counselling session case study

Writing a Counselling Case Study

As a counselling student, you may feel daunted when faced with writing your first counselling case study. Most training courses that qualify you as a counsellor or psychotherapist require you to complete case studies.

Before You Start Writing a Case Study

However good your case study, you won’t pass if you don’t meet the criteria set by your awarding body. So before you start writing, always check this, making sure that you have understood what is required.

For example, the ABC Level 4 Diploma in Therapeutic Counselling requires you to write two case studies as part of your external portfolio, to meet the following criteria:

• 4.2 Analyse the application of your own theoretical approach to your work with one client over a minimum of six sessions.
• 4.3 Evaluate the application of your own theoretical approach to your work with this client over a minimum of six sessions.
• 5.1 Analyse the learning gained from a minimum of two supervision sessions in relation to your work with one client.
• 5.2 Evaluate how this learning informed your work with this client over a minimum of two counselling sessions.

If you don’t meet these criteria exactly – for example, if you didn’t choose a client who you’d seen for enough sessions, if you described only one (rather than two) supervision sessions, or if you used the same client for both case studies – then you would get referred.

Check whether any more information is available on what your awarding body is looking for – e.g. ABC publishes regular ‘counselling exam summaries’ on its website; these provide valuable information on where recent students have gone wrong.

Selecting the Client

When you reflect on all the clients you have seen during training, you will no doubt realise that some clients are better suited to specific case studies than others. For example, you might have a client to whom you could easily apply your theoretical approach, and another where you gained real breakthroughs following your learning in supervision. These are good ones to choose.

Opening the Case Study

It’s usual to start your case study with a ‘pen portrait’ of the client – e.g. giving their age, gender and presenting issue. You might also like to describe how they seemed (in terms of both what they said and their body language) as they first entered the counselling room and during contracting.

If your agency uses assessment tools (e.g. CORE-10, WEMWBS, GAD-7, PHQ-9 etc.), you could say what your client scored at the start of therapy.

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Describing the Client’s Counselling Journey

This is the part of the case study that varies greatly depending on what is required by the awarding body. Two common types of case study look at application of theory, and application of learning from supervision. Other possible types might examine ethics or self-awareness.

Theory-Based Case Studies

If you were doing the ABC Diploma mentioned above, then 4.1 would require you to break down the key concepts of the theoretical approach and examine each part in detail as it relates to practice. For example, in the case of congruence, you would need to explain why and how you used it with the client, and the result of this.

Meanwhile, 4.2 – the second part of this theory-based case study – would require you to assess the value and effectiveness of all the key concepts as you applied them to the same client, substantiating this with specific reasons. For example, you would continue with how effective and important congruence was in terms of the theoretical approach in practice, supporting this with reasoning.

In both, it would be important to structure the case study chronologically – that is, showing the flow of the counselling through at least six sessions rather than using the key concepts as headings.

Supervision-Based Case Studies

When writing supervision-based case studies (as required by ABC in their criteria 5.1 and 5.2, for example), it can be useful to use David Kolb’s learning cycle, which breaks down learning into four elements: concrete experience, reflective observation, abstract conceptualisation and active experimentation.

Rory Lees-Oakes has written a detailed guide on writing supervision case studies – entitled How to Analyse Supervision Case Studies. This is available to members of the Counselling Study Resource (CSR).

Closing Your Case Study

In conclusion, you could explain how the course of sessions ended, giving the client’s closing score (if applicable). You could also reflect on your own learning, and how you might approach things differently in future.

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Therapy Session Case Study: Dealing with Anxiety, Stress and Poor Self-Confidence

Therapist and counsellor dr. dawn ferrara gives her perspective on a uptv client session.

We’ve got something a little different for you this time. As you know, often I like to describe therapeutic approaches in depth.

This piece describes one therapy session in detail, but it’s a little different because it’s not written by me but by an “outside pair of eyes.”

Dr. Dawn Ferrara is a Licensed Professional Counsellor and Licensed Marriage & Family Therapist specializing in Anxiety/Stress disorders.

Dawn looks at the session from the perspective of her understanding and experience. It’s so valuable to get a perspective other than your own so we asked Dawn, a skilled psychologist to write a case study for us.

What you have here is an overview of one session with Alice* an  Uncommon Practitioners TV client who came for help with anxiety, stress and low self confidence. Please let me know in the comments section if you find this useful and whether you’d like more professional summations of these therapy sessions.

Here’s to improving psychological knowledge and emotional health,

Identifying information

Alice (age unspecified) is a female client who works in the Information Technology (IT) industry. She has been in the IT field for 25 years and has run her own business successfully for the last 10 years. She is married and she and her spouse work together.

Presenting problem

Alice is seeking help for anxiety, stress and poor self-confidence.

Social history

Alice is married with one daughter. She reports a good personal and professional relationship with her spouse.

Alice’s parents divorced when she was young. She describes feeling “cheated” by that situation. Her father died in 1994 from cancer and never met her daughter. Alice expresses some regret that her father didn’t live to see her succeed as an adult or to meet his granddaughter. Alice’s mother is alive but Alice describes the relationship as strained.

Alice owns her own technology company. She reports that she learned her IT skills as an early adopter of emerging technology and built a career on those skills. She did not receive formal training.

Alice describes her job as quite stressful. She reports that she sometimes has difficulty dealing with demanding clients, especially when she is unable to help them in the ways they expect her to.

These situations evoke bothersome feelings of disappointment and anxiety, and worries about being criticized or judged. She states she becomes annoyed and that these feelings affect her wellbeing.

Mental health history

Alice reports that she has a history of anxiety and depression , for which she has received treatment. Past treatments have included antidepressant medication (unspecified) and diazepam for panic attacks. She is not currently taking medication.

Alice says that following her father’s death, her symptoms worsened.

Alice reports that she has previously used hypnosis for smoking cessation . It appears to have been only partially successful, as she continues to use an e-cigarette.

Session summary

This video is a single therapy session. The first part of the session consists of information gathering and a number of suggestions and reframes to encourage relaxation and assist Alice in gaining insight into some of her issues. The latter part of the session is direct hypnosis. Throughout the session, Mark uses a relaxed, conversational approach .

Mark engages Alice in conversation to clarify and discuss her concerns. As she becomes more comfortable, Alice offers more information and insight into her issues.

She admits to having bursts of intense anxiety but has had a reduction in panic episodes. She attributes that to making better choices about managing situations that she finds provoke anxiety. She identifies criticism and self-doubt as particularly problematic triggers.

Because of her history, Mark asks Alice a series of questions to assess the risk of post-traumatic stress disorder (PTSD). It does not appear that PTSD is a diagnostic consideration at this time.

Mark then reframes anxiety symptoms as an “exercise response”. This is done in order to normalize the anxiety response and reduce the tendency to pathologize its symptoms.

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A metaphor for stress and anxiety

To create a visual representation of anxiety, Mark makes an analogy between unchecked anxiety and a mental bucket of water. Anxiety (water) pours into the bucket and, if left unchecked, eventually fills the bucket and overflows (panic). He equates regular relaxation to emptying the mental bucket so that it doesn’t overflow (anxiety/panic).

Throughout the session, Mark references water creating a sense of calm and flow: filling the bucket, anxiety response as a whirlpool, the surface of water calm and reflective, feelings of calm streaming over.

During this discussion, Alice is attentive and calm with a relaxed posture. She makes good eye contact and responds with ease.

Depressive thinking styles

Now Mark describes the biases of globalizing , internalizing negatives and externalizing positives using a number of examples and analogies. Alice is able to recognize some of those biases in herself. Mark frames Alice’s insight into her biases as “seeing through” them.

As Alice becomes more aware of her biases, she becomes less affected by them because she can recognize them for what they are: inaccurate. The purpose of this reframing is to help Alice to separate herself from her biases, and accept that they do not define who she is.

Because Alice is particularly sensitive to perceived criticism, Mark makes a similar distinction between complaint and criticism, framing them as separate and not reflective of who she is as a person.

Tools for reducing anxiety

Following a discussion of Alice’s physical anxiety symptoms, Mark explains the dynamics of tactical breathing and invites Alice to try the technique. She readily responds and is able to practise the technique successfully and feel the sensation of relaxing.

Using conversational strategies, Mark encourages Alice to visualize scenarios and notice her reactions, first recalling her feelings in the bothersome scenario then visualizing it from afar and noticing differences while breathing and remaining in the moment.

This therapeutic presupposition allows Alice to see that she can react differently to difficult situations and allows her to move towards the hypnotic state.

Guided relaxation

The hypnotic induction begins with Mark describing hypnosis. He references Alice’s enjoyment of mandala painting on stones as an anchor, a way to help her connect with the state of mind-body relaxation and its link to unconscious thought.

The focus of the induction is relaxation training and helping Alice learn to manage her anxiety response. Using a series of embedded commands and visualizations, Alice is able to recognize her anxiety without panic or heightened responses and gently reduce it or brush it aside. She is able to experience remaining in control of her physical and thought responses.

Mark then gives several suggestions for actions going forward. These actions empower Alice to continue to recognize and manage her anxiety response by remaining calm and in control.

“What I’d like you to do is just to notice in the coming weeks and months what you notice about yourself, maybe after the event… telling yourself perhaps that: “at one point this would have been a problem for me but I just didn’t feel anything. I just put it in perspective.”

“You can just notice those times in coming weeks and months and forever.”

Further strengthening the link between conscious and unconscious thought, the induction is completed with a final suggestion that her unconscious mind and body will continue to be accessible when needed.

Did you find this case study useful? Let us know in the comments below if you’d like to see more professional summations of therapy sessions from Uncommon Practitioners TV, and if there’s anything we can add to them to make them more useful to you.

And if you haven’t joined yet, you can read about Uncommon Practitioners TV here and sign up to be notified when it’s open for new members.

About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses .

You can get my book FREE when you subscribe to my therapy techniques newsletter. Click here to subscribe free now.

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Person-Centered Therapy Case Study: Examples and Analysis

Introduction

Welcome to The Knowledge Nest's in-depth exploration of person-centered therapy case study examples and analysis. We aim to provide you with comprehensive insights into the therapeutic approach, techniques, and outcomes associated with person-centered counseling. Through real-life case scenarios, we demonstrate the effectiveness of this humanistic and client-centered approach in fostering personal growth and facilitating positive change.

Understanding Person-Centered Therapy

Person-centered therapy, also known as client-centered therapy or Rogerian therapy, is a compassionate and empathetic therapeutic approach developed by the influential psychologist Carl Rogers. This person-centered approach recognizes the profound significance of the therapeutic relationship, placing the individual at the center of the therapeutic process.

Unlike traditional approaches that impose solutions or interpretations on clients, person-centered therapy emphasizes the innate human capacity to move towards growth and self-actualization. By providing a supportive and non-judgmental environment, therapists aim to enhance clients' self-awareness, self-acceptance, and self-discovery. This holistic approach has proven to be particularly effective in addressing a wide range of mental health concerns, empowering individuals to overcome challenges and achieve personal well-being.

Case Study Examples

Case study 1: overcoming social anxiety.

In this case study, we explore how person-centered therapy helped Sarah, a young woman struggling with severe social anxiety, regain her confidence and navigate social interactions. Through the establishment of a strong therapeutic alliance, her therapist cultivated a safe space for Sarah to explore her fears, challenge negative self-perceptions, and develop effective coping strategies. Through the person-centered approach, Sarah experienced significant improvements, enabling her to participate more actively in social situations and regain a sense of belonging.

Case Study 2: Healing from Trauma

John, a military veteran suffering from PTSD, found solace and healing through person-centered therapy. This case study delves into the profound transformation John experienced as he worked collaboratively with his therapist to process unresolved trauma. By providing unconditional positive regard, empathetic listening, and genuine empathy, the therapist created an environment where John felt safe to explore his traumatic experiences. With time, he was able to develop healthier coping mechanisms, embrace self-compassion, and rebuild a sense of purpose.

Case Study 3: Enhancing Self-Esteem

In this case study, we examine Lisa's journey towards building self-esteem and self-worth. Through person-centered therapy, her therapist empowered Lisa to identify and challenge deeply ingrained negative self-beliefs that inhibited her personal growth. By offering non-directive support, active listening, and reflective feedback, the therapist enabled Lisa to develop a more positive self-concept, fostering increased self-esteem, and self-empowerment.

