Counseling Psychology Comprehensive Examination
Psychologists need to understand what the patients require through applying different testing techniques during the psychological assessment process (Groth-Marnat, 2009). This ensures that there is thorough comprehension of the underlying problems affecting the well-being of the patient. In this vein, psychological assessment is presented as a practice of categorically collecting information regarding a person with relevance to his/her background in order to make conclusions founded on this data, which is in the individual’s best interests. Several questions are significant to consider by a clinical psychologist including the past, present and expectations of the patients in the assessment process. Nevertheless, to examine issues arising from the questions methodically, a procedure was developed carefully and analyzed through the psychology field. According to Framingham (2011), to instigate the assessment process, the patient must meet a psychologist to enable him/her to get information from the formulated set of questions.
The patient must not perceive the process as being told to visit a psychologist due to failed somatic evaluations of their problems. This is because they may infer this as being stigmatized or being “shoved off”. A large part of psychological assessment involves developing a good rapport with the patient and non-verbal communication. Researchers and theories have identified that body language of non-verbal nature for instance maintaining a comfortable distance, attending additional non-verbal cues, leaning toward the patient, eye-contact, and mirroring body language conveys empathy and enhances trust (Gallagher, 2004). Additionally, research studies have demonstrated that patients who perceive their therapist as caring and empathic are more prone to treatment benefits. Nevertheless, the therapist-patient relationship is also responsive for deterioration or improvement of the patient’s condition even with the application of a particular treatment approach. With this in mind, the therapist should apply different approaches, only when the case of the patient is fully known (Ong & Keng, 2003).
Accordingly, a psychological assessment embraces identification of possible biological, psychological and social facets of the patient’s problem. This aids in painting a clear picture of the expectations of the assessment, while applying diagnostic procedures that can enable accomplishment of these objectives. As Julie’s therapist, I would first analyze her case to identify the three facets of the assessment. The main concern highlighted in the case suggests interplay of issues arising from Julie’s early childhood years, the onset and chronic back pain, the subsequent symptoms arising from these issues, which have led to influence of her current medical and social status. With this regard, I would perform a biopsychosocial assessment of the patient. This will aid in attaining a complete image of the chronic pain syndrome with relevance to all the affected facets including behavioral, cognitive, affective, and somatic and the individual outcomes for the patient. Each of the biopsychosocial dimensions can be additionally subdivided into detailed treatment interventions (Ong & Keng, 2003).
The medical chronic pain management usually revolves around three fundamental constituents. These include the electrical, chemical and physical treatment aspects. The physical element entails all the therapeutic interventions that can directly influence the musculoskeletal structure. They include exercise, traction, massage, and chiropractic manipulations among others. They are intended to correct the body imbalances brought about by the chronic pain (Groth-Marnat, G. 2009). The significance of this intervention is the capability of identifying the root pain cause even in the chronic phases of the problem. The chemical treatment element attempts to decrease the chronic pain through influencing certain chemical structure imbalances that emerge from the pain conditions. The applied approaches comprise antidepressants, anti-inflammatory, membrane stabilizers, and narcotics. There is topical, oral, and intraspinal administration of these elements.
According to Gatchel (2004), the electrical element of treatment is presented on the theory that there is electrical conduction of all pain signals to the patient’s central nervous system (CNS). Psychosocial approaches towards chronic pain rotate around four major elements. They include managing social outcomes, chemical dependency concerns, characterological and cognitive factors, and treating affective distress of the chronic pain. Inside the area of anxiety, depression and affective distress can be treated and managed with both medication and psychotherapy (Keller, 2002). It will be significant as Julie’s therapist, to explain the biopsychosocial pain nature with her during the early duration of the treatment.
Relevant Background Information and Assessment
The cultural background of Julie is African American. She is 72 years old. In addition, she is a divorced woman with two previous marriages. She has three children living away from her. In addition, she works as a psychiatric nurse working two 12-hour night shifts at the hospital. Different psychological assessment tools will be applied in testing the biopsychosocial status of Julie.
Julie has exhibited anxiety as one of her previous psychiatric and psychological problems, following her surgery intended to treat the left leg numbness and chronic pain. With regard to this, she was prescribed Welbutrin, an antidepressant that ceased working two years ago. This resulted to a replacement of the antidepressant with Celexa. She has not had her family around during these occurrences, which translates to feelings of sadness and loneliness. In order to identify more information regarding Julie’s psychological history, I would apply the P-3™ (Pain Patient Profile) assessment tool. The tool measures somatization, anxiety and depression. It is applicable in evaluating psychological factors associated to chronic pain disorders. The tool is able to recognize patients in need of anxiety and depression treatment and those prone to somatization. In addition, it provides a basis for comparing the degree of somatization, anxiety and depression.
Since according to the information provided there are manifestations of stressors that may lead to anxiety, other psychological assessment tools will be used including PDS™ (Post Traumatic Stress Diagnostic Scale) and PAI™ (Personality Assessment Inventory) and a genogram among others.
The medical history section of the biopsychosocial assessment aims to evaluate the biological dimension of Julie and her family history in relation to chronic pain (Gallagher, 2004). Hospitalizations experienced by Julie are because of the surgery that led to numbness in her left leg and chronic pain. These are the most significant illnesses identified, and that seem to be the underlying causes of both psychological and social problems. No member of her family has been identified to have these conditions. I would consult Julie’s physician to identify any additional diseases that can be linked to her current somatic condition. Julie also experiences fatigue following each 12-hour shift. In addition, I would discuss the likelihood of the interplay of different conditions that may result in her current state. Since biopsychosocial assessment is a three-dimension process, a surgeon, specialist, a physical therapist, a pain medicine specialist, a rehabilitation psychologist, a health psychologist and a psychiatrist should be involved (Corales, 2005). All these people should give their views regarding Julie and her condition and recommend different steps to facilitate her healing process.
The personal history of the patient ranges from her childhood and occurrences that may trigger her current psychological problems. Julie describes the family she grew up in as very strict, and any affection in the family was given to her younger sister, who according to Julie could do no wrong in their parents’ eyes. Julie, on the other hand, felt like she could not do anything right for her parents, no matter how hard she tried. Julie’s family was extremely active in their conservative church while she was growing up, but Julie now describes herself as an atheist. There is a transformation noted from her childhood to her current decisions that attempt to deviate from the ways through which she was brought up. With regard to this form of history, I would apply MMPI-2™ (Minnesota Multiphasic Personality Inventory- 2nd edition ™) tool, used in a more comprehensive evaluation of a patient. It enables linkage of the patient’s background to possible causes of delayed treatment outcome (Weiner, 2003).
Julie has gone through various stressful events ranging from her childhood to her current chronic pain condition. To assess the relation of these events to her current condition, I would use the Battery for Health Improvement 2 (BHI™2) tool. It is applied in the general assessment of patients to identify different stressors in both the past and current status of the patient (Weiner, 2003). Julie has also gone through two marriages, which she describes as disasters. This has discouraged her to date again, which elicits different emotional responses. These are marked by feelings of sadness, loneliness, anxiety, anger and low self-esteem. Using Battery for Health Improvement 2 (BHI™2), I would be able to assess how different psychosocial stressors all through Julie’s life have resulted in poor treatment outcomes.
