Unit 24
P.4-describe the importance of referral to other agencies
What is a referral? What is the difference between a referral and a recommendation?
As a counsellor you will often find yourself in situations where you can’t provide an appropriate or on-going service to your clients. This might be because your agency policies state that you can only assess clients, or work with clients for a specified timeframe. It also might be because you don’t have the skills necessary to deal with certain issues such as child abuse, sexual assault, marital issues, loss and grief and so on. It is important to realise that acknowledging you haven’t the necessary skills isn’t a sign of failure but rather a professional assessment of your strengths and weaknesses. By referring a client on to someone who can help them with their particular issue you are effectively meeting your client’s need and thus helping them move a step closer to resolve whatever is troubling them.
Making a referral usually means putting people in touch with services that have the resources to help them achieve their goals. It is not just about handing out a number. You are responsible for bringing the person and the service together. When we make a referral, we are basically sending a person to another professional who specialises in working with particular needs or problems. Referring a client to another professional doesn’t mean that we stop working with that client but rather that we work as part of a team to best meet all that person’s needs. Counselling has a role across a wide range of services. Therefore, use of the resource must be appropriate. Client choice is a consideration for referral but not the only one: all referrals to counsellors should be based on an assessment. This assessment should consider the appropriateness of counselling to the client’s presenting problem and should make reference to the anticipated outcome or gain in the client health or wellbeing. There should be an explicit intention for health improvement as a result.
A recommendation can be seen as giving advice to someone on what the best thing to do is or a suggestion that something is good or suitable for a particular purpose of job. A recommendation is very different to a referral because it is less formal and does not require reporting back, whereas when a counsellor refers you to a specific professional it will usually be followed up and a report is often sent back to the counsellor to see how the patient is doing, because they don’t necessarily stop working with the client. There are many types of referrals one being referred by a professional, but there is also self-referral which is making an appointment for yourself and going there by yourself with your free will. There can also be referrals by others for example your parents making an appointment for you, or someone that lives at home with you e.g. husband, lastly there is recommendations which anyone can do, but usually someone that knows you and what you’re going through, will usually make a recommendation that leaves you with options to pick from.
There are many reasons why an individual may be referred to another professional for example someone that may have specific needs e.g. someone that suffers from a mental illness such as schizophrenia, substance abuse e.g. over drinking etc. Doctors may refer clients to counselling as through counselling they may be able to overcome this addiction as the counsellor will look further into why they may be using this certain drug (or drinking alcohol) what is it that they are trying to suppress by emerging in such substances. Doctors can only spend so much time with a patient as they are solely focused on the individual overcoming whatever they are going through by having medication, but certain things cannot be cured with medication e.g. addictions. In many cases people who are addicted are not aware of their addiction and the impact it may be having on their work, relationships and health. As a result, many are unable to quit on their own and treatment is required. Addiction treatment such as counselling is crucial for helping sufferers to recognise their condition and how their emotional needs are affecting their behaviour. This can be an important step on the road to recovery and, eventually abstinence.
Another reason an individual may be referred is would be emotional limits such as an individual going through bereavement, child abuse, divorce, this would require other attention such as counselling as they specialise in treating certain issues that the individual may be having/ going through. This is because these emotional limits can lead to an individual going through depression and anxiety and these are again regarded as mental issues which again are linked to individuals also developing an addiction to either drugs or alcohol. That is why the earlier they are sent to counselling the easier it is to overcome the problems they may be facing in life. It can provide a safe and regular space for you to talk and explore difficult feelings. The counsellor is there to support you and respect your views. They won't usually give advice, but will help you find your own insights into and understanding of your problems.
Another reason an individual may be referred is because of agency limits for example language barriers. If the client speaks another language that you cannot it will be very difficult for them to explain to you how they feel and what is going in because you are not able to converse with them, so referring them to another counsellor who can communicate with them in that particular language is essential, as this will help the client and make them feel more comfortable because someone can actually understand them, and are able to help them without them getting frustrated in trying to explain to someone that don’t understand them. Another agency limit is waiting times, if someone urgently needs counselling for example someone that may have tried to commit suicide or are having suicidal thoughts they will be referred to a counsellor who has no waiting time for them to be seen quicker. Another agency limit is that not everyone can be provided with a counsellor that is the same gender as them, but due to the fact that this is client request it would out duty to provide this service which is why referral is so important because in certain religions such as Islam women are not allowed to talk men outside of their extended family that are not linked to them by blood or is not their husband. So they would need a women counsellor that they could talk to. Another agency limit that many counsellors face is timing. Timing is extremely important for example when the session starts and finishes. It is entirely in the clients hand if they want to come to the session or not, but the client should never view you as their friend as they will be then stepping over the boundaries set out, which in some cases means they have become very comfortable and start to take advantage, which is why referral in this case may be essential.
Equal opportunities are essential when being referred for counselling. Just because certain individuals may have difficulties with hearing doesn’t mean they should be deferred from counselling or being referred. Finding someone that can sign would make the individuals life much easier as they could sign to them in BSL. Also expecting others cultures religions whilst being referred is also another important aspect because in order to get the best out of the sessions both clients and counsellors have to be accepting of each other for example geniuses. How is the client going to progress if their counsellor is unpleasant to be around and makes them feel uncomfortable?
P.5-Describe the potential boundary issues that could occur in a helping relationship
Counselling boundaries are a set limits, inclusions and exclusions appropriate for counselling. Clear boundaries are essential in counselling to create a safe therapeutic space for clients. Counselling boundaries are embedded into codes of practice. Boundaries in many ways are the relational framework within which the counsellor and client work together. It is these boundaries that make it transparent to the client the limitations of the counsellor and the counselling process, while also distinguishing the self of the client from the self of the counsellor. In this way, boundaries are a safety net, a way of preventing harm to clients because rules and roles are clearly establishing and therefore expectations can be met. This is also important for the health and well-being of the counsellor.
As a counsellor you would be expected to have (or have access to) the following for each client: a referral form, Initial assessment form, attendance record, final discharge form and lastly client feedback/evaluation form. So a potential boundary issue in counselling would be confidentiality as counsellors are expected to have opportunities to discuss this information with their line manager in order to evaluate and improve services. The need to respect client confidentiality is a core principle of counselling. It is therefore important to be fully aware of the wide range of agencies or individuals that can gain access to personal information disclosed and explored in therapy. Counselling relationships are built upon trust. Disclosure may be impeded if the client feels insecure or suspicious of what happens to the material offered during a counselling session. It is essential that issues of confidentiality be clearly and openly discussed with the counsellor and the client before engaging in counselling. It is important that clients understand the limitations of confidentiality with the client counsellor relationship and are clear under what circumstances exceptions in confidentiality may occur. Counsellors may work in multi-disciplinary teams in which sharing of information is considered necessary, for example, case conferences, team briefs and supervision. This should always be in the interest of the client and should not compromise the counselling relationship. Prior and explicit agreement should be obtained from the client and not merely be assumed.
Another potential boundary issue that may arise is client resistance this is for example the client not turning up the sessions, coming late, or the client simply having a dislike towards you. As a counsellor you may come across cases where certain clients show you this type of resistance and this will indefinitely cause boundary issues, because you are not entitled to allocate this time to other people even if they come late, or they don’t turn up at all because this is part of the BACP which is to keep promises, contracts and agreements and try and act in a fair and reasonable manner. It is up to the client if they want to attend the sessions or not but as a counsellor in order to be able to build a relationship with the client, you have to spend time with them, talking/listening etc. but if that is not taking place at all in any of the sessions it will cause boundary issues because it will become awkward and a lot of tension which is rather than resisting the force of your opponent’s energy and conflicting with it, you direct it and ‘help’ them… well, become more closely acquainted with the mat. But we can do this in therapy by working with our clients’ resistance to help them rise above what’s troubling them. There is a risk that we might see clients as being ‘resistant’ when they are just disagreeing with us. But they are in fact just pushing you away which is why you have to pull them in.
Another potential boundary issue is when the counsellor is resistant themselves, there may be many reasons why the counsellor is resistant them self for example when they start to over identify, they may have gone through a similar situation themselves but because they don’t want to disclose this kind of information because they may feel vulnerable, and feel as though the client is their counsellor which is clearly not the case but sometimes counsellors can find it hard to admit that they may have gone through that particular situation because they themselves might be having counselling as well as being a counsellor or are going through it at the moment. Another reason the counsellor may be resistant is that they may have had many cases where clients show the same symptoms of the same situation and the counsellor may feel uncomfortable in approaching the situation at hand because they are scared they will have the same response e.g. the client shutting down and not wanting to talk anymore, the clients stops coming to lessons, the client starts to become very negative.
Another potential boundary issue is self-disclosure and physical contact; counsellors are often advised to remain a ‘blank screen’ onto which clients can then project their transference subjects. To this extent, self-disclosure by a counsellor may interfere with the process and contaminate the transference. However, an investigation into the benefits of self-disclosure by the therapist found that clients receiving counselling in which the counsellor revealed information about his/her personal life reported lower levels of symptom distress and also reported liking their therapist more. The authors concluded that self-disclosure by the therapist may improve both the quality of the therapeutic relationship and the outcome of treatment (Barrett and Berman, 2001). From this we can see that self-disclosure is indeed helpful but it can also make it seem as though you want the client to feel sorry for you and you as the counsellor are meant to be the one listening and providing help and support to the client rather than the other way around, also sometimes it can lead the client to mistaking you for their friend, which can lead them to treating you like one for example greeting you with a hug or when saying goodbye hugging you, and as a counsellor physical contact plays a very big factor in your therapeutic relationship. We have boundaries for a reason and one of them is keeping the client as well as the counsellor safe, this is because sometimes the client can start to like you, more than a friend so you have to be-careful the impression you give of in the first place.
M.1-assess how integrating counselling skills should support clients
During my work placement at rose Taylor I found that I used a lot of counselling skills for example active listening. Active listening is paying careful and sustained attention to what is being said by a person or persons. It may include making brief comments at times and asking careful questions to clarify matters, it doesn’t require you to necessarily speak you can be active listening by using eye contact, facing the client when they are speaking to you, nodding your head to show you understand. At rose Taylor I used active listening when I was talking to a client about their youth and the problems that she faces at home with her daughter. I knew that my use of active listening was successful when she had remembered me the next week that I saw her as well as her saying ‘thank you dear, for listening to me’ and kissing my cheek to say goodbye. I believe my use of eye-contact and the fact that I was nodding my head really showed her that I was interested in what she was saying and the fact she remembered me despite suffering from dementia means a lot because someone actually took time out of their day to listen to her. I believe the career that I want to pursue which is children’s nursing, active listening will be a skill that is transferable because it is needed a lot for when you are building a caring and supportive relationship with someone. Active listening infers to the individual that is talking that the other person cares enough to know how they feel and what they think, it also builds trust in the person and the individual will be able to confide in you, because you are listening to what they are saying. However there sometimes can be a lot of disadvantages to active listening for example takes time and energy; in some instances, a lot of time, it requires continuous, disciplined, and persistent effort and concentration. Lastly sometimes it can lead people to use you as a “listening post.” You may find that someone seeks you out often to “let off steam.”
Another counselling skill that I found myself using was use of questions. When wanting to build an effective relationship you have to be careful the way you word your questions and the type of questions you ask, for example open/closed questions. For example, during my placement when I was talking to the client about her relationship with her daughter I asked her questions like ‘so how is your relationship with your daughter now?’ this is an open ended question as it gives her a variety of ways to reply and she won’t feel as though she is being interrogated. That is a disadvantage of use of questioning also another disadvantage is that can sometimes detract away from active listening because I keep interrupting her to ask her questions. However, the advantages of use of questions is that it keeps the client talking and you are able to understand where they are coming from because they are disclosing more information to you. I feel with the career that I want to pursue it will be essential that I know how to word the questions I ask especially with children, I need to be more aware of the questions I ask and I have to avoid using terms that they don’t understand in order to get them to open up to me, because children are very stubborn compared to adults, and if they don’t like you, it’s hard to build a relationship with them and then get to the questioning part.
Another skill that I found myself using was Reflection paraphrasing and summarising. This particular skill usually comes in a three when you do reflection you are essentially going to do a bit of paraphrasing and summarise at the end of what you have said. For example, when the client told me that ‘she felt like nothing to her daughter, when she hurt herself, she felt very lonely and that her feelings meant nothing to no one etc.’ I reflected back to the client by saying ‘you feel as though your feelings are disregarded by everyone and that you feel alone in this world, and you feel as though you mean nothing to your daughter’. The aim of reflection is to reflect back to the client their feelings so they can hear it from another person’s point of view, it is also to clarify that I have the right idea of what she is feeling. I paraphrased by using some of words and some of hers to show that I understand what she is saying when reflecting back to her. I summarised what we talked about by saying ‘so you feel like nothing to your daughter and you want to be able to rebuild with her relationship?’ this is summarising and how she feels and what we are going to do about it in the future. I believe these skills will be essential in the field of nursing because as a children’s nurse you will need to sow your understanding of their feelings a lot so you will have to rephrase what their saying a lot for them to know that you understand for example ‘if a child said that my daddy is scary I can’t say anything otherwise he will hurt me’ from this you can infer that the child is scared of their dad and he will start to abuse them if they say something so a way in which you would reflect and paraphrased and summarise would be ‘ will daddy hit you if you say something naughty?’ you have immediately reflected and paraphrased and summaries the situation at hand.
Another skill I found myself using was goal setting. So during placement the individual that I was working with wanted to go back to where she grew up and spend a few weeks there in her family home because she misses it, so I encouraged her to ask her son who she is living with, to help her achieve that goal and take her’. Goal setting is helpful as it helps the client identify certain things they want to achieve in life, as the individuals that I was working with in placement were old they may want to do things in their life that they have never had the chance to e.g. visit a certain country, do a certain activity etc. so working with them and helping them to achieve that goal is important as this helps strengthen your relationship with the individual which is what I did when the client was telling me about her life story. I encouraged her to go back to the place she grew up in as that is something she had been wanting to do for a very long time, she wanted to revisit the place in Scotland where she used to work as a baker and just be able to relive the certain memories she had there again. Except she was frightened to ask her son if she was allowed to go because she did state that she wasn’t even allowed to get bus on her own, which she was really upset about as she felt as though she had no freedom. So I encouraged her to speak to her son about it as it is something she wants to do before she dies, and I didn’t want her to feel regretful because she was too frightened to speak to her son because she felt as though she was a burden. I feel as though in nursing I will always have to encourage my clients to goal set as this what will motivate my clients to very give up and stop trying. As a nurse you have a very supportive role in your clients life and sometimes me being the motivational person in their life can really push them to carry on trying and never give up for example someone that suffers from cancer may not want to carry on with chemotherapy, I as their nurse will know that chemotherapy is possibly their only chance of survival so encouraging the child to try as well as their parents/guardians can really give them that motivation that their lacking.

Bibliography http://www.nhsggc.org.uk/media/220579/nhsgg_standards_counselling_primary_care_full.pdf http://www.bacp.co.uk/ethical_framework/good_standard.php http://www.counselling-directory.org.uk/addictions.html http://www.nhs.uk/conditions/Counselling/Pages/Introduction.aspx