Analysis of Person-Centered Therapy

The therapeutic relationship.

Person-centered therapy places profound importance on the therapeutic relationship as the foundation for positive change. The therapist cultivates an atmosphere of trust, respect, and authenticity, enabling the individual to feel heard and valued. By providing unconditional positive regard, therapists create a non-judgmental space where clients can freely explore their thoughts, emotions, and experiences.

Client-Centered Approach

The client-centered approach encourages individuals to take an active role in their therapeutic journey. The therapist acts as a facilitator, guiding clients towards self-discovery and personal growth. By allowing clients to set the agenda and directing the focus of sessions, the person-centered approach acknowledges the unique needs and perspectives of each individual.

Empowering Self-Awareness and Growth

Person-centered therapy seeks to unlock individuals' innate capacity for self-awareness and personal growth. Through empathic understanding, therapists support clients in gaining insight into their emotions, thoughts, and needs. This heightened self-awareness helps individuals develop healthier coping mechanisms, make meaningful choices, and move towards a more fulfilling life.

Person-centered therapy, as exemplified through the case studies presented, offers a powerful and transformative path towards holistic well-being and personal growth. The Knowledge Nest is committed to providing a platform for sharing knowledge, experiences, and resources related to person-centered counseling. Together, we strive to facilitate positive change, empower individuals, and create a more compassionate and understanding society.

Explore more case studies and resources on person-centered therapy at The Knowledge Nest to discover the profound impact of this therapeutic approach.

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How To Plan Your Counseling Session: 6 Examples

As a process, it is ongoing and shared between therapist and client, involving setting goals, establishing a treatment plan, and monitoring progress throughout therapy (Nelson-Jones, 2014).

While vital to managing treatment, planning is also a skill clients can learn from and use to achieve more meaningful lives.

This article explores the counseling planning process, introducing key concepts, strategies, and valuable examples along the way.

Before you continue, we thought you might like to download our three Goal Achievement Exercises for free . These detailed, science-based exercises will help you or your clients create actionable goals and master techniques to create lasting behavior change.

This Article Contains

• Counseling Sessions Explained: Examples & Scripts

How To Plan Your Counseling Session

• 6 Templates & Examples of Topics To Address
• How To Perform an Intake & Termination Session

10 Insightful Questions To Ask Your Clients

How to write effective progress notes.

• Evaluation Form & Checklist For Therapists

Resources From PositivePsychology.com

A take-home message, counseling sessions explained: examples & scripts.

From the outset of therapy, mental health professionals support clients as they grow their skills, helping them reach their goals and tackle the problems that stand in their way (Nelson-Jones, 2014).

While plans will capture the higher-level approach and timelines involved in treatment, they are typically broken down into individual counseling sessions that serve vital functions and help the client progress toward a successful outcome (Gehart, 2016; Nelson-Jones, 2014).

Counseling sessions are opportunities for the therapist and client to get to know one another and for the client to talk about the issues that have brought them to counseling.

Each session will vary between clients based on their specific challenges and the treatment style.

Examples of individual sessions and samples of scripts include (Nelson-Jones, 2014):

Early (and ongoing) sessions

Early on in counseling, session time is spent developing each of the following five therapeutic elements:

• A strong relationship A robust therapeutic bond is vital to successful counseling.
• A working model The therapist builds a working model – a “set of hypotheses about how clients function in problem areas and is a statement of how they feel, think, and act” (Nelson-Jones, 2014, p. 125).
• A shared definition of problems in terms of skills Client problems should be restated in terms of skills (or lack of skills) that perpetuate issues.
• Working goals and interventions Aim to agree on preliminary statements of working goals as skills to be developed.
• A framework for future work Decide on a practical approach for how, when, and where to meet–potentially digital–plus fees.

Meeting and greeting counseling skills are fundamental early on and may include the following types of opening statements and scripts (modified from Nelson-Jones, 2014, p. 127):

• Meeting outside the office “ Hello [client’s name], I’m [your name]. Please come in. ”
• Permission to talk “ Please tell me what has brought you here today. ”
• Acknowledging a referral “ You’ve been referred by [other person’s name]. Now how do you see your situation? ”
• Responding to bodily communication “ You seem nervous. Would you care to explain what is bothering you? ”

Crisis counseling sessions

Therapists will sometimes face a client in crisis. They must make “immediate choices to help clients get through their sense of being overwhelmed” (Nelson-Jones, 2014, p. 139).

During crisis sessions, the following is vital (Nelson-Jones, 2014):

• Define the crisis The therapist must be able to define the crisis and know what is causing excessive stress;
• Acts accordingly The therapist should be ready for a crisis, maintain a sense of calm, listen closely and observe well, and assess the severity and risk of damage to the client and others.
• Understands the client’s strengths and coping skills The client may be unaware or have forgotten that they have the tools to cope. The therapist can remind them by asking selective questions. Variations of the following comments can be helpful (modified from Nelson-Jones, 2014):

“You have spoken a lot about the negative aspects of your life. Can you think of any positive aspects as well?”

“From what I’m hearing, you are facing your problems all on your own. Can you think of any friends or family members who may be able to offer you some support?”

Where problems are complex, several sessions may be needed to fully understand where help is most needed (Sommers-Flanagan & Sommers-Flanagan, 2015).

A therapeutic plan offers a potential route from initial engagement to termination —both of which are vital to the overall therapeutic outcome (Joyce et al., 2007).

It should be individual and specific to the client and their needs while remaining flexible for adaptation in response to new information or changing circumstances.

A typical therapeutic plan contains placeholders for each of the following elements (Gehart, 2016; Nelson-Jones, 2014):

1. Assessment

Counseling begins with some form of evaluation—often before the client attends their first session and may include the client’s history, symptoms, and current situation to determine an appropriate counseling approach to treatment.

‘ Case conceptualization ’ involves organizing the information about the client, including their “situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination” (Sperry & Sperry, 2020, para 6).

2. Goal setting

Specific, measurable, achievable, relevant, and time-bound (SMART) goals should be developed collaboratively and goal setting form an essential part of the therapeutic process.

They must be tailored to the client’s needs, preferences, and expectations and align with the therapeutic approach.

3. Specific treatment plans

Following assessment and goal setting, the therapist and client collaborate to develop a more detailed treatment plan outlining the strategies and interventions required to address the client’s needs and overcome what stands in the way of a meaningful and fulfilling life.

4. Monitoring progress

Tracking client progress during treatment is essential for supporting them in achieving their goals. It involves regularly reviewing treatment plans, tracking symptom changes, and identifying and addressing obstacles or setbacks to ensure the therapy remains effective and relevant.

5. Evaluation and termination

Once significant progress has been made toward the client’s goals (or the predetermined time frame for therapy is nearing the end), the therapist and client should evaluate the overall effectiveness of the treatment.

Working together, they reflect on their therapeutic relationship , explore additional areas of growth, decide on the appropriate time to terminate therapy, and agree on a plan for maintaining gains and addressing any potential relapses.

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6 Templates & Examples of Topics To Address

Clients arrive in counseling for many different reasons. Understanding coping styles, setting goals, identifying negative thoughts, exploring character strengths, and managing irrational and unhelpful beliefs are valuable for supporting client growth (Nelson-Jones, 2014).

The following six templates help assess some of their needs and the obstacles that stand in the way of working towards goals:

1. Coping styles formulation – it is essential that the client and therapist arrive at a shared understanding of the problems the former is facing and develop more adaptive coping strategies. 2. Goal setting for self-esteem – goal setting is a powerful and vital tool within counseling. In this worksheet, the client reflects on areas where they feel inadequate or upset and use goals to boost their self-esteem. 3. Identifying ANTS: Challenging different types of automatic thoughts – automatic thoughts impact how we think, feel, and behave – often without us being aware. This worksheet helps clients understand their ‘automatic negative thoughts’ (ANTS). 4. Exploring character strengths – awareness and understanding of personal strengths can help clients overcome challenges, meet value-driven goals, and lead more energized and fulfilling lives. 5. Decatastrophizing  – often, we filter out positive beliefs and only think of worst-case scenarios. This worksheet is helpful for decatastrophizing and seeing the challenges we face more realistically. 6. It could be worse…  – learning how to move forward from setbacks and find a new path if necessary is essential. In this worksheet, the client identifies problems they are struggling with and puts them into context by imagining how they could be much worse.

How To Perform an Intake & Termination Session

Performing an intake session

When conducting an intake session with a new client, gathering as much information as possible is essential to ensure that the therapist provides the best care and support (Intake interview, n.d.).

The intake session typically includes (Beck, 2011; Nelson-Jones, 2014):

• Reviewing client intake forms Pay close attention to any information that may indicate a need for immediate attention, such as suicidal ideation, self-harm, or abuse. Note any concerns and prepare to address them with the client during the session or refer them for specialist help if appropriate.
• Using active listening skills Allow clients to share their stories and express their concerns. Show that you are present, available, and open to hearing about their experiences.
• Asking open-ended questions Gather additional information and deeply explore the client’s thoughts and feelings. Examples of open-ended questions include “Tell me more about that,” “What led you to seek counseling at this time?” and “What do you hope to achieve through counseling?”
• Being mindful of your reactions and biases Work to create a safe and non-judgmental space for the client to share; counseling should center on the client, not the therapist.
• Summarizing and reflecting back to the client Ensure you have understood their concerns and experiences accurately – help the client feel heard and validated.

Following these steps while being compassionate, respectful, and non-judgmental will support you in gathering essential information about the client and building a therapeutic relationship based on trust and empathy (Nelson-Jones, 2014).

Client intake forms can be completed, reviewed, and stored digitally using advanced online platforms like Quenza .

7 Questions for your first session

Questioning will vary according to the type of therapy and the client’s reason for attending, and yet the following seven questions can be helpful in most situations (Beck, 2011; Nelson-Jones, 2014):

• What brings you to therapy today?
• Can you tell me a little bit about your background?
• Have you been in therapy before? What was your experience like?
• How is your relationship with your family?
• What are your goals for therapy?
• Is there anything else you’d like to share?

Performing a closing session

The termination or ending phase is critical to therapy, as it can impact the client’s progress and future behavior (Joyce et al., 2007).

Unless planned, termination may occur hastily without careful consideration.

Therefore, the therapist must plan–and communicate–a closing session effectively to ensure a successful outcome (Barnett, 2016).

6 Activities for your closing session

Closing session counseling activities may include (Joyce et al., 2007; Barnett, 2016):

• Reviewing progress against treatment goals to help the therapist and client evaluate progress and identify areas where further work is needed.
• Helping clients plan for their future and develop relapse prevention strategies by identifying potential triggers and coping mechanisms.
• Developing a support system for ongoing care, such as group therapy or follow-up sessions with the therapist.
• Acknowledging the client’s work and progress throughout therapy.
• Recognizing that problems are a part of life and an opportunity for future learning, developing, and practicing new skills.
• Performing a final review of the treatment itself by asking:

What went well? What didn’t go so well? What has the client gained from therapy? What skills have been acquired that will help with future coping?

For more information on termination in therapy, check out Termination in Therapy: The Art of Gently Letting Clients Go .

Also, check out our article 20 Useful Counseling Forms & Templates for Your Practice for further information and templates.

Ten of our favorites therapy questions include:

Problem-related questions:

• What is the problem from your point of view?
• How does this problem typically make you feel?
• What makes the situation better?
• Think of a time when things didn’t go well for you. What did (and didn’t) you do?
• Think of something that somebody else does that makes the problem better. Who are they, and what do they do?

General questions:

• Overall, how would you describe your mood?
• How connected do you feel to the people around you?

Think of a behavior that you consider unhelpful:

• What do you typically feel before that happens?
• What happens to you physically before this happens?
• How do you usually act right before this happens?

Our article Counseling Interview Questions contains various other questions that help prompt further discussion and increase understanding of a client’s needs.

“The Subjective, Objective, Assessment and Plan ( SOAP ) note is an acronym representing a widely used method of documentation for healthcare providers.” It is a helpful guide for writing practical and valuable progress notes, as follows (Podder & Ghassemzadeh, 2022, para 1):

• Subjective Record the client’s experiences, feelings, or perspectives. Include information provided by the client’s family or other individuals involved in their care.
• Objective Capture objective data obtained during the session, including measurements, assessments, and observations; be specific and concise while avoiding making assumptions or subjective interpretations of the data.
• Assessment Analyze the information collected in the subjective and objective sections to help make diagnoses, identify patterns, and develop treatment plans. Consider the client’s strengths, limitations, and goals when writing the evaluation.
• Plan Outline the next steps in the client’s treatment, including interventions, referrals, and follow-up appointments. The plan should be continuously updated and tailored to the client’s specific needs and goals.

