COSCA Counselling in Scotland

An article by Ian Fuller

in COSCA Counselling in Scotland Winter/Spring 2008 p.21-24

Introduction

The Lothian Centre for Inclusive Living (LCiL) Peer Counselling Service (PCS) ran from 1992 until March 2006. It was the only counselling service in Scotland where a group of professionally trained disabled volunteer counsellors worked with disabled clients and their carers / family members. LCiL also ran the only counselling Diploma training programme in Scotland aimed specifically at training groups of disabled people with a range of impairments as counsellors.

The aim of this paper is to review the work of the PCS, and to inform the counselling community in Scotland about recent developments in the service.

History

The PCS developed from the recognition by LCiL Independent Living Officers (ILOs) in the early nineties that disabled people who were attempting to access Direct Payments (DPs) often required emotional support as well as practical support to progress their aim of independent living.

Attempts to place those DP applicants who wanted counselling with mainstream voluntary counselling services were often unsuccessful due to difficulties with physical accessibility, and on occasion difficulties with the attitudes of non-disabled counsellors. These counsellors sometimes assumed that the person's main issue was centred around their impairment, rather than on one of the many other issues which bring people to counselling. Attempts to place people with counsellors in private practise resulted in similar accessibility and attitudinal difficulties, with the further problem of the additional expense incurred by people who were in the main financially dependent on benefits.

Against this background the LCiL Peer Counselling Service was born. One of the aims of the service was to challenge the barriers in society which prevent disabled people accessing counselling and counselling training. These barriers include financial difficulties, a lack of physical accessibility, and attitudinal barriers. This mirrored the growing significance of the disability movement in wider society.

At the same time, the development of the PCS also mirrored the increasing professionalisation of counselling in wider society.

Initially counsellors were untrained, then trained to COSCA Certificate level only. When it became apparent that this level of training was insufficient in the face of the sometimes profound issues counsellors were encountering in their clients (and in themselves), further training was contracted. At first, this took the form of modules on specific subjects, taught by individual trainers over a short period of time. Eventually this modular approach evolved into the LCIL Diploma in Integrative Counselling, with the core theoretical models of the Person Centred Approach and Transactional Analysis.

At the time when the PCS closed due to funding difficulties at the end of March 2006, it was a three day per week service with twelve volunteer disabled counsellors, ten of whom were trained to Diploma level over four years by accredited trainers. These counsellors offered one-to-one face to face counselling for between 70 and 80 people per year. The majority of PCS clients were disabled people, including people with physical impairments and people with learning difficulties, although some family members of disabled people were also seen. In addition, the PCS had a limited telephone counselling and couple counselling facility.

The PCS was mainly based at one site in Edinburgh, but also worked with clients in day centres and hospitals, and had an outreach service in Livingston, West Lothian.

Development of the service

Over the years, the counselling service and the counselling training changed and developed in response to the needs of the clients and the student counsellors, as well as responding to the field of counselling as it grew in Scotland.

Development of training programme

In selecting disabled people as applicants for counselling training, it is necessary to ensure that the same rigour is applied to the selection process as with any counselling training programme. Just because a person has an impairment does not mean that they have the personal attributes necessary to make them a peer counsellor.

It is important to make this statement because, although it is obvious to counsellors and counselling trainers, it may not necessarily be obvious to non-counselling professionals and managers seeking to develop a counselling training programme.

In the case of LCiL, an initially all-inclusive approach towards student selection in the early 1990s developed into a more careful approach, with applicants asked to attend a week long counselling skills taster course and assessment interview before selection on to the COSCA Counselling Skills Certificate, the first part of the four year journey towards the Diploma.

In addition to adopting a stringent selection process for potential students, the structure of the training programme itself evolved over a twelve year period. It developed from an initial 'ad hoc' approach to a modern professional counselling training programme.

The initial modular approach in the 1990s was adopted as a response to fragmentary funding. Trainers were brought in to teach separate topics as time limited modules as and when money became available. Individual trainers would only meet the students for 6-8 weeks. There was no overall training co-ordinator, and nobody had responsibility for guiding the students through their training.

In practice the modular approach was less than satisfactory; students did not feel 'held' in their training, and there was no consistency of assessment between modules and between trainers.

The more structured formal programme was successful, both in terms of supporting a coherent training group and in terms of numbers of Diplomas awarded. Students were taught by a group of three accredited 'core trainers' who stayed with them for the three year duration of the Diploma training. There were training terms, allowing for summer and winter breaks. Each core trainer was assigned as tutor to a group of students. Most importantly, personal development was identified as a priority and the students were required to attend a regular therapy group as part of the training. While individual personal therapy was not costed into the programme, students were encouraged to pursue this and many did so.

The formal programme was modular in approach, as previously, with separate topics being taught as modules. However the majority of the training was undertaken by the three core trainers, with only a limited recourse to external trainers for specialist topics. There were also regular meetings of the core trainers to discuss students' progress. Disability issues were an integral part of the training programme, including discussions on the relevance of the politics of disability to counselling and vice versa.

The success of this approach can be measured by the fact that the majority of recent graduates of the Peer Counselling training went on to find volunteer work in other contexts after closure of the service.