Mental Health Status/Behavioral Observations
A mental health evaluation of the patient enables to create a general image of their emotional wellbeing. This encompasses their level of remembering, reasoning and thinking, generally outlined as cognitive functioning (Katsounari, 2011). A mental health status assessment is created in order to identify and recognize existing or potential health problems like anorexia nervosa, Alzheimer’s disease, schizophrenia, depression and anxiety. The assessment is also intended to tell apart both physical and mental health problems. This is done through identifying different problems existent either at home, work or school of the patient. Behavior disorders seem to manifest in people with psychological disorders. Krippner, Daniel and Jeannine (2012) outline that different elements should be considered in the evaluation of the patient’s mental status within the biopsychosocial dimensions. Cognitive processes comprise perceptions of others, perceptions of self, perception of control and contingency, beliefs regarding events cause and intellectual functioning.
Emotional processes in the mental health assessment comprise emotional reactivity, trait emotions levels, and mood states (Zaers, Melanie & Ulrike, 2008). On the other hand, overt behavior measure includes standardized task performance, observations of a patient’s conduct in simulated circumstances as well as the natural environment of the patient. Additionally, the different environmental aspects are multi-dimensional. These focus levels include distal, intermediate and distinctions environment and subjective versus perceived or objective environmental features. In Julie’s case, I would ask her questions that focus on her relationship with friends, family and other people. Additionally, she also frequently gets very upset when driving.
Julie describes feeling nervous and angry at how inconsiderate and dangerous other drivers behave, to the extent that she often finds herself yelling and screaming at other cars when she is driving. On two occasions, she has become so upset that she has turned around and gone home rather than complete her trip. This outlines anxiety, which results from different people behaving in ways that she does not see appropriate. She also exhibits feelings of hopelessness, sadness, and possible depression observed through her behavior after a 12-hour night shift. I would apply a PRIME-MD (Primary Care Evaluation for Mental Disorders) to assess the possible mental disorders that may be affecting Julie. The tool considers the observation of affect, reported mood, thought content, thought process, judgment, reasoning, level of insight, style/quality of speech, memory, orientation, level of alertness, attitude, general behavior and general appearance (Katsounari, 2011).
After conducting a psychological assessment of Julie according to the case provided and identifying the appropriate tools for a comprehensive examination, the subsequent step is to perform differential diagnosis. The differential diagnosis involves identification of the vital issues in the case, and categorize them to enable identify the underlying causal factors. After a comprehensive assessment of Julie’s, the symptoms lead into a possibility of PTSD and GAD in the patient. Julie explains that due to her surgery, the results have been chronic back pain and numbness in her left leg. These two results are directly linked to her back pain surgery, which presents as one of the traumatic events that have occurred in Julie’s life. In addition to this, other occurrences can also be perceived as traumatic. The interplay of these occurrences would be favorable for the onset of anxiety, which can then lead to PTSD or GAD (Zayfert & Carolyn, 2008). Arrival at a conclusion on the two disorders was made following evaluation of the symptoms of other anxiety disorders. They include panic disorder, Obsessive-compulsive disorder, social phobia, and specific (simple) phobia.
Post-traumatic stress disorder (PTSD) presents as a psychological disease in the categorization of anxiety disorders. Conversely, it develops due to a terribly alarming, critical or otherwise highly precarious experience (Corales, 2005). People affected by this disease have a predisposition of evading some people, places and elements that trigger memory of the traumatic events. They are also exquisitely susceptible to ordinary life experiences also perceived as hyperarousal. The defects affect all sexes and genders if there has been an occurrence of one or series of traumatic events. These events include rape and sexual abuse, war, physical domestic violence or witnessing a violent event. People who experience PTSD may be familiar with intrusive reminiscences of the traumatic incident, feel less psychologically responsive than prior to the occurrence and feel augmented irritability, anger and anxiety (Borkovec & Ruscio, 2001).
Many people who have anxiety disorders undergo physical symptoms linked to anxiety and consequently visit the healthcare providers. Regardless of the high predominance rates of the disorders, there are usually the undertreated and under-recognized medical problems. The DSM-IV-TR categorizes the disorders into; Anxiety caused by a clinical condition; Anxiety disorders due to substance-induction; Panic disorder; acute stress disorder; Generalized anxiety disorder; Posttraumatic Stress disorder (PTSD); Social phobia (Social anxiety disorder); Obsessive-compulsive disorder (OCD), specific phobia and adjustment disorder. DSM-IV-TR has classified the specific phobias into the different types (Gum, King-Kallimanis & Kohn, 2009). Anxiety disorders may be embodied by contact with bio-psychosocial factors. These may include genetic susceptibility and trauma or stress to create medically important syndromes
Anxiety disorders that have been mentioned above belong to Axis I of the DSM-IV-TR. While there are various disorders that fall under Axis I, PTSD and GAD disorder present as the most likely disorders being suffered by Julie. As she explained, Julie frequently gets upset especially when driving. The emotions of anger and nervousness are directed at doctors who drive dangerously and are inconsiderate to other drivers. In some cases, she has become upset to the extent of turning around and going back home. While PTSD mostly emphasizes on the patient’s earlier traumatic experiences, GAD is a condition in which the patient usually complains of either anxiety or bitterness at times (Börjesson-Hansson, Waem & Östling, 2011). This occurs even when they have previously consulted physicians. The patients become easily jumpy and startled, and sudden movements or loud noises can be particularly alarming or irritating to them. Therefore, the patient may have sleepless nights due to inability to relax. Without treatment interventions, the patient may develop chronic GAD (Byers, Yaffe & Covinsky, 2010).
However the following factors are linked with augmented probability of developing an anxiety disorder during the old age; being divorced, single or separated (in comparison to being married); having numerous chronic medical conditions; being female; stressful life events; neuroticism; lower education; bodily restrictions in daily activities; impaired subjective health; and unpleasant events in childhood (Börjesson-Hansson, Waem & Östling, 2011). In Axis I, Julie also has sleeping disorders marked by a lot of sleeping. Sleep disorders entail chronic disturbance in normal patterns of sleep. In Julie’s case, she is suffering from hypersomnia, which falls under Dyssomnia. It is a condition characterized by too much sleeping.
In Axis I, Julie also presents somatoform disorders. This includes frequent complaints regarding medical concerns or physical symptoms that have not been completely tackled from a medical perspective. Julie’s chronic back pain falls under this category. The last category suffered by Julie in Axis I are other conditions that receive clinical attention focus. These are problems or conditions, which require the patient to seek professional help. They include relational problems, psychological factors influencing medical condition and others such as occupational, religious, academic, bereavement and problems relating to phase of life. Axis II disorders are personality disorders. According to Julie’s behavior, she exhibits fearful or anxious behavior, which is avoidant and obsessive-compulsive in nature. She tends to avoid facing problems that involve other people. On the other hand, she exhibits anxiety and anger in cases where people do not perform tasks her way.
In Axis IV of the DSM-IV-TR, Julie’s problems belong to four categories. The first problem category is problems emerging from the adult primary support group. In this category, Julie has gone through divorce and tensions with her two previous husbands. In the category of parent-child with primary support group, Julie experienced partial neglect as a child when compared to the treatment given to her younger sister. On the occupational problems category, Julie faces job dissatisfaction, with chronic back pain and left leg numbness being the major cause of it. In the category for problems associated to her social environment, Julie lives alone, which is a form of social isolation. This is confirmed when she outlines that she feels sad and lonely in her current condition.
In Axis V, this is the Global Assessment of Functioning Scale, Julie’s level of symptoms rates at 41-50. This is characterized by serious symptoms available or any extreme impairment in school, occupational and social functioning. It is essential to ensure that the medical and psychological history of the patient is thoroughly evaluated as a therapist. This ensures that accurate diagnosis is made. This will ensure that there is accuracy in conducting treatment interventions that are appropriate enough to ensure that there are improved outcomes.
Diagnosis for Julie
Axis I – 300.02 Generalized Anxiety Disorder, Post-traumatic Stress Disorder, Pain disorders, Hypersomnia, Relational problems, Psychological factors influencing medical condition and other conditions, NOS
Axis II – 301.9 Personality Disorder, NOS
Axis IV– problems with primary support group (adult), problems with primary support group (parent-child), problems related to the social environment, occupational problems
Axis V- GAF- 55 last known GAF-unknown
Focusing on theoretical conceptualization of Julie’s case can help to identify different issues that are linked together to cause the current condition (Byers, Yaffe & Covinsky, 2010). In addition, they can help in her biopsychosocial assessment. This is the best method through which her treatment plan can be based on. The major element that can help in a more comprehensive understanding is the relationship between chronic pain, PTSD, and GAD.
Pain presents as a perceptual, subjective and complex occurrence with several facets. They include personal meaning, impact, time course, quality, and intensity (Byers, YafFe & Covinsky, 2010). These are distinctively experienced by every individual. Therefore, they can only be evaluated indirectly. Pain occurs as a subjective phenomenon. It is not possible to quantify it objectively. As a result, patient pain assessment relies on their overt communication, including behavioral and verbal. Given the complexity of the pain, a person ought to evaluate the sensory (somatic) elements but also family member responses, resources, coping efforts, attitudes, moods and the effect the pain has had on their daily lives. This impact can now be measured by the occurrence of disorders that may be indirectly caused by the occurrence of pain (Ayers, Andrew & Helen, 2006).
Therefore, the biological, psychological and social effects of pain embrace the events that occur before and after the phenomenon. The response of the individual towards different factors and occurrences in their childhood, adulthood can help to discern the underlying functions of the pain in the onset of different disorders. Patients who experience chronic pain can undergo treatment in a diversity of settings. For instance, Julie’s pain keeps on reoccurring, which translates to frequent visits to the hospital to seek professional help. However, since this process has not yet yielded the desired results changing her treatment method into a more interdisciplinary setting may be necessary (Byers, Yaffe & Covinsky, 2010). This would be necessary since practices such as holistic caring of the patient given that the pain is chronic can help in ensuring that the treatment touches on the three dimensions.
Krippner, Daniel and Jeannine (2012) outline that various rationalizations of PTSD focus principally on the process by which traumatic incidents influence the mind. Theorists speculate upon experiencing devastating trauma, the mind becomes incapable of processing feelings and information in a normal manner. The characterization reveals that the causal traumatic event seems to take on an individual form that intrudes on the perception causing distress. Julie developed a chronic pain following a back surgery. The relationship of this to PSTD is that different traumatic occurrences in life trigger the disorder (Fletcher, Mark & David, 2010). In this case, her childhood was marked with neglect from her parents, which affected her self-esteem negatively. Additionally, life events such as her two marriages that resulted to divorce played a big role in affecting her self-esteem too. Her perception towards life does not portray enthusiasm. Therefore, the result of PTSD is largely affiliated to chronic pain and these experiences.
Pre-traumatic psychological causes such as low self-worth may exacerbate this process. For instance, in the occurrence of divorce, physical beating or rape, there may be reinforcement of low self-worth with the person feeling that the reason for this traumatic incident is their worthlessness. In different cultures, there are particular beliefs that may play a role in the development or aggravation of PTSD (Krippner, Daniel & Jeannine 2012). For example, in some cultures there is a perception that demonstrates a woman as ‘dirty’ due to the experience of rape or divorce. In this case, this acts as a post-traumatic response by the community or family towards the patient after the occurrence of the traumatic event. The self may also act as a causal factor towards PTSD where a resulting physical discomfort may be a constant rejoinder of the trauma. It also plays a principal responsibility in influencing the persistence of the symptoms. Chronic pain may be used as a rejoinder by Julie, reminding her of the traumatic events that have occurred. Researchers hypothesize that only subsequent to fruitful reprocessing of the distressing incidents do PTSD symptoms reduce.
Katsounari (2011) depicts that neurological elucidations also demonstrate how the mind and brain are significant in PTSD development. Current studies accentuate on two brain compositions namely hippocampus and amygdala. The amygdala is responsible for how people gain knowledge about fear. This composite is hyperactive in people with PTSD. The characterization of amygdala is as a false apprehension. On the other hand, hippocampus takes the important responsibility in the construction of memory. In people who experience PTSD, there is proof of a loss of quantity in this composite perhaps explaining some deficits in memory and other PTSD symptoms.
Another explanation of the PTSD causes is the neurochemicals that take part in development of PTSD. Research that focuses on this factor reveals that hypothalamic-pituitary-adrenal (HPA); a hormonal coordination axis becomes interrupted in PSTD (Garske, 2011). Usually, this coordination occurs in normal stress responses and its interruption in PTSD appears to be also a false apprehension. Conversely, suggestions from researchers are that HPA coordination dysfunction leads to hippocampal harm in people experiencing PTSD.
General Anxiety Disorder (GAD)
GAD is a chronic disorder characterized by symptoms waning and waxing over years. It is usually not clear whether this may occur as an episodic illness typified by long intervals devoid of symptoms. GAD is also recognized as “chronic anxiety neurosis” and attributed through free-floating anxiety, which is chronic in nature. In some cases, it is accompanied by diaphoresis, tachycardia and tremor (Garske, 2011). This disorder may occur in childhood or adolescence years. Nevertheless, it is capable of also appearing during the early years of an adult. Symptoms develop insidiously and gradually. Complaints from the patient exhibit both anxiety and bitterness. This is observed with Julie’s inability to cope with the behavior of other people. She believes that these people should follow certain guidelines in order to perform tasks the right way. The disorder requires a clear defined intervention method that can help in getting rid of anxiety onsets. The underlying element in the treatment of chronic pain, PTSD and GAD involves identification of different events that are responsible for triggering the onset of anxiety (Mowery, 2011). Through this, a clear defined treatment plan can be created for Julie.
Cognitive-Behavioral Therapy (CBT)
The aim of CBT is to recover control of responses to stimuli and stress, hence decreasing the helplessness feeling that frequently comes with anxiety disorders. CBT acts on the theory that the patient’s thoughts that elicit and sustain anxiety can be identified and changed through the application of different methods that transform behavioral reactions (Scott, 2011). These methods also get rid of anxiety reaction. Medication and CBT presents as effective individually. However, numerous research studies demonstrate that a combination made of medication and CBT is the best strategy for anxiety disorder treatment. However, the combination is best suited when treating adolescents and children (Zayfert & Carolyn, 2008). Evidence clearly shows the benefits for combination approach for treating children with obsessive compulsory disorders, social phobia, separation anxiety and GAD.
Studies advocate that there are positive benefits attained from CBT in patients who possess extra conditions for instance alcohol dependency, another anxiety disorder or depression. However, in these cases there is a tendency of the treatment to take a long period before it shows the positive outcomes. Nevertheless, the therapy can be offered along medication treatment often. CBT is divided into basic cognitive therapy approaches, systematic desensitization, modeling treatment and anxiety management therapy (Scott, 2011).
Basic Cognitive Therapy Approaches
This form of treatment mainly takes approximately 12-20 weeks. In the treatment, the necessary cognitive therapy goal is to comprehend the realities brought about by situations that provoke anxiety. In addition, there is a reaction to reality with novel actions founded on reasonable anticipations (Börjesson-Hansson, Waem & Östling, 2011). Initially, it is important for Julie to learn how to identify anxious thoughts and reactions as they take place. One method of achieving this is through maintaining a daily journal that identifies the anxiety attacks occurrences and any events or thoughts linked to them. These automatic and entrenched thoughts and reactions must be understood and challenged. The approach of this method involves play back and recording of the anxious thoughts or acts of Julie. Through this method, she can be over exposed to them leading to a decrease in their impacts.
One effective treatment approach for patients who have been diagnosed with GAD marks their intolerance of insecurity and aids them create approaches of coping with this problem (Gatchel, 2004). Patients are mainly provided homework assignments of behavior to assist them alter their existent problematic behavior. As the patient carries out the assignment, they view any unrealistic thoughts and fears elicited through that form of an occurrence. As the patient keeps on performing the self-observation, they start to understand the underlying false assumptions in anxiety. During this stage, the patient can start replacing novel coping ways with the feared situations and objects.
This presents as a detailed approach that collapses the connection between the anxiety- aggravating stimulus as well as the anxiety reaction (Gatchel, 2004). This approach needs the patient to confront the feared object progressively. In order to accomplish this, there are three fundamental components of the procedure.
- Relaxation training
- A record comprised through the patient that precedes anxiety-inducing circumstances through a fear degree
- The desensitization process itself, tackling each item present on the list, beginning with the event that shows the most harmless stress (Blanchard, et al., 2003)
This treatment approach is particularly efficient in PTSD, social phobias and agoraphobia.
Exposure and Response approach
This is aimed at eliciting anxiety while allowing the patient to go through the feared situation or object frequently, either using visualization and/or imagination. This treatment method applies the most fearful motivation first. This is different from the process of desensitization since it fails to include a gradual approach or relaxation to the anxiety source (Blanchard, et al., 2003). Exposure treatments are generally identified either as graduated or flooding exposure:
- Flooding usually exposes the patient to the stimulus that produces anxiety for a period of approximately 1-2 hours.
- With relevance to the approach, graduated exposure offers the patient a larger control degree over the frequency and length of exposures.
In both circumstances, the Julie can attain an anxiety experience recurrently until the provoking circumstance finally loses its impact. Merging standard cognitive therapy with exposure may be predominantly beneficial (Zaers, Melanie & Ulrike, 2008). This advance has assisted some patients who belong in most categories of anxiety disorder, for instance PTSD.
Anxiety Management Therapy
This form of treatment approach of CBT that can be applied as a substitute for CBT intended for GAD (Zaers, Melanie & Ulrike, 2008). The approach includes subjection to stimuli that provokes anxiety, relaxation training, and patient education but does not comprise cognitive retraining exercises. CBT will work effectively on the treatment of Julie’s condition likelihood. This is because; it has been ranked as a treatment approach that ensures the comprehensive assessment and treatment of Julie according to the symptoms she is exhibiting. In relevance to this, since the main concern lies with PTSD, and GAD caused by anxiety, CBT has been recognized as the best treatment approach for these disorders. A combination of the approach and medication when tackling GAD is vital.
In order to create a systematic treatment plan for Julie, there needs to be addressing of both GAD and PTSD. PTSD treatment generally starts with a specified evaluation and the creation of treatment criteria that satisfy the distinctive needs of Julie. The treatment plan is based on the CBT concept in order to ensure that there is harmonization of the both PTSD and GAD. Generally, PTSD and GAD treatment is introduced only following the safe removal of the survivor from a crisis circumstance (Krippner, Daniel & Jeannine, 2012). The crisis involves homelessness, abuse, community or domestic violence. In this situation, Julie is still undergoing a continuous trauma exposure, which involves her chronic back pain and anxiety. Therefore, it is significant to tackle these forms of crisis issues as an initiation of the first treatment phase. The first phase embraces educating the patients as well as their families regarding how PTSD and GAD are acquired, their effects on loved ones and survivors and other issues related to the disorders.
It is vital to note that PTSD and GAD is a medically identified anxiety disorder experienced by normal individuals undergoing severe stressful circumstances. This ensures that the treatment given is efficient (Katsounari, 2011). Subjection to the occurrence using guided imagery will permit Julie to go through the event again but in a controlled and safe environment. This will occur while I am carefully monitoring her beliefs and reactions in relation to the occurrence. One dimension of the initial PSTD and GAD treatment phase is to ensure that Julie herself examines and determine strong feelings like guilt, shame and anger. Another phase in the treatment plan is to teach Julie to deal with post-traumatic feelings, reactions, reminders and memories without being emotionally numb or overwhelmed (Krippner, Daniel & Jeannine, 2012).
During treatment of PSTD and GAD, health professionals prefer to combine psychotherapies with medication use. This is because; medications help in the relieving symptoms, such as feelings and flashbacks of original trauma. Antidepressants include selective serotonin reuptake inhibitors (SSRI) which comprise of sertraline, paroxetine and fluoxetine. They decrease panic, depression and anxiety. Atypical antipsychotics are the most widespread alternative medications to antidepressants. They are inclusive of quetiapine, risperidone and olanzapine. These medicines are the most practical for people who have dissociations, intense paranoia, agitation, or brief psychotic reactions. Other less directly efficient medications for handling PSTD comprise of mood stabilizers such as divalproex sodium, Gabitril and Lamictal (Fletcher, Mark & David, 2010).
Effectiveness of Working with Julie’s Background
With the application of a treatment plan based on CBT for Julie, it is clear that since she has a problem dealing with her anxiety, she can be able to understand all the causes and how to deal with them. In addition, the treatment plan will work if Julie is helped to identify the use of a holistic and interdisciplinary care to enable a comprehensive therapy (Hillerbrand & Stone, 1986). This would ensure that the recurrent episodes of chronic back pain and leg numbness are treated along with anxiety.
Limitations of Working with Julie’s Background
While the treatment plan is intended to help resolve all the health concerns experienced by Julie, the limitations of the plan are her religious background. A holistic and interdisciplinary assessment needs to incorporate the religious background of the patient. With respect to this, there should be communication with the patient on the most appropriate method of dealing with her sentiments towards the church and her status of an atheist.
Interpersonal Effectiveness – Self-Awareness
In a therapy background, transference is presented as re-bearing of the feelings of the client from an important person to a therapist (Arundale, & Bellman, 2011). Hence, manifestation of transference is as an erotic appeal towards a therapist although it can be identified in many other modes like extreme dependence, parentification, mistrust, hatred, and rage. It also involves placing the acting therapist in a guru or god-like status. When Freud first observed transference in psychological assessment, he perceived it as a hindrance to success of treatment. However, he learnt that transference evaluation was the work to be accomplished (Arundale, & Bellman, 2011).
The psychodynamic psychotherapy focus is largely the client and therapist identifying the transference association and evaluation the relationship meaning. As Julie’s therapist, I realize that the transference association takes place an unconscious extent. Julie has a childhood memory that is embodied by neglect and low self-esteem. Due to this, I will apply the transference relationship in exploring these relations and ensuring that these issues are resolved. It would be significant to begin treatment after considering the different occurrences that took place from Julie’s childhood.
On the other hand, countertransference is outlined as a rebearing of the feelings of the therapist towards those of the client (Wiener, 2009). In general, it translates as an emotional entanglement elicited by a therapist to the client. The attunement of the therapist to his individual countertransference is almost as crucial as his transference understanding. This does not only assist the therapist to moderate their emotions that arise in the therapeutic association, but also provides valuable insight to the therapist. The insight is regarding the form of emotions that the client tries to provoke in them. Once there is identification, the therapist can inquire what form of feelings exists toward the therapist (Wiener, 2009). In addition, the therapist evaluates the client’s feelings and the means through which they associate to unconscious fears, desires and motivations. In Julie’s case, I will work towards ensuring that I understand the feelings and thoughts that might be directed from her to me.
Through understanding these feelings, I can find ways through which I can engage her to recognize the source and intention of the client. I will work towards identifying ways to ensure that the motivation of Julie to continue with her therapy is sustained. This will enable me to evaluate her closely in order to identify the underlying issues that may influence her quick or slow recovery.
While providing my services as a therapist, I have encountered numerous patients who find it relatively difficult to reveal their problems to a counselor due to confidentiality issues. Such clients need constant assurance that their problems will not be shared to any third party without their consent. In this case, “without assurance of confidentiality, clients would be unlikely to self-disclose the thoughts and feelings so essential to therapeutic change” (Guindon, 2010, p. 77). According to Hawtin (2000), confidentiality is the premise that whatever a patient says to the counselor will stay with the counselor and at no point will the information be discussed with other individuals whatsoever. It plays a significant role in convincing patients to undergo the counseling process.
In the process of dealing with Julie’s case, doctor-patient confidentiality will present a possible ethical dilemma. In this case, I strongly feel that other parties need to be involved in the process of treating Julie. Since the surgery, Julie finds working a 12 hour shift to be especially exhausting. Equally, she has been on antidepressant medication on and off for most of her life. She had taken Wellbutrin for a number of years, but she reports it stopped working about two years ago. She has recently begun taking Celexa. In this vein, Julie’s case requires more than counseling. A doctor has to be involved to establish the causes of Julie’s exhaustion after a 12 hour shift. Equally, the doctor will play a significant role in providing a medical recommendation as her body has developed resistance to Wellbutrin and she is now taking Celexa.
Before involving the doctor as a third party in Julie’s case, Julie must be made aware of the possible confidentiality issues that will arise. Bond (2000) points out that in extreme cases when patients need medical attention other than counseling, client information may be shared with other parties responsible for providing the required medical attention. However, the nature of the medical attention required plays a significant role in determining whether the patient’s identity will be protected. In minor cases, the patient’s identity is protected, or he/she is advised to seek medical attention from another party that is not involved in the counseling process. The acute nature of Julie’s case calls for urgent medical attention; in this case, the doctor will be provided access to Julie’s information to ensure that he/she is fully aware of Julie’s medical problems. Nonetheless, this information will be provided to the third party with Julie’s consent.
On overall, Julie’s case has to be treated with absolute confidentiality and high level of counseling professionalism due to the private and medical nature of the information provided by Julie. It calls for the application of an ethical decision-making model to provide guidance towards an ethical resolution. Cohen and Cohen (1999) observe that the available ethical decision-making models in counseling are indispensable to counselors facing ethical challenges in the counseling process. This is in line with the fact that the decisions and advice provided by the counselor to the patient play an integral role in guiding the patient towards the process of recovery. In this case, I will utilize a practice based ethical decision making model by Welfel (1998) as a step-by-step procedure of promoting reduced emotional impact on my ability to think rationally during the counseling process. This model will also ensure that my guidance complies with ACA Ethical Codes of Conduct. Finally, the model will provide a basis for support in case I have to testify in a civil or criminal action.
The first step will entail the development of ethical sensitivity to the moral dimensions of counseling. In counseling, the basis of making an ethical decision lies on the ability of the counselor to recognize an ethical dilemma when it occurs. According to Welfel (2010), many counselors are inadequate in the identification of ethical dilemmas. In this case, ethical sensitivity is a highly significant skill that enables counselors to identify an ethical dilemma, as opposed to assuming that ethical dilemmas will be identified when they happen. Without ethical sensitivity, I would risk arriving at an unethical conclusion in Julie’s case hence reducing my efficiency in helping Julie to recover fully. In this case, I will review how my personal principles and worldviews will affect the decision making process.
Having all these considerations in mind, I clearly understand that Julie’s case puts my ethical sensitivity into test. I clearly understand what Julie has been going through since the surgery. Equally, I understand all the challenges that Julie has faced in her upbringing and in her two marriages. As such, I am aware that the process of counseling and making effective decisions will encounter ethical dilemmas especially when dealing with confidentiality and sharing of information with third parties.
The second step in this decision making process will involve the definition of the existing ethical dilemmas and different options that can be used to promote efficiency. After having been already sensitive to the dilemma at hand, the counselor is expected to identify and organize all the available information about the case particularly the social and the cultural dimensions of the case (Welfel, 2010). The central dilemma in this case is whether or not I need to disclose Julie’s exhaustion after work and the use of antidepressants to a doctor so that Julie can get medical help. I will ensure that I have all the necessary information that I am supposed to have about Julie. If I realize that somehow some information is missing, I will improvise effective mechanisms of retrieving such information from Julie. In line with the arguments of Welfel (1998), my reasoning will be guided by the available facts about Julie to ensure that I make an effective decision that will help Julie to recuperate efficiently.