Platforms like Quenza –explicitly created for the counselor or therapist–offer a powerful solution for capturing and storing therapy progress notes .

Evaluation Form & Checklist For Therapists

Treatment feedback and evaluation offer vital information for therapeutic interventions given to the client and the overall development opportunities for the therapist (Nelson-Jones, 2014).

This Session Feedback Form provides a helpful set of prompts and an opportunity for the client to evaluate the therapist and the treatment provided.

Feedback forms can be hosted and completed online (using tools such as Quenza ) and tailored to the branding of the mental health professional making evaluations readily available for future reference.

While client feedback is vital, so too is practicing self-care. The Self-Care Checkup is a valuable checklist for the therapist to ensure they maintain their wellbeing and good health.

A Look At Online Counseling Sessions

With dramatic technological advances and improved software design, online counseling has become a practical solution to clients’ hectic schedules (Richards & Vigano, 2013).

Clients can meet their therapist on video calls and receive digital counseling interventions when circumstances do not allow them to meet at the therapist’s practice. And despite the need for counselors to acquire new skills, client attitudes to remotely offered counseling have been chiefly positive (Tuna & Avci, 2023).

17 Tools To Increase Motivation and Goal Achievement

These 17 Motivation & Goal Achievement Exercises [PDF] contain all you need to help others set meaningful goals, increase self-drive, and experience greater accomplishment and life satisfaction.

Created by Experts. 100% Science-based.

We have plenty of resources available to support counselors as they plan and engage with clients.

While the following tools are described in brief below, more extensive versions are available with a subscription to the Positive Psychology Toolkit© :

Practitioner’s Strength

The therapist’s contribution to treatment success is well documented. Knowing their strengths can help the mental health practitioner perform at their best, more of the time, while protecting them from burnout:

• What do you think they are?
• How do you use them?
• How have they developed over time?
• When are they most helpful?
• How could you use them more often?
• How could you develop your strengths further?

Countering Compassion Fatigue

Compassion is a vital element of therapy. And yet, over time, it can take its toll on therapists – professionally and personally.

Practicing self-care and self-compassion is essential to providing good service to clients:

• Find a comfortable position and take several slow, deep breaths.
• Focus on your in-breath – thinking of whatever you need right now [for 30 seconds].
• Next, focus on your out-breath. Visualize a loved one or someone that is suffering [for 30 seconds]
• Repeat the process for several minutes, savoring the experience of self-compassion flowing in and out of your body.

17 Motivation & Goal-Achievement Exercises

If you’re looking for more science-based ways to help others reach their goals, this collection contains 17 validated motivation & goals-achievement tools for practitioners. Use them to help others turn their dreams into reality by applying the latest science-based behavioral change techniques.

Counseling is a relationship, a process, and a repertoire of interventions – all of which benefit from good planning (Nelson-Jones, 2014).

Indeed, detailed yet flexible planning can leave the therapist confident that the client can navigate from what brought them to counseling to a successful outcome based on their needs and the challenges they wish to overcome.

When done well, it is possible to create stronger relationships, clear working goals and interventions, and a framework for future success.

The counseling plan will likely define the treatment approach and include assessments, goal-setting, interventions, monitoring, and evaluation that will increase the likelihood of a successful client outcome.

Along the treatment journey, a clearer understanding of the client’s concerns, difficulties, and negative thinking can be sought and managed through improved coping styles and increased awareness and use of strengths.

This article introduces examples of sessions and samples of scripts, templates, and checklists to plan and manage your counseling sessions more effectively to help build a meaningful, value-driven life for the client.

We hope you enjoyed reading this article. Don’t forget to download our three Goal Achievement Exercises for free .

• Barnett, J. E. (2016, October). 6 strategies for ethical termination of psychotherapy. Society for the Advancement of Psychotherapy . Retrieved April 18, 2023, from https://societyforpsychotherapy.org/6-strategies-for-ethical-termination-of-psychotherapy/
• Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond . Guilford Press.
• Gehart, D. R. (2016). Theory and treatment planning in counseling and psychotherapy . Cengage Learning.
• Intake interview. (n.d.). In APA dictionary of psychology. Retrieved April 18, 2023, from https://dictionary.apa.org/intake-interview/
• Joyce, A. S., Piper, W. E., Ogrodniczuk, J. S., & Klein, R. H. (2007). Termination in psychotherapy: A psychodynamic model of processes and outcomes . American Psychological Association.
• Nelson-Jones, R. (2014). Practical counselling and helping skills . Sage.
• Podder, V., & Ghassemzadeh, S. (2022). Soap notes – StatPearls – NCBI Bookshelf. SOAP Notes . Retrieved April 19, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK482263/
• Richards, D., & Vigano, N. (2013). Online counseling: A narrative and critical review of the literature. Journal of Clinical Psychology, 69(9), 994–1011 .
• Sommers-Flanagan, J., & Sommers-Flanagan, R. (2015). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques . Wiley.
• Sperry, J., & Sperry, L. (2020, December 7). Case conceptualization: Key to highly effective counseling . Counseling Today. Retrieved April 20, 2023, from https://ct.counseling.org/2020/12/case-conceptualization-key-to-highly-effective-counseling.
• Tuna, B., & Avci, O. H. (2023). Qualitative analysis of university counselors’ online counseling experiences during the COVID-19 pandemic. Current Psychology, 1–15 .

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Below you’ll find case studies of real clients that have attended couple’s counselling at All in the Family Counselling with our professional trained marriage expat counsellor. These cases do not represent all cases seen at our centre but rather are intended to give you insight into what makes for successful outcomes and the time and effort the clients choose to put in to make their relationship change. Each couple’s relationship is unique and has its own history which our therapist will attend to. But we hope you will find it helpful to see what successful clients choose to do and their outcomes.

Case Study 1

Profile : Professional couple married for 6 years but known each other for 10 years. The couple is in their early 30s.

Reason for Counselling : Couple came into counselling because of husband’s excessive use of pornography, a reduced sexual life and overall lower intimacy in the relationship. Wife was prepared to file for divorce if things didn’t improve rapidly. Wife had loss of trust due to pornography use.

Number of Sessions:   Couple had a total of 4 sessions with husband attending to 2 individual sessions. At the client’s initial session everyone agreed to the problem and what a positive marriage would look like for them.  They were taught basic relationship skills and given homework to practice. At their 2 nd  session, which was 10 days later, we reviewed their homework and both individuals had great revelations about themselves, each other and the relationship. They were taught additional relationship skills and given more homework to practice for 14 days.  The 3 rd  session we reviewed homework and refined skills and integrated new relationship concepts into the relationship including negotiating win-win for the relationship and managing perceptions in communication. Final session was 30 days later in which we reviewed their homework, revised some of their skills and gave them a framework to help identify and remedy problems if they were heading back into old relationship habits.

Success Factors:   This is an unusual case for a couple in crises to come to counselling and so dramatically turn their relationship around. The reason the couple experienced such dramatic success was that they had come into counselling early once the issue of intimacy and pornography were discovered. This couple was also highly motived to make counselling work and they energetically completed their homework in between sessions. The couple also had a lot of positive regard for each other and good personal insight into themselves and each other. The husband also attended a couple of individual sessions to work on stress management.

Case Study 2

Profile : Couple married for over 10 years in their mid 30s. Both have a college education and are professionally employed. Couple has no children.

Reason for Counselling : Counselling was initiated by the wife who had found out only 4 days prior to contacting our agency that her husband had an affair and both of them wanted to repair and improve the relationship.

Number of Sessions:   Couple had a total of 6 sessions over 3 months.  The first session was getting agreement that both couples wanted to repair and improve the relationship. Both parties agreed to not introduce punishment into the relationship as a result of the affair. The couples were given some new basic relationship skills and given homework to complete in between session including not discussing the affair.  Session 2 was 10 days later and the focus was on building a unified goal for the relationship. Four goals for the relationship were mutually identified and agreed to. Couples were given more relationship skills and homework to practice. The next 3 sessions were spread out over 2 months and focused on relationship skills that targeted communications, perceptions and internal control all with the couple doing homework in between sessions. The final session the clients evaluated how they did meeting their goals and they felt they got about 70–85% of each of their goals which was satisfactory for them. They felt confident with their new relationship skills. Trust had been restored, forgiveness was given and communication dramatically improved and the couple was established in their new and improved relationship behaviours.

Success Factors:   Couple came in quickly after finding out about the relationship. Both individuals in the relationship agreed to not introduce punishment into the relationship. This couple was focused on the present and building the future relationship.  The incident and issues of the past were only used as guidelines to help us know what worked and did not work. The couple was highly motivated to repair and improve their relationship and would complete their homework and came prepared to fully engage during the counselling sessions.

Case Study 3

Profile : Professional couple married for 7 years. The couple is in their late 30s. Had a history of infertility and infertility treatments that resulted in 2 children in last 3 years prior to treatment.

Reason for Counselling : Couple came into counselling because of dramatically reduced intimacy, increased fighting, difficulty communicating and negative perceptions of each other’s behaviours.

Number of Sessions:   Couple had a total of 12 sessions with each client engaging in 2 individual sessions within 5 months. The first session focused on stabilizing the relationship and providing them with basic relationship skills. The homework started to focus the couple on building positive regard towards each other.  Then next 2 sessions were focused on developing a new relationship base from which to make all decisions-shifting it away from the children as the base and back to the couple.  The next 4 sessions included reviewing the homework the clients were completing in between sessions, the lessons and observations they were learning as well as modifying and enhancing basic communication skills that included perception taking, learning to negotiate a win–win for the relationship and continuing to build positive regard.  The individual sessions were focused on personal issues that were affecting the relationship.  Individual sessions addressed some of the loss and trauma related to infertility treatments and stress and anxiety management.

Complicating & Success Factors:   This couple had a more complex prolonged history of infertility, stress and trauma that went on for a couple of years prior to entering counselling resulting in a more negative view of each other that reduced trust and positive regard for each other. This increased the number of sessions for the couple and individuals session were recommended.

However, the couple still had enough positive regard for each other and was committed to the counselling process because they really valued what they had earlier in their relationship. While the couple experienced some setbacks initially and was slower to implement their new relationship skills than the previous couples, they managed to keep coming to counselling and do most of the work.  As they start the client was successful because they gave counselling enough time to work and practice their new skills and continue to get feedback and guidance while working both on their relationship issues and individual issues. This couple needed more sessions because there were complicating factors and the issues had been developing for a longer period before coming for help.

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Introduction, research design and method, opening of the encounter: developing a reciprocal relationship, active listening: power sharing, vision of the future: emphasizing the positive, conclusions.

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Empowering counseling—a case study: nurse–patient encounter in a hospital

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Tarja Kettunen, Marita Poskiparta, Leena Liimatainen, Empowering counseling—a case study: nurse–patient encounter in a hospital , Health Education Research , Volume 16, Issue 2, April 2001, Pages 227–238, https://doi.org/10.1093/her/16.2.227

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This study illustrates practices that a nurse uses in order to empower patients. The emphasis is on speech formulae that encourage patients to discuss their concerns and to solicit information about impending surgery. The study is a part of a larger research project and a single case was selected for presentation in this article because it differed from the rest of the data by manifesting empowering practice. A videotaped nurse–patient health counseling session was conducted in a hospital and transcribed verbatim. The investigator interviewed the nurse and the patient after the conversation, and these interviews were transcribed as well. The encounter that is presented here as a case study is a concrete example of a counseling session during which the patient is free to discuss with the nurse. The empowering practices that the nurse employed were as follows: encouraging the patient to speak out, tactfully sounding out the patient's concerns and knowledge of impending surgery, listening to feedback, and building a positive vision of the future for the patient. We suggest that nurses should pay attention to verbal expression and forms of language. This enables them to gain self-awareness and discover new tools to work with.

In recent literature, empowerment has become an important concept of health education ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ), health promotion ( Labonte, 1994 ; Tones, 1994 , 1995 ; Williams, 1995 ; McWilliam et al. , 1997 ) and health counseling ( Poskiparta et al. , 2000 ). The process of empowerment has been related more to community and organizational levels than to micro levels of practice ( van Ryn and Heaney, 1997 ) where it is constantly crucial ( Tones, 1994 ). In addition, operationalization of the concept of empowerment has been relatively vague. According to Tones ( Tones, 1994 ), empowerment is a major goal of health promotion. This article focuses on health counseling as a means of interpersonal health education practice and uses health promotion as an umbrella term.

Empowerment is as much a process as an outcome of developing the skills and perceptions of clients. It is not only something that happens but a process that is facilitated. In interpersonal health counseling, the primary goal is not to change clients' behavior and seek their compliance with the presented message but rather to raise critical awareness through learning and support, to give clients tools for making changes on their own. The aim is personal empowerment, control and choice, which means that patients become aware of changes in their knowledge and understanding, decision-making skills, enhanced self-esteem/sense of personal control, and development of various social, health and life skills ( Labonte, 1994 ; Tones 1994 ; Anderson et al. , 1995 ; Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ; Kar et al. , 1999 ).

The basic point of departure for empowerment is taking into consideration the interactive nature of the individual and the environment: people are not completely controlled by their environment nor can they fully control their physical, social or economic circumstances ( Tones, 1994 ). Empowering health counseling is based on recognizing clients' competence, resources, explanations of action styles of coping and support networks. Client initiative, clients' realizations and clients' expressions of their opinions and interpretations are the basis on which clients can approach health issues in collaboration with professionals. They are of crucial importance for their decisions on future action ( Anderson, 1996 ). All this supports the notion that empowering health counseling is significant.

Because learning about personal health is complex, the key issue of empowering health counseling is partnership and reciprocal conversation in a confidential relationship. This means that clients not only analyze their situation but also have an opportunity to plan what to do next, and how to go on and to construct their own solutions to health issues. In this type of hospital health counseling, either patients raise the issues (i.e. determine the topics) or the nurses do so in a sensitive and non-threatening manner ( Poskiparta et al. , 2000 ). Nurses recognize and respect patients' experiences, knowledge and skills, and make their own professional knowledge and expertise available to them ( Williams, 1995 ; McWilliam, et al. , 1997 ), which are important aspects of nurse–patient relationships that are also reported by patients ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Lindsey and Hartrick, 1996 ; Wiles 1997 ). The emphasis is placed on patient-driven [see ( Lindsey and Hartrick, 1996 )] health counseling, where patients' life situations are respected, patient-initiated actions are supported, and shared knowledge and deep understanding are nurtured.

The nurse's institutional task is not only to facilitate patient participation but also to promote patients' awareness of their routines and preconceptions as they are revealed to both interlocutors. This should lead to the aim of interaction, which is to activate self-reflection and re-evaluation and reorganization of patients' activities. The assumption is that new knowledge is gained in this process as a result of empirical realization and deliberation ( Feste and Anderson, 1995 ), which means that both patients and nurses have linked new knowledge to existing knowledge. Thus, patients learn to interpret and outline even familiar health problems in new ways that conform to their worldview [ cf . ( Mattus, 1994 )]. As for nurses, empowerment calls for not only sensitivity but also an ability to accurately perceive patients' messages.

From this point on, the focus is on the content of the interactive process. Tones ( Tones, 1994 ) discusses empowerment theoretically, Labonte ( Labonte, 1994 ) expresses ideas for practice in general, while Feste and Anderson ( Feste and Anderson, 1995 ) provide three empowerment tools for facilitating patients' empowering process: using questions, behavioral language and storytelling. According to them, questions maintain the process of pursuing wisdom, i.e. exploring the meaning of health problems in the context of everyday life. This kind of questioning involves broad questions that relate to one's personal philosophy and lifelong dreams. In addition, it includes practical, day-to-day issues of successfully integrating into one's personal, family, social and professional life. Behavioral language means using words such as `list', `describe', `identify', `decide', etc., in order to encourage patients to act and make choices instead of being satisfied with receiving information. Stories help to facilitate the process of self-discovery because diseases affect all areas of life and each individual's health status is unique.

Van Ryn and Heaney ( Van Ryn and Heaney, 1997 ) pay attention to interpersonal relations by suggesting concrete strategies and examples for empowering practice. In their article, they demonstrate two principles of interaction: (1) provide clients with unconditional positive regard and acceptance, and (2) facilitate client participation. Both principles include several practical strategies (Table I ).

However, the authors pay less attention to empirical findings ( Northouse, 1997 ). The present article describes some linguistic realizations of empowering practice. This article describes a nurse's empowering speech formulae during her efforts to give a patient information about an impending surgical operation and to strengthen her feelings of security by providing her with an opportunity to discuss her concerns. This study adopts a holistic approach to interaction and does not focus on isolated sentences or dialogue structure. The relationship of language and context in comprehension, as well as non-verbal communication, are also discussed.

This article describes a single case derived from qualitative data collected from a total of 38 counseling sessions in a Finnish hospital. Nurse–patient encounters were videotaped and transcribed verbatim. Interviews with the nurses and the patients after the sessions were transcribed as well. All participants volunteered to take part in the research, signed a research license and granted permission for the transcribed data to be used in publications. Nineteen nurses participated in this study. Each nurse conducted two videotaped counseling sessions with different patients. There was only one male nurse while the patient group consisted of 24 female and 14 male patients. The research material took shape as nurses volunteered in the hospital and it was found to be adequate for qualitative analysis. The length of the nurses' careers varied from 1 to 25 years. The ages of the nurses were between 24 and 50 years (mean age 36.9 years) while the patients' ages ranged from 18 to 70 years (mean age 47.9 years). The researcher did not attend the counseling sessions, which lasted from 5 to 45 min. The participating patients were experiencing diverse health problems. Various surgical problems, e.g. knee surgery, hernia operation, breast surgery, hip operation, back operation, post status of brain bleeding and post care of bypass surgery, were among the most representative. In addition to the health problems that had led to hospitalization, many patients also suffered from chronic diseases, such as hypertension, asthma, rheumatic illnesses or diabetes. Many patients also found themselves in an insecure situation when a chronic disease had suddenly been manifested or they were undergoing examinations. There were also some mothers in the group who had delivered recently and had no health problems.

The health counseling sessions were genuine counseling situations that were related to the patients' treatment. A single video camera was used, which meant that the observation of non-verbal communication was limited to examining the session as a whole, including only eye contact, smiles, laughter, tone of voice, gestures and, to some extent, facial expressions. Consequently, the emphasis of this study was examining verbal communication. Separate interviews with the nurses and the patients where both parties were encouraged to express their evaluations of the health counseling were used for partial support of the interpretations, e.g. when describing the patients' opinions about health counseling. We also checked if there were any nurses or patients who were nervous about the videotaping.

This article concentrates on videotaped data. When we examined all of the data we found many encounters that involved some empowering features from time to time, but there were none that were consistently empowering. In this article, we present a single case from the data. This particular encounter was selected because it differed from the rest of the data ( Stake, 1994 ) by manifesting empowering practice most widely. In order to study the interactive nature of communication, the coding and analysis of the videotaped data was based on principles of Conversation Analysis ( Drew and Heritage, 1998 ). The videotapes were transcribed word by word, including stammering, etc. At the same time, additional data were added to the transcriptions, such as pauses during and between turns, onset and termination of overlapping talk, intonation information, and some non-verbal communication. The following transcription symbols were used to indicate this information:

ha+ hands support speech

vo+ rising voice

vo– falling voice

[ ] at the beginning and end of overlapping speech, words enclosed

(( )) transcriber's comments, e.g. smile, laughter, body movements

(.) small but detectable pause

underlining emphasis

… omission of text

=no interval between the end of prior and start of next speech unit

°speech° speech in low volume, words enclosed

`speech'pitch change, words enclosed

The analysis was carried out on a turn-by-turn basis. The principle behind this analysis was to examine how turns were taken with regard to other participants' speech and what sequential implications each turn had for the next. After reading the transcript and watching the recording several times, we discovered a number of empowering expressions in the nurse's speech and concluded that this case was the one which best manifested empowering action in the data.

The particular case describes at the individual level information about the patient's situation, the nurse's interview after the encounter, an in-depth description of the nurse–patient conversation and the observational data derived from it. Pearson ( Pearson, 1991 ) and Patton ( Patton, 1990 ) indicate that a case study can be used, for example, for examining how different concepts emerge or change in particular contexts. However, an even more important question is what can be learned from a single case. Stake ( Stake, 1994 ) suggests that one should select a case that seems to offer an opportunity to learn and contributes to our understanding of specific phenomena. Here, a detailed single case analysis illustrates how empowerment may be practiced during health counseling and demonstrates how new working tools for empowerment can be developed on the basis of a single encounter ( Laitakari, 1998 ). The present study describes the speech of a nurse when she helped a patient to deal with anxiety and to receive information about surgery in an empowering way.

The nurse anesthetist has come to see a patient who is scheduled to have surgery the next day. The encounter involves, besides interviewing, producing a lot of information about the operation, counseling on the preparations for the surgery and advising how to manage after the surgery. The encounter takes place at a table, with the nurse and the patient facing each other. Both are women; the nurse is 50 and the patient 41 years old. The patient had had problems with her back for 10 years and was suddenly admitted to the hospital because of these problems. The patient has recently been examined and a decision has been made to operate on her the next morning. The interviewing session lasted 14 min.

At the beginning of a conversation the participants evaluate each others aims and concerns, and the communication situation as a whole, and this evaluation directs the entire discussion because the participants base their actions on it (Goffman, 1982). In a hospital, it is typical that nurses initiate a discussion ( Leino-Kilpi, 1991 ) and that is what happened in this case ( Extract 1 ). Professional dominance common in medical encounters ( Fairclough, 1992 ) is not so obvious in this conversation. After greeting the patient, the nurse refers to the goal of the discussion and individualizes it by using familiar `you' (line 1) instead of the formal, plural form of `you'. This form of address can be viewed as an act of communicating an appropriate degree of informality. It implies intimacy and mutual respect when a relationship is established ( van Ryn and Heaney, 1997 ).

1 N: Hello, Rose (.) you are going to have surgery 
 2 tomorrow…but now I would like to ask you 
 3 you well about the operation tomorrow if 
 4 there is (.) something that would influence 
 5 the preparations for your operation (.) and 
 6 then you ((ha+)) can bring things up ask well 
 7 er if something is unclear to you ((nod+)) If 
 8 you want to know anything about what's 
 9 going to happen to you tomorrow ((vo–))

((at first the nurse looks at papers on the table, while she speaks she turns her eyes to the patient and nods))

This opening was not typical of the other interviews in the data set, because in the data these encounters were usually initiated with the nurses' brief statements about the impending operation. They explained that they interviewed patients in advance in order to get information and that they could provide information to the patients as well. Nurses usually used formal, plural forms of address when speaking. When referring to the preoperative encounter, they used the plural, institutionalized form `we' [see ( Drew and Heritage, 1998 )], instead of first person singular `I', and plural `you', instead of the singular, when addressing the patient. Other nurses did not individualize their speech. On the contrary, they maintained a distance from the patients. In this particular case, a familiar mode of address reduces social distance, which is very important in health education practice [ cf . ( van Ryn and Heaney, 1997 )]. We explain our interpretations in more detail below.

The nurse uses the verb `ask' (line 2), but her remark further on (line 6–9) `then you can bring up ask well er if you were unclear about something if you want to know something about what's going to happen to you tomorrow' introduces a context for the discussion. Even though the nurse goes on to ask a question about previous operations, the interview becomes an interactive dialogue, with the patient actively participating. On her own initiative the patient discloses symptoms that she has experienced during the last few months, what happened when she needed to come to the hospital and the doctor's decision to perform surgery.

Thus, the nurse introduces the context of the discussion with her opening words [ cf . ( Peräkylä, 1995 )]. She expresses her acceptance by offering collaboration [ cf . ( van Ryn and Heaney, 1997 )] when asking questions. The verb form `would like to' (line 2) gives the discussion an air of voluntariness. The conditional form softens the notion of the necessity of the questions, and the verbal mode implies respect for the patient. At the beginning of the session (lines 1–9), the nurse combines two topics into a single long sentence, which also encourages (lines 6–9) the patient to clarify matters that are unclear to her. The nurse's words leave room for the patient's own thoughts and invites her to look for a personally meaningful way to connect the nurse's questions about the preparations (line 5) for the operation to her lack of information (lines 7–9). Encouraging statements can stimulate the patient to think in a way that is personally meaningful to her and to participate in the conversation ( van Ryn and Heaney, 1997 ; Tomm, 1988). Here, encouragement takes a form that is different from what Feste and Anderson ( Feste and Anderson, 1995 ) suggested; it is given in a more sophisticated manner. The opening words ( Extract 1 ) correspond with the goal that the nurse states later during the interview: `that the patient would receive the information she needs, what she wants to know and that she would feel safe to come, that at least those worst fears would be like forgotten. That she would feel safe'.

An encounter can threaten a patient's need for autonomy and freedom because it gives the nurse the legitimate power to request information about the patient's private life ( van Ryn and Heaney, 1997 ). Here, the nurse is mitigating her power by avoiding threatening terms and using tentative formulations (`would like to, well er, you you'), the emphasis being on the patient's needs. The opening of the interview by the nurse plays an important role in the development of the atmosphere. The act has been planned in advance but is not thoroughly thought out. In addition to conveying information, the main consideration in setting the goal for the discussion is to help the patient deal with her concerns. These are issues that have also been stressed in earlier studies ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Breemhaar et al. , 1996 ; Leinonen et al. , 1996 ; Lindsey and Hartrick, 1996 ; Otte, 1996 ).

Tactful exploration: activation of reflection

Later during the interview, the patient mentions having thought about the impending surgery, which the nurse interprets as an indication of fear for the operation ( Extract 2 ). She indirectly gives the patient an opportunity to deal with her fears. The patient's words (lines 1, 3, 5 and 7) are related to the previous topic and her status during the operation and conclude the discussion. The nurse changes the subject (line 9) by praising the doctor's skill. The nurse and the patient look at each other.

1 P:mmm[think about during the day]= 
 2 N:[of] course ((nod+)) 
 3 P:=what's going to happen and (.) 
 4 N:right ((nod+)) 
 5 P:°like[that]° (.) 
 6 N:[mmm] 
 7 P:°it's[okay]° ((nod+, vo–)) 
 8 N: [that's] right (.) ((glance at papers: doctor's 
 9 name)) is is an excellent surgeon so in that 
 10 respect you can definitely (.) ((vo–)) feel 
 11 safe ((nod+)) that 
 12 P:yes of course I am 
 13 N:mmm 
 14 P: and and absolutely 110% (.) I trust that (.) 
 15 the thing is that (.) this is small case for 
 16 him but this is a horribly big thing for me…

The nurse's comment about the operating surgeon contains an allusion to fear of surgery. Instead of soothing the patient by telling her not to be afraid or asking if the patient is scared, the nurse indirectly comments on the doctor's professional skill (line 9) and emphasizes the expertise as a guarantee of success (line 10 and 11). Thus, the nurse allows the patient to save face when she leaves her to interpret her words. Her indirectness implies politeness and gives the patient options: if she does not want to deal with her fear, she may choose not to take the hint [see ( Brown and Levinson, 1987 )]. Here, politeness can also be linked to and interpreted through empowering practice, where the nurse holds the patient in high regard [ cf . ( van Ryn and Heaney, 1997 )].

The extract might have been interpreted as an example of the nurse cutting the patient off if one had not seen the videotape. Our interpretation is supported by a number of factors. First of all, the entire conversation until this extract has been tranquil and calm, the nurse has spoken and asked questions at a gentle pace, with pauses, and she has explored the patient's experiences. In this extract, the situation is similar, and she looks at the patient and nods. She speaks quite slowly, and her voice is low, friendly, and convincing ( van Ryn and Heaney, 1997 ). We can also see that the patient completes her speech by pausing (lines 3 and 5) and lowering her voice (lines 5 and 7). Therefore, after the nurse's words (lines 8–11), the patient presents her fear for discussion (lines 15 and 16) and also returns to the matter later during the interview. The extract shows how the issue has been constructed together by the nurse and the patient. The nurse raises the theme in a sensitive and non-threatening manner, and the patient continues the same topic. It also shows that the relationship is confidential enough for the patient to disclose her concerns and become aware of her own understanding, and thus contributes to empowerment. Salmon ( Salmon, 1993 ) has stressed that the main goal in the discussions between nurses and patients before surgery is not to reduce the patients' fears but to help them to deal with them.

Indirectness is a polite feature of discourse. There is `strategic indefiniteness' in indirectness that offers patients an opportunity to continue a discussion according to their own wishes ( Brown and Levinson, 1987 ). In general, nurses' empowering acts are mostly manifested in the form of questions ( Poskiparta et al. , 2000 ). In some cases, an indirect comment by a nurse, instead of a question, may encourage patients to talk about topics that they fear. Here it generates reflection in the patient. After disclosing her concerns, the patient analyzes the situation and recounts the conversation that she had with the doctor who explained the reason for her back surgery ( Extract 3 ).

Extract 3 .

1 P:this morning ((doctor's name)) said that 
 2 N:`this morning' ((surprised)) 
 3 P:this morning 
 4 N:that's recent for sure 
 4 P:yes 
 5 N:well it happened so 
 6 P: so it happened suddenly because yesterday 
 7 it became evident that (.) there was in the 
 8 X-ray ((doctor's name)) said that there was 
 9 a cause when I asked if there was anything 
 10 that caused the pain or if I was just imagining 
 11 it (.) so he said that yes there was a 
 12 genuine cause…

The amount of information given always depends on the situation and the nurse needs to continually evaluate the patient's needs: what it is that the patient knows, wants to know and how much she does want to know. This is also important because there are several persons that the patient sees before surgery ( Breemhaar et al. , 1996 ). Furthermore, nurses and doctors may deal with the same issues in their counseling. In Finland, the doctors, the surgeon and the consultant anaesthetist inform patients about the medical facts, risks, and benefits of operations. The patient also has an interview with a nurse on the surgical ward and, in addition to these encounters, there will occasionally be an encounter with a nurse anesthetist.

The nurse's empowering approach is manifested in how she raises issues or questions from time to time as if with hesitation. A pause precedes questions [`I don't have any (.) questions to ask you any more but do you—you have anything to ask from me like such things about tomorrow that worry you') ((looks at the patient))]. She asks the questions more quietly than normal and looks at the patient. According to Beck and Ragan's ( Beck and Ragan, 1992 ) study, nurses' softening words and their hesitant and tentative manner of speaking indicate discretion and tact and are aimed at not embarrassing patients. In our data, slow and hesitant speech also encourages the patients to comment more than nurses' more usual and brief question does: `Do you have any questions?'.

The nurse's tentative manner of asking questions makes it easier for the patient to start dealing with her concerns. She repeatedly pauses briefly and, in addition to the closed questions in the medical history questionnaire, she asks open-ended questions that explore the patient's experiences: `What kind of memories do you have of previous operations?' `Is there anything else you remember (.) is there something?'. Open-ended questions encourage the patient to speak and participate, e.g. in the naming and solving of a problem [ cf . ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 )]. In this particular case, indirectness and hesitation are polite speech formulae that help the patient to save face ( Fairclough, 1992 ). They can also serve as empowering strategies that provide unconditional positive regard and acceptance for patients.

Despite these quite extensive empowering acts, the nurse subsequently evaluated her information skills only. She indicated how difficult it was for her to decide what kind of information to give to the patient:

I wondered if I should have maintained a more professional role, I mean more facts, if the patient got all that she wanted. Because this is not really medical science, you know, that's up to the doctor. It has to happen on the patient's terms, what she wants to know. I tried to check the patient's needs several times.

The content of the session satisfied the patient as well:

I got enough information about the operation, things that occupied my mind, so I didn't, she even told me before I asked. There's nothing to find out any more. As I said to her, I'm terribly afraid but I'll go ahead with confidence.

The nurse's way of posing questions builds up interaction. With her questions she steers the discussion thematically. This is how she controls the conversation. On the other hand, it is the patient who determines the content of the discussion. Her answers are reflective and bring up new issues. When the patient speaks, the nurse supports her with various feedback (e.g. Extracts 2 and 3) `mmm, right, of course, yes, exactly' and sometimes by paraphrasing. She nods a lot, bends toward the patient and looks at her. The feedback also occasionally includes completing the patient's sentences. According to van Ryn and Heaney ( van Ryn and Heaney, 1997 ), such non-verbal cues signal acceptance and, according to Caris-Verhallen et al. ( Caris-Verhallen et al. , 1999 ), they are patient-centered. With her feedback the nurse shows that she is there to listen to the patient, that she does not want to interrupt. Her feedback encourages the patient to speak in a similar way as in the doctor–patient conversation of an alternative medical interview described by Fairclough ( Fairclough, 1992 ). The patient interprets the feedback as encouragement, goes on to discuss the matter, and indicates her intention to continue by using the expressions `What I have been wondering…', `I did that when…' and `on the other hand, it's…'. This is how the nurse supports the patient's right to speak, which is not necessarily typical of a medical conversation ( Fairclough, 1992 ). The nurse's multi-facetted listening feedback is empowering, and this can be seen here and there in the data [see also ( Poskiparta et al. , 2000 )]. In this encounter, the feedback is exceptional because it disregards the participant's status. Generally, this type of feedback is directed to the dominant person ( Hakulinen, 1989 ). In a medically oriented environment, the hospital staff are viewed as superior to patients in knowledge ( van Ryn and Heaney, 1997 ; Tones, 1994 ). In this particular case, the nurse's listening feedback manifests power sharing.

When the patient discusses the reason for her admission to the hospital, the nurse builds up a positive, healthier vision of the future through other patients' experiences ( Extract 4 ). She makes her professional knowledge and expertise available to the patient ( Williams, 1995 ; McWilliam et al. , 1997 ). This lends a touch of reality and possibly builds on the patient's strengths ( van Ryn and Heaney, 1997 ) in this situation. The nurse attempts to dispel the patient's concerns about the risks of the operation. Her tone is convincing, and her non-verbal messages also inspire confidence: she looks at the patient, reinforces her message by nodding her head and gestures with her hands. Encouraged by the nurse, the patient can have a vision of her postoperative future.

Extract 4 .

1 N:these these ((ha+)) back operations are 
 2 like such that patients in them are usually 
 3 really grateful ((nod+)) after the operation 
 4 because if the operation like succeeds and 
 5 something is found (.) then the pain will be 
 6left in the operating room (.) ((ha+)) and 
 7 in that in that this is like like different from 
 8 other operations (.) and then because the 
 9 woundpainisinthebacksomehowit's 
 10 different than in here if the wound was here 
 11 inthestomach(ha+))andit'snotthatthat 
 12bad when it is if[you]= 
 13 P:[yeah] 
 14 N:=afterthosestomachoperationsyouoften 
 15 often hear that these patients who have had 
 16their back operated are such fortunate 
 17((nod+)) cases in the sense [that]= 
 18 P:[yeah] ((nod+)) 
 19 N:= because the pain will be left in the 
 20 operating room and and that's it then 
 21 ((nod+/ha+))

The nurse encourages the patient to examine her life at some hypothetical future point of time when the operation will have succeeded. Hypothetical questions encourage patients to discuss issues that they fear [ cf . ( Peräkylä, 1995 ; Tomm, 1987 )], while a hypothetical positive situation encourages patients indirectly. In this case, discussing the past would not calm the patient but rather lead her thoughts to the incident that caused her hospitalization. The vision of the future that the nurse provides to the patient with may help relieve her. A positive example is an empowering message and displays the nurse's understanding of the patient's anxiety. This vision can tap new resources in the patient for facing the future that is suddenly uncertain [ cf . ( van Ryn and Heaney, 1997 )]. Some manifestations of this can be seen in the patient's words: `…I'm very happy that if it's going to be over (.) yes I'm ready though I feel nervous' or `…I'm going ahead with confidence…'. A skilful use of future focus by the nurse helps the patient to find new solutions to her problems [ cf . ( Tomm, 1987 )]. As Atwood ( Atwood, 1995 ) suggests, confining the clients' thoughts to their problems is not sufficient in therapy work (focus on the past). In addition, we need to assist clients to expand their outlook by re-visioning their lives (future focus).

The encounter that is presented here as a case study demonstrates empowering nursing practice in hospital. It is a concrete example of a discussion during which the official and formal nature that characterizes the role of an institutional nurse is not emphasized. It actually emphasizes partnership and reciprocal conversation [ cf . ( van Ryn and Heaney, 1997 ; Poskiparta et al. , 2000 )], with the nurse's social interaction skills at the heart of the encounter [ cf . ( Wiles, 1997 )]. The patient is free to discuss her thoughts, concerns, experiences and even fears with the nurse, and the nurse adopts an empowerment strategy in order to facilitate the patient's participation. This encounter included the following empowering practices: (1) opening the session in an encouraging and constructive manner, which improves the atmosphere, (2) tactful exploration when examining the patient's need for information and concerns for surgery, (3) active, power sharing listening, and (4) building up a positive vision of the future.

The descriptions of empowerment strategies reported by van Ryn and Heaney ( van Ryn and Heaney, 1997 ) support our findings. However, we agree with Northouse's ( Northouse, 1997 ) criticism that the reported strategies are not completely separated. In our study, empowerment was manifested through intimacy and mutual respect. The nurse's encouragement of the patient's participation and her attempt to share power signaled acceptance, and perhaps gave the patient new insights for controlling her feelings about the impending surgery. Furthermore, the perceptions of active listening feedback and questioning are consistent with our previous studies ( Poskiparta et al. , 1998 , 2000 ; Kettunen et al. , 2000 ), where we found them to be a means of activating patients' self-evaluation and self-determination. In this study, we did not find evidence for empowering stories or questions that relate to patients' personal philosophy, as mentioned by Feste and Anderson ( Feste and Anderson, 1995 ). In addition, the nurse's encouragement was more sophisticated than what Feste and Anderson suggest with their empowering tools.

Our research data consisted of only one videotaped session per patient. Thus we have no evidence about how patients' decision-making skills develop or their self-esteem improves. During the interviews we did not ask the patients' opinion on the effects of counseling and that is why the patients evaluated conversations at a quite general level. In this particular case, the patient said that an encounter was ` illuminating ' for her. She mentioned that she received enough information and again spoke about her fears but used the same words as the nurse did when she emphasized a positive vision of future (see Extract 4 , lines 5, 6, 19 and 20): `if it's a fact that the pain will be left in the operating room, if it really is possible…that there's going to be an operation and they'll do it tomorrow, then that's how it's going to be'. This could, perhaps, signify some kind of relief or new resources to face an uncertain future. During the interview it also became evident that the patient's fears had not been diminished, but she talked about them and stressed a strong reliance on the professionals and on the operation as a whole: `I believe what I'm told'. This is in line with the perspective of Salmon ( Salmon, 1993 ), who emphasized that patients' anxiety about surgery should not be seen as a problem but rather as a normal phenomenon, a sign of patients' emotional balance, of an ability to feel fear. Thus, the nurse's task is not to diminish the patient's fears but to facilitate the patient's disclosure and offer help for dealing with fear.

With caution, we can speculate on the factors behind this kind of empowering practice, which became evident during the subsequent interviews. There was no evidence that nurses' or patients' age, education or work experience influenced the format of the counseling. What makes this case different from traditional rigid counseling sessions is that the nurse had a goal that she had planned in advance and pursued flexibly. This indicates that she had reflected on the significance of this situation from the patient's perspective. In most cases, nurses approached counseling without any goal or the hospital provided a detailed agenda based on professional knowledge of diseases, their care and prevention. Then, different kinds of institutionalized health counseling packages seemed to restrict nurses' communication, and health counseling often followed the standard institutional order of phases mentioned by Drew and Heritage ( Drew and Heritage 1998 ).

This study highlights empowering opportunities that arise in actual situations and that nurses can consciously use in their work. The results of this study can be applied to other health counseling practices and we would argue that every nurse should consider how (s)he initiates discussion. The analysis of the encounter shows that a tentative discussion style gives the patient a chance to deal with her concerns and to absorb the information that she needs. Thus, the patient has an opportunity to participate more actively in the discussion from the beginning than she could in the case of filling out a questionnaire in a strict predetermined order.

Clearly there are limitations to the generalizability of these findings. For example, both interlocutors were women, and this could in part explain the nature of the conversation since the highest levels of empathic and positive behavior occur between females [see ( Coates, 1986 ; Roter and Hall, 1993 ), p. 63]. There is also some concern whether the nurse may have been subject to a performance bias because she was aware of being videotaped and possibly behaved differently. However, we think that this was limited because only two nurses discussed this type of bias in the interviews afterwards and other nurses did not even notice the camera or did so only briefly at the beginning of counseling [see also ( Caris-Verhallen et al. , 1998 )]. Techniques to enhance the credibility of the findings included data and methodological triangulation of research data ( Patton, 1990 ; Stake, 1994 ; Begley, 1996 ), and acquiring data that included both verbal and non-verbal communication from the videotaped health counseling sessions and the subsequent interviews. In addition, team analysis sessions (investigator triangulation) ensured the accuracy of data interpretation (Polit and Hunger 1995). Different expertise helped us to get more complete picture from this case and empowerment philosophy when we discussed interpretations together.

However, in the last analysis, the effect of an empowering encounter could be checked after the operation by checking the patient's perspective, e.g. her satisfaction, recovery rate, etc. Evidence from nursing and medical staff might also be offered as additional evidence. Further research from larger numbers of patients is needed and more evidence from different settings will be required for a more extensive description of empowering practice. We will continue our research, and, for example, present qualitative analysis of interaction by describing how power features and patients' taciturnity are manifested in nurse–patient counseling. In addition, we will investigate how student nurses make progress in empowering counseling.

We suggest that nurses should pay attention to verbal expression and forms of language, in addition to non-verbal messages, because then they can empower patients by opening new and important perspectives for them. Nurses' every question, remark or piece of advice leads to individualized understanding and interpretation by the patient. It is important to remember that each communication situation is a unique, dynamic and transforming process. Nurses should observe what figures of speech they use and thus gain self-awareness and discover new tools to work with. We suggest a training program where the development of health care professionals' empowering skills can occur in practical, dynamic communication situations, be videotaped and transcribed for later theoretical, conscious and instructive evaluation. Analyzing the transcripts of video or tape-recorded counseling sessions opens up the possibility of an exact evaluation of empowering skills.

In health counseling, it is important that patients are able to maintain and strengthen a positive image of themselves as communicators. Positive experiences build up patients' self-esteem and increase their confidence in their ability to influence their care. The mere opportunity to discuss one's opinions and interpretations or different health concerns with a nurse may have the effect of unlocking patients' mental resources. This article demonstrates particularly how unconditional acceptance and facilitation of participation can be used in interpersonal counseling [see ( van Ryn and Heaney, 1997 )]. The empowering practices that are presented in this article should not be regarded as rigid and formalistic, rather they should be adapted to one's personal style.

Empowering principles of interpersonal practice ( van Ryn and Heaney, 1997 )

This study was supported by the Ministry of Health and Social Affairs of Finland and by the Finnish Cultural Foundation. We are sincerely grateful to all that participated in this study.

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A Case Using an Integrative Approach to Relationship Counselling

Author: Jan McIntyre

Mark is 28 and has been married to Sarah for six years. He works for his uncle and they regularly stay back after work to chat. Sarah has threatened to leave him if he does not spend more time with her, but when they are together, they spend most of the time arguing, so he avoids her even more. He loves her, but is finding it hard to put up with her moods. The last few weeks, he has been getting really stressed out and is having trouble sleeping. He’s made a few mistakes at work and his uncle has warned him to pick up his act.

This study deals with the first two of five sessions. The professional counsellor will be using an integrative approach, incorporating Person Centred and Behavioural Therapy techniques in the first session, moving to a Solution Focused approach in the second session. For ease of writing the Professional Counsellor is abbreviated to “C”.

After leaving school at 17, Mark completed a mechanic apprenticeship at a service station owned by his uncle and has worked there ever since. His father died from a heart attack when Mark was six years old and his uncle, who never married, has been a significant influence in his life. He is the youngest of three children, and the only boy in the family. One sister (Anne) is happily married with two children and the other (Erin) is single and works overseas. Mark and his mother have a close relationship, and he was living at home until his marriage.

Some of Mark’s friends are not married and say he was a fool for ‘getting tied down’ so young. Mark used to think that they were just jealous because Sarah is such a ‘knockout’, but lately he has started to wonder if they were right. In the last couple of months, Sarah has been less concerned about her appearance and Mark has commented on this to her. Sarah had been looking for work, but doesn’t seem to do much of anything now.

Three months ago, Sarah found out she can’t have children. According to Mark, she hadn’t spoken about wanting kids so he guessed it wasn’t a big deal to her. When she told him, Mark had joked that at least they wouldn’t have to go into debt to educate them. He thought humour was the best way to go, because he had never been very good at heavy stuff. Sarah had just looked at him and didn’t respond. He asked if she wanted to go out to a movie that night, and she had started to shout at him that he didn’t care about anyone but himself. At that point, he walked out and went to see his brother-in-law, Joe and sister, Anne.

Since then, he and Sarah hardly spoke and when they did it often turned into an argument that ended with Sarah going into the bedroom, slamming the door and crying. Mark usually walked out and drove over to Joe’s place. When Anne tried to talk to Sarah about it, Sarah got angry and told Anne to keep out of it, after all what would she know about it. She had her kids. Joe and Anne had kept their distance since then. Mark talked to his mother, but she said that this was something he and Anne had to work out together. It was she who suggested that Mark come to see C.

Session One

When Mark arrived for the first session, he seemed agitated. C spent some time developing rapport, and eventually Mark seemed to relax a bit. C described the structure of the counselling session, checked if that was ok with Mark, then asked how C could help him.

Mark: “I really wanted Sarah to come; my wife, but she said that I need to sort myself out. I have to tell you, I don’t think counselling is really for men. Women are the ones that like to talk for hours about their problems. I only came here because she insisted and I don’t want her to walk out on me.”

C: “Your marriage is important to you.”

Mark: “Yeah, sure. We’ve had fights before, but they weren’t anything major. And we always made up pretty quickly. But this is different. It seems like whatever I say is wrong, you know? Lately, I haven’t been able to concentrate properly at work and I wake up a lot through the night. I’m feeling really tired and I wish Sarah would get off my case.”

C used encouragers while Mark described what had been happening over the past few months. When he had finished ventilating his immediate concerns, C, moving into Behavioural techniques, summarized and asked Mark to decide what issue he wanted to deal with first. “Mark, you have discussed a number of issues: you are concerned that communication between you and Sarah has been reduced to mostly arguments; you’re unsure how to deal with the fact that Sarah cannot have children; you want to improve your relationship with Sarah; you are worried that Sarah might leave you, and you are feeling very stressed out. What area would you like to work on first?”

Mark: “I just want her to talk to me without arguing. All this is making it really hard for me to concentrate at work, you know.”

C: “Sounds like two goals there, to reduce your stress and to improve communication between Sarah and yourself.”

M: “Yeah, I guess so. If she would just talk to me instead of crying.”

C used open questions and reflections to encourage Mark to look at his feelings. “How do you feel when she goes into the bedroom and starts crying?” Mark: “Well, she’s never been a crier, and I don’t know what to say to her. If I mention not having children, she will probably cry even more.”

C: “So you feel confused about what to do, and anxious that you may upset her even more.”

Mark: “Yes, I just can’t seem to think straight sometimes. Like, I want things to be the way they were, but it’s just getting worse.”

C informed Mark about the use of relaxation techniques to reduce his stress and checked out if he would like to give it a try. “Mark, you appear to be having difficulty coping because you are feeling very stressed. I believe that learning relaxation techniques would decrease the level of stress and help you think more clearly. How does this sound to you?”

Mark: “I’m not into that chanting stuff if that’s what you mean.”

C explained that there are many forms of relaxation and described the deep breathing and muscle tensing method; Mark agreed to do this for 10 minutes twice a day.

As the first session drew to a close, C reviewed the relaxation technique and asked Mark to practise it as often as possible. A second appointment was arranged for the following week.

At the next session, C asked Mark how the relaxation exercise had helped. “I forget to do it some mornings, so I did it for twenty minutes at night instead. I told Sarah what I’m doing and she just leaves me to it. Not sure if it’s making any difference but I’ll keep doing it. It’s nice to have twenty minutes of peace and quiet.” At this point, C moved into a Solution Focused approach.