Training Disabled Volunteers

The training programme followed COSCA guidelines for Diploma validation, in terms of course structure, core course content, counselling practice and practice supervision, trainers and tutors etc, but validation itself was not sought owing to resource considerations.

The course provided the same kind of learning and supervisory support as other counselling courses, but in addition it supplied the necessary conditions required to support disabled people towards successful completion of their training. This took two forms:

* Generic support. General policies and training approaches adopted in order to optimise the training experience for the majority of students.
* Individual support. Specific adaptations required to support individuals with particular impairments.

Generic support

Financial support was particularly important. Lack of finance is probably the biggest barrier faced by disabled people seeking to access counselling training.

Students were not in a position to pay fees for their tuition nor could they pay for therapy and supervision. Other costs included transport to and from the training venue, supervision and counselling placements; the cost of personal assistance and child care, and the cost of scribes and other support for completing assignments and assessments.

It is important to ensure that the financial resources are in place prior to embarking on a training programme, particularly if the programme is taking place in the voluntary sector. Breaks in funding, and therefore the training programme, can have an adverse effect on student morale.

Training premises, based in the Norton Park Centre in Edinburgh, were fully physically accessible. In addition to physical accessibility, it was important to ensure accessibility at all levels in the training programme. For example, a personal assistant was on hand for all training events to assist with transfer from taxis, at lunch and tea-breaks, and with personal care.

Students' energy levels also influenced the design of the training. It was necessary to prioritise the students' health over the demands of the training programme. LCiL found that it was inadvisable in terms of the students' health to ask the students to attend training for more than two days a week during term time. In addition, the training days were shorter than in other courses. It takes some disabled people a significant amount of time to get up in the morning so they start work later than might otherwise be the case, and depleted energy levels resulted in training days finishing by 4 p.m.

LCiL also adopted a 'time out' policy, whereby students could take time out from training or client work during periods of illness or low energy. This proved particularly important in the case of those with impairments with ongoing health implications.

Individual support

At the commencement of training, each student was asked to complete an access support sheet listing the support they might need (information format, support with writing, operating tape recorders etc.). This varied with each person, and LCiL strived as far as possible to meet their requirements.

Students with visual impairments were supplied course material on tape and in large print format. Students with difficulty in writing or using a computer keyboard would dictate their assignments to a scribe. Other students might require help with eating or drinking; yet others might need help in transferring from a wheelchair to a chair for the duration of the training session.

Assessment

Support was particularly important for students undergoing assessment at the end of their four-year training programme. In order to reach this point, students needed to have first successfully completed all modules of the training programme by means of submitted assignments.

The final assessment itself comprised the submission of three pieces of written work (personal philosophy of counselling, a case study, and a tape transcript from a counselling session with written commentary), followed by an interview with two external examiners and an observer.

The large amount of work required for the final assessment process took a physical toll on some students, despite the use of scribes, and support in operating tape machines. Two students opted not to go forward for full Diploma assessment because of this, preferring instead to put their energies into counselling clients. Students who completed all coursework successfully, but chose not to undergo final assessment, received an Advanced Certificate rather than a Diploma.

Running a Counselling Service for Disabled People

As with the training programme, support for counselling clients could be divided into generic and individual support.

Generic Support

Despite recent changes in legislation, many counselling services are still physically inaccessible to some disabled people. Most counselling services are keen to increase their accessibility, but are faced by financial constraints.

Many disabled people are financially dependent on benefits, and cannot afford the fees charged by counsellors in private practice. Lack of affordable, accessible transport can also be a barrier to disabled people wishing to access counselling.

The LCiL Peer Counselling Service provided a fully accessible physical environment, PA support and some help with transport costs. These factors served to increase the accessibility of the service to disabled people.

The counselling service premises in the Norton Park Centre in Edinburgh were fully physically accessible, with accessible toilets and wide doors. Counselling rooms were large enough to comfortably accommodate two wheelchair users. LCiL provided information to prospective clients in accessible formats, including large-format print, audio tape and e-mail. Appointment cards were also available in different formats.

Ideally, it would have been best to have premises on the ground floor of the building to allow for ease of evacuation for disabled people in the event of fire. However this was not the case; a lift brought counsellors and clients to the second floor where the service was based. Fire safety measures were addressed, for example by the use of 'safe areas' in stairwells for people with impairments which affected their mobility.

Some help was provided with transport costs for those who needed it.

Many LCiL counsellors needed taxis to get to work, supervision, or in-service training. As with the counsellors, some clients needed taxi transport and some did not. It was the PCS experience that less expensive transportation methods catering for disabled people were less flexible than taxis, more likely to be unavailable due to heavy demand, and require booking sometimes up to three weeks in advance. Payment for client taxi journeys to counselling was negotiated at intake, again depending on the client's ability to pay.

Support and administrative staff had wider duties in the PCS than they might have had in a mainstream counselling service. In addition to dealing with appointments, cancellations, record keeping and greeting clients as in any counselling service, they were required to help clients and counsellors in other ways. This would include, for example, assisting a counsellor transfer from a car to a wheelchair, or from a wheelchair to a chair in the counselling room. It might also include setting up a tape recorder for a counsellor to record a session for supervision purposes, or helping a client with personal care.

Finally, when disabled counsellors are working with clients, each counselling room needs some accessible form of communication equipment available to make support staff aware that the session has come to an end, or in case of emergency. In addition, some counsellors may have limited use of their hands, so the equipment must be easily operable. Other counsellors may have visual impairments and need the equipment close to hand.

The PCS used a two-way radio, operated by a push button on the end of a flexible lead which is pressed by the counsellor, and set to elicit both an audio and a visual (in the form of a blinking light) signal from the receiver in the support staff office. It was important to ensure that the receiver was manned at all times when counselling was in progress.

Individual Support

It is important in a disability-oriented counselling service to take account of an individual's impairment at the practical and process levels.

Impairment - related issues can be very specific. For example some clients may need their feet or legs supported in the counselling room, others with memory impairments may need reminding of an appointment on the morning of an appointment, and some clients may only be able to communicate through a picture board. It may only be possible to work with some clients through a home visit or via telephone counselling.

Other impairment related issues include the impact of a person's energy levels on their ability to attend counselling (which may mean more missed appointments than in a comparable mainstream service) and, particularly in the case of clients with learning difficulties, the need to make arrangements through a third party, whether this is a family member or support worker.

Some counsellors may not consider working with this client group; others may be cautious. However it has been the LCiL experience that it is feasible to work effectively with people in this client group using the skills gained in a normal Diploma training, but with a little extra input specifically on this topic.

The term 'learning difficulty' covers a wide range of people, with an equally wide range of outlooks, capacities, willingness to engage and ability to engage in the counselling process. Some of the approaches LCiL has found useful with this client group include having a flexible approach towards the length of sessions, using drawing, toys, models or other creative approaches to help the client in telling their story, and allowing support workers to remain in the room to help with communication with the client, until the counsellor can communicate unaided.

In addition, clients with learning difficulties sometimes ask for the presence of a support worker during counselling sessions. Sometimes this is because they feel vulnerable, and sometimes it's because they want to give their support network a message and can't find any other way of doing it (!). The LCiL approach to this situation was to allow the support worker to stay present in the initial sessions, and to ask them to stay quiet. In addition the client was gently encouraged to relinquish the support worker's presence as early in the counselling relationship as possible. Generally this would happen after two-three sessions.

A related issue is that clients with learning difficulties are often referred to counselling via their support workers. These 'third party' referrals require careful attention from counselling service staff. It can be difficult to tell whether or not the client actually wishes to attend counselling, or whether somebody in their support network thinks it would be a good idea for them to attend. Sometimes this can only be ascertained with certainty during the initial meeting, or even later. Once the client's true wishes regarding counselling are ascertained, they are honoured.

Non-Disabled Counsellors and Disabled Clients

The majority of voluntary sector counsellors have no specific training in counselling disabled people. This can have an impact on their work with disabled clients.

Jean Morrison, a previous LCiL trainer and supervisor, carried out a study involving disabled student counsellors from LCiL, and non-disabled student counsellors from the PF, another Edinburgh counselling service. In one set of experiments, disabled students worked as counsellors with non-disabled students as their clients. In another set, non-disabled students worked as counsellors and the disabled students were their clients.

In both cases, there was a tendency for the disabled person's impairment to become the 'elephant in the room' - the subject which both counsellor and client carefully avoided. This awkwardness interfered with the natural flow of counselling and resulted in less easy, more stilted counselling relationships.

While this had implications for training LCiL counsellors, it also has implications for training non-disabled counsellors, who make up the majority of counsellors in Scotland. It is important to remember that many voluntary sector counselling services provide work experience for student counsellors. Whereas more experienced counsellors may have the capacity to work effectively with a client with an impairment, the example above suggests that student counsellors in particular may find this difficult.

LCiL would therefore recommend that all student counsellors receive some training in working with disabled people at an early stage in their counselling training - before they start working in placements. This could include an element of Disability Equality Training (DET)

Effectiveness of the Peer Counselling Model

Two final questions regarding counselling disabled people might be:

* Does a counselling service aimed at working with a particular client group hold any advantage for that client group over a more generic counselling service?
* Is it an advantage for a disabled client to have a counsellor who also has an impairment?

In LCiL's case the answer to both questions would be 'Yes'.

In terms of the first question, on a purely practical level, it would be very difficult for many of LCiL's clients to access other counselling services because of difficulties with accessibility and transport costs. Further, the PCS was based within a CIL (Centre for Inclusive Living) with a range of resources and information available for its client base.

On a process level, LCiL counsellors shared their experience of working with this client group with their colleagues in supervision and built up a body of knowledge around common issues encountered (e.g the impact of a person's impairment on their family life, methods of working with clients with learning difficulties, working with clients who are dying) which supported the work of all the counsellors.

In terms of the second question, there is evidence that the knowledge that their counsellor would also have an impairment made clients approach the service more readily. In a survey carried out for the PCS by RSR consulting in 2002, 63% of the 35 clients who completed questionnaires stated that they had chosen the PCS because they wanted to work with a disabled counsellