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Picking A Path: Counselling versus Non-Counselling Intervention

Distinctions in a Community Addiction Service

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 The Irish Psychologist | April 2015 | Volume 41 | Issue 06

Article

Picking a Path: Counselling versus non-

Counselling Intervention Distinctions
in a Community Addiction Service
Colin O’Driscoll
Colin O’Driscoll is an associate fellow of PSI and works as a counselling and forensic psychologist. He is clinical lead at the HSE
Mid-West Region Drug and Alcohol Service. In the past, Colin has worked in both mental health and addiction settings in the UK and
Ireland. Correspondence regarding this piece should be addressed to the author at colin@changepsychologyservices.com

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 The Irish Psychologist | April 2015 | Volume 41 | Issue 06
Article
Introduction
A redesign and implementation of a clinical overhaul in the HSE Mid-
West region’s specialist community addiction service gave rise to an
interesting set of clinical findings. The HSE Mid-West Drug and Alcohol
Service is a regional statutory community based service that provides
harm reduction, medical and counselling interventions to those in
the region struggling with addiction issues. There is a region-wide
methadone programme, outreach and counselling services provided
by a range of staff including Level II GPs, nurses and multitask
attendants (methadone clinic), outreach workers, counselling staff and
clinical leads (psychosocial services) led by the regional coordinator
who assumes operational responsibility for clinical processes. These
services serve the mid-west region of Ireland including Limerick city
and county, North Tipperary and Co. Clare.
The clinical experiences of interest in the current article pertain to the
psychosocial services provided, specifically the screening and referral
process for internal clinical pathways and the distinctions between
them. These experiences offer an insight into the nature of counselling
and non-counselling interventions and the decision making rules that
inform these respective pathways. As clinical lead in this process and
chair of the various clinical meetings that informed this process, I have
enjoyed the opportunity to engage with competent and experienced
clinical colleagues in the review of many presenting service users
with complex clinical needs. This created the prospect of developing
insights into the nature of such concerns and the clinical possibilities
we accordingly recommend.
Background Context
Following a review of the referral process for a regional specialist
community addiction service a screening and initial engagement
process was designed and implemented. The screening involved
a weekly drop-in during which all those who would present for
treatment would be initially engaged (screened) by counselling or
outreach staff. The results of these initial engagement sessions were
brought to and discussed in a clinical meeting (chaired by myself as
clinical lead and attended by outreach and counselling staff ). Each
individual would be considered in relation to his or her own unique
presentation. For each individual, a variety of treatment pathways
would be considered and subsequently recommended.
The internal psychosocial services that would be offered could
broadly be described as counselling and outreach, which would
frame the service departments providing treatment. Hence, the staff
providing the various treatments would do so either as counsellor or
outreach worker and the intervention itself would thus become either
counselling or non-counselling based psychosocial interventions. See
Table 1 for an illustration of these distinctions.
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Table 1. Illustration of interventions associated with counselling and
outreach services
Outreach Counselling
• Advocacy Counselling, whilst an intervention within
itself (taking into account the various
• Awareness and education
counselling and psychotherapeutic models
• Blood borne virus awareness
that make up an approach), often includes
• Brief intervention other interventions (e.g., harm reduction,
• Case management motivational interviewing, CRA, groupwork,
onward referral).
• Contact in the community
• Detox planning and support These would be surplus to various regional
services that the individual may benefit from
• Group work
in addition to (or exclusive of) the community
• Harm reduction service context.
• Key working
• Meditation groups
• Motivational interviewing (MI)
• Community reinforcement approach (CRA)
• On-going support
• Onward referral
• Outreach
• Planning and preparation for residential
treatment
• Relapse prevention
The key decision to arrive at in both the screening and referral meeting
process (assuming that a service is deemed suitable and appropriate)
relates to whether the service being offered would be counselling or
outreach, as outlined above in Table 1. In this process, I found that
the key to understanding the clinical decision-making process is best
understood with consideration for what a counselling intervention is,
what a non-counselling intervention is, and indeed why one might
choose one over the other.
Considerations for Outreach, Non-counselling
Interventions and Counselling Interventions
Most individuals who present for help to the service may benefit
from either counselling or outreach interventions. Once there is some
structure of approach, evidence base and empathy governing how
the individual is engaged, most interventions are likely to be beneficial
to an individual presenting for help and guidance to make a change.
However, there is not necessarily an equal weighting to these benefits,
and certain individuals will benefit more from some interventions and
less from others. Additionally and importantly, the individual may
only desire certain types of interventions and this preference was
considered centrally and fundamentally.
In order to understand how to consider this difference in weighting
(and thus the more beneficial portioning of resources), we found it
clinically necessary to have a generic appreciation of when counselling
interventions are more preferable than non-counselling interventions.
Thus it would be necessary to consider both ‘What’ the difference is
and ‘Why’ one might choose one over the other.
 The Irish Psychologist | April 2015 | Volume 41 | Issue 06