C congratulated Mark on commencing the relaxation practice, then checked out if it was okay to ask him some different types of questions. Mark agreed and C asked a miracle question. “Imagine that you wake up tomorrow and a miracle has happened. Your problem has been solved. What would other people notice about you that would indicate things are different?”

Mark looked at C, who waited in silence. Eventually Mark responded. “Ok, they would see me and Sarah talking a lot more, without arguing.”

C: “What else would they notice about you?”

Mark: “I would probably be spending more time at home. You know, not staying back so late at work.”

C: “What would they notice that was different about Sarah?”

Mark: “That’s easy. She wouldn’t be crying and yelling all the time.”

C: “So what would she be doing instead?”

Mark: “I guess she would be talking to me, and smiling.”

After spending some time exploring what would be different if the miracle happened, C asked Mark what he had tried in the past to improve communication. Mark revealed that he bought Sarah some flowers and a box of chocolates (his uncle’s suggestion) but it hadn’t really made any difference. C complimented Mark on his efforts and continued with an exception question.

“Can you think of a recent occasion, when you would have expected a quarrel to start and it didn’t?”

Mark furrowed his brow and appeared to be thinking deeply for some time. C waited in silence. Finally, Mark answered. “Actually, about a week ago, I was a bit late home from work and I was expecting another tongue-lashing, but it never came.”

C asked Mark what was different about that night.

Mark: “Well, Sarah was happier.”

C: “How did you know she was happier?”

Mark: “She talked to me, you know, just talked about something she had seen on the telly or something like that.”

C: “And how was that for you, Mark?”

Mark: “Not bad. Actually, it wasn’t too shabby. We did get to chat, and we haven’t done that for ages.”

C: “Can you explain, “Wasn’t too shabby”; I haven’t heard that term before?”

Mark: “Oh, it means it was all good, you know, it was okay.”

C: “So you came home and chatted with Sarah over a cuppa and you found that wasn’t too shabby?” Both smiled

Mark: “I really liked it. I remember thinking I would have come home earlier if I had known it was going to be like that.”

C: “If I was to ask Sarah what was different about that night, what do you think she would say?”

Mark: “Boy, this is getting weird.”

Mark: “Let’s see. She would probably say, “He actually sat and had a cup of coffee with me, instead of just flopping in front of the telly. She’s always griping about that.”

At the appropriate time, C called for a break. “I’d like to take a break and give us both time to consider all the things we’ve talked about. After that, I will give you some feedback.” After the break C summarized what had been discussed and complimented Mark on the work he had put into exploring his problems. He seemed less stressed and had shown that he was committed to improving his relationship with Sarah.

Counselling continued for another three sessions, by which time Mark’s stress had reduced considerably, he was coming home from work earlier and making an effort to talk more to Sarah. The arguments were less frequent and not so heated.

Session Summary

The Person Centred approach allows the client to take the lead and discuss issues as they see them. This encourages the client to talk openly, which was especially useful in this instance since the client showed a reluctance to do so at first.

• The Behavioural technique of goal setting is used to clarify what the client wants to achieve out of the sessions.
• Solution Focused Therapy , this approach acknowledges that the client has the ability to solve his own problem.
• Miracle questions assist the client to examine how they and others would be behaving if the problem were already dealt with. This helps the client to look at their current behaviour and see what they can do to bring about the required change.
• Exploring what the client has tried in the past highlights that the client is committed to solving the problem. Exception questions help the client to see that there are times when the problem does not occur, and that they have contributed to that situation. This shows the client that they have control over the problem.
• Clarifying client’s words, eg. “Not too shabby” shows respect for the client’s language and emphasises that the client is the expert.

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Case Study on Anxiety Counselling

• Published: 04 Aug '21
• Updated: 19 Feb '24

Table of Contents

Recently, I received a call from Ramesh who was experiencing anxiety after the outbreak of Coronavirus and lockdown. He was wondering whether therapy can help him. After having an initial conversation over the phone, we scheduled a online consultation session.

Anxiety Counselling – Complete Session Flow

Initial consultation or pre-therapy session: .

Ramesh : So Nitin, I will tell you everything from the beginning. 

I got married 2 years back. I have been working as a financial consultant for around 4 years. My wife, Radha, is an executive at a call center. And one fine day, the both of us were discussing having a child. Since the two of us are earning enough, we felt that we would be able to handle the additional responsibility of the child prior to the lockdown.

After the lockdown, Radha’s company decided to distribute only 50% of salary and the place where I work, had also reduced my pay drastically. This has put our future plans in question as both of us are worried about the finances.

After hearing Ramesh’s challenges, I began by psycho-educating Ramesh about the core concepts behind the process I follow. I suggested Cognitive Hypnotic Psychotherapy (which is an eclectic approach to Psychotherapy) for working with anxiety. Then I walked him through the pre-coaching process. 

After helping him understand the therapy process, I added that in his case, once we have defined the current problem and outcome clearly, I will help him –

• Defining the Existing problem clearly
• Defining the expected outcome from the sessions clearly
• Understanding the kind of future, he would like to create
• Understanding the current plans, they had including planning for the child
• With updated timelines to accommodate the financial challenges being currently faced 
• Including additional steps that can be taken or things that can be done to generate additional income from home 
• Identifying the specific thoughts and emotions that may stop him from following the new plan of action.
• Identifying the various triggers for anxiety
• Restructuring the thoughts about the anxiety causing triggers
• Systematically working towards applying the new plan of action for generating additional income and working confidently towards the desired future.

Session 1: Defining Challenge and Desired Outcome

The first session of anxiety counselling focused on helping Ramesh define his current situation, desired outcome, and expected future. 

I started the first session by asking Ramesh to summarize the challenges he wanted to overcome through therapy in his own words. 

Ramesh : I am worried about my future because of the financial strain caused by lockdown and I am finding it difficult to transition to working online.

I then asked Ramesh to reframe her problem statement using the following format: 

I feel …………… about …………… when ……………

I feel anxious, worried and overwhelmed about my finances and future when I am trying to transition work online.

I asked Ramesh to read the statement a couple of times and tell me what was the desired outcome that he wanted to achieve at the end of these sessions in the format:

 I wish ……………………….

Ramesh: I wish to be able to calmly and confidently make the transition to working online with my consultancy services.

Nitin : Can you describe the dream future that you would love to work towards?

Ramesh : Nitin, I had recently attended a goal setting workshop, where I was asked to write down my future in detail, create a vision board based on the future and create a detailed plan of action as a part of the activity. I have noted down in a word document, I can screen share that with you.

I went through all his notes and was satisfied with the format in which the future and the plan of action was listed. 

For home assignment, I asked Ramesh to update both the future and the plan of actions keeping in mind the new challenges that he was facing as a result of the lockdown along with the steps he was now required to take to move consultancy services online. 

Session 2: Exploring Additional Options and Primary Task List

We began session 2 in the next week by asking him about the week and any changes that he noticed in his behaviors, thoughts, or emotions. Ramesh mentioned that while he was writing about the future, he actually started believing that it was possible to achieve that specifically.

I was going through his home assignment and I noticed that he was able to add a few more steps to the plan of action. Ramesh said that he was not really sure about how to move the services online and offer them via his website.

I asked him to think and make a list of steps he can take to understand or to find how other people were doing online consultation sessions. Ramesh said that can speak to a couple of his friends who have successfully moved to online consultancy and also a website developer on how the technology works with respect to online consultancy.

I asked him to do this as a part of his home assignment, I also asked Ramesh when he would be able to connect with his friends and the website developer?

Ramesh assured that he would be able to do that in that week itself.

During the session, I asked him to add the desired feeling that he would like to have while doing those tasks.

The constant desired emotion that he wanted to feel was Calmness. 

I asked him to tell me 1 situation from the past wherein he has experienced the most calm and list down 3 situations in the future where he would like to feel Calm.

Ramesh made a list of them and I did the NLP Anchoring process* 1 with him.

At the end of the session, Ramesh looked visibly calm through his facial expressions.

(During the week, I asked Ramesh to have this conversation and also review and update the plan of action if required with additional details and steps.)

Session 3: Creating detailed Task List

In the next session Ramesh informed me that he was able to get a better understanding of how the online consultancy would work and had also given the website developer the green signal to work on adding systems for booking consultancy services on his website and conducting the anxiety counselling sessions as well. 

Ramesh said, I was able to convince the web developer to take his payments in installments over a period of next 3 months.

I asked him meta model questions* 2 to make all the tasks in the plan more detailed and literally step by step. We chunked down literally each task into tiny bits, added hindrances that may occur while working towards those tasks and also created a weekly schedule to help Ramesh do the tasks in a timely and effective manner.

Session 4: Working with Anxiety and Worry

In the next session, the plan was ready, I started working on Ramesh’s thoughts that were the cause of worry and anxiety. 

I asked Ramesh what was the specific time when he mostly felt anxious, i asked him specific triggers, his thoughts and at the end i asked him to tell me:

• Desired Thought
• Desired Emotions

Once he listed down his desired thoughts and emotions, I worked with thought restructuring* 3 . The new restructured thoughts were in sync with Ramesh’s plan of action and reinforced the idea that he was following the plan of action. Things were getting better and he was getting prepared to handle the current challenges more effectively.

I then used the emotional anchoring process* 1 to help Ramesh develop confidence for being able to take the consultancy sessions online effectively.

Session 5: Closure

At the beginning of the session, Ramesh mentioned that his past week was really nice and that he was no longer feeling worried or anxious about the future. 

Ramesh mentioned that he is still a bit concerned but was also confident about his ability to adapt to the new requirements more effectively.

I taught him self hypnosis* 4 for any future concerns.

My Observation: 

When a client is worried or anxious about the future, a detailed plan of action along with restructuring of thoughts can show wonderful results.

References for techniques used

• Thought Restructuring
• Self Hypnosis

The concepts and techniques discussed during this case study are based on the topics covered during the PROS Anxiety Counselling Certification , Cognitive Hypnotic Coaching® Diploma and the  Cognitive Hypnotic Psychotherapy™ Diploma Program .

• Category: Psychotherapy & Coaching
• Tags: Case Studies , For Therapists , Intense Emotions

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Counselling Case Study: Working with Grief

Grief is a complex and individual process. There are a number of well documented stages to the grief process such as numbness, guilt, despair, panic and acceptance to name a few. The order in which these stages are experienced and the intensity and duration of each stage will be different for each individual.

It is therefore understandable that an eclectic counselling approach to grief can be beneficial in allowing for the flexibility needed to work with individuals through various stages of the grief process. The following case study is a practical application of a variety of counselling approaches to one client and her experience of grief.

The client’s name is Joan. Joan sought counselling to deal with the unexpected loss of her daughter in a car accident. She received counselling about 2 weeks after her daughter’s death and continued with the counselling process over a period of 8 months.

The key features of Joan’s grief were her feelings of guilt and despair. In these areas, the counsellor worked mainly from a Person-Centered approach (PCT). The counsellor also utilised some techniques from Solution-Focussed Therapy (SFT) and Cognitive-Behaviour Therapy (CBT). A brief analysis of the case study and application of the various techniques are provided below.

Case Information

Joan is a semi-retired accountant, maintaining contract work with a few long-term clients to support herself in retirement. Joan is a divorcee, who lives on her own, in her family home. She is a mother of 2 children, Kirsten and Mathew, aged in their mid 20s. Joan has a supportive network of family and friends, including her sister, father, children, and friends from her gardening club.

Joan’s relatively steady life was overturned with the sudden death of her daughter, Kirsten. Kirsten was 24 when she died from head injuries caused during a car accident. She was admitted to hospital in a coma. Joan spent several anxious days with Kirsten, before she passed away.

In the days that followed, Joan arranged her daughter’s funeral and affairs and deferred her work commitments. Joan described this as a whirlwind period, where she operated in a mechanical way. She was completely absorbed in the organisation of Kirsten’s funeral and pushed aside her feelings of grief. Joan said that she found some security in the numbness that filled her during that time.

After a couple of weeks, however, Joan became concerned that she was not coping as she couldn’t move on from these feelings. People had commented that she should try to carry on as usual, however her numbness persisted and she couldn’t motivate herself to “carry on” as if nothing had happened.

Joan thought that there must have been something wrong with her and it was this fear that led her to counselling some weeks after her daughter’s funeral.

For ease of writing, the professional counsellor in this case will be referred to as “C”.

The Initial Stages

(Numbness) In the first session, Joan appeared somewhat vague and tired. She seemed focussed on describing the details of the funeral, the family members who attended and her concern about her daughter not having a will. “C” observed that Joan’s behaviour reflected a need to be in control of the situation and was a useful coping strategy for Joan at this time. “C” used PCT to build an empathetic understanding of Joan’s experience. She did not attempt to move Joan towards experiencing her grief, but trusted that Joan would reach this stage in her own time.

Joan began discussing the rapid way in which the whole event had occurred and the numbness that she was feeling. “C” used paraphrases and encouragers to assist Joan to express herself. “Everything has happened so quickly that you haven’t had time to absorb it all, is that right Joan?” “Yes”, Joan replied, “I’ve hardly had time to miss my little girl.” “You miss her,” responded “C”.

With this encourager, Joan began to cry and express her grief. Joan cried for some time whilst “C” sat with her in silence. At one point Joan apologised for her crying. “C” responded “It seems that you have a lot to cry about Joan. It shows me how much you loved your daughter.”

In the first session, Person-Centered therapy and Active Listening techniques enabled “C” to be guided by Joan’s readiness to express her feelings. The encouragers and reflection of feeling used, demonstrated to Joan that “C” understood her and allowed Joan to experience her feelings of grief, rather than to keep them at arms length.

Whilst “C” could have indicated to Joan that she was avoiding her grief, “C” instead trusted in Joan’s ability to express her grief in her own time. If Joan had not expressed her grief in this session, “C” would not have pressed the issue, although she may have encouraged Joan to have a further session within a few days.

(Grief and Despair) The following sessions were characterised by further experiences of grief and despair. Joan had found that her grief was no longer avoidable and her days were mostly filled with mourning. Joan abandoned her daily routines such as grooming, making meals and other basic self-care practices.

Joan’s disheveled appearance at the counselling sessions were concerning. At this point, “C” became more directive and suggested that Joan might have someone live-in with her for a while. Whilst “C” was encouraged by Joan’s regular adherence to the counselling sessions, she felt that Joan may need some extra support at home.

Joan contacted her sister Kerrie, who was available to stay with her for a month. Kerrie proved to be good support for Joan and provided her with gentle, yet insistent encouragement to face the everyday challenges.

Over several weeks of counselling, Joan had moved further into stages of despair and guilt. She described her life as being swallowed by a black hole and felt that she would never get over her daughter’s death. She felt that every day dragged by with no release from the pain. She had difficulty getting out of her bed in the morning and was constantly tired from lack of solid sleep.

“C” continued to employ PCT to allow Joan to explore and express her feelings and thoughts about her daughter’s death. Joan focussed heavily on her pain and seemed to stay with these feelings for a long time. “C” observed that Joan’s thoughts did not seem to be focused; she quickly moved from one topic to the next. “C” used summarising skills to help Joan highlight the key recurring issues from her thoughts.

“C” continued to trust that Joan would move through her feelings of grief in her own time. “C” did however experience some frustration with Joan’s continual despair. “C” sought the counsel of a colleague, who advised her to maintain her faith in Joan’s ability to grow and heal and reminded “C” of how the resolution of grief can often be a long-term process. The colleague also suggested some role-play techniques that “C” could use to work on Joan’s experience of her feelings.

(Guilt) Guilty feelings about her inability to prevent her daughter’s death were also of concern for Joan. “C” avoided telling Joan that she was not responsible for Kirsten’s car accident, and encouraged Joan to explore her guilt. In many instances grieving people feel guilt in relation to their loss. Often they will be told that they are not at fault, by well meaning people. The concern for counsellors is that grieving people are feeling guilty and will benefit more from expressing their guilt.

Dismissing guilty feelings won’t stop the grieving person from feeling blame and may lead to the increase of these feelings. “C” realised that Joan’s guilt was a means of expressing how fervently she wished to have her daughter with her still. “C” invited Joan to express her sorrow and guilt to Kirsten in a role play activity.

Afterwards, “C” encouraged Joan to debrief and talk about the effect of the activity. Joan was able to acknowledge the depth of her love and concern for Kirsten. “C” supported Joan by offering encouraging feedback. “C” was particularly taken with the extent of love and devotion that Joan displayed towards her daughter.

Joan left the session a little lighter for the experience. She said that she had been able to release some of her guilt and that she felt her despair ease a little. After two months of counselling, both Joan and “C” recognised this as a small breakthrough of acceptance.

Middle Stages

Joan’s grief and despair continued into the middle phase of the counselling sessions. Her emotions came in waves, rather than the constant fog of despair that had characterised her earlier sessions. “C” was continuing to utilise PCT with Joan to explore her issues. Joan expressed a readiness to establish goals during this stage. “C” implemented some CBT techniques for this purpose.

(Feelings of Panic) Kerrie had been encouraging Joan to take on small, everyday tasks such as walking to the shops, or posting the mail, in order to get out of the house for a while. Joan said she had done these tasks reluctantly as she was concerned about trying to “put on a brave face” in public.

Joan related a particular incident where she was at the local shop. She explained that when picking items from the shelves, she had selected her daughter’s favourite brand of biscuits. Feelings of panic had come over her as she realised that she no longer needed to buy the item, but she couldn’t bring herself to return the item to the shelf. In this state, she left all her purchases in the shop and walked straight home.

This incident had increased Joan’s anxiety about her ability to cope and accept her daughter’s death. In the session, “C” validated Joan’s experiences as being normal and a legitimate part of her grieving. As a part of the CBT process, “C” clarified and identified the causes and effects of Joan’s feelings of panic. These were as follows:

A realisation that her daughter was absent in her everyday life A rejection of awareness that her daughter was absent in her everyday life Conflicting emotions about acceptance of daughter’s absence

• Causing anxiety
• Causing a belief that she will never be able to accept her daughter’s loss
• Causing a fear of losing control in public places

“C” and Joan discussed the nature of the anxious feelings, and Joan’s associated beliefs and fears. Together they devised a number of goals, including (1) the development of new beliefs, (2) relaxation and (3) taking it one step at a time – otherwise referred to as a graded-task assignment.

Joan’s new beliefs included:

• It is normal to want my daughter back
• I am normal to grieve for and miss my daughter
• It doesn’t matter if I cry in public
• Time will help me to heal

She kept notes in a personal journal about when she used these new beliefs. The journal writing was also a process that allowed her to identify other problematic beliefs and thoughts. Once identified, she developed more appropriate and accepting beliefs.

In preparation of taking it one step at a time, Joan and “C” devised some relaxation techniques for Joan to use when she felt a sudden onset of panicky or anxious emotions. Joan had used imagery before and found that an effective method of relaxation. Joan was to imagine a warm, white light surrounding her whenever she felt even slightly anxious. They also devised some imagery to help Joan continue to experience the overwhelming nature of her grief.

Joan often referred to her feelings as a fog, and so “C” encouraged her to imagine sitting in a fog, which was black, thick and impenetrable. Little by little, she suggested that Joan should try to make the fog thin out with her mind. (It is important to note that this imagery was to be used at times when Joan felt bogged down in despair, but not during her anxious moments).

Joan was to record her practice of her relaxing imagery (white light) and to note her responses to the technique. She also recorded the times she used her despairing imagery (black fog) and the extent to which she was able to thin the fog with her mind. The purpose of the exercise was to increase her relaxation and to give her an image of her despair and a means to control it as time went on.

The ‘one step at a time’ goal consisted of Joan taking small steps towards running errands and taking on more of her everyday responsibilities. Her tasks involved the following:

• Plan meals for week
• Write a grocery list
• Go shopping with Kerrie.

Using her relaxation imagery, Joan completed the following graded tasks:

• Imagine walking around the shops
• Drive with Kerrie to the shop and stay in the car
• Walk with Kerrie to the shop door
• Walk with Kerrie around the shop for 10 minutes approximately
• Start to purchase a small number of items
• Complete an entire grocery shopping task

Each week, Joan completed a harder task. It took her only 4 weeks to complete a full shopping trip, although she experienced several occasions of feeling overwhelmed. Each time this occurred she gripped the shopping trolley and imagined the white light. Kerrie encouraged her to breathe deeply and relax. A couple of times, they left the shop (abandoned the trolley) when Joan felt she could not cope. They came back the following day to complete the shopping.

The important thing for Joan was to accept the times when she could not cope. Kerrie proved to be a supportive role model for Joan, helping her to accept her reduced ability to cope by offering encouraging comments and faith that Joan would heal.

Joan applied the graded-task technique to other areas of her life. “C” observed Joan’s increasing attention to self-care and other routines of everyday living.

Final Stages

(Acceptance) Joan’s increasing acceptance of the loss of Kirsten became more obvious with the passing of time. By dealing thoroughly with her despair and grief, she naturally moved on with her life and mourned less and less. After six months, the rewards for both “C” and Joan were evident in her long term improvement and growth.

Joan’s ability to develop goals for herself was greatly improved, as was her motivation. Joan was living independently again and without Kerrie around, she took on more responsibility and began to make plans for her life without Kirsten. Joan’s plans included a number of support mechanisms, as well as long-term goals for herself.

Joan had taken to visiting her daughter’s grave on a monthly basis. During her intense despair, she had been unwilling to venture to the cemetary. Due to her increasing acceptance, she was more inclined to visit and found the visits to be a sad, yet calming experience. The visits allowed her the opportunity to tell Kirsten the things she had left unsaid, and to update her daughter about her life, as she would have when Kirsten was alive. Joan found the visits kept Kirsten’s spirit and memory alive within her.

In these stages, “C” continued using PCT, and incorporated SFT to assist Joan to define her goals. “C” complemented Joan on her inventive ways of honoring her daughter’s memory. “C” was encouraged to see that Joan was actively seeking personal ways to express her grief.

Together, they worked to build Joan’s miracle picture. Joan expressed an interest to honor Kirsten’s life, by writing a book. Joan wanted to combine her own and Kirsten’s journals to recount the significance of her life and death. The process would also be a means to resolve her grief and offer a parting gift to her daughter.

Joan’s miracle picture included redefining her life goals to determine what was important for her. Kirsten’s death, whilst painful, had also brought growth and changes with it, and Joan was increasingly inclined to shed parts of her life that no longer held meaning for her. She threw out material things such as old furniture, files and boxes of junk and mentally discarded the maintenance of acquaintances that she no longer felt obliged to remain in contact with.

She renewed her bonds with close friends and family. Kirsten’s death allowed her family to grow closer to one another. Joan was buoyed by the love and support of these few, special people during her long months of despair.

Joan accepted that she would never completely ‘get over’ Kirsten’s death and that that was okay. Counselling assisted her to realise that her daughter would remain a part of her forever. She made a pledge to herself that she would continue to learn ways to live with Kirsten’s absence. Her journal writings and the possibility of publishing a book for Kirsten, would provide her with some therapeutic means of coping and expressing her grief. Joan would also draw from the support of her family and friends in times of need, particularly around the times of Kirsten’s birthday and the anniversary of her death.

End of Session

The case study has illustrated some of the stages that clients may experience due to the loss of a loved one. It has also attempted to demonstrate the way in which PCT lent itself to the complex and individual experience of Joan. The key issue from the PCT perspective was “C’s” respect for Joan to grieve and grow to acceptance in her own way and time.

CBT was applied to changing Joan’s negative thoughts about her ability to cope with her daughter’s loss and the fear of losing control of her emotions in public places. The imagery was a technique that Joan had prior experience with and was therefore ideal for her. Another client, may prefer other relaxation methods. It is important to identify strategies that the client is comfortable with.

Graded task assignments, journal writing, role plays, homework and other practical strategies such as developing support networks are also invaluable CBT techniques. Timing is important when introducing strategies, and the client should not be pushed into solutions before they are ready to accept them. Wherever possible, the counsellor should consult with the client about their ideas for, and their suitability to, particular techniques.

Once the client is ready to focus on solutions to their problems, SFT can be an invaluable tool for identifying the client’s goals through development of the miracle picture. The use of SFT has been briefly presented in the case of Joan, to illustrate its effectiveness in drawing out the plans and goals that Joan aspired to.

Author: Jane Barry

Related Case Studies: A Case of Grief and Loss ,  A Person Centred Approach to Grief and Loss , A Case of Acceptance and Letting Go

• March 15, 2007
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• Case Study , CBT , Person-centred , Solution-focused
• Case Studies , Loss & Grief

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