of guilt or thinking about the past, and subjective feelings
of irritability or excessive anger.
Because the depressed mood is long-lasting, dysthymia has sometimes been
considered a personality disorder. However, most researchers include it in the
group of mood disorders and believe it is biologically related to depression.
Dysthymia and major depressive disorder have been found to have a high degree
of comorbidirty. This means that both types of mood disorders are likely to occur
in the same individual.
A person with dysthymic disorder develops symptoms of major depression
because the criteria for both diagnoses are met. This dual state occurs quite
frequently
Although dysthymia seems to make people more vulnerable to major depression,
dysthymia itself is different from major depression in terms of the ages at which
people are most likely to be affected. In major depression, rates increase in certain
age groups, but in dysthymia, the rate is stable from about age 18 until at least
age 64.
Dysthymic disorders tend to be chronic, persisting for long periods. In contrast,
periods of intense depression are usually described as time-limited, which means
that even without treatment the symptoms naturally tend to lessen over time.

1) What is meant by seasonal affective disorder?
...............................................................................................................
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14
Depression
2) What are the typical symptoms of SAD?
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3) Discuss the symptoms of unipolar disorder.
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1.5 CAUSES OF DEPRESSION

Interpersonal and social factors that might affect the development of depression
include social isolation and either separation from a partner or divorce.
Biological factors that might influence the development of depression include

changes in neurotransmitter levels within the brain. Neurotransmitters carry
chemical messages between neurons and can influence mood and behaviour.
Three types of neurotransmitters – serotonin, dopamine and norepinephrine assist
in the regulation of emotions including stress, sleep functions and appetite. All
three are often found at lower levels in depressed people than in nonsufferers.
1.5.1 Genetic Factors

Researches indicate that people are between one and a half and three times more
likely to develop depression if one of their parents or brothers or sisters has the
disorder. Twin studies also have shown that if one identical twin develops
depression, the chances of the other twin developing the disorder can be as high
as 75%. This provides the evidence of the role of genetics in the development of
the disorder.
Researchers also considered the possibility that the combination of genes might
be involved in the development of a vulnerability to depression, which increases
a person’s chances of developing depression. Vulnerability to depression does
not mean that they will develop the disorder but it means that they develop
depression if other factors or situations also occur. Examples include growing
up with parents who are overly critical or rejecting, losing friends or jobs or
being placed in stressful or traumatic situations.

Factors which influence the possibility of developing depression include medical
illnesses, traumatic experiences such as abuse, war or accidents, job stress,
substance abuse and the adjustment required following serious injury. 15
Counselling for Mental Psychological theories of depression consider these factors as important in the
Disorders
development of the disorder. They focus on sufferer’s subjective experiences
and how they interpret the vents that occur in their lives. The three main theories
are psychoanalytic, interpersonal and cognitive.
1.5.3 Psychoanalytical Theories

Sigmund Freud suggested that depression occurs as a result of anger being turned
inward, especially after the loss of a valued family member or friend. This loss
can be either real such as after the end of a relationship or imagined, for example,
people who feel that they will never be loved again.
Freud stated that this internally directed anger leads to self-criticism and blame
and that the aim of this treatment is to release this anger. A consistent feature of
major depression can be irritability often directed toward family members or
close friends.
The criticism levelled against this view is that depression can affect people who
have not suffered the loss of a loved one. Freud’s theory that depressed people
have internalised anger is also not supported by dream analysis research.
Some of the latest psychoanalytic theories of depression have tried to address

these limitations. They proposed that depression develops when people believe
they have not reached their true potential such as achieving good grades in school
or gaining promotion or a pay raise at work. The effects of recognising and
accepting that they have not reached heir expected goals affects their ego. The
result is a general feeling of helplessness and low self-esteem that leads to
depression.
1.5.4 Interpersonal Theories

Theories suggest that depressed people have poorer social skills than people not
experiencing depression. Social skills include the ability to relate to other people
by making appropriate eye contact, being able to communicate clearly, being
able to show empathy and having a positive regard for others. People experiencing
depression have also been observed to have poor problem solving skills and
make poor day –day decisions. It is also found that people who experience
recurrent depression make poor decisions between depressive episodes.
Depressed people are more likely to be rejected by their friends or peers as they
have an aversive interpersonal style.
1.5.5 Cognitive Theories

According to these theories depression is caused by the misinterpretations or
errors people make about themselves, their world and the future. These errors
are negatively focussed. For example, sufferers might see themselves as useless,
the world as uncaring and the future as hopeless despite being successful in their
jobs and having devoted families.
Beck’s Cognitive Triad

He observed that depressed people tend to make specific errors in their thinking.
For example, deciding that they are stupid simply because they make one mistake
in a test. He suggested that depressed people develop specific beliefs with strong
16
negative elements based on these thought errors. A number of factors might lead Depression
to the development of these beliefs, including critical parents or rejection by
friends.
Cognitive Errors or Biases in Depression

1) Arbitrary inference – Drawing a conclusion from an event or situation
when there is lack of evidence to support this conclusion.
Situation: Waiters in a restaurant forget to take your dinner order.
Thought: They are ignoring me. I am obviously not worth their time.
2) Black and white thinking – Taking an extreme view of a situation.
Situation: Getting a test back and achieving 70%.
Thought: If I don’t get 100%, Iam a total failure.”
3) Magnification/ minimisation – Exaggerating or ignoring a particular aspect
of a situation.
Situation: A woman finds out she hasn’t been invited to a friend’s party.
Thought: They obviously don’t like me anymore. I must be a bad person.
4) Overgeneralisation – A gross generalisation based on a single event.
Situation: Being unable to answer a question asked by a teacher.
Thought: I am going to fail the rest of the year.
1.5.6 Helplessness Theories

These theories explore the specific thoughts of an individual when depressed.
The concept of learned helplessness was demonstrated by Seligman. He believed
that sufferers believe or find that they have little control over their lives and
become passive. Theories also use the concept of attribution. Attribution refers
to people’s explanation of a particular event and their response to it. For example,
depressed people might attribute failure to themselves when faced with a situation
they have difficulty controlling such as a difficult science test.

1) Delineate the causes of depression.
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2) State genetic factors as causing depression.
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17
Disorders 3) Elucidate the psychological factors causing depression.
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4) What is psychoanalytical explanation for depression?
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5) How do interpersonal theories explain depression?
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6) Explain cognitive theories for depression.
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7) Elucidate the helplessness theory of depression.
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18
Depression
1.6 TREATMENT OF DEPRESSION
1.6.1 Biologically Based Treatment
This approach includes antidepressant medication and electroconvulsive therapy
(ECT). This approach is often successful in lessening depression. ECT is faster
– acting than antidepressant medication and is often used if an effective medication
cannot be found.
There are many types of treatment for depression and some of the most frequently
used include:
• antidepressant tablets
• mood stabilising medications
• support with day-to-day matters while ill or recovering.
Treatments that are used less often, but which can also be helpful especially in
severe depression, of a specific type or has proved difficult to treat include:
• electroconvulsive therapy (ECT)
• special types of operation (psychosurgery)
• bright light therapy for seasonal affective disorder (SAD).
Lastly, there are potential treatments that are still either experimental or for which
more evidence needs to be found before they can be considered truly effective
and safe:
• herbal remedies (e.g. St John’s wort)
• trans-cranial magnetic stimulation (TMS), which involves applying brief
magnetic pulses to the brain. This is done with the patient awake and sitting
in a chair. A doctor holds an electric coil near to the head that emits repeated
short magnetic pulses. The procedure is painless. At the present time, TMS
is still under investigation as a treatment for depression. However, current
evidence suggests that it may be as effective as ECT, but safer.
Broadly speaking, treatments for depression can be broken down into two types:
• Firstly, there are those that aim to correct the chemical and biological
abnormalities that occur in the illness. These are: antidepressants, mood
stabilising medications, ECT and psychosurgery.
• Secondly, there are the psychological ones, talking treatments. These involve
regular appointments to talk to a professional person who is skilled in a
particular type of counselling or psychotherapy to help with depression.
The biological and psychological treatments are certainly not mutually exclusive
and are often used in combination.
Neither group of treatments or therapies should be considered better than the
other.
The treatment (or combination of treatments) used should be the one most likely
to help a person when all the different factors that have led to their illness are
taken into account.
19
Counselling for Mental This is the reason that approaching a professional is so important in deciding
Disorders
how best to cope with and treat depression.
Antidepressant Tablets
There are a number of different groups of these and they include:
• Tricyclic antidepressants (TCAs), e.g. amitriptyline, imipramine, lofepramine.
• Selective serotonin reputake inhibitors (SSRIs), eg fluoxetine, paroxetine,
citalopram.
• Monoamine oxidase inhibitors (MAOIs), eg moclobemide, phenelzine,
tranylcypromine.
• Other medicines that do not quite fit neatly into these groups, but that have
effects similar to one or more of these groups (eg venlafaxine, mirtazapine,
reboxetine, trazodone).
The oldest antidepressants are the monoamine-oxidase inhibitors (MAOIs) and
tricylic antidepressants (TCAs). The TCAs are still in wide use today and remain
effective medicines.
The MAOIs require a special diet to avoid unpleasant and potentially serious
side-effects, and they can interact with many other medicines.
They are therefore generally used only for people whose depression has not
responded to other treatments.
The SSRIs are a much newer group of antidepressants, but they have been widely
and successfully used for about twenty of years.
• All antidepressants work by boosting one or more chemicals (called
neurotransmitters) in the nervous system. These chemicals may be present
in insufficient amounts in depression, resulting in the symptoms of the illness.
• All antidepressants take a minimum of two weeks (and sometimes up to
eight weeks) to start to work, and once they have started working the
depression recovers gradually.
• It’s vitally important, therefore, that if a person is given antidepressants
they should keep taking them regularly, even if they don’t seem to make
much difference to begin with.
• Some antidepressants can cause mild unpleasant effects if they are stopped
very suddenly, but even these can normally be avoided if the medicine is
tailed off over a period of time.
• A rule of thumb is that antidepressants should be taken for at least six months
at the same dose after the person has recovered. This reduces the risk of the
depression coming back again.
• A few people whose depression does return every time they come off
antidepressants may need to be on treatment on a long-term basis.
• There is no evidence to suggest that any one antidepressant or antidepressant
group is better than any other in terms of the number of people who will
benefit from it. (Generally around two-thirds of people will find that their
symptoms improve on any particular medication).
20
• But one may be a better choice than another on the grounds of its side effects: Depression
for instance a person who finds that their sleep is disturbed may benefit
from an antidepressant that is also quite sedative. By contrast someone who
is sleeping reasonably and has to be able to listen out for their children
would clearly find this effect a problem, and would be better with a non-
sedative medication.
• If an antidepressant from one group does not work very well, then there is a
good chance that one from another group may work.
Mood Stabilisers
• In depression, these medicines are used to boost the effects of antidepressants.
• The best-known mood stabiliser is lithium. It is also the best-proven one,

but one drawback is that regular blood tests are needed to check its level.
(Lithium is also used in bipolar affective disorder – ‘manic depression’.)
• There are some newer mood stabilisers available now that offer alternatives
to lithium, such as sodium valproate (Epilim) or semisodium valproate
(Depakote).
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is a treatment that has been used for many
decades for depression. But it is controversial.
The facts are:
• it is a very effective treatment for depression, perhaps the single most effective
treatment.
• it is especially effective for severe depression and depression that has a lot
of physical symptoms, such as changes in appetite, sleep and concentration.
• it is as safe as any minor procedure that needs a general anaesthetic.
• it can be life saving as it can work more quickly than antidepressant medicines.
• there’s no good evidence for any permanent damage to the nervous system.
Like all treatments, ECT does have some side effects. These can include:
• headache
• forgetfulness around the time of treatment.
1.6.2 Psychodynamic Approach to Treatment of Depression

According to Freud, depressed person had a strong and punishing conscience
and the reason for it was to control anger and aggressive feelings that otherwise
come forth to hurt others. Psychoanalytic theorists have suggested that clinical
episodes of depression happen because the events that set off the depression
revive dimly conscious, threatening views of the self and others that are based
on childhood experience. Bowlby also believed that childhood experiences that
contribute to these depressed feelings were not single events but developed from
long – term patterns of familial reaction.
This approach helps the client to become aware of their beliefs that originated in
childhood. The therapist facilitates the process of transference so that the client
21
Counselling for Mental exhibits all his reactions that were suppressed. The therapist helps the client to
Disorders
identify his reactions and help him in alter these reactions.
1.6.3 Interpersonal Psychotherapy

It focuses on teaching people to be more socially effective as a way to improve
their relationships with their significant others. It integrates the psychodynamic
perspective which emphasises early childhood experiences with the cognitive
behavioural perspective which emphasises current psychosocial stressors such
as chronic marital discord. This therapy works well when paired with the use of
antidepressant medications and has been demonstrated to be effective, both in
lessening depressive symptoms and in extending the period of remission for
individuals who have a history of recurrent depressions.
1.6.4 Behavioural Therapy

As depressed people lack skills necessary to develop satisfying relationships
with others, one behavioural approach to this problem is through social skills
training. Social skills’ training consists of several parts. First clients are taught
basic verbal and nonverbal skills. When these are learned, the clients practice
gradually putting the basics together. Then clients are given “homework”
assignments in which the goal is to adapt the new skill so it is useful in the
everyday environment. Clients are also trained to be more perceptive about cues
other people in the environment give and they learn how to change their own
behaviour in response. Finally, clients learn to adopt realistic criteria for evaluating
their performance and are taught how to be self reinforcing.
Role play is necessary so that the client gets the practice needed to use new
behaviours in the real – life situations. The practice gained from these assignments
is in turn critical for success in learning new habits.
1.6.5 Cognitive Behavioural Therapy

This therapy makes use of both behavioural and cognitive theoretical perspectives
based on the client’s skills, degree of depression and on the chosen goals of
therapy. The main focus of CBT is to help clients think more adaptively and as a
result to experience positive changes in mood, motivation and behaviour.
The more severely depressed the client, the more likely the therapist is to use
behavioural techniques at the beginning of the treatment process. Clients are
taught how to self – monitor their experiences, noting which gave pleasure and
feelings of mastery and which lowered their mood. They are also taught to monitor
and record their negative thoughts. Special emphasis is put on automatic thoughts,
recurring thoughts that come into a person’s mind almost as if by habit rather
than as a specific response to what is currently going on.
Therapists use several techniques to help clients identify these thoughts, including
direct questioning, asking the client to use imagery to evoke the thoughts, or
eliciting them by means of a role – play situation. The clients are also asked to
keep a daily record of their thoughts. The record includes notes on the situation,
emotions, automatic thoughts and the outcome. In this way the client learns that
a person’s view of reality can be quite different from the reality itself. The therapy
can help change dysfunctional thinking and thus alleviate the depression by
challenging parts of the client’s belief system.
22
Depression
1) Discuss the biologically based treatment for depression.
...............................................................................................................
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2) What is the psychodynamic approach to treatment of depression?
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3) How does interpersonal psychotherapy function as treatment for
depression?
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4) Explain behavioural therapy as treatment of depression.
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5) Elucidate cognitive behavioural therapy as treatment for depression.
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23
Disorders 1.7 LET US SUM UP
The term depression is commonly used to refer to normal feelings experienced
after significant loss such as the breakup of a relationship or the failure to attain
a significant goal. These feelings are not classified as a depressive disorder by
DSM –IV. Symptoms of grief over the death of a loved one also are not classified
as depression unless they continue for an unusually long period.
Depression can refer to a symptom or disorder. The symptom of depressed mood

does not necessarily mean a person has a depressive disorder. Some symptoms
of depression occur frequently in people who ‘have the blues’ but are not clinically
depressed. But, those who meet DSM – IV criteria experience symptoms that
are more severe.
Depressive disorders include dysthymic disorder and major depressive disorder.