Article
What may complicate this further is the emphasis on evidence- Non-Counselling Interventions
based practice in addiction treatment services; the more evidence
Offset against counselling are a range of other therapeutic activities,
for the intervention practices (assuming efficacious adherence to
which take place, in the current context, within the outreach services.
that evidence), the more likely the service users are to benefit from
The interventions being referred to as non-counselling interventions
improved therapeutic outcomes. We consider this to be critical in the
for the purposes of this narrative are listed in Table 3.
consideration of methods and models that define and underpin a
service. This emphasis has led to a dramatic increase in the amount Table 3. Non-counselling interventions.
of training in evidence-based therapeutic conversations being rolled
out to non-counselling staff. The result may be considered positive Advocacy
and negative. On the positive side, most importantly, outcomes Awareness, Education and Psychoeducation
are undoubtedly better as service users are engaged in a way that
BBV awareness
is more evidenced to be effective and there is a lesser incidence of
broad conversational approaches. However, on the negative side it Brief Intervention
becomes increasingly difficult to differentiate what is and what is not
• Relapse prevention
counselling, as the difference between the two becomes narrower,
interpretively. For instance, Table 2 represents some potential points • Community Reinforcement Approach
of confusion relating to this consequent narrowness of differentiation, • Motivational Interviewing
when considering non-counselling interventions.
Case Management
Table 2. Points of potential confusion
Contact in the Community
Conjunction/ Overlap in application
Detox Planning and Support
• Some non-counselling interventions are • And by extension are referred to in this
also used in counselling context as counselling Harm Reduction Contact Session
Key Working
Understanding differences
• Some interventions are therapeutic • Yet these interventions are not necessarily Meditation Groups
therapy Motivational Interviewing
Semantic conundrum On-going Support
• Counselling and non-counselling
Onward Referral
interventions are therapeutic and so
we refer to the latter as a therapeutic Outreach Contact
intervention, yet the former as therapy Planning and Preparation for Residential Treatment
(‘being in therapy’)
Relapse Prevention
• Non-counselling interventions (for
example, key-working) are often referred Support
to as informal counselling
Non-counselling interventions are provided by outreach staff and
Theoretical background
in other contexts, support staff, care workers, project workers, etc.
• The theoretical frameworks and • As a result the language used in These interventions are largely evidence based in their own right
research context that support and counselling and non-counselling and staff have had specific training in some. In essence, they are
inform counselling and non-counselling interventions is quite similar structured approaches that create a therapeutic process by shaping
interventions are exactly the same the conversations between staff and clients, framing it in clinical
procedure. Ultimately this gives a manualised framework of sorts to
These points of potential confusion, blurring and narrowness of govern conversations so that they are validly helpful and effective in
distinction in turn increase the necessity for services and their staff to promoting change, rather than just conversations. Therefore, staff are
clearly understand the difference. Furthermore, there is a consequent encouraged and trained to think about the type of conversation that
necessity to develop a fluency in conveying this understanding to they have, have some clinical structure guiding how to have these
their service users, and indeed colleagues of other disciplines and conversations, and indeed why.
industries with overlapping clients. There is, as previously mentioned, a drive towards more intervention
Whilst individuals may benefit from either counselling or non- styled approaches, and indeed with very good reason as it increases
counselling interventions, it is essential to decipher which is most the likelihood of conversations in clinical contexts being more
appropriate in any given case, at any given time and within any given therapeutic. Without these frameworks and approaches the variability
context: how much a client may benefit relates directly to our clinical across services and staff would be chaotically unmanageable, at best.
understanding of this distinction. This does however make the brief non-counselling intervention look