In line with the views of Arredondo et al. (1996), I will consider my experience in the counseling profession and my unlimited exposure to diversity as significant information when dealing with Julie’s case. Being a Christian, my perceptions and worldviews on religion would affect negatively on such a case because Julie regards herself as an atheist. However, I will consider my experience in helping out atheists to ensure that I provide informed and effective guidelines towards Julie’s recuperation. Julie is an African American woman aged 72 years, and I am a male counselor; in this case, I will examine my multicultural counseling competencies to identify the skills, attitudes, and knowledge whose application will be significant in helping Julie.
According to Garcia et al. (2003), a stakeholder is an individual or a group of individuals connected directly to the patient and who might be harmed or helped by the actions of the counselor when dealing with a case. With this in mind, I will consider the impact of my response to Julie’s situation to other individuals related to Julie; these individuals are the stakeholders. Julie is a driver who encounters other drivers and pedestrians in the course of driving. Equally, she is a semi-retired psychiatric nurse who interacts with patients and fellow colleagues at work. She also has three children with whom she has good relationships. These individuals are Julie’s stakeholders. I have to ensure that my decisions have positive impacts on them.
In the third step, I will consider the central issues of the dilemma and the available options. The central dilemma in this case is whether I need to disclose Julie’s exhaustion after work and the use of antidepressants to a doctor so that Julie can get medical help. The main issue contributing to this dilemma is the question of whether or not there are legal requirements to disclose such information to a medical practitioner so that Julie can get medical help. On this note, Hillbrand and Stone (1986) point out that a counselor ought to consider all the available options when dealing with the arising personal, professional, and legal dilemmas in the counseling process. In this case, my possibilities include; maintaining confidentiality and allowing Julie to decide what she intends to do with her medical problems, informing a medical practitioner about Julie’s problems while maintaining anonymity, advising Julie to share her problems with a doctor, sharing Julie’s problems with a doctor without anonymity, or waiting for more sessions to unearth more information and advice Julie further.
Step four will entail making references to the existing professional standards, laws and regulations. Welfel (2010) argues out that reference to the existing professional standards narrows down a counselor’s options enabling the counselor to be more efficient when dealing with the patient. In this case, different professional codes (ACA, 2005; AMHCA, 2000; APA, 2002) have it that my primary responsibility is to assist Julie to recover fully. This responsibility is based on patient-doctor trust and is developed through effective and confidential working relationships. These professional regulations will guide me in establishing whether to break confidentiality and share Julie’s information to a doctor so that she can get the required medical help.
In step five, I will consult with the existing professional literature on the prevailing ethical dilemma to guide my actions as I ponder on the way forward. The existing scholarly literature provides detailed answers on doctor-patient confidentiality, cultural diversity in counseling, and conflicts between the professional ethics and laws (Jain & Roberts, 2009; Nagy, 2000; Donner et al., 2008). My familiarity with the existing scholarly literature will guide my actions and will provide a basis for providing moral and legal explanation towards my actions.
In step six, I will ensure the application of ethical principles to the prevailing ethical dilemma. In this case, the ethical and moral principles developed by Kitchener (1984) will guide the application of the necessary ethical principles to the prevailing ethical dilemma. As noted by Pipes, Belvins and Kluck (2008), these ethical and moral principles include; fidelity, justice, autonomy, beneficence, and non-maleficence. They provide the counselors with an efficient framework of regulating their relationships with their parents. In line with respect for autonomy, I will respect Julie’s freedom and choices, non-maleficence will enable me not to harm Julie, beneficence will enable me to do well as a counselor, justice will guide me in treating Julie fairly, and fidelity will enable me to be faithful and honest to Julie in the course of the counseling process.
Step 7 will provide me with the opportunity to consult my supervisor and senior colleagues on the prevailing ethical dilemma. In this step, Welfel (2010) points out that a counselor must maintain patient confidentiality when consulting. As such, I will consult in a manner that maintains confidentiality. In line with ACA Code (2005), consultation provides a counselor with an objective perspective. In this case, consultation will alleviate the feeling of isolation. I will identify colleagues who are willing to assist in solving the existing dilemma. I will weigh the nature of information received after consultations to ensure that I utilize the most appropriate information in the process of providing Julie with the most efficient counsel. According to Welfel (2010), this step can be employed in any stage of the model as it provides the counselor with insights on the way forward.
In step eight, I will make deliberations based on the available information and decide on the best way to proceed. In this case, I will consider all the moral principles, virtue ethics, and personal values that may affect the process of decision-making. This step will be challenging since I will have to review all the available information alone; nonetheless, I will employ my experience in counseling to guide me in taking the most appropriate course of action. In step nine, I will inform my supervisor, implement and document the actions. This step will call upon my “ethical courage” (Welfel, 2010) in implementing my decision regardless of the challenges or resistance that will be on my way. I will then proceed with the documentation of my decision, how I implemented it, the conversations I had with Julie, my conversations with my supervisor and colleagues, the justification for my decision and follow up notes for future reference. Step ten will be the last step where I will reflect on the experience. I will review my decision and establish other different ways of handling the situation. This will provide me with the required knowledge to handle future cases.
In counseling, it is essential to understand other cultures. In this case, a culturally competent counselor is one who has cultural skills, cultural knowledge and is culturally aware of the existence of different belief systems. When handling a client from a different cultural background, the effectiveness of the counselor is determined by his/her awareness of the client’s way of life. Equally, it is of great significance that the counselor understands his/her personal bias and how it may affect his/her relationship with the client during the counseling period (Bond, 2000). Dobson (2009) explains that honest appraisal of their own biases and blind spots must be made by therapists who work with people who are different from themselves. Though Julie and I are both Americans, we belong to different cultural backgrounds; Julie is an African American/black American while I am a white American. Understanding the cultural background of black Americans will eliminate cultural barriers hence playing a significant role in promoting my efficiency while providing counseling services. According to Adams (1995), culture defines how individuals view the world; as such, cultural differences must be addressed efficiently to promote effective counseling. Equally, counselors must have multi-cultural knowledge and skills in addition to extensive training on cultural values to harness competency in the process of dealing with individuals from other cultures different from that of the counselor. They should also understand clearly that the attainment of cultural competence is a process that can never be completed because culture is a complex and dynamic system (Betancourt & Lopez, 1993).
Self-awareness has been labeled as the first step towards being a culturally competent counselor. Before embarking on the process of understanding others, one must sharpen his/her self-understanding. In this vein, interpersonal and intrapersonal dynamics are addressed as significant components in the understanding of one’s values, opinions, beliefs, and attitudes. When a counselor understands his/her thoughts and feelings, he/she is in a better position to understand the perceptions, viewpoints, judgments and other stereotypical viewpoints that will emerge in the counseling process. As an important step towards attaining cultural competence, self-understanding enables the counselor to evaluate personal perceptions that might interfere with his/her efficiency in the process of counseling a client (Adams, 1995). In this case, I clearly understand my values, perceptions, and worldviews on different societal issues. This understanding will help me in controlling my personal opinion that might interfere with my efficiency in the process of providing effective counseling service to Julie. I understand that I share different perceptions, value and worldviews with Julie; this understanding will be ultimate in the elimination of prejudices and judgmental ideas that may affect the counseling process.
Awareness of one’s own culture also plays a significant role in promoting cultural competence in counseling. This is in line with the argument that counselors bring cultural baggage to the counseling situation. Cultural baggage makes a counselor take some things for granted or have expectations on how the client should behave. In this case, any behavior from the client that falls behind the expectations of the counselor is seen as an abnormality. However, awareness of one’s culture enables a counselor to understand and appreciate cultural diversity hence free him/herself from the stereotypical ideas and expectations that facilitate cultural baggage in the counseling process (Adams, 1995). Being a white American, my cultural ascription is very different from that of Julie. Understanding the values and the way of life that I subscribe to will be particularly vital in helping me to embrace cultural diversity and hence overcome stereotypical concepts that may interfere with effective counseling.
According to Betancourt and Lopez (1993), over-generalizing values learnt about a specific culture as applicable to all members of the culture is the greatest pitfall of the novice counselor. Cultural group membership does not take away individualism and uniqueness; as such, counselors ought to consider their clients as unique individuals and as members of their particular cultural groups. There different cultural values that are identified with the African American people, but this do not imply that all the African Americans are similar. They are distinct in the fact that they have personal values that guide their interactions. This knowledge will help me acquire a deeper understanding of Julie’s problems hence provide wise counsel to Julie as a unique African American woman.
To ensure that cultural differences existing between Julie and me, I will apply the trans-cultural integrative model (TIM) as discussed by Garcia et al. (2008). This trans-cultural model “draws primarily from the integrated model of ethical decision making developed by Tarvydas (1998), but added significant aspects that reflect multicultural theory” (p. 21). This model combines both the principle and the virtue ethics. It defines an ethical dilemma “as a conflict involving ethical principles that are in opposition to each other, such as when client autonomy conflicts with client non-maleficence” (p. 21). According to Garcia et al. (2008), this model has four significant steps that promote effective counseling in a multi-cultural society.
Using this model, the first step will entail awareness and fact-finding. On this note, Garcia et al. (2008) point out that enhancing sensitivity and awareness entails many factors. It is not only based on becoming aware of the ethical component of a dilemma but also the effect of a dilemma on the different stakeholders involved. The cultural values and identity together with the gender role socialization of the counselor play a significant role in determining the degree to which the counselor perceives a situation as a dilemma. In this case, differences in cultural values between two counselors may lead to differences in the perception of a situation as a dilemma. Equally, differences in gender role socialization between counselors may also lead to differences in the perception of a situation as a dilemma (Sue & Sue, 2003).
Sue and Sue (2003) further opine that the gender identity perspective and the ethnic identity perspective lead to differences in perceiving a situation as a dilemma. Equally, the culture of the client may bring out particular reactions in the counselor based on the existing differences between the counselor’s and the client’s culture. In this step, I will ensure that I clearly understand my cultural values and Julie’s cultural values and embrace the existing differences. This will help in eliminating any expectations that I may have, and those that might affect the entire counseling process.
The second step of this model entails the establishment of appropriate courses of action and the best ethical decision. This step will be guided by the cultural information collected about the client in the first step (Garcia et al., 2008). I will pursue the following procedures in this step; critically analyze all the cultural information I will have gathered about Julie in step one, analyze the existing laws and regulations particularly against discrimination, ensure that the considered course of action is in line with the views and perceptions of the relevant stakeholders, evaluate the pros and cons of the opposing courses of action in line with the cultural perspective of Julie, seek for the views of other cultural experts, and decide on the most appropriate course of action. In this step, Cottone’s (2001) three step interpersonal process can also be applied in cases where reaching on a decision is quite challenging. The process entails; arbitrating, consensus seeking, and negotiating. Nonetheless, this model is not applicable in Julie’s case since I will be the only counselor who will be making decisions on the psychological wellbeing of Julie.
The third step involves the identification of the competing non-moral values that may hinder successful implementation of the selected course of action. In this case, I will identify the most suitable courses of action that will be compatible with Julie’s cultural values. This will ensure that Julie’s culture does not challenge the implementation of the selected course of action. The fourth and the last step involve the implementation, documentation, and evaluation of the plan of action. In line with cultural values, Garcia et al. (2008) note that this step involves securing clients’ culturally relevant resources. It also involves developing counter-measures for the identified potential contextual barriers in other steps. In this step, I will empower Julie and the involved stakeholders (including her patients and her children) with mechanisms of dealing with emerging prejudices and stereotypes to ensure that she is strong in the process of recovering from her psychological problem.
In the urban areas, counseling services have continued to be significant in enabling the urban dwellers overcome some of the major challenges faced in urban areas including; drug abuse, crime, sexually transmitted diseases, lack of employment, high costs of living and so forth. Particularly, such challenges are common to low-income urban dwellers because the high costs of living in urban areas and their low income force them to inhabit urban slums and other areas of sub-standard housing where the cost of living is relatively cheaper. Such areas are characterized by lack of basic amenities, overcrowding, and other similar characteristics that negatively affect the human wellbeing. In line with this argument, counseling services play a significant role in enabling low-income urban dwellers to deal with the pressures of urban life effectively.
The aim of this study is to establish the usefulness of counseling services for low-income urban dwellers. Particularly, this study examines the level of benefits attained from counseling by low-income urban dwellers.
Overview and challenges of low-income urban dwellers
In the last three decades of the 20th century, low-income urban communities in large urban areas of the United States have live in deteriorating social conditions characterized by; high poverty and unemployment rates, high prevalence of diseases and violence, drug abuse and drug trafficking, deteriorating housing among others (Cohen & Cohen, 1999). The low-income urban dwellers in the US are from a variety of racial and ethnic backgrounds; majority of them are poor immigrants who are in the US illegally. This group of individuals has been identified with the worst health of any group of individuals in the US and has the fastest growing rates of HIV infection in the United States (AMHCA, 2000).
Being illegal immigrants, many fail to seek medical attention for fear of deportation. This results to high prevalence of acute diseases in low-income urban areas where they live. Equally, their racial and ethnic backgrounds present language and cultural barriers that challenge culturally incompetent outsiders from providing the much-needed medical assistance (AMHCA, 2000). To overcome such challenges in low-income urban areas, counselors have a huge responsibility of providing their much-required services to these individuals to ensure that they conform to the societal expectations. Equally, with the existing cultural obstacles, culturally competent counselors are the most appropriate professionals to help the low-income urban dwellers because they understand the precautions required while providing counseling services to individuals from diverse cultural backgrounds.
Benefits of counseling to low income urban dwellers
Low-income urban areas are characterized by high crime prevalence. As a result, many individuals living in these areas are in constant fear of the social evils that they are exposed to. Counseling services provide the victims of crime with an opportunity to recover from crime-related trauma that affects them in their day-to-day activities. It is during the counseling sessions that these victims identify the criminals responsible for these atrocities hence aiding the authorities in prosecuting these criminals. This eventually leads to justice and reduced crime in low-income urban areas. This is because many criminals are locked up in jail while others are undergoing transformation through counseling.