Depression is the result of an interaction between biological characteristics,
psychological vulnerabilities and stressful events or ongoing stressful life
situations. Treatment to depression includes biological, psychodynamic,
interpersonal, behavioural and cognitive behavioural approaches.

1) Discuss the causes for the occurrence of depression.
2) Explain depressive disorders.
3) Explain the significance of different approaches in treating depression.
1.9 GLOSSARY
Dysthymic disorder : It is a stable condition in which a depressed
mood is dominant over long periods of time
even if is interrupted by short periods of
normal mood.
Major depressive disorder : It is diagnosed when a person has experienced

one or more major depressive episodes but
has never experienced either a manic or
hypomanic episode.
Recurrent major depressive : When a person who has experienced one

disorder major depressive episode develops the
symptoms again at a later time, the diagnosis
is known as recurrent major depressive
disorder.
Major depressive episode : If someone experiences delusions or other

with psychotic features psychotic symptoms during a major
depressive episode, it is diagnosed as major
depressive episode with psychotic features.
24
Depression
Carson, R.C. Butcher, J.N. & Mineka, S. (2000). Abnormal Psychology and
Modern Life. Pearson Education, India.
Coleman, J. C. (1976). Abnormal Psychology and Modern Life. Scott Foresman

and Company.
Sarason,I.G. & Sarason, B. R.(2002). Abnormal Psychology: The Problem of

Maladaptive Behaviour. Pearson Education, India.
25
Disorders UNIT 2 PERSONALITY DISORDER
Structure
2.0 Introduction
2.1 Objectives
2.2 Nature of Personality Disorders
2.3 Origin and Different Types of Personality
2.3.1 Paranoid Personality
2.3.2 Cyclothymic Personality
2.3.3 Schizoid Personality
2.3.4 Explosive Personality
2.3.5 Obsessive Compulsive Personality
2.3.6 Hysterical (Histrionic) Personality
2.3.7 Asthenic Personality
2.3.8 Antisocial Personality
2.3.9 Passive Aggressive Personality
2.3.10 Inadequate Personality
2.3.11 Sexual Deviations
2.4 Diagnosis
2.5 Features of Personality Disorders
2.6 Causes of Personality Disorders
2.6.1 Biological Factors
2.6.3 Socio-Cultural Factors
2.7 Clusters of Personality Disorders
2.7.1 Cluster A Personality Disorders
2.7.2 Cluster B Personality Disorders
2.7.3 Cluster C Personality Disorders
2.8 Treatment of Personality Disorders
2.9 Let Us Sum Up
2.11 Glossary
2.0 INTRODUCTION
‘Personality’ is the characteristics or qualities that form an individual’s character.
For example the way they feel, behave and their pattern of thoughts all make up
someone’s personality and this is what makes each person the individual they
are. Generally speaking someone’s personality does not normally change very
much, but it can develop as people go through different experiences in life, and
as their circumstances change. People are usually flexible enough to learn from
past experiences and change their behaviour to cope with life more effectively,
but if someone has a personality disorder they are likely to find this more difficult.
In this unit we learn about personality disorders. We start with nature of personality
26
disorders and follow it up with origin of and different types of personality. Under Personality Disorder
this we discuss different types of personality even in normal persons. Then we
discuss the features of personality disorders followed by causes of personality
disorders. Then we present the clusters of personality disorders followed by
treatment of personality disorders.
2.1 OBJECTIVES
• Define personality and personality disorders;
• Explain Nature of personality disorders;
• Trace the Origin and diagnosis of personality disorders;
• Elucidate the Types of personality disorders; and
• Describe the Treatment for personality disorders.
2.2 NATURE OF PERSONALITY DISORDERS

The term “personality disorder” simply refers to a diagnostic category of
psychiatric disorders characterised by a chronic, inflexible, and maladaptive
pattern of relating to the world. This maladaptive pattern is evident in the way a
person thinks, feels, and behaves. The most noticeable and significant feature of
these disorders is their negative effect on interpersonal relationships. A person
with an untreated personality disorder is rarely able to enjoy sustained, meaningful,
and rewarding relationships with others, and any relationships they do form are
often fraught with problems and difficulties.
To be diagnosed with a “personality disorder” does not mean that someone’s

personality is fatally flawed or that they represent some freak of nature. In fact,
these disorders are not that uncommon and are deeply troubling and painful to
those who are diagnosed with these disorders. Studies on the prevalence of
personality disorders performed in different countries and amongst different
populations suggest that roughly 10% of adults can be diagnosed with a personality
disorder.
Unlike many types of disorders that are indicated by symptoms that are not usually
found in the general population (e.g., seizures), personality disorders cannot be
understood independently from healthy personalities. Since everyone has a
personality (but not everyone has seizures), personality disorders reflect a variant
form of normal, healthy personality. Thus, a personality disorder exists as a special
case of a normal, healthy personality in much the same way as a square is a
special case of the more general construct of a rectangle. Therefore, it is useful
for us to begin our discussion of personality disorders by first discussing the
broader, more general construct of personality.
The term ‘personality disorder’ describes various clusters of symptoms and slots
different groups into separate categories of disorder. There are many different
types and it is not uncommon for someone with one type of personality disorder
to have other types of personality disorder as well.
27
Counselling for Mental Personality disorders are long standing, maladaptive, inflexible ways of relating
Disorders
to the environment. Such disorders can usually be noticed in childhood, or at
least by early adolescence, and may continue through adult life. They severely
limit an individual’s approach to stress – producing situations because his
characteristic styles of thinking and behaviour allow for only a rigid and narrow
range of responses.
They may have great difficulty controlling their impulses and emotions, and
often have distorted perceptions of themselves and others. As a result, these
individuals may suffer enormous pain and have significant difficulty functioning
at home, work, and in relationships.
Families commonly endure episodes of explosive anger and rage, extreme

depression (e.g., person rarely gets out of bed), self-mutilation (self-inflicted
cuts and burns), and suicide attempts by family members with personality
disorders. These individuals are often referred to treatment by loved ones who
recognise a troubling pattern, or who have reached their personal limit in trying
to cope with them.
Case 1: Sunitha is 37 years old, married, and the mother of two children. She
experiences unstable moods, and has repeatedly cut herself, usually when feeling
very stressed or abandoned. She often feels empty and bored. She has abused
alcohol and drugs in the past. She is extremely sensitive to criticism, and angrily
reacts to perceived rebuffs.
Personality Disorders usually become noticeable in adolescence or early

adulthood, but sometimes starts in childhood. It can make it hard for people with
a personality disorder to start and keep friendships or other relationships and
may find it hard to work effectively with other people.
People with mild personality disorders usually manage to live normal lives but
in times of increased stress the symptoms of the personality disorder are likely to
impact seriously on how they think and feel and they can find it hard to cope.
2.3 ORIGIN AND DIFFERENT TYPES OF

PERSONALITY
A personality disorder, as defined in the Diagnostic and Statistical Manual of
the American Psychiatric Association, Fourth Edition, Text Revision (DSM-IV-
TR), is an enduring pattern of inner experience and behaviour that differs markedly
from the expectations of the individual’s culture, is pervasive and inflexible, has
an onset in adolescence or early adulthood, is stable over time, and leads to
distress or impairment. Personality disorders are a long-standing and maladaptive
pattern of perceiving and responding to other people and to stressful
circumstances. Ten personality disorders, grouped into 3 clusters (ie, A, B, C),
are defined in the DSM-IV-TR.
Disordered patterns of behaviour characterised by relatively fixed and inflexible

lifelong reactions to stress. Individuals may show repetitive, maladaptive, and
frequently self-defeating patterns of behaviour, inadequate handling of impulses,
or restricted and inappropriate feelings. The individual has a limited variety of
responses to stress, and in the face of failure to cope may show anxiety, denial,
28
or psychotic behaviour. In the absence of environmental frustration, he tends to Personality Disorder
show little anxiety or mental or emotional symptoms, and the behaviour patterns
are said to be “ego syntonic,” i.e., they are felt by the person to be “normal” and
“right.” Thus, such a person rarely seeks help because of his own anxiety and
discomfort; more often he is referred by a family or society with whom he is
unable to live in harmony. If the patient seeks help, it usually follows
environmental frustrations and he shows typical neurotic symptoms and conflicts.
The maladaptive behaviour patterns seen in personality disorders tend to be

exaggerations of mechanisms used at times by, most people. Diagnosis of
personality disorders is based on behavioural manifestations and patterns and
need not reflect a subjective sense of conflict or distress. Frequently, though, one
recognises low self-esteem, paucity or relative superficiality of intimate
relationships, difficulty in sustaining interests, low frustration tolerance, difficulty
in postponing gratification, and inability to learn from experience.
The causes of these disorders are unknown, but constitutional factors may play a
role in some instances (schizoid, cyclothymic, antisocial personalities), In general,
it is assumed that patterns of response are a result of early experiences and
conditioning, and that early interpersonal relationships are important in
establishing modes of defense and their rigidity.
2.3.1 Paranoid Personality

These people tend to be hypersensitive, with an underlying suspicion of others
and their motivations. They are often rigid and inflexible in behaviour and react
poorly to criticism or suggestions for change. They feel isolated and project onto
others harmful motives and blame for misfortune. It is assumed that these traits
are the person’s ways of dealing with feelings about himself which he regards as
unacceptable, demeaning, or dangerous. Often the suspicious attitude leads to
aggressive feelings and/or behaviour, with resultant further isolation. The
individual’s sense of self-adequacy and self-esteem seems particularly impaired.
Often the behaviour of these people is designed to, prove their adequacy, while
their sense of worthiness becomes exaggerated and is accompanied by belittlement
of others. In many spheres: they may be highly efficient and conscientious, though,
lacking flexibility. Positions of power and recognition may be achieved, but
frequently at the expense of the ability to relax and to maintain a sense of humor.
Often their suspiciousness and hostility bring about rejection by others, which
seems to justify their original feelings, but they are unable to see their own part
in this cycle. They may be litigious, especially when they feel a sense of righteous
indignation.
2.3.2 Cyclothymic Personality

Behaviour is frequently characterised by alternating and recurrent states of
depression or elation. While elated, these persons feel active and outgoing; are
ambitious, optimistic, and enthusiastic; and may show high levels of energy. At
such times they are gregarious and capable of attracting friends who may find
them fascinating though unpredictable or eccentric. Periods of depression are
characterised pessimism, low levels of energy, and a sense of hopelessness and
worry. Moods of cheerfulness and sadness are part of normal behaviour and no
doubt there is a continuum with cyclothymic personalities. However, with a
cyclothymic disorder, the mood swings are precipitated more by internal than 29
Counselling for Mental external events, tend to be more intense, and are apt to be cyclic. At times there
Disorders
is not a regular swing from high to low moods but, rather, a more sustained
depression or euphoria. It is uncertain whether the cyclothymic personality
disorder lies on a continuum with manic-depressive illness or is a different entity.
2.3.3 Schizoid Personality

These persons are oversensitive, withdrawn, seclusive, and shy, and avoid close
or prolonged relationships. They may be characterised as eccentric and their
thinking as “autistic” (somewhat idiosyncratic but without loss of reality testing).
Daydreaming is common, with difficulty in expressing feelings, and detachment.
The range of adaptive responses is limited and withdrawal is the main reaction
to stress. Often they develop highly stylised and distinct interests which further
separate them from their peers, and, in general, their attention is directed to
asocial endeavors.
2.3.4 Explosive Personality

This pattern is characterised by sudden, tantrum like outbursts of rage or verbal
or physical aggressiveness. Despite guilty and regretful feelings, these individuals
are unable to control their outbursts. They are easily excited by environmental
frustrations. Recently, questions have been raised as to whether underlying minor
organic brain changes predispose to this explosiveness.
2.3.5 Obsessive Compulsive Personality

Patterns of behaviour are characterised by concern for perfection and orderliness,
conformity to social norms, and high personal standards of conscience. Persons
with this reaction have difficulty dealing with ambiguous situations; need to
define, compartmentalise, and conceptualise problems; and also show some
rigidity, inhibition, and difficulty in relaxing. There is a drive to control the
situation, and to reduce ambiguity. When faced with new, uncertain, and complex
situations, they display anxiety. The quality of compulsiveness is in tune with
Western cultural standards, and when the disorder is not too marked these people
are often capable of high levels of achievement, especially in the sciences and
academic fields where order is desirable. On the other hand, they often feel a
sense of isolation and difficulty with interpersonal relationships in which one
must rely on others and in which one’s feelings are less under strict control and
events are less predictable.
2.3.6 Hysterical (Histrionic) Personality

This pattern is characterised by dramatic and attention seeking behaviour,
excitability, emotional instability and over-reactivity, self-centeredness, and a
provocativeness or sexualisation of nonsexual relationships often combined with
sexual frigidity or fears. Though superficially self-assured, such people have
major doubts as to their identity and goals. Their difficulty in expressing genuine
feelings further prevents intimate relationships. Such relationships are affected
by the individual’s seemingly insatiable need for affection. Behind their sexually
seductive behaviour lies a child-like wish for nonsexual affection and protection.
2.3.7 Asthenic Personality

This category is characterised by lack of enthusiasm, low energy and capability,
30 difficulty in developing a broad sense of enjoyment and pleasure, and a poor
response to even small physical or emotional stresses. These persons never seem Personality Disorder
to mobilise resources to meet distress and, as a result, feel helpless, wishing they
could do more but seemingly unable to feel up to doing it.
2.3.8 Antisocial Personality

This pattern, formerly referred to as “sociopathic,” includes those whose
behaviour is repetitively in conflict with social mores. Delinquent behaviour is
not the sole pattern, but is accompanied by impulsiveness, irresponsibility, either
a low sense of guilt or guilt that appears only after an event, callousness toward
others, and a superficiality of emotional involvement. These people seem to
have a keen capacity for rationalising and explaining their behaviour as a
consequence of another’s. They also show little foresight. Onset is usually before
age 12 to 15. Typical childhood symptoms are theft, lack of discipline, and truancy
together with habit disturbances such as enuresis, sleepwalking, and nail-biting.
As adults they have continued problems with school, poor work records, and
unstable marital histories, besides showing belligerency, social isolation, sexual
deviations, and frequently excessive alcohol or drug use. They also complain of
anxiety and somatic complaints. The disorder is preponderant in males; there is
some evidence to believe that there is a “maturing out” of the disorder between
ages 30 and 40, followed by a decrease in gross antisocial behaviour.
2.3.9 Passive Aggressive Personality

This group is subdivided into passive, passive-aggressive, and aggressive types.
The passive type is characterised by helplessness, indecisiveness, and a clinging
dependency even when given support from others. Such passivity may serve to
gain attention and affection, to avoid responsibility, and/or to control others
covertly. Passive-aggressive behaviour is characterised by obstinacy, inefficiency,
procrastination, and sullenness, often disguised under a superficial compliance.
Frequently these people agree to perform a task and then proceed to subtly
undermine its completion with complaints and passive obstructionism. The
aggressive type is characterised by sullenness, tantrum-like behaviour,
provocativeness, and argumentativeness, especially with those in authority. Such
behaviour usually serves to deny or conceal marked dependency needs. The
behaviour is maladaptive in that, ironically, it drives others away and prevents
the individual from receiving even a normal amount of support.
2.3.10 Inadequate Personality

The term describes individuals whose response to any form of stress seems
ineffectual. Their behaviour shows poor judgment, ineptness, lack of energy,
poor long-range planning, and poor performance. Incentive is lacking, especially
to achieve culturally desired levels. These people are marginally involved in
social relationships, tend to drift, and take non-demanding jobs. There is no
evidence for physical or mental defects. However, there does seem to be some
social value-judgment essential to this diagnosis, since those diagnosed as
inadequate personalities tend to be in the lower socioeconomic level on the other
hand, this may reflect early social, cultural, and experiential deprivation which,
together with the repeated experience of failure, leads to passive styles of
behaviour. Often these people are welfare recipients or reside in institutions.
31
Counselling for Mental 2.3.11 Sexual Deviations
Disorders
This category refers to those who repetitively and somewhat compulsively direct
their sexual interests toward objects other than the opposite sex, toward sexual
acts not associated with intercourse, or toward intercourse only when associated
with stylised behaviour (e.g., sexual sadism). The term carries a moral connotation
and is somewhat related to cultural norms. However, it is believed that this
behaviour reflects at least developmental difficulties, if not psychopathology,
and that “deviant” sexual behaviour is an attempt to achieve some sexual
gratification while avoiding fears associated with usual adult sexual practices.
Clinicians use different theories to explain the origin and development of each
of these disorders. Some argue that personality disorders are inherited while
others suggest that the environment in which we grow up is responsible for our
personality traits.

1) Discuss the nature of personality disorders.
...............................................................................................................
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2) What are the different types of personality that we obtain even in normal
persons?
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3) Discuss paranoid, cyclothymic, schizoid and explosive personality.
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32
Personality Disorder
4) Elucidate the obsessive compulsive personality, hysgterical ersonality
and asthetic personality.
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5) Describe antisocial personality, passive aggressive personality and
inadequate personality.
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6) What is sexual deviation?
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2.4 DIAGNOSIS
Personality disorders are diagnosed on DSM-IV’s Axis II and they are near
permanent disorders. On the other hand, Axis I disorders are called symptom
disorders which may come and go. Symptom disorders may be triggered by events
or environmental factors and may disappear when conditions change. People
with Axis I disorders often see themselves as having personal problems
(symptoms) that are troublesome and require treatment. People with Axis II
disorders are far more likely to say that their difficulties are attributable to the
environment and that they do not require clinical treatment.
Clinicians also differ on diagnosis. For example, when a highly unpredictable,

exuberant patient walks into a psychiatrist’s room, one psychiatrist might diagnose
him as having antisocial personality disorder and psychopathy, while another
might say that he has borderline personality disorder. This is because the diagnostic
methods used such as questionnaires are not very reliable. However, better
methods are being devised that might show more of a clear pattern for diagnosis
– even across different cultures.
33
Disorders 2.5 FEATURES OF PERSONALITY DISORDERS
The features of personality disorders are:
• Early onset: This is evident at least since late adolescence.
• Stability: No significant period when not evident.
• Pervasive: This is evident across a wide range of personal, social and
occupational situations
• Clinically significant maladaptation resulting in personal distress or
impairment in social and occupational functioning.
2.6 CAUSES OF PERSONALITY DISORDERS

There is no single cause of personality disorder. It is thought that a combination
of factors may contribute to people being vulnerable to the development of a
personality disorder due to genetic factors. However, it may be related more to
the fact that people affected have not had the opportunity to learn at an early age
how to act or react and manage their feelings.
A personality disorder may also relate to incidents or traumas in childhood like
physical or sexual abuse or where there have been difficulties in parenting. Figures
show that around 80% of those diagnosed with borderline personality disorder
have been diagnosed as having a childhood trauma.
Dissociative Identity Disorder (previously referred to as ‘multiple personality
disorder’) and other dissociative disorders are now understood to be fairly
common side effects of severe traumas in childhood.
Personality disorders are more common when stress levels are high. So treatment
tends to focus on coping and learning how to relate to others. This is because
people diagnosed with personality disorders have often missed the opportunity
in childhood to learn how to cope and manage their feelings.
Many people do not even know they have a personality disorder. They may just
think that they are miserable and that their lives are pointless. Part of the problem
is they are not able to think about their feelings, so they may even resort to drugs
and alcohol, self harm or even overdoses, which make things worse.
The role of causal factors in personality disorders is not known much as these
disorders received attention only since the publication of DSM –III and also
because they are less amenable to study. One major problem in studying the
causes of personality disorders stems from the high level of co morbidity among
them i.e. patients who are qualified for one personality disorder diagnosis also
qualified for one or more than one other personality disorders. Another problem
is that many people with these disorders are never seen by clinical personnel.
2.6.1 Biological Factors

It has been suggested that infant’s constitutional reaction tendencies (high or
low vitality, behavioural inhibition) may predispose them to the development of
particular personality disorders. As most of the personality traits are found to be
moderately heritable, there is increasing evidence for genetic contributions to
certain personality disorders like paranoid personality disorder, schizotypal
34
personality disorder, borderline personality disorder and antisocial personality Personality Disorder
disorder. Some progress is also made in understanding the psychobiological
substrate of at least some of the personality disorders. For example, people with
borderline personality disorder appear to be characterised by lowered functioning
of the neurotransmitter serotonin due to which they show impulsive aggressive
behaviour as in parasuicidal acts such as cutting their arms with a knife. Patients
with borderline personality disorder may also show disturbances in the regulation
of noradrenergic neurotransmitters that are similar to those seen in chronic stress
conditions such as PTSD. Moreover, deficits in the dopamine system may be
related to a disposition toward transient psychotic symptoms.

Early learning experiences are usually assumed to contribute the most in
predisposing a person to develop a personality disorder. Numbers of studies have
suggested that abuse and neglect in childhood may be related to the development
of certain personality disorders. Patients with borderline personality disorder
reported significantly higher rates of abuse than patients with other personality
disorders.
Psychodynamic theorists also expressed their views on the causes of personality

disorders. For example, with regard to narcissistic personality disorder they
believed all children go through a phase of primitive grandiosity during which
they think that all events and needs revolve around them. For a normal
development to occur beyond this phase, parents must do some mirroring of the
infant’s grandiosity. This disorder is also likely to develop if parents are neglectful,
devaluing or unempathetic to the child.
2.6.3 Socio-Cultural Factors

The role of socio-cultural factors is not clearly found. However, the changing
culture, emphasis on impulse gratification, instant solutions and pain free benefits
are leading more people to develop the self –centered life – styles that we see in
more extreme forms in the personality disorders.

1) How do you diagnose personality disorders?
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2) Delineate the features of personality disorders.
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35
Disorders 3) Discuss the biological causative factors of personality disorder.
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4) Elucidate the psychological causes of personality disorder.
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5) What are the socio-cultural factors contributing to personality disorders?
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2.7 CLUSTERS OF PERSONALITY DISORDERS

There are 10 different types of personality disorder. Each one is linked with a
different set of attitudes, emotions and behaviours. These personality disorders
are grouped into three clusters – A, B and C.
2.7.1 Cluster A Personality Disorders

Cluster A features odd or eccentric behaviour. The personality disorders in this
cluster include:
1) Paranoid Personality Disorder
People with this disorder can be cold and detached and find it hard to form
relationships. They are often suspicious in their surroundings and can act
angrily towards other people. This distrust and suspiciousness is indicated
by four (or more) of the following (from DSM-IV, American Psychiatric
Association, 1994):
1) Suspects, without sufficient basis, that others are exploiting, harming,
or deceiving him or her
2) Preoccupied with unjustified doubts about the loyalty or trustworthiness
of friends or associates.
3) Reluctant to confide in others because of unwarranted fear that the
36 information will be used against him or her
4) Reads hurtful or threatening meanings into kind remarks or events Personality Disorder
5) Unforgiving of insults or injuries

6) Perceives attacks on his or her character or reputation that are not
apparent to others and is quick to react angrily
7) Has recurrent suspicions, without justification, regarding faithfulness
of spouse or sexual partner.
2) Schizoid Personality Disorder
People diagnosed with this disorder can be cold, distant and reclusive, shying
away from closeness or intimacy. They can get caught up in their own
thoughts and hold back from getting involved with other people. This pattern
is indicated by four (or more) of the following (from DSM-IV, American
Psychiatric Association, 1994):
1) neither desires nor enjoys close relationships, including family
relationships
2) often chooses activities that don’t involve other people.
3) has little interest in having sexual relations with another person
4) enjoys few activities
5) lacks close friends other than immediate family
6) appears indifferent to praise or criticism
7) shows emotional coldness, detachment, or little emotional expression.
3) Schizotypal Personality Disorder
It has the same traits as the schizoid personality disorder. But, in addition to
the above they can have chaotic thoughts and views and are poor
communicators. This disorder is indicated by five (or more) of the following
(from DSM IV, American Psychiatric Association, 1994):
1) ideas of reference, i.e., believes that casual and external events have a
particular and unusual meaning that is specific to him or her
2) odd beliefs or magical thinking that influences behaviour and is
inconsistent with cultural norms (e.g., belief in superstitions or
clairvoyance, telepathy, or “sixth sense”
3) unusual perceptual experiences (e.g., hears a voice murmuring his or
her name; reports bodily illusions)
4) odd thinking and speech (e.g., unusual phrasing, speech which is vague,
overly elaborate, and wanders from the main point)
5) excessively suspicious thinking
6) inappropriate or constricted emotions (reduced range and intensity of
emotion) behaviour or appearance that is odd or peculiar (e.g., unusual
mannerisms, avoids eye contact, wears stained, ill-fitting clothes) lack
of close friends or confidants other than immediate family excessive
social anxiety that remains despite familiarity with people and social
situation. The anxiety relates more to suspiciousness about others’
motivations than to negative judgments about self.
37
Counselling for Mental 2.7.2 Cluster B Personality Disorders
Disorders
Cluster B features dramatic, emotional or erratic behaviour. The personality
disorders in this cluster include:
a) Borderline Personality Disorder
People with this disorder have a shaky, unsure view of themselves and have
problems with relationships. They can be moody and see things in black
and white. They feel they lost out on nurturing as children and can become
very needy and clingy as adults. When their needs are not met, they feel
empty, angry and abandoned and may react in a desperate and impulsive
way.
This pattern begins by early adulthood, occurs in various contexts, and is

indicated by five (or more) of the following (from DSM IV, American
1) frantic efforts (excluding suicidal or self-inflicted cuts or burns) to avoid
real or imagined abandonment.
2) a pattern of intense and unstable interpersonal relationships that may
quickly alternate between extremes of idealisation (the other person
may be “put on a pedestal”) and devaluation (the other person’s negative
qualities are now exaggerated).
3) identity disturbance: sudden and dramatic shifts in self-image in terms
of shifting values (e.g., sexual identity, types of friends) and vocational
goals.
4) impulsiveness in at least two areas that are potentially harmful (e.g.,
spending, sex, substance abuse, reckless driving, binge eating, excluding
suicidal or self-mutilating behaviour).
5) repeated suicidal behaviour or threats, or self-inflicted cuts or burns
(e.g., self-mutilating behaviour).
6) significant, sudden changes in mood and observable emotion (e.g.,
intense periodic sadness, irritability, or anxiety, usually lasting a few
hours and rarely lasting more than a few days; extreme reactivity to
interpersonal stresses).
7) chronic feelings of emptiness; also may be easily bored.
8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights) temporary,
stress-related psychosis (symptoms such as paranoia or grossly distorted
body image).
b) Antisocial Personality Disorder
People diagnosed with this disorder disregard the feelings, property and
authority of others; they often have violent and aggressive behaviours and
tend to show a lack of remorse.
Individuals with Antisocial Personality Disorder show a pervasive disregard
for, and violation of, the rights of others since age 15 years, as indicated by
three (or more) of the following (from DSM IV, American Psychiatric
Association, 1994):
38
1) repeated acts that are grounds for arrest Personality Disorder
2) deceitfulness, i.e., repeated lying, use of aliases, or conning others for

personal profit or pleasure
3) impulsiveness or failure to plan ahead
4) irritability and aggressiveness, such as repeated physical fights or assaults
5) reckless disregard for the safety of self or others
6) consistent irresponsibility, i.e., repeated failure to sustain consistent work
behaviour or honor financial obligations
7) lack of remorse, as indicated by indifference to, or rationalising having
hurt, mistreated, or stolen from another.
To receive this diagnosis, an individual also needs to be at least 18 years
old, to show evidence of a conduct disorder (which begins before age 15),
and to show antisocial behaviour that does not only occur during a manic
episode or the course of schizophrenia.
Case 1: Krishna is 46 years old, divorced, and currently unemployed. He
has worked for most of his adult life, and at one time owned a business. He
has a history of intense, unstable relationships, and has been violent toward
his wives and his children. He experiences periods of rage and frequent
fighting. Usually the fights are verbal, but occasionally they are physical.
When a neighbor spoke to him rudely, he seriously wounded his neighbour.
He is in prison at this time.
c) People diagnosed with Narcissistic Personality Disorder
They display an abnormally high opinion of themselves, are oversensitive
to criticism and resent those people who do not admire them. This pattern is
indicated by five (or more) of the following (from DSM IV, American
1) has an inflated sense of self-importance (e.g., exaggerates achievements
and talents, expects to be recognised as superior without corresponding
achievements)
2) is overly concerned with fantasies of unlimited success, power, brilliance,
beauty, or ideal love
3) believes that he or she is “special” and unique and can only be understood
by, or should associate with, other special or high-status people (or
institutions)
4) requires excessive admiration
5) has a sense of entitlement, i.e., unreasonable expectations of very positive
treatment or automatic compliance with his or her expectations
6) takes advantage of others to achieve his or her own ends
7) lacks empathy: is unwilling to identify with the feelings and needs of
others
8) is often jealous of others or believes that others are jealous of him or
her
9) shows arrogant or domineering behaviours or attitudes.
39
Counselling for Mental d) People diagnosed with Historic Personality Disorder: are obsessive about
Disorders
their appearance and constantly demand attention. Their behaviour is often
seen as over the top and they may be referred to as being ‘shallow’. This
pattern is suggested by five (or more) of the following (from DSM IV,
American Psychiatric Association, 1994)
1) discomfort in situations in which he or she is not the center of attention
2) frequent, inappropriate, seductive or provocative behaviour in
interpersonal interactions
3) rapid shifts of emotions, and shallow expression of emotions; emotions
often appear to be “turned on and off too quickly” to be deeply felt
4) consistent use of physical appearance to draw attention to self
5) excessively dramatic style of speech that lacks detail; opinions are
strongly presented, but underlying reasons may be vague, without
supporting facts and details
6) self-dramatic, theatrical, and exaggerated expression of emotion
7) easily influenced by others or circumstances (e.g., fads)
8) views relationships as more intimate than they actually are.
2.7.3 Cluster C Personality Disorders

Cluster C features anxious or fearful behaviour. The personality disorders in this
cluster include:
a) Dependant Personality Disorder
Where people depend on their opinion and judgement. Their insecurity,
indecision and lack of self esteem can make it difficult for them to take care
of themselves. A person with Dependent Personality Disorder shows an
extreme need to be taken care of that leads to fears of separation, and passive
and clinging behaviour. This disorder is indicated by five (or more) of the
following (from DSM IV, American Psychiatric Association, 1994):
1) difficulty making daily decisions without an excessive amount of advice
and reassurance from others
2) needs others to assume responsibility for most major areas of his or her
life
3) difficulty voicing disagreement with others because of fear of loss of
support or approval (excluding realistic fears of punishment)
4) difficulty starting projects or doing things on his or her own (because of
little self-confidence in judgment or abilities, rather than a lack of
motivation or energy)
5) excessively attempts to obtain support from others such that he or she
volunteers to do unpleasant tasks
6) feels uncomfortable or helpless when alone because of exaggerated fears
of being unable to care for himself or herself
7) urgently seeks another relationship as a source of support when a close
relationship ends
8) overly worried about being left to take care of himself or herself.
40
b) Avoidant Personality Disorder Personality Disorder
This disorder causes people diagnosed to avoid situations which can cause
conflict because they cannot face the possibility of being rejected. By doing
so, however, they make their own situation worse by isolating themselves
and avoid forming any relationships.
An individual with Avoidant Personality Disorder typically is socially
inhibited, feels inadequate, and is oversensitive to criticism, as indicated by
four (or more) of the following (from DSM IV, American Psychiatric
Association, 1994):
1) avoids work-related activities that involve much social contact, because
of fears of criticism, disapproval, or rejection
2) is unwilling to get involved with people unless certain of being liked
3) fears of shame or ridicule lead to excessive shyness within intimate
relationships
4) is overly concerned with criticism and rejection in social situations
5) is inhibited in new social situations because of feelings of inadequacy
6) views self as socially incompetent, personally unappealing, or inferior
to others unusually reluctant to take personal risks or do new activities
because of fear of embarrassment
7) People diagnosed with Obsessive Compulsive Personality Disorder are
so inflexible in their approach to things that they become anxious and
indecisive and normally end up not completing any tasks they have
started. They like to be in control and have difficulty in sustaining healthy
relationships.
This pattern is indicated by four (or more) of the following (from DSM IV,
American Psychiatric Association, 1994):
1) is overly concerned with details, rules, lists, order, organisation, or
schedules such that the major point of the activity is lost
2) is unable to complete a project because his or her own overly strict
standards are not met
3) excessive emphasis on work and productivity such that leisure activities
and friendships are devalued (not accounted for by obvious economic
need)
4) is overly conscientious and inflexible about issues involving morality,
ethics, or values (not accounted for by cultural or religious identification)
5) is unable to throw out worn-out or worthless objects despite lack of
emotional value
6) is reluctant to delegate tasks or work with others unless they agree to
exactly his or her way of doing things
7) adopts a stingy spending style toward both self and others; money is
seen as something to be gathered for future catastrophes
8) rigidity and stubbornness
There also is a diagnosis known as “Personality Disorders Not Otherwise
Specified”, which is separate from the above three groups of disorders. 41
Counselling for Mental This diagnosis would be given for disturbed personality functioning that does
Disorders
not meet criteria for any specific personality disorder, but which leads to distress
or harm in one or more important areas of functioning (e.g., social or work-
related). The clinician also may give this diagnosis if a specific personality disorder
that is not included in the DSM IV Classification seems to apply to an individual
(e.g., depressive personality disorder, or passive-aggressive personality disorder;
DSM IV, American Psychiatric Association, 1994).

1) Discuss the cluster A personality disorders.
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2) Elucidate the Cluster B personality disorders.
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3) Explain the cluster C personality disorders.
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2.8 TREATMENT OF PERSONALITY DISORDERS

There are various kinds of help available. Family doctor can be a good start as
he/she will be to refer you to someone who knows how to offer the best help.
Psychological and drug therapies provide some benefit for people with personality
disorders. Counselling and psychotherapy give people the chance to talk about
their difficulties. Therapy aims at helping people bring their true feelings to the
surface, so that they can experience and understand them better. Other forms of
help available include Cognitive Behavioural Therapy (CBT) which is a
combination of cognitive therapy and behavioural therapy. It helps to weaken
the links between upsetting situations and your normal reaction to them, teaching
you how to calm your mind and body and feel good. It also helps you to recognise
patterns that make you angry, anxious or depressed.
42
Medical Treatment and Support Groups are also other forms of help available Personality Disorder
for people suffering from personality disorders.
Treatment will vary depending on the view the clinician holds regarding the
origins of personality disorders and will also depend on services available. In the
case of psychopathy, it is thought that because people who have this diagnosis
feel no emotion, it is impossible to treat them with any kind of talking therapy.
The other disorders are mainly treated with a combination of drug and talking
therapies.
Treatment of Borderline personality Disorder includes the following steps:
• Identify disturbances, chronic feelings of emptiness or boredom and their
intolerance of being alone. These people have a strong need for involvement
with others and a reliance on external support for self- definition.
• Affective disturbances, reflected in their intense, inappropriate anger,
emotional instability and unstable interpersonal relationships.
• Impulsive disturbances, reflected in their self-damaging acts and impulsive
behaviours.
2.9 LET US SUM UP

Personality disorders appear to be extreme or exaggerated patterns of personality
traits that predispose an individual to maladaptive behaviour. A number of
personality disorders have been delineated in which there are persistent patterns
of perceiving, thinking and relating to the environment. Three general clusters
of personality disorders have been described – Cluster A which includes
individuals with paranoid, schizoid and schizotypal personality disorders who
seem odd or eccentric. Cluster B which includes individuals with histrionic,
narcissistic, antisocial and borderline personality disorders who share a common
tendency to be dramatic, emotional and erratic and Cluster C which includes
individuals with avoidant, dependent and obsessive – compulsive personality
disorders who show fearfulness or tension as in anxiety – based disorders.
Research indicated that constitutional and genetic factors play a role in borderline,
paranoid, schizotypal and antisocial personality disorders. Some evidence
suggests that early childhood abuse may play a role in causing borderline
personality disorder.
Treatment of the Cluster C disorders which includes dependent and avoidant

personality disorder seems most promising, although a new form of cognitive-
behaviour therapy for borderline personality disorder (dialectical behaviour
therapy) also shows considerable promise in treating this very serious condition.
Cluster A disorders such as schizotypal and paranoid are most difficult to treat.

1) Define personality disorders. Discuss the origin and diagnosis of personality
disorders.
2) What are the various personality do we come across?
3) Explain Cluster A, Cluster B and Cluster C personality disorders.
43
Counselling for Mental 4) Delineate the causes of personality disorders.
Disorders
5) Discuss the symptoms of Cluster C personality disorders.
6) Explain the strategies to treat personality disorders.
2.11 GLOSSARY
Personality disorders : Gradual development of inflexible and distorted
personality and behavioural pattern that result
in persistently maladaptive ways of perceiving,
thinking about and relating to the world.
Paranoid personality : Pervasive suspiciousness and distrust of others

disorders
Histrionic personality : Excessive attention seeking, emotional instability

disorders and self – dramatisation.
Narcissistic personality : Exaggerated sense of self importance,

disorders preoccupation with being admired and lack of
empathy for the feeling of others.
Antisocial personality : Continual violation and disregard for the rights

disorders of others through deceitful, aggressive or
antisocial behaviour, typically without remorse
or loyalty to anyone.

Carson, R.C. Butcher, J.N. & Mineka, S. (2000). Abnormal Psychology and

and Company.

44
Personality Disorder
UNIT 3 GENDER IDENTITY DISORDER
Structure
3.0 Introduction
3.1 Objectives
3.2 Definition and Description of Gender Identity Disorder
3.3 Origin of Gender Identity Disorder
3.3.1 Transgender
3.4 Components of Gender Identity Disorder
3.5 Criteria for Gender Identity Disorder
3.6 Symptoms of Gender Identity Disorder
3.7 Causes of Gender Identity Disorder
3.8 Treatment of Gender Identity Disorder
3.8.1 Action Steps in Treatment for Gender Identity Disorder
3.9 Let Us Sum Up
3.11 Glossary
3.0 INTRODUCTION
In this unit we will be dealing with gender identity disorder. We start with
Definition and description of Gender Identity Disorder and follow it up with
Origin of Gender Identity Disorder and Transgender issues. Then we take up
Components of Gender Identity Disorder and elucidate Criteria and Diagnosis
of Gender Identity Disorder. Then we enlist the Symptoms of Gender Identity
Disorder and present the Causes of Gender Identity Disorder. The finally we
take up the Treatment of Gender Identity Disorder and indicate the Action Steps
in Treatment for Gender Identity Disorder.
3.1 OBJECTIVES
• Define and describe gender identity disorder;
• Trace the Origin of gender identity disorder;
• Elucidate the Components of gender identity disorder;
• Explain the Criteria for diagnosis;
• Delineate the Symptoms of gender identity disorder;
• Discuss the Causes; and
• Describe the Treatment interventions of gender identity disorder.

45
Disorders 3.2 DEFINITION AND DESCRIPTION OF GENDER
IDENTITY DISORDER
Gender identity, a basic feature of personality, refers to an individual’s feeling of
being male or female. Children become aware that they are male or female at an
early age and once it is formed, their gender identity is highly resistant to change.
Gender identity disorder (GID), is a condition in which a person has been assigned
one gender (usually at birth), but identifies as belonging to another gender, or
does not conform with the gender role their respective society prescribes to them.
It is a psychiatric term for what is widely known by other terms such as
transsexuality, transgender, transvestism or cross-dressing.
This disorder is different from transvestism or transvestic fetishism where cross
dressing occurs for sexual pleasure, but the transvestite does not identify with
the other sex. Transsexualism should also not be confused with the behaviour of
drag queens and drag kings. Also, transvestic fetishism usually has little, if
anything, to do with transsexualism. As a general rule, transsexual people tend
to dress and behave in a manner consistent with the gender with which they
identify.
3.3 ORIGIN OF GENDER IDENTITY DISORDER

During the 1950’s and 60’s, psychologists began studying gender development
in young children, partially in an effort to understand the origins of homosexuality
which was viewed as a mental disorder at the time. Psychoanalyst Robert Stoller
is credited with introducing the term gender identity and behavioural psychologist
John Money was also instrumental in the development of early theories of gender
identity. His work popularized an interactionist theory of gender identity,
suggesting that, up to a certain age, gender identity is relatively fluid and subject
to constant negotiation.
Sigmund Freud also had a unique theory for the development of gender identity.
He believed it was developed during the phallic stage of development. During
this time, young boys develop an Oedipus complex and young girls an Electra
complex. Freud believed that during this time, the child has an unconscious
sexual desire for the parent of the opposite sex and jealousy or hatred for the
same sex parent. That jealousy eventually turns into emulating and the child
wants to be like that parent, eventually identifying with it.
The notion of gender identity appeared in the Diagnostic and Statistical Manual
of Mental Disorders in its third edition, DSM-III (1980), in the form of two
psychiatric diagnoses of gender dysphoria – gender identity disorder of childhood
(GIDC), and transsexualism (for adolescents and adults). The 1987 revision of
the manual, the DSM-III-R added a third diagnosis – gender identity disorder of
adolescence and adulthood, non transsexual type. This later diagnosis was
removed in the subsequent revision, DSM-IV (1994), which also collapsed the
GIDC and transsexualism in a new diagnosis of gender identity disorder.
3.3.1 Transgender
There are many political points of view in the literature of transgender, but the
generally agreed definition of transgender covers everything that does not fall
46
into society’s narrow terms of “man” and “woman.” Some of the people who Gender Identity Disorder
consider themselves as transgendered would include transsexuals (who mayor
may not have had sex reassignment surgery), transvestites (who wear clothing
and adopt behaviour of the opposite sex), people with ambiguous genitalia, and
people who have chosen to perform either an ambiguous gender role or no gender
role at all.
There are four main categories in the study of transgender:
1) Essentialist or naturalist: This group believes that there is no difference
between sex and gender, that there are only two genders, and these cannot
be changed.
2) Social constructivist: This group believes sex and gender can only be
considered as part of a social interaction. In other words, sex and gender are
a “construction” assigned by society.
3) Performance: Gender performance theorists believe gender is best
understood through performance studies and they look at what is revealed
from clues such as body position, gesture, facial expression, proximity, voice
modulation, speech pattern, social space, clothing, adornment and cosmetics.
4) Memory and language generation: This group looks at the body as the
expression of the symbols of words, gestures and a larger cultural language.
On a gut level, the body has deeper knowledge that may not be registered by
the mind.
While transgender theorists do not always agree on definitions and underlying
philosophies, this is an emerging field with many avenues for scholarly and
political dialogue. As the study of transgender develops, it will influence many
other disciplines such as anthropology, psychology, psychiatry, sociology,
women’s studies, men’s studies, and gender studies.
A gender identity disorder causes the person to experience serious discomfort
with his/her own biological sex orientation. The gender identity disorder can
also causes problems for the person in school, work or social settings. The need
for treatment is emphasised by the high rate of mental health problems, including
depression, anxiety, and drug and alcohol addiction, as well as a higher suicide
rate among untreated transsexual people than in the general population. Many
transgender and transsexual activists, and many caregivers, point out that these
problems usually are not related to the gender identity issues themselves, but to
problems that arise from dealing with those issues and social problems related to
them.
3.4 COMPONENTS OF GENDER IDENTITY

DISORDER
People with gender identity disorder frequently report their feelings as “having
always been there”, and the disorder can be evident in early childhood. Most
people know whether they have a gender identity problem by the time they reach
adolescence, although in some cases it seems to appear in adulthood.
Gender identity disorder is a diagnosis given to persons who meet a certain number
of clinical criteria related to feelings of discontent regarding one’s biological
47
Counselling for Mental sex, and identification with the opposite biological sex. The individual may
Disorders
identify to the point of believing that they are, in fact, a member of the other sex
who is trapped in the wrong body.
There are two components of Gender Identity Disorder, both of which must be
present to make the diagnosis.
i) There must be evidence of a strong and persistent gross-gender identification,

which is the desire to be, or the insistence that one is, of the other sex. This
cross-gender identification must not merely be a desire for any perceived
cultural advantages of being the other sex.
ii) There must also be evidence of persistent discomfort about one’s assigned
sex or a sense of inappropriateness in the gender role of that sex.
Gender identity disorder can affect children, adolescents, and adults. Individuals
with gender identity disorder have strong cross-gender identification. They believe
that they are, or should be, the opposite sex. They are uncomfortable with their
sexual role and organs and may express a desire to alter their bodies. While not
all persons with gender identity disorder are labelled as transsexuals, there are
those who are determined to undergo sex change procedures or have done so,
and, therefore, are classified as transsexual.
Adults with gender identity disorder sometimes live their lives as members of
the opposite sex. They tend to be uncomfortable living in the world as a member
of their own biologic or genetic sex. They often cross-dress and prefer to be seen
in public as a member of the other sex. Some people with the disorder request
sex change surgery.

1) Define Gender Identity Disorder.
...............................................................................................................
...............................................................................................................
...............................................................................................................
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...............................................................................................................
...............................................................................................................
2) Describe the features of gender identity disorder.
...............................................................................................................
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...............................................................................................................
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48
Gender Identity Disorder
3) Trace the origin of gender identity disorder.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
4) What is transgender? Explain
...............................................................................................................
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...............................................................................................................
...............................................................................................................
...............................................................................................................
5) Elucidate the components of Gender Identity disorder.
...............................................................................................................
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3.5 CRITERIA FOR GENDER IDENTITY DISORDER

According to the American Psychiatric Association and the Diagnostic and
Statistical Manual of Mental Disorders IV (DSM-IV) the following criteria must
be met before a person can be given the official diagnosis of gender identity
disorder:
• There must be evidence of strong and persistent cross-gender identification.
This cross-gender identification must not merely be a desire for any perceived
cultural advantages of being the other sex.
• There must also be evidence of persistent discomfort about one’s assigned
sex or a sense of inappropriateness in the gender role of that sex.
• The individual must not have a concurrent physical intersex condition (e.g.,
androgen insensitivity syndrome or congenital adrenal hyperplasia).
• There must be evidence of clinically significant distress or impairment in
The DSM-IV also provides diagnostic criteria for gender disorders that do not
meet the criteria for the general gender identity disorder diagnosis. The following
criteria are sufficient for a diagnosis of Gender Identity Disorder in Children as
well as for Gender Identity Disorder Not Otherwise Specified (GIDNOS). For
49
Counselling for Mental the former diagnosis, criteria must be identified before a person is 18 years of
Disorders
age.
a) Intersex Conditions
(e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia)
and accompanying gender dysphoria
Transient, stress-related cross-dressing behaviour.
Persistent preoccupation with castration or penectomy without a desire to
acquire the sex characteristics of the other sex, which is known as skoptic
syndrome.
Cross-gender identification (not merely a desire for any perceived cultural

advantages of being the other sex). In children, the disturbance is manifested
by four (or more) of the following:
1) repeatedly stated desire to be, or insistence that he or she is, the other
sex.
2) in boys, preference for cross dressing or simulating female attire; in
girls, insistence on wearing only stereotypical masculine clothing.
3) strong and persistent preferences for cross-sex roles in make-believe
play or persistent fantasies of being the other sex.
4) intense desire to participate in the stereotypical games and pastimes of
the other sex.
5) strong preference for playmates of the other sex.
6) In adolescents and adults, the disturbance is manifested by symptoms
such as a stated desire to be the other sex, frequent passing as the other
sex, desire to live or be treated as the other sex, or the conviction that he
or she has the typical feelings and reactions of the other sex.
b) Persistent Discomfort with his or her Sex

Or sense of inappropriateness in the gender role of that sex. In children, the
disturbance is manifested by any of the following, as for instance in boys,
assertion that his penis or testes are disgusting or will disappear or assertion
that it would be better not to have a penis, or aversion toward rough and
tumble play and rejection of male stereotypical toys, games, and activities.
In girls, rejection of urinating in a sitting position, assertion that she has or

will grow a penis, or assertion that she does not want to grow breasts or
menstruate, or marked aversion toward normative feminine clothing.
In adolescents and adults, the disturbance is manifested by symptoms such

as preoccupation with getting rid of primary and secondary sex characteristics
(e.g., request for hormones, surgery, or other procedures to physically alter
sexual characteristics to simulate the other sex) or belief that he or she was
born the wrong sex.
c) The disturbance is not concurrent with a physical intersex condition.
50
d) The disturbance causes clinically significant distress or impairment in Gender Identity Disorder
Specify if (for sexually mature individuals):
• Sexually Attracted to Males
• Sexually Attracted to Females
• Sexually Attracted to Both
• Sexually Attracted to Neither
3.6 SYMPTOMS OF GENDER IDENTITY

DISORDER
Symptoms
A strong and persistent cross-gender identification (not merely a desire for any
perceived cultural advantages of being the other sex). In children, the disturbance
is manifested by four (or more) of the following:
1) repeatedly stated desire to be, or insistence that he or she is, the other sex
2) in boys, preference for cross dressing or simulating female attire; in girls,
insistence on wearing only stereotypical masculine clothing
3) strong and persistent preferences for cross-sex roles in make-believe play or
persistent fantasies of being the other sex
4) intense desire to participate in the stereotypical games and pastimes of the
other sex
5) strong preference for playmates of the other sex
In adolescents and adults, the disturbance is manifested by symptoms such as a
stated desire to be the other sex, frequent passing as the other sex, desire to live
or be treated as the other sex, or the conviction that he or she has the typical
feelings and reactions of the other sex.
Persistent discomfort with his or her sex or sense of inappropriateness in the
gender role of that sex.
The disturbance is not concurrent with a physical intersex condition.
The disturbance causes clinically significant distress or impairment in social,
Gender identity disorder in children is often reported as “having always been
present,” and persons with the disorder do not remember a time when they were
satisfied with their gender.
Other persons with the disorder report that symptoms began in adolescence or
adulthood, and seemed to grow in intensity over time.
There is usually strong and persistent preferences for cross sex roles in make
believe play or persistent fantasies of being the other sex, an intense desire to
participate in the stereotypical games and pastimes of the other sex, and usually
a strong preference for playmates of the other sex.
51
Counselling for Mental Issues regarding gender identity can manifest in a variety of ways. For example,
Disorders
some people may cross dress, while others may seek a sex change surgery. Below
is a list of other common “symptoms” of gender identity disorder.
Children
• Express a desire to be the opposite sex
• Find their genitals or indicators of their gender cross
• Believe that they will grow up to become the opposite sex
• Are often rejected by their peers
• Become isolated and shy
• Develop moderate to severe anxiety
• Present low self-esteem
• Drop out of school
• Develop moderate to severe anxiety.
In adolescents there is a preoccupation with getting rid of primary and secondary
sex characteristics (e.g., request for hormones, surgery, or other procedures to
physically alter sexual characteristics to simulate the other sex).
Adults
• Desire to live as a person of the opposite sex
• Pursue a sex reassignment operation
• Both dress and act in a way that is indicative of the opposite sex
• Become socially isolated or ostracized
• Develop moderate to severe depression
• Develop moderate to severe anxiety.
Some persons with gender identity disorder have genitalia and secondary sex
characteristics in line with their biological sex. Others may have ambiguous
genitalia, or are hermaphroditic. Not all transsexual persons (persons who dress
or act as persons of the opposite gender) have gender identity disorder. Generally
homosexuals do not have gender identity disorder. The majority of homosexuals
identify strongly with their biological gender. Homosexuality involves only a
sexual attraction to persons of the same gender.

1) What is intersex condition?
...............................................................................................................
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52
2) What is meant by cross gender identification?
...............................................................................................................
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...............................................................................................................
3) Describe the symptoms of Gender Identity Disorder.
...............................................................................................................
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4) Describe the GID symptoms of children.
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5) Elucidate the symptoms of GID in adolescents and adults.
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3.7 CAUSES OF GENDER IDENTITY DISORDER

John Money has coined a useful term “gender maps” to describe the phenomenon
of gender identity. He defined gender map as the entity, template, or schema
within the mind and brain that codes masculinity and femininity and androgyny.
This map or coding imprint is established very early in life through an interaction
of nature and nurture. Because gender map development is highly influenced by
hormones emanating from the developing fetus, sex and gender identification
are generally closely matched. But like most aspects of being human, there are
no guarantees. As a result an individual may, as early as the age of four, find
themselves aware of being caught between having the anatomy of one sex but
being equipped with a gender map much more typical of an individual of the
opposite sex. It is also apparently possible for an individual to have no clear
sense of gender whatsoever.
53
Counselling for Mental There is no clearly understood cause for Gender Identity Disorder.
Disorders
The biological theory is based on evidence that high levels of the male hormone
testosterone are associated with high levels of aggression in boys and
tomboyishness in girls.
Social learning theory proposes that gender typing is the result of a combination
of observational learning and differential reinforcement.
Cognitive-Developmental theory, states that gender understanding follows a

prescribed time line. The pattern put forth is that children recognise that they are
either boys or girls by the age of two or three, followed shortly by recognition
that gender is stable over time. By the age of six or seven children understand
that gender is also stable across situations.
No matter what theory one adopts, for most children, whose sex and gender map
are congruent, this insight typically goes unnoticed. However, if there is sex/
gender map incongruence, the child is left perplexed about his or her gender
status and begins a lifelong, often compulsive search for resolution of the
discrepancy.
All children naturally comply with the demands of their internal sense of gender.
Boys generally express male behaviour and girls generally express female
behaviour even when raised in closely monitored gender neutral conditions. If
there is any confusion in the child, he or she quickly learns from adults and peers
that certain gender expression behaviours are inappropriate for that individual.
This is true even of gender dysphoric children. Some gender dysphoric children
internalise their dilemma and make heroic efforts to display the gender behaviour
expected of them, while expressing their internal sense of gender through secret
play, cross-dressing, and cross-gender fantasies. Others may continue to struggle
by insisting that they be allowed to openly express maleness or femaleness
irrespective of their assigned sex. Either way, the problem becomes subsumed
into the child’s personality.
The arrival of adolescence increases the difficulties for people who are gender
dysphonic. Without fail, the subsequent development of secondary sex
characteristics counter to the individual’s desires increases anxiety. Often,
frustration sets in, and determination to finally resolve the problem becomes the
individual’s driving force in life. This is especially true for gender dysphoric
males. Since the obvious first effort is to accept the physical evidence of their
genitalia as reality, it is very common to see many of these people push through
these early years of adulthood by engaging in stereotypical, even supermale
activities. Since outward behaviour has no permanent influence on internal gender
understanding, these activities serve only to complicate the individual’s social
involvement, resulting in anxiety about expressing his true felt gender.
This anxiety state is characterised by feelings of confusion, shame, guilt, and

fear. These individuals are confused over an inability to handle their gender
identity problem in the same way they readily handle other problems in life.
They feel shame over an inability to control what they believe society considers
to be sexually perverse activities. Even though cross dressing and cross gender
fantasies provide much needed temporary relief, these activities often leave the
individual profoundly ashamed of what she or he has done.
54
Closely associated with shame is guilt over being dishonest by hiding secret Gender Identity Disorder
needs and desires from family, friends, and society. For example, people
commonly get married and have children without telling their spouse of their
gender dysphoria before making the commitment. Typically it is kept secret
because they have the mistaken conviction that participation in marriage and
parenting will in itself erase their gender dysphoria. All of this then leads to fear
of being discovered. With some justification, gender dysphoric people fear being
called sick, uncaring, selfish and even being left alone by the people they love
the most.
The psychological diagnosis of gender identity disorder (GID) is used to describe

a male or female who feels a strong identification with the opposite sex and
experiences considerable distress because of his or her actual sex.
Thus, Gender identity disorder can affect children, adolescents and adults.
Individuals with gender identity disorder have strong cross-gender identification.
They believe that they are, or should be, the opposite sex. They are uncomfortable
with their sexual role and organs and may express a desire to alter their bodies.
While not all persons with GID are labeled as transsexuals, some are determined
to undergo sex change procedures or to pass socially as the opposite sex.
Transsexuals alter their physical appearance cosmetically and hormonally, and
may eventually undergo a sex change operation.
Children with gender identity disorder refuse to dress and act in sex stereotypical
ways. It is important to remember that many emotionally healthy children
experience fantasies about being a member of the opposite sex. The distinction
between these children and gender identity disordered children is that the latter
experience significant interference in functioning because of their cross gender
identification. They may become severely depressed, anxious, or socially
withdrawn.
Psychologists who work with children and teens on gender identity note that
cross gender behaviours generally become less overt with time and by late
adolescence, GID is usually no longer present.
Long term studies of children referred to a specialty clinic for GID show that
cross gender behaviour is tolerated in girls to a far greater degree than it is in
boys. Thus, parents are quicker to bring boys in for evaluation. The clinicians
who conducted the study theorized that girls may be under referred for GID
because there is more social tolerance of “tomboys” than there is of “sissies.”
While much more research is needed, scientists theorize that there are other
social factors in play as well.
It is much more common for males to wish to cross to the female gender, but
there are exceptions. In Poland, the ratio of women who wish to change gender
is five times the rate of men who wish to change. Researchers theorize that
Polish women face unfavourable living conditions and gender related economic
and occupational hardships to a degree that they seek relief by changing gender.
The biological causes of gender identity disorder are not known. According to
one theory, a prenatal hormonal imbalance may predispose individuals to the
disorder. Problems in the individual’s family interactions or family dynamics
may play a part.
55
Disorders 3.8 TREATMENT OF GENDER IDENTITY
DISORDER
Treatment for children with gender identity disorder focuses on treating secondary
problems such as depression and anxiety, and improving self esteem. Treatment
may also work on instilling positive identifications with the child’s biological
gender. Children typically undergo psychosocial therapy sessions; their parents
may also be referred for family or individual therapy.
Children and adolescents with GID have never been systematically counted, but
gender identity disorder is generally regarded as a rare phenomenon. In Europe,
there are treatment centers in London, England; Utrecht, the Netherlands and in
Frankfurt, Germany. In North America, patients may seek treatment at special
centers for gender identity disorder in Toronto; in New York City; at the University
of California, Los Angeles; at Johns Hopkins University in Baltimore; and at
Case Western University in Cleveland. The larger number of GID patients in
North America may be related to a less permissive attitude toward gender
nonconformity. Traditionally, Europe is more tolerant of gender nonconformity
and parents are less likely to see their children’s GID symptoms as requiring
treatment.
With adolescents, there are many variations in gender role behaviour and
experienced gender identity specialists avoid making premature decisions,
particularly when sex reassignment surgery is under consideration. One study
described in a review in the American Journal of Psychotherapy showed that a
large number of children with GID grow up to be homosexual or bisexual. The
concept of treatment for GID children and adolescents has become highly
politicized, since some groups fear that treatment of GID is actually a thinly
veiled attempt to curb or even prevent homosexuality.
Hormone and Surgical Treatments

Transsexual adults often request hormone and surgical treatments to suppress
their biological sex characteristics and acquire those of the opposite sex. A team
of health professionals, including the treating psychologist or psychiatrist, medical
doctors, and several surgical specialists, oversee this transitioning process.
Because of the irreversible nature of the surgery, candidates for sex change surgery
are evaluated extensively and are often required tospend a period of time
integrating themselves into the cross gender role before the procedure begins.
Usually sex reassignment surgery is not offered to anyone under 18. Before surgery
can be considered, candidates undergo at least a year of psychotherapy. A “real
life” test of living for at least a year as a member of the desired gender is
recommended.
A male who has been cleared for surgery will have a vagino plasty, the surgical
technique for creating a neo vagina. The penis and testes are removed. Surgeons
permanently remove male hair growth and perform corrective plastic surgery on
the larynx. For the patient to successfully pass as a woman, the growth of facial
and body hair must be suppressed, and this can be accomplished with a drug
such as cyproterone acetate. The surgery for changing a man into a woman is
simpler than the surgery for changing a woman into a man, and many more men
than women undergo sex change operations.
56
A woman who has been cleared for surgery will undergo surgical removal of the Gender Identity Disorder
breasts, uterus and ovaries. In some cases, a phallo plasty will be performed,
creating a neo phallus. Premenopausal women who receive sex change operations
are given a drug such as lynestrenol to suppress menstruation. Long-term follow-
up studies have shown positive results for many transsexuals who have undergone
sex-change surgery. However, significant social, personal, and occupational issues
may result from surgical sex changes, and the patient may require psychotherapy
or counselling.
In the ongoing debate on gender stereotypes, new areas of inquiry have opened
up. Scholars and activists have sought new responses to the questions of gender
dysphoria (dissatisfaction or discomfort with one’s biological gender). In the
literature on issues of transgender, some scholars point out that gender is a
performance that everyone learns from birth. Under this theory, by the time people
are old enough to recognise that their gender identity is a kind of performance, it
is so ingrained that people do not think of their gender identity as a separate
entity.
Treatment of psychological disorders in GID

According to the American Psychological Association, the transgendered suffer
from a higher than average rate of depression, anxiety, suicide and self-mutilation,
yet rarely seek treatment. Untreated gender identity disorders may manifest in
associated disorders and emotional distress that can interfere with the individual’s
ability to function socially at school and work or in relationships. Treatment
helps a patient achieve and maintain a healthy and stable life.
For children with GID, individual and family counseling, along with social and
physical interventions are recommended. Children with gender identity disorder
may develop symptoms of depression, generalised anxiety and separation anxiety
disorder. Adolescents may be at risk for depression, suicidal thoughts or suicide
attempts. Counseling should focus on improving self-esteem and treating
associated complications.
Parents are encouraged to allow their child to explore fantasies about being a
member of the opposite gender in a safe and tolerant environment. Additionally,
parents are offered suggestions such as using gender-neutral language, making
gay-friendly media available, and encouraging the child to participate in any
activities she or he is interested in without judgment.
Other Psychological Techniques

Psychological techniques that attempt to alter gender identity to one considered
appropriate for the person’s assigned sex have typically been shown to be
ineffective. However, psychological therapy can help alter the course of gender
identity disorder problems and can be critical in helping the person adjust. Today,
most medical professionals who provide transgender transition services now
recognise that when able to live out their daily lives with both a physical
embodiment and a social expression that most closely matches their internal
sense of self, transgender and transsexual individuals live successful, productive
lives virtually indistinguishable from anyone else.
Counselling individuals with gender identity disorder should include an

understanding of the differences between true transsexualism and other disorder
57
Counselling for Mental issues such as transvestic fetishism, non-conformity to stereotypical sex role
Disorders
behaviours, gender dysphoria, and homosexuality. Patients and their families
need to be educated about the complexities of these issues, the enduring nature
of these disorders, and the challenges that gender disorders typically present.
Multifaceted Therapeutic Approach

When GID is diagnosed in an adult, a multifaceted therapeutic approach begins.
In addition to support groups and counseling (both individual and couples
counselling), patients may choose hormone therapy, undertake a Real-Life
Experience (living full time in their desired gender for a year or longer) and
gender reassignment surgery. Patients desiring gender reassignment surgery
undergo extensive evaluation, therapy and a transition period before they can be
approved for surgery.
It is generally accepted that a reasonable and effective course of treatment for
transsexual people can be sex reassignment therapy. This can include hormonal
treatment and surgery. Sex reassignment surgery consists of procedures which
transsexual women and men undergo in order to match their anatomical sex to
their gender identity. While genital reassignment surgery (GRS) refers only to
surgeries that correct genital anatomy, sex reassignment surgery (SRS) may refer
to all surgical procedures undergone by transsexual patients.
Hormone therapy may also be helpful. In male to female individuals, original
sex characteristics can be suppressed, and breasts, increased body fat, and a more
feminine body shape can be promoted. In female-to-male individuals, facial and
body hair promotion may be achieved with testosterone.
“Transgender transition services”, the various medical treatments and procedures
that alter an individual’s primary and/or secondary sexual characteristics, are
now considered medically necessary interventions for many transgender persons.
Prior to this kind of surgery, the person usually goes through a long period of
hormone therapy which attempts to suppress same sex characteristics and
accentuate other sex characteristics. For instance, males that have gender identity
disorder will be given the female hormone, estrogen.
The estrogen causes the male breasts to enlarge, testes to become smaller, and
body hair to diminish. Females with gender identity disorder will be given the
male hormone, testosterone, to help them develop a lower voice and possibly a
full beard. Following the hormone treatment, the adult will be asked to live in a
cross-gender role before surgery to alter their genitalia or breasts is performed. A
team of health professionals, including the treating psychologist or psychiatrist,
medical doctors, and several surgical specialists, oversee this transitioning process.
Because of the irreversible nature of the surgery, candidates for sex-change surgery
are evaluated extensively and are often required to spend a period of time
integrating them into the cross-gender role before the procedure begins.
Counselling and peer support are also invaluable to transsexual individuals.
Follow up studies have shown positive results for many transsexuals who have
undergone sex-change surgery. However, significant social, personal, and
occupational issues may result from surgical sex changes, and the patient may
require psychotherapy or counseling.
Speech therapy may help individuals use their voice in a manner more appropriate
58 to their preferred sex.
3.8.1 Action Steps in Treatment for Gender Identity Disorder Gender Identity Disorder
Treating gender identity disorder can be a slow and complicated process. With
gender identity disorder, better recovery outcomes are associated with early
diagnosis and treatment.
Step 1: Identify and Challenge Negative Thoughts about One’s Biological Sex
First, identify any negative thoughts that are being had in regards to
one’s gender. For example, a male suffering from gender identity disorder
may say, “Men are pigs. They are crude, crass, and uncaring. Unlike
me, men are athletic and sportsmanlike. Men don’t enjoy art and
fashion.”
Look at these negative statements and note if there are any “lies” or
half-truths that are being said. For example, many men are not crass,
are un-athletic, and enjoy art.
Step 2: Find ways that one can identify with one’s Biological Sex
A person with gender identity disorder generally believes they cannot
identify with their biological sex.
Assess what things are present in one’s lives that do correspond with
their biological sex. For example, a woman suffering from gender
identity disorder may feel that she does not identify with cosmetics.
Note these similarities and continue to identify things that one does
have in common with others of the same biological sex.
Step 3: Neutralise Physical Issues
Some persons with gender identity disorder have genitalia and secondary
sex characteristics in line with their biological sex (meaning they have
physically developed normally). However, others may be experiencing
either ambiguous genitalia, or a hermaphroditic physical condition.
If the latter is present, consider that even though one’s external
appearance is different from the average person of a particular sex;
genetically one is always fully male or fully female.
This male or female designation does not occur in one’s phenotype (the
way their body looks externally), it occurs in their genotype, whether
they present XX or XY chromosomes.
Confirming one’s gender based on genetics, and considering outward
biology as only secondary, may be an effective tool in reframing thoughts
about gender identity.

1) What are the causes of GID?
...............................................................................................................
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...............................................................................................................
59
Disorders 2) What theories are associated with GID?
...............................................................................................................
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...............................................................................................................
3) Describe the various treatments available for GID?
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4) What are hormonal and surgical treatments for GID?
...............................................................................................................
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5) Describe the psychological treatments for GID.
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6) What are the Action Steps in the treatment of GID?
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60
3.9 LET US SUM UP
Gender may well be the most basic thing in the elements that make up human
personality. In fact, gender is so basic to our identity, most people mistakenly
assume our sense of being male or female is defined with absolute certainty by
our anatomical sex. Contrary to popular belief, one’s sense of gender and one’s
anatomical sex are two distinct elements – each developing at different times in
different parts of the body.
Gender Identity Disorder is a real and serious problem. Although we don’t know
all of what may be the cause or causes of the problem that these individuals feel
toward their assigned sex, we can be reasonably certain that it is connected with
either a congenital irregularity, an irregularity that occurs in the first few years of
childhood or some combination of the two.
We also know that every individual’s sense of gender, once established, is
unchangeable over the individual’s life time. If the individual’s gender dysphoria
is a relatively minor one, cross-gender, lifestyle changes in periodic dressing and
behaviours may be all that is necessary to ease the anxiety. However, if the
individual’s dysphoria is profound, a life style change may be insufficient. In
this latter case, gender expression moves from a lifestyle problem to a life-
threatening imperative.

1) Define and describe Gender Identity disorder.
2) Discuss the origin of gender identity disorder.
3) Describe the component factors in GID
4) Explain the symptoms of gender identity disorder.
5) How would you diagnose the existence of gender identity disorder?
6) Explain the various treatments for gender identity disorder.
3.11 GLOSSARY
Gender Identity Disorder : It is defined by strong, persistent feelings of
identification with the opposite gender and
discomfort with one’s own assigned sex.
Gender Dysphoria : When the gender identity of a person makes
them one gender, but their genitals suggest
a different sex, they will likely to experience
this.
Gender map : It is the entity, template, or schema within
the mind and brain that codes masculinity
and femininity and androgyny.
Sex reassignment surgery : It consists of procedures which transsexual
women and men undergo in order to match
their anatomical sex to their gender identity.
Genital reassignment surgery : It refers only to surgeries that correct genital
anatomy. 61
Disorders 3.12 SUGGESTED READINGS
Boenke, Mary (1999). Trans Forming Families: Real Stories About
Transgendered Loved Ones. Imperial Beach, CA: Walter Trook Publishing.
Cohen-Kettenis,P.T.& Pfäfflin,F(2003). Transgenderism and Intersexuality in

Childhood and Adolescence. Sage Publications.
Diagnostic and Statistical Manual of Mental Disorders IV (1994). 4th ed.

Washington, D.C. American Psychiatric Association
Money, J (1995). Gender Maps: Social Constructionism, Feminism, and

Sexophical History. New York, The Continuum Publishing Company.
62
UNIT 4 EATING DISORDER
Structure
4.0 Introduction
4.1 Objectives
4.2 Definition and Description of Eating Disorders
4.2.1 Sociocultural Comparison with America
4.2.2 Eating Disorders in Other Countries
4.2.3 Eating Disorders in India
4.3 Types of Eating Disorders
4.3.1 Anorexia Nervosa
4.3.2 Diagnosis of Anorexia Nervosa
4.3.3 Diagnostic Criteria for Anorexia Nervosa
4.3.4 Prevalence of Anorexia Nervosa
4.3.5 Bulimia Nervosa
4.3.6 Diagnostic Criteria for Bulimia Nervosa (DSM IV)
4.3.7 Impact of Bulimia
4.3.8 Binge Eating
4.3.9 Triggers of Binge Eating
4.4 Causes of Eating Disorders
4.4.1 Biological Theories
4.4.2 Cultural Theories
4.4.3 Family Theories
4.4.4 Other Possible Causes
4.5 Treatment of Eating Disorders
4.5.1 The Biological Treatment
4.5.2 Family Treatment
4.5.3 Cognitive Behavioural Treatment
4.5.4 Psychoanalytic Treatment
4.6 Let Us Sum Up
4.0 INTRODUCTION
Eating is one of life’s great pleasures. But some people have difficult in controlling
their food intake. Eating disorders are relatively recent additions to psychiatric
classification systems. The vast majority – more than 90% of those affected with
eating disorders are adolescents and young adult women. The reason for women
being vulnerable to eating disorders is their tendency to go on strict diets to
achieve an “ideal” figure.
Eating disorders are sometimes symptoms of a physical ailment, but they might
also be external manifestations of mental disorder. The social causes of mental
disorder, the interchange between people and society, and the influence that culture
has on our perceptions of reality are probably most clearly demonstrated in the
mental disorders anorexia nervosa and bulimia nervosa.
63
Counselling for Mental Many news papers and magazines feature glamorous celebrities who devised a
Disorders
special diet and shed pounds to become new, healthy, more confident people.
Many psychological and social theorists believe that the influx of media images
of thin women, many directed at the young, is a prime cause of the massive
increase in eating disorders in the western world. In this unit we are going to
deal with eating disorders. First we start with definition and description of eating
disorders. This is followed by sociocultural comparison of eating disorders within
different parts of America and then follow it up with other countries including
India. Then we present different types of eating disorders such as anorexia nervosa,
bulimia nervosa, binge eating etc. Then we deal with causes of eating disorders
in which we present biological, cultural, family and other theories. This is followed
by treatment of eating disorders and the different types of treatment.
4.1 OBJECTIVES
• Define eating disorders;
• Describe the prevalence of this disorder;
• Explain the types of eating disorders;
• Elucidate the Causes of eating disorders; and
• Describe the Treatment for eating disorders.
4.2 DEFINITION AND DESCRIPTION OF EATING

DISORDERS
“Eating disorder” is when a person eats, or refuses to eat, in order to satisfy a
psychic need and not a physical need. The person does not listen to bodily signals
or perhaps is not even aware of them. A normal person eats when hungry and
stops eating when the body doesn’t need more, when he feels the signal of
satisfaction.
Eating disorders are usually classified as anorexia nervosa, bulimia nervosa and
binge eating disorders, in accordance with the symptoms. However, a person
may have an eating disorder without belonging exactly to any of these categories.
Those who lose weight because of illness, e.g., cancer, are not considered to
have an eating disorder.
Eating disorders do not seem to manifest as Anorexia Nervosa and Bulimia in

non Western cultures like India, but occur infrequently in milder forms with
fewer symptoms, In the absence of the major disorders, standard questionnaires
such as the Eating Attitudes Test appropriate for detecting severe disorders, may
not be useful in identifying low prevalence milder disorders.
Culture has been identified as one of the etiological factors leading to the
development of eating disorders. Rates of these disorders appear to vary among
different cultures and to change across time as cultures evolve. Additionally,
eating disorders appear to be more widespread among contemporary cultural
groups than was previously believed. Anorexia nervosa has been recognised as a
64
medical disorder since the late 19th century, and there is evidence that rates of Eating Disorder
this disorder have increased significantly over the last few decades. Bulimia
nervosa was only first identified in 1979, and there has been some speculation
that it may represent a new disorder rather than one that was previously overlooked
(Russell, 1997).
However, historical accounts suggest that eating disorders may have existed for
centuries, with wide variations in rates. Long before the 19th century, for example,
various forms of self starvation have been described (Bemporad, 1996). The
exact forms of these disorders and apparent motivations behind the abnormal
eating behaviours have varied.
The fact that disordered eating behaviours have been documented throughout
most of history calls into question the assertion that eating disorders are a product
of current social pressures. Scrutiny of historical patterns has led to the suggestion
that these behaviours have flourished during affluent periods in more egalitarian
societies (Bemporad, 1997). It seems likely that the sociocultural factors that
have occurred across time and across different contemporary societies play a
role in the development of these disorders.
4.2.1 Sociocultural Comparisons with America

Several studies have identified sociocultural factors within American society
that are associated with the development of eating disorders. Traditionally, eating
disorders have been associated with Caucasian upper socioeconomic groups,
with a “conspicuous absence of Negro patients” (Bruch, 1966). However, a study
by Rowland (1970) found more lower and middle class patients with eating
disorders within a sample that consisted primarily of Italians (with a high
percentage of Catholics) and Jews. Rowland suggested that Jewish, Catholic
and Italian cultural origins may lead to a higher risk of developing an eating
disorder due to cultural attitudes about the importance of food.
More recent evidence suggests that the pre-valence of anorexia nervosa among
African Americans is higher than previously thought and is rising. A survey of
readers of a popular African American fashion magazine (Table) found levels of
abnormal eating attitudes and body dissatisfaction that were at least as high as a
similar survey of Caucasian women, with a significant negative correlation
between body dissatisfaction and a strong black identity (Pumariega et al., 1994).
It has been hypothesized that thinness is gaining more value within the African
American culture, just as it has in the Caucasian culture (Hsu, 1987).
Other American ethnic groups also may have higher levels of eating disorders
than previously recognised (Pate et al., 1992). A recent study of early adolescent
girls found that Hispanic and Asian American girls showed greater body
dissatisfaction than white girls (Robinson et al., 1996). Furthermore, another
recent study has reported levels of disordered eating attitudes among rural
Appalachian adolescents that are comparable to urban rates (Miller et al., in
press).
The notion that eating disorders are associated with upper socioeconomic status
(SES) also has been challenged. Association between anorexia nervosa and upper
SES has been poorly demonstrated, and bulimia nervosa may actually have an
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Counselling for Mental opposite relationship with SES. In fact, several recent studies have shown that
Disorders
bulimia nervosa was more common in lower SES groups. Thus, any association
between wealth and eating disorders requires further study (Gard and Freeman,
1996).
4.2.2 Eating Disorders in Other Countries

Outside the United States, eating disorders have been considered to be much
rarer. Across cultures, variations occur in the ideals of beauty. In many non Western
societies, plumpness is considered attractive and desirable, and may be associated
with prosperity, fertility, success and economic security (Nassar, 1988). In such
cultures, eating disorders are found much less commonly than in Western nations.
However, in recent years, cases have been identified in nonindustrialised or
premodern populations (Ritenbaugh et al., 1992).
Cultures in which female social roles are restricted appear to have lower rates of
eating disorders, reminiscent of the lower rates observed during historical eras
in which women lacked choices. For example, some modern affluent Muslim
societies limit the social behaviour of women according to male dictates. In such
societies, eating disorders are virtually unknown. This supports the notion that
freedom for women, as well as affluence, are sociocultural factors that may
predispose to the development of eating disorders
Cross cultural comparisons of eating disorder cases that have been identified
have yielded some important findings. In Hong Kong and India, one of the
fundamental characteristics of anorexia nervosa is lacking. In these countries,
anorexia is not accompanied by a “fear of fatness” or a desire to be thin; instead,
anorexic individuals in these countries have been reported to be motivated by
the desire to fast for religious purposes or by eccentric nutritional ideas (Castillo,
1997).
Such religious ideation behind anorexic behaviour also was found in the
descriptions of saints from the Middle Ages in Western culture, when spiritual
purity, rather than thinness, was the ideal (Bemporad, 1996). Thus, the fear of
fatness that is required for the diagnosis of anorexia nervosa in the Diagnostic
and Statistical Manual, Fourth Edition (American Psychiatric Association) may
be a culturally dependent feature (Hsu and Lee, 1993).
Anorexia nervosa has been described as a possible “culture-bound syndrome,”

with roots in Western cultural values and conflicts (Prince, 1983). Eating disorders
may, in fact, be more prevalent within various cultural groups than previously
recognised, as such Western values are becoming more widely accepted. Historical
and cross cultural experiences suggest that cultural change, itself, may be
associated with increased vulnerability to eating disorders, especially when values
about physical aesthetics are involved. Such change may occur across time within
a given society, or on an individual level, as when an immigrant moves into a
new culture. In addition, cultural factors such as affluence and freedom of choice
for women may play a role in the development of these disorders (Bemporad,
1997). Further research of the cultural factors influencing the development of
eating disorders is needed.
66
4.2.3 Eating Disorders in India Eating Disorder
Most people in India struggle to get enough to eat and it is estimated that 60% of
India’s women are clinically malnourished. But psychiatrists in urban areas are
reporting cases of anorexia nervosa, the so-called slimming disease that can cause
sufferers to starve themselves to death. Most people in India have still not heard
of the condition but some psychiatrists are of the view that there is an explosion
in anorexia cases over the past few years.
The arrival of cable television and Western fashions and films has given today’s
teenagers the idea that thin is beautiful. Western fast foods have arrived too but
as the young girls at Delhi’s pizza and burger bars tuck in, they also say they
want to lose weight. The irony is that India’s traditional idea of beauty is of
healthy, well-fed women with rounded figures.
One report states that there is obsession with physical appearance on rise amongst
college going crowd in India. Youngsters in the age group of 12-25 years are
using diet pills, fat burners, fasting, resorting to self induced vomiting etc. in
order to stay slim and look attractive. They are deeply influenced by modern
lifestyles together with ubiquitous show of a perfect 10 figure and airbrushed
faces in advertisements & pictures of ramp models, film/sports personalities etc.
in newspapers, magazines etc, says ASSOCHAM study.
Kids as young as 12 years old are resorting to severe dieting, consuming fat
burners and protein shakes thereby developing serious eating disorders, according
to the Chamber study. ASDF team conducted a survey in 10 major cities of
Delhi-NCR, Mumbai, Kolkata, Bangalore, Chennai, Hyderabad, Ahmedabad,
Chandigarh, Jaipur and Lucknow and interacted with around 2500 young folks
(almost equal number of males and females) in the age group of 12-25 years.
The study was carried out during October 2010 to March 2011.
According to the ASSOCHAM study, “an interesting aspect that emerged out of
the survey was that youngsters in urban India feel the need to diet as they aspire
to be thin and beautiful as cine stars, models, celebrities and feel that they will
be popular if they are able to attain that ‘ideal body image’.”
The study stated that today, even the kids are not off limits from the celebrity
driven trend of staying slim to look perfect and are dieting and starving themselves
to achieve desired results. This trend is equally prevalent both in males and
females.
This is likely to have an adverse impact on young people, especially females as

they suffer from eating disorder and psychological problems like that of a distorted
body image, sense of insecurity and a low self-esteem owing to fear of rejection
etc. Parents tend to overlook the strange eating habits of their growing kids without
realising that this is robbing them off their childhood.
Youngsters (12-25 years old) in Mumbai topped the chart with around 55 per
cent of them admitting to dieting over three days a week and 35 per cent admitting
to following a daily diet plan. Youth in Delhi –NCR ranked 2nd with 40 per cent
of them admitted to dieting over thrice a week and 30 percent said that they diet
daily. Chandigarh ranked third where 25 per cent said that they follow a strict
diet regime everyday and 35 per cent said that they diet at least 3 days per week.
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Counselling for Mental Ahmedabad stood on the 4th rung with 30 per cent admitting to dieting over three
Disorders
days a week and 20 per cent said that they diet daily. Figures in Lucknow and
Jaipur were almost equal as 25 per cent in said that they diet daily whereas 15
per cent respondents admitted to have been following a daily diet chart.
Majority of respondents agreed to following severe diet regimens but were

ignorant about the fact that it was affecting their growth. Besides, ASSOCHAM
study has revealed that youngsters obsessed with dieting are becoming anorexic
by starving themselves relentlessly and are prone to diseases like depression,
anxiety, insomnia etc.
While sharing their views with ASSOCHAM representatives the respondents

said that they feel worthless for being over-weight and constantly fear of becoming
obese, that’s the reason they starve themselves to attain a lean look. Majority of
them said admitted that they exercise compulsively, often to the point of
exhaustion to compensate for the calorie intake.
1) Define and describe eating disorders.
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2) Elucidate the prevalence of eating disorders.
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3) Present eating disorders in countries other than USA.
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4) Discuss eating disorders as prevalent in India.
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Eating Disorder
4.3 TYPES OF EATING DISORDERS
Although there are several different types of eating disorders, psychiatrists and
psychologists generally tend to divide them into two broad categories – anorexia
nervosa, bulimia nervosa and binge eating.
Anorexia nervosa is a condition characterised by a refusal to maintain a minimal

normal body weight, voluntary self starvation and an intense fear of becoming
fat. These individuals achieve abnomally low weight by severely dieting fasting
and often by exercising compulsively. Most cases are female coming from the
upper or middle class.
Bulimia nervosa is characterised by recurrent episodes of binge eating while

experiencing a subjective sense of lack of control over the eating, the regular use
of extreme weight compensatory methods (for example, self induced vomiting,
laxative abuse, diuretic abuse, excessive fasting and compulsive exercise) and
dysfunctional beliefs about weight and shape that unduly influence self-evaluation
or self worth. 90 per cent of the cases happen to be women. Bulimia nervosa is
likely to result from a combination of genetic, familial, psychological, and socio-
cultural factors.
Binge eating disorder is characterised by recurrent episodes of binge eating but,

unlike bulimia nervosa, no extreme weight control behaviours are present. A
decreasing weight goal, increasing criticism of the body, increasing social
isolation, disruption of menstruation, reports of purging in the context of dieting
are some of the warning signals for parents. Parents are largely responsible for
shaping a child’s body image and eating lifestyle. It is believed that parents who
are themselves preoccupied with body image and weight increase the ranks of
childhood anorexics. Parents should communicate with their children and try to
maintain a healthy lifestyle at home for the sake of their children.
Depression, stress and genetics are important factors when it comes to eating
disorders. It has been observed that those who suffer from anorexia nervosa are
usually sensitive, intelligent people who have a tendency to turn into control
freaks. On the other hand, Anorexia bulimia is associated with those who are
very emotional They then alternate between periods of overeating and then a
self-inflicted punishment in the form of starvation.
Since, eating disorders usually begin in teens, parents can play an important role
in curbing them. Eating disorders in children can often be a result of unhealthy
eating habits at home. Parents should realise that children unconsciously follow
most of their dietary habits. For this reason parents have to be careful about their
own diet and make sure that they are setting a healthy example for their kids.
Second, meal time should be fun. Painful or stressful topics should be kept away
from the dinner table. This is not a time to discuss your child’s bad performance
in exams. Instead, make it a family bonding time. Keep conflicts away from
meal time. Parents should also try to make a healthy diet palatable. Incorporate
interesting recipes so that eating becomes an enjoyable activity.
A balanced diet consists of adequate amount of carbohydrates, proteins, fats and

vitamins. An average Indian meal consisting of chapatis, dal, green vegetables
and curd forms an ideal diet. Deviating greatly from this for more than three
weeks would be considered as a disorder. There can be several reasons for this. 69
Counselling for Mental First, there is tremendous peer pressure on young people to look good. Girls
Disorders
compete with one another to fit into a smaller size as thin is in. The pressure to
look attractive is so great that they cut down blindly on the first thing that happens
to be in their control, which is their food. In the absence of proper guidance they
blindly follow crash diets. Some even deprive themselves of all food. There are
others, who only go by calorie count, skip healthy meals and binge on junk
foods. In their mind they are not doing anything wrong as long as they do not
exceed the calorie count. This lack of information about a balanced diet can lead
to severe consequences.
Parents in such a situation should not coerce or nag their children. They, instead
have to lead by example. If kids see a healthy and an active lifestyle at home,
they will automatically emulate it. Do not sermonise, subtle guidance is the need
of the hour.
Sometimes eating disorders are a result of severe emotional stress r depression.

Parents have to understand their children and ensure that their emotional needs
are being fulfilled. These situations have to be tackled sensitively. In case, you
are not able to diagnose the cause, medical help should be considered.
In reality it is difficult to differentiate between the two since there is a lot of

overlap in the behavioural characteristics and psychological process of each.
Many theorists suggest that people’s eating habits and their perception of their
own body image lie on a continuum- along a scale that extends from extremely
distorted eating habits and an unrealistic body image at one end to no
psychological or behavioural distortions at all at the other. Every one stands
somewhere within in this range.
Sometimes, we see people who think they are fat and sometimes starve
themselves, or who are on permanent diets. This does not necessarily mean that
they have an eating disorder, but it does show how anorexia and bulimia might
be extreme versions of common occurrences.
4.3.1 Anorexia Nervosa

Anorexia nervosa literally means “nervous loss of appetite” yet people with
anorexia do not lose their appetites but are often hungry and preoccupied with
food. They want to eat but seem to be starving themselves. Anorexics might
even love to cook for others. They might read recipe books, prepare meals, shop
for food, and even work in restaurants, but they always avoid eating any caloric
rich food themselves. They usually have a distorted body image and think they
are fat when, in fact, they are wasting away and many anorexic people try to hide
their bodies in oversized clothes.
4.3.2 Diagnosis of Anorexia Nervosa

People are diagnosed as anorexic if they weigh less than 85 per cent of the expected
weight for their age and height in the normal circumstances. They might look
extremely thin and feeble because of their significant weight loss, and they often
have other health problems, including low blood pressure, constipation,
dehydration, and low body temperature.
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4.3.3 Diagnostic Criteria for Anorexia Nervosa (DSM-IV) Eating Disorder
• Refusal to keep body weight or above 85% of the generally recognised normal
level for age and height.
• Intense fear of gaining weight or becoming fat, even when underweight.
• Disturbance in experience of body weight or shape, undue influence of these
factors on self-esteem or denial of the seriousness of the health risks of the
current low body weight.
• If menstruation has begun, the absence of three consecutive menstrual cycles.
Two types of anorexia are recognised:
1) The restricting type in which the main focus is on restricting food intake
and
2) The binge – eating/purging type in which there is regular binge eating
followed by purging by vomiting, laxatives, etc;
4.3.4 Prevalence of Anorexia Nervosa

Anorexia nervosa occurs mainly in women. For every male sufferer there are 15
females who have the disorder. However, there is evidence that the number of
men with eating disorders is rapidly increasing, Anorexia usually starts at between
14 and 16 years, although two researchers from Great Ormond Street children’s
Hospital in London, England, have reported cases of anorexia in children as
young as eight year old. It is estimated that between 5 and 15 percent of people
with anorexia die from it or from related disorders.
4.3.5 Bulimia Nervosa

Bulimia nervosa is characterised by sporadic episodes of compulsive binge eating.
People with bulimia rapidly eat lots of carbohydrate-rich foods in a seemingly
uncontrolled way. They eat more than just a load of cookies – they could eat a
whole of pizza, a whole tub of ice-cream, several giant packs of potato chips, a
whole creamy desert, a whole quiche, or lots of fizzy or milky drinks. They
usually choose foods that are soft and easy to eat. The binge usually ends with
stomach pains or some kind of purging-either self-induced vomiting or defecating
as a result of taking laxatives.
Some people begin their binges by eating coloured marker food so they will be
able to tell when they have thrown up all the food they took in. Although many
people describe themselves as binge eaters, it is the severity and frequency of the
binge eating in bulimia that makes it such a severe disorder. In mild cases a
person might binge two or three times a week. In more extreme cases it might
occur 30 times a week.
4.3.6 Diagnostic Criteria for Bulimia Nervosa (DSM IV)

Frequently occurring episodes of binge eating that are characterised by both
a) eating an amount of food that is definitely larger than most people would
eat within a specific period of time and in similar circumstances; and
b) a sense of lack of control over eating during the overeating episode.
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Counselling for Mental • Recurrent behaviour to compensate for the overeating and prevent weight
Disorders
gain, including vomiting, laxatives, fasting or excessive exercise.
• The occurrence of both the binge eating and the compensatory behaviours
atleast twice a week for at least a 3 – month period.
• Self – evaluation that is over influenced by weight and body shape
• Bulimic behaviour that does not occur only during episodes of anorexia
nervosa.
Two types of bulimia nervosa are recognised:
1) the purging type, in which vomiting or doses of laxatives are used during
the current episode; and
2) the nonpurging type in which fasting or excessive exercise, but not purging
is used to prevent weight again.
4.3.7 Impact of Bulimia

The process of bingeing and purging can have all sorts of side effects on the rest
of the body.
Bulimia sufferers often have puffy cheeks, a bit like those of a chipmunk. That is
because vomiting swells the parotid glands in the lower jaw.
Their tooth enamel can often decay because of the acid that they bring up when
vomiting.
You might also notice little calluses on the back of their hands, caused by the
rubbing against the upper teeth while sticking their fingers down their throats to
make themselves sick.
Bulimia sufferers also have problems with their digestive tract, dehydration, and
nutritional balances, and anxiety, depression, and sleep disturbance.
4.3.8 Binge Eating

It is characterised by episodes of bingeing without the use of compensatory
behaviours such as purging that are seen in bulimia nervosa. Two common patterns
characterise binge eating – compulsively snacking over long intervals ( such as
all day at work or all evening in front of the computer or television) or a
consumption of large amounts of food at one time beyond the requirements to
satisfy normal hunger. Binge eating disorder often leads to problems with weight
regulation and sometime obesity. In clinical practice, it is difficult to distinguish
between a binge eating disorder and nonpurging bulimia nervosa. Some studies
found that binge eating women experienced more negative affect (depression
and anxiety). This suggests that treatment approaches should focus on helping
binge eaters learn to cope more adaptively with poor mood. In addition to mood,
situational and cognitive factors often play important roles in binge eating.
4.3.9 Triggers of Binge Eating

• Particular stressful situations
• Particular upsetting thoughts
• Feeling guilt about something one has done
• Feeling socially isolated or excluded
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• Worries about responsibilities, problems or the future Eating Disorder
• Boredom

1) What are the various types of eating disorders? Explain
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2) Discuss Anorexia nervosa in terms of symptoms, diagnosis and its
prevalence.
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3) Discuss bulimia nervosa in terms of diagnostic criteria and impact.
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4) What is binge eating? Discuss the triggers nof binge eating.
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4.4 CAUSES OF EATING DISORDERS

There is no single theory that can explain why people experience anorexia and
bulimia. There are many biological, psychodynamic, family and socio-cultural
theories that, when combined, can provide some understanding of what is
happening. The theories can lay the foundation for the types of treatment the
person might receive, but as yet there is no scientific explanation of why people
suffer from eating disorders.
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Counselling for Mental 4.4.1 Biological Theories
Disorders
Some theories have suggested that anorexia is caused by damage to various parts
of the hypothalamus, the part of the brain that helps balance, monitors bodily
functions and control the endocrine system via the pituitary gland. The endocrine
system consists of glands such as the hypothalamus, the pituitary, and the adrenal
glands. Glands communicate with each other through chemicals called hormones.
To understand the development and maintenance of eating disorders, researchers

have developed the concept of the “weight set point”. In experiments with
laboratory rats they located two different areas in the hypothalamus that control
eating. The lateral hypothalamus (LH) produces hunger when it is activated.
Even when a laboratory rat has recently been fed, it will still eat if the LH is
stimulated. The ventromedial hypothalamus (VMH) reduces hunger when it is
activated. When the VMH is destroyed, the laboratory rat will not stop eating
and grows obese.
The theory proposes that the various parts of the hypothalamus work together to
create something like a weight thermostat – a weight set point- that predisposes
people to stay at their natural body weight. When the set point falls below a
certain level, parts of the hypothalamus would also decrease the metabolic rate
if a person is expending too much energy. If people exceed their set point, then
another point in the hypothalamus is activated that reduces hunger and therefore
reduces eating and restores the weight balance.
The set point is thought to be determined by a person’s genetic makeup, early
eating practices, and the body’s need to maintain equilibrium.
The problem with these biological theories is that it is unclear whether brain
dysfunction and changes in the neurotransmitters are causes or effects of the
eating disorder.
Some people have wondered whether genetics plays a part in the development
of eating disorders. Over the years there have been a series of studies of twins
that have tried to determine whether anorexia and bulimia are caused by nature
or nurture. But with much debate and controversy regarding the research, the
conclusion seems to be that genetic factors play a minimal role.
According to some theorists, the distorted perception that anorexics have of their
bodies might be connected to a blood-flow deficiency in the anterior temporal
lobes of the brain. The anterior temporal lobes interpret vision; and if there is
less blood flowing there, it might explain why anorexics see themselves as a fat
when they are thin. However, this alone could not cause anorexia- there must be
other triggers that lead to the development of the disorder.
4.4.2 Cultural Theories

Many theorists believe that pressures in western societies are mainly responsible
for the origin and maintenance of eating disorders. Between 1995 and 1997 Paul
Garfinkel and David Garner examined the look of Miss America contestants and
playboy centrefold models over a 27 year period and found that average bust,
waist, and hip size of the women featured in the magazine decreased significantly
over this period. They also looked at articles in various women’s periodicals
from 1959 to 1970 and found that in the 1960s there was an average of 16 articles
a year on dieting. By the 1970s that figure had increased an average of 23 a year.
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Society’s emphasis on appearance has historically exerted much greater pressure Eating Disorder
on women than on men. Some sociological theorists believe that this double
standard of attractiveness has made women overly interested in their appearance,
dieting, and body image. The idea is supported by trends in advertising that have
presented and even to some extent defined a desirable male physical form that
has led men to become more concerned than before about their own eating habits.
The increasing preoccupation of the media and leisure world with male
attractiveness seems to correlate to an increase in the number of men who now
appear at clinics with eating disorders.
4.4.3 Family Theories

The family functions like mini society and can often be the starting point for the
development of eating disorders. Research shows that about half of the families
of people with eating disorders have a history of making big issues of thinness,
food, and body image. From early childhood food can be powerful tool for
communication between parents and children. Systems theorists are scientists
and thinkers who see relationships between all sorts of systems, big or small,
physical or abstract, scientific or social. Psychologists who subscribe to systems
theory take the view that a family will come to set its own level of homeostasis,
or balance. They suggest that the presence of someone with an eating disorder in
the family is really only an expression of some pre-existing family disturbance.
The family therapist Salvador Minuchin is a leading systems theorist who has
suggested that an enmeshed family pattern often leads to the development of an
eating disorder in one of the children. Enmeshment occurs when parent and
child are overly involved in each other’s lives. On the one hand, enmeshment
can create affectionate, close, and loyal relationships. On other hand, it can prevent
a child or young adult from growing up and becoming independent.
Adolescence can be a real crisis point for enmeshed parents and children since
the young are trying to establish themselves in the grown-up and are searching
for identity. It can disrupt the balance of the family. The parents might no longer
feel needed, the roles need to change, and as the family seeks to regain its balance,
the child is moved to take on a sick role. If the family functions to look after the
sick child, the pain of growing up and many other potential conflicts are avoided.
In such instances family therapy can be used to help the family face the underlying
tensions and shift the eating pattern.
Anorexia is prevalent in the middle-class female children from families with

high aspirations whose parents have a professional back ground. It is also more
common in those who go on to higher education than in those leave school at the
earliest opportunity. Anorexia suffers are often A-grade students who give
perfection in all they do – including the way the look. The pressure on these
young women to succeed might just to be great, and it sends them into a spiral
anorexia or bulimia and anxiety or depression.
4.4.4 Other Possible Causes

Cognitive behavioural and psychodynamic theories are derived from the
increasingly popular idea that eating disorders are linked with dieting behaviour.
It is akin to a stimulus response mechanism.
75
Counselling for Mental Anorexics might be striving for perfection and so go on diets to achieve their
Disorders
ideal weight. When they reach this goal, they might well receive admiration
from those around them. And this further reinforces their dieting behaviour and
so it goes on in a vicious circle. Reward for not eating might come in the form of
attention from family and friends. There might also be approval-the anorexic
looks like an athlete or a supermodel and gets admired for it. For bulimia sufferers
the reinforcement might come from bingeing and purging, which reduce their
anxious thoughts.
Psychiatrist Hilde Bruch was particularly influential in cognitive and psychodynamic

understandings of anorexia and bulimia. She argued that disturbed mother-child
interactions lead to ego deficiencies in the child (poor sense of autonomy and
control), and this causes severe perceptual and other cognitive disturbances.
According to the theory, parents fail to respond to their children effectively. For
instance, a child cries, and rather than trying to understand what the crying is
about- the child might be tired, hungry or scared- the parent will give food for
comfort. According to Bruch, children treated this way fail to develop cohesive
self. They grow up confused and not sure of when they are hungry or when they
are tired. As they grow to adolescents, they need to develop and increased sense
of autonomy yet become stuck because they are unable to be independent and
judge their own sense of self.

1) Discuss the biological causes of eating disorders.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) What are the cultural theories of eating disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) Elucidate the family theories as applicable to eating disorders.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
76
Eating Disorder
4) Discuss the other possible causes of eating disorders.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
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4.5 TREATMENT OF EATING DISORDERS

A wide variety of treatments have been used with eating disorders. Treatments
used range from biologically based approaches involving antidepressants,
antianxiety drugs and appetite stimulants to psycho therapy and family therapy
based on psychodynamic principles, behavioural and cognitive behavioural
therapies and educational therapies such as nutritional education. Most of the
treatment approaches use a combination of medication and behaviour
modification or psychotherapy.
4.5.1 The Biological Treatment

The biological treatments show that in 33% cases there is drop out from the
treatment. This when compared to the cognitive therapy, which has only a rate of
5% drop out.
4.5.2 Family Treatment

Treatment includes neither biweekly nor monthly family meetings. Sometimes
friends of the client and other people can also attend the meetings. The therapist
encourages the family to explore its beliefs and behaviours about the disorder
and other related family issues.
Therapists work in pairs or teams. The family is encouraged to do homework

tasks. The specific nature of intervention is based on the therapist’s working
hypothesis.
4.5.3 Cognitive Behavioural Treatment

Weekly to biweekly therapy with cognitive therapist. The therapist focuses on
interaction between thoughts, feelings and eating behaviours. Behaviours that
creat and maintain thinness are negatively reinforced (reduced) by the removal
of anxiety. The client and therapist explore society’s perception of physical
attractiveness. They also examine the client’s beliefs about body image. An
educational component of the therapy consists of assessing dietary and physical
possibilities. The client’s monitoring negative automatic thoughts , keeping food
diaries and completing rating scales.
4.5.4 Psychoanalytic Treatment

Weekly to 5 times a week individual therapy. The therapy seeks to make the
unconscious motivation as conscious motivation of disordered behaviours. It
uses the relationship between the therapist and client to explore important
relationships in the client’s early life, as for example the one that the client had
with his or her parents. 77
Disorders 4.6 LET US SUM UP
The prevalence of eating disorders appears to have increased over the past 50
years. The major eating disorders are anorexia nervosa, in which the individual
seems obsessed with thinness and loses a great deal of weight. Bulimia nervosa,
in which excessive quantities of food are eaten followed by purging and binge
eating in which large quantities of food are eaten but there is no purging.
Personality, family and cultural factors play significant role in causing these
disorders. Most of the treatment approaches use a combination of medication
and behaviour modification or psychotherapy. Most of the treatment approaches
use a combination of medication and behaviour modification or psychotherapy.

1) What are eating disorders? Explain their nature and symptoms.
2) What is the prevalence of eating disorders? Discuss eating disorders as being
obtained in India.
3) What are the various types of eating disorders?
4) Elucidate the causes of eating disorders.
5) Differentiate anorexia nervosa and bulimia nervosa.
6) Discuss the treatment methods used in treating eating disorders.

Carson,R.C. Butcher, J.N. & Mineka, S. (2000). Abnormal Psychology and

and Company.

78

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Introduction to Counseling

UNIT 1 INTRODUCTION TO COUNSELING and Characteristics of a

1.2 DEFINITION OF COUNSELING

Counseling as a profession is relatively new. It grew out of the guidance

Counseling is often performed face to face in confidential sessions between the

It emphasises on exploration and understanding the problem and stresses the

Biswalo (1996) defines counselling as a process of helping an individual to

According to British Association for Counseling and Psychotherapy (2002),

1.2.1 Counseling and Guidance

Guidance is giving leadership, supervision, direction, or professional guidance

Guidance is pre problem, that is there is no specific problem that is identified in

Counseling is not giving opinion, instruction or advice, it is using facilitative

1.2.2 Characteristics of Guidance

It is both generalised and a specialised service. It is a generalised service because

It is a generic term as it includes information giving and research activities. It is

1.2.3 Counseling and Psychotherapy

Self Assessment Questions

1.3 HALLMARKS OF A COUNSELLOR

1.4 CHARACTERISTICS OF A COUNSELOR

Effective counselling requires an understanding of self and a detailed awareness

A counselor needs to be equipped with advanced listening skills. They must be

Counselling demands a process of negotiation and problem solving. A clear goal

Self disclosure is a powerful tool that can be used by an effective communicator

An understanding of the complexity of communication is a basic foundation

Counsellors must be competent in their communication to be credible and must

Confidentiality is the key of successful counseling. The ability to uphold a

Counselors achieve credibility by being honest and consistent in their statements

1.4.1 Educational Qualifications of a Counselor

1.4.2 Education and Training

Counselors working in certain settings or in a particular specialty may face

The information regarding Continuing Rehabilitation Education (CRE) topics

To upgrade the knowledge and skills of in service and practicing Rehabilitation

To update Professional knowledge of masters trainers working in the field of

1.4.4 Other Qualifications

1.4.5 Certification and Advancement

The Commission on Rehabilitation Counselor Certification offers voluntary

Certification requirements vary, however, according to an applicant’s educational

Other counseling organisations also offer certification in particular counseling

Some counselors choose to work for a State’s department of education. Some

1.4.6 Counsellor and Values

1.5 LET US SUM UP

1.6 UNIT END QUESTIONS

1.7 SUGGESTED READINGS

Nelson-Jones, R. (2002). Basic Counselling Skills: A Helper’s Manual. Sage

Samuel T. Gladding (2009). Counseling: A Comprehensive Profession. Pearson

2.2.1 Counseling Process

The client’s personal commitment to helping him or herself is crucial to an

Counselling is a process with a beginning, a middle and an end, where the

2.2.2 Steps in Counseling Process

2.2.3 Stages of Counselling Process

Counselling may be helpful in a number of ways. It can enable the client to

2.2.4 Counselling Process Followed by Counsellors

2.2.5 Procedure in the Counseling Process

Broadly, three major stages in the process can be described as follows:

2.2.6 Developing a Relationship

• Laying foundations for trust

i) Predictability and consistency

iii) Establish confidentiality