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 The Irish Psychologist | April 2015 | Volume 41 | Issue 06
Article
and feel more like the counselling intervention, both to the client and
the worker. However, it is not of course counselling - counselling is
something entirely different.
Counselling and Psychotherapy
Counselling and psychotherapy are terms that are often used
interchangeably. They both relate to a therapy that is administered
by a trained, qualified and accredited counsellor, addiction counsellor
or psychotherapist. Some differences relate to the period of focus
(for example, here and now focus of counselling, and the more
developmental influence focus of psychodynamic). One may think
about the range of interventions from non-counselling to counselling
to psychotherapy as being broadly based on the level of intensity of
engagement, which reflects variation in the emotional experience and
the period of focus, such as in Figure 1 below. For the purposes of this
article counselling and psychotherapy will be grouped as counselling
interventions. The specific training and supervised experience
required to achieve accreditation is what equips the counsellor to
engage a client in a psychotherapeutic process.
Level of intervention intensity
(Emotional experience and length of period of focus)
Non-counselling Counselling Psychotherapy
Figure 1. Psychosocial intensity continuum
Counselling is a focused and highly skilled therapeutic process by
which the counsellor engages the client in a collaborative process to
address a specific issue. In the context of addiction it involves looking
at the process of addiction that is both common and unique to the
individual’s personality structure and emotional experience. The
counsellor pays particular attention to the unique way that the client
experiences their problems at an emotional and psychological level,
how the individual feels about their circumstances and why they feel
this way, including an appraisal of the developmental process and
earlier life experiences that contribute to the current issue.
The counsellor is trained to fluently interpret the clients’ unique view
of the world and the language structure with which they frame it.
This is the starting point for understanding both the nature of the
issue as experienced by the client and by extension the unique
approach required to resolve the presenting issue. Therefore clinical
formulation (an accurate appreciation of the nature and development
of the presenting issue) is central to the counselling process and the
technique of engaging a client in a counselling relationship.
The objective of counselling is to engage the client in a process of
exploring various aspects of themselves, their lives and their thoughts
and feelings about the issue. It involves inviting the client into a safe
and structured space that is separate to their daily experiences, a
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space within which they may safely and without judgement, press
pause on their lives, so that they may systematically explore what has
been happening, how they feel about that and what they may do
about it. It is important that the counsellor is also seen as separate
to this life that is temporarily paused. These are the reasons for the
very structured approach to session scheduling and the boundaries
between the counsellor and client, to support and increase the level
of safety and separateness for day-to-day experience outside of the
counselling.
Counselling draws from a range of theories, models and frameworks.
Common examples of these include person-centred theory,
behaviourist approaches, humanistic approaches, psychodynamic
approaches and cognitive behavioural approaches. However, more
than the approaches themselves, the counselling is geared towards the
functioning (and functional management) of the clinical relationship
and the skill of the counsellor to develop rapport, understand their
client effectively through active and reflective listening techniques,
and guide them through a therapeutic process in a fundamental air of
empathy, in addition to the accurate demonstration of such empathy.
Why Counselling?
Counselling has a more focused sense and appreciation of
the uniqueness of the problem presentation. Non-counselling
interventions tend to borrow from approaches that frame the
commonality of problem presentation and thus are often more likely
to be the correct approaches to guiding change.
As may be seen above there is a significant and clear difference
between a counselling and non-counselling intervention. How
though, might we interpret from a brief screening contact and a
clinical presentation, which is best for any individual, at any given
moment?
Decision Making Rules
From evaluations of clinical presentations in exactly this way, in the
HSE Mid-West Drug and Alcohol Services, certain decision-making
rules emerged as being fairly evident with respect to the already
articulated underpinnings. It became clear for instance, that when
an individual found pausing their current experiences in order to
reflect on them systematically particularly difficult or inappropriate,
that they would not be currently cognitively or emotionally available
for a counselling intervention. Three considerations appeared to be
necessary at this point:
1. Is the individual considered to be appropriate/available for
counselling?
2. Is counselling deemed to be the best option for the individual at
this time?
3. Is the individual interested in counselling?
A “yes” response to the first question became a minimum bar. A “no”
to this meant that counselling would not be considered, nor offered.
A “yes” however did not necessarily mean that the counselling
intervention was the best option. For this to be a counselling
recommended pathway, it needed to be a “yes” to both first and
 The Irish Psychologist | April 2015 | Volume 41 | Issue 06
second question. Following the recommendation, of course the
individual’s preference features centrally (as indeed this would also
represent a minimum bar), and so for counselling to take place three
yes’s were required.
It also became clear that certain issues tended to suggest that
counselling was by default more appropriate. For instance, when
issues associated with complicated bereavement, trauma, complex
interpersonal functioning or relationship issues, childhood abuse,
victim experience, and dual diagnosis, this tended to point towards
a counselling intervention being more appropriate. However, this is
not automatic. The individual may be experiencing problems with
some of these areas, yet it may sit alongside the presenting problem
(addiction) rather than acutely interacting with it. The person may not
wish to address such issues therapeutically. Indeed, they may already
be receiving support for these other issues and not wish for them
to feature in this intervention process. Therefore, whilst decision-
making rules were emerging, the referral meeting itself as the context
for making the decisions and recommendations, was critical to the
process.
Summary of Key Points
In summary, counselling interventions are effective and potentially
more useful when;
» There is an appetite to engage in a counselling process;
» Client can pause to reflect and can focus for long enough;
Minimum Bar
» There is a developmental process otherwise blocking progress;
» There are traumatic experiences requiring attention;
» There are active bereavement issues surfacing;
» There are dual diagnosis issues;
» There are complex interpersonal functioning issues to address;
» There are victim experience issues to be addressed.
Non-counselling interventions on the other hand may be more
suitable when;
» There is a specific intervention based request for which there is an
intervention designed and available, such as relapse prevention,
addiction awareness education, pro-social activities, refusal skills,
or harm reduction;
» There is a requirement specifically for key working or case
management to help the individual link in with and coordinate
with other services;
» The individual is looking to get into residential treatment, in which
case there is a need for some residential pre-treatment preparation;
» The individual is only available for treatment for a short period of
time;
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» There is no obvious requirement or appetite to engage in a
counselling process and the broad objective is exclusive harm
reduction, advocacy, care planning or key working;
» There has been a specific request not to engage in counselling;
» Much of the work involves inter-agency collaboration that is
deemed to be more suited to outreach;
» There are no obvious blocks to surface therapeutic progress
additional to motivation itself;
» The likelihood of adhering to structured session scheduling is
minimal;
» The request is contextually outreach based, for instance including
contact that is Off premises, Within other services, In the
community, Sporadic, and Community based harm reduction.
Conclusion
The process of reviewing each case presentation following an initial
engagement session in a clinical referral meeting has given focus
and insight to the critical differences associated with the differing
treatment pathways on offer. This has led to a process of articulation
and clarification relating to both the differences between counselling
and non-counselling interventions, and the decision-making rules
that frame the process of allocating these pathways. The process
pathways presented in this article offer clarification into the nature of
such interventions, and the professional consideration associated with
matching clients to more suitable, and helpful, treatment pathways.
This aids in the development of the clarity and fluency of health
professionals in understanding and speaking about therapeutic
intervention provision and in particular the nature of the difference
between counselling and non-counselling interventions. The case-
by-case clinical review process, in addition to the actual decision
making rules, are fundamental to effective treatment allocation.
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