Equally, the low-income urban areas are identified with drug trafficking and abuse. Counseling services thus play a significant role in rehabilitating drug addicts to become reformed individuals in the society. Due to the existing doctor-patient confidentiality in counseling, majority of low-income urban dwellers reveal confidential information to counselors and due to the legal dilemma surrounding the nature of such cases, the information is used to prosecute criminals hence reducing the prevalence of crime in these areas. Overall, many low-income urban dwellers are illegal immigrants who fear deportation to their countries of origin. In this case, counseling provides them with the much required safety and confidentiality in the process of getting professional help.
Research approach and philosophy
This study will employ an inductive approach in establishing the usefulness of counseling services for low-income urban dwellers and the level of benefits attained from counseling by low-income urban dwellers. The study will start with data collection to provide descriptions to the research phenomenon. This process will be followed by the data analysis process to provide clear conclusions from which study hypothesis and theory explanation will be based. Using this approach in the study will promote flexibility (Cohen, Manion & Morrison, 2007) as there will be no pre-determined theory or hypothesis to control the research process.
Interpretivism research philosophy will be used in establishing the usefulness of counseling services for low-income urban dwellers and the level of benefits attained from counseling by low-income urban dwellers. This philosophy will enable the study to establish the reality behind the research problem. It will also promote the use of a research sample that will be evaluated keenly to understand the views of the entire research population.
A qualitative research design will be employed in the process of establishing the usefulness of counseling services for low-income urban dwellers and the level of benefits attained from counseling by low-income urban dwellers. Qualitative research involves an inquiry process of constructing a holistic description of the research phenomenon under investigation. Qualitative research is conducted using a variety of research skills such as observation, document reviews, participation and interviews among other skills. The main advantage of qualitative research is that the research phenomenon under investigation is studied in its natural settings. As such, the assumptions, definitions, or limitations of the researchers are not imposed upon the phenomenon under investigation (Bryman, 2001).
A case study research strategy will be used to establish the usefulness of counseling services for low-income urban dwellers and the level of benefits attained from counseling by low-income urban dwellers. The case study will involve 20 low-income urban dwellers who have successfully sought for counseling services within the past two years. Through the case study, the research phenomenon will be studied in its immediate context hence increasing the validity and reliability of the collected information.
Research population and sampling
A research population refers to the total number of subjects, participants or individuals being investigated by the researcher in the process of answering the existing research questions (Meriwether, 2001). In this study, all low-income urban dwellers who have successfully sought for counseling services within the past two years will be the research population. However, due to the constraints of time and other resources, a sample of 20 low-income urban dwellers who have successfully sought for counseling services within the past two years will be selected to participate in the study. These participants will provide the required information and guide in establishing the usefulness of counseling services for low-income urban dwellers and the level of benefits attained from counseling by low-income urban dwellers.
According to Meriwether (2001), a research sample is a proportion or a sub-group of the entire research population that is selected to participate in the study. It is selected from the target population scientifically to avoid bias and thus promote the validity and reliability of the research findings. Bias in the selection of the research sample leads to lack of effective representation of the target population resulting to acquisition of research findings that do not represent the views of the entire target population. To this end, simple stratified random sampling technique will be employed in the selection of the 20 study participants.
Data collection process is highly significant in research studies as it enables the researcher to gather relevant answers to the prevailing research questions (Saunders, Lewis & Thornhill, 2007). A researcher can utilize either, both, or any of the two methods of data collection namely; the primary and the secondary methods of data collection. Primary method of data collection will be employed to collect data with the intention of establishing the usefulness of counseling services for low-income urban dwellers and the level of benefits attained from counseling by low-income urban dwellers. Primary data collection enables a researcher to collect study data using firsthand experience. The uniqueness of primary data collection is that the researcher collects specific data in line with the research questions. Some of the methods used in the process of collecting primary data include questionnaires, interviews, focus groups, case studies and so forth (Saunders, Lewis & Thornhill, 2007).
Collection and instrumentation
Semi-structured interviews will be used to collect data from the research participants. The use of the semi-structured interviews will promote a two-way communication between the interviewer and the interviewee. This will provide the involved parties, the interviewer and the interviewee, with the opportunity to ask questions and provide expressions in an understandable manner. The interviews will also inform the study through confirming what is already known and through providing an efficient opportunity for learning more. In the same vein, the information from the interviewee will not only provide answers for the posed questions but also efficient reasons for the answers. Through semi-structured interviews, the interviewees will be in a better position to discuss other sensitive issues about benefits of counseling to low-income urban dwellers that would not have been captured using any other method. Semi-structured interviews will also provide a chance for the interviewers to be acquainted with the research participants hence promoting access to more confidential information that the participants would not have disclosed to strangers.
After the data collection process, the collected data will be analyzed using the interpretive approach to give explanations and descriptions. The use of an interpretive process in analyzing the research data qualitatively will make the data more meaningful and illustrative. The data collected will be analyzed in line with the research aim to ensure that the research findings clearly address the research problem.
Study Constraints and Limits
Calling upon their participation of 20 participants in the research procedures will be a challenging activity. Equally, the process of data collection will be time consuming. In the same vein, the limitations of resources will not pass without being realized in the course of this research process. To facilitate effectiveness in the process of establishing the usefulness of counseling services for low-income urban dwellers and the level of benefits attained from counseling by low-income urban dwellers, all the limitations present will be addressed effectively. To save time in the data collection process, the final semi-structured interview questions will be adjusted to make them more comprehensive as a means of saving the respondents’ time. This step will also encourage increased respondent participation in the study. Effort will be expended in utilizing the available minimal resources in terms of time, personnel and money to collect valid and reliable data.
Ethical considerations in the research processes have been perceived by some researchers as a hindrance to their research activities (Gillham, 2000). Nonetheless, Schicktanz and Dusche (2011) point out that a majority of individuals fails to understand that ethical considerations in the research processes ensure that the conducted research procedures are in line with the rules and regulations of research. Research ethics are particularly significant when the researcher is using questions to inquire about a certain research phenomenon from a respondent or a third party (Groth-Marnat, 2009). In this case, ethics have it that the researcher should seek the consent of that respondent and at the same time assure the respondent of his/her confidentiality (Schicktanz & Dusche, 2011).
Before the participants are selected from the research population, the research aim will be explained to ensure that the participants are fully aware of what the study entails. The research study will further seek the consent of the respondents before proceeding with the process of data collection. On the same note, the respondents will be assured of their anonymity as well as the use of their responses for the purposes of research only. This will enable the respondents to open up and share their genuine opinion without fear of being implicated due to their views.
This methodology will play a significant role in the establishment of the usefulness of counseling services for low-income urban dwellers and the level of benefits attained from counseling by low-income urban dwellers. The results, being an actual representation of the facts on the ground, will clearly outline the importance of counseling services to low income urban dwellers hence provide evidence of the value of the agency’s services in order to help secure ongoing funding for the agency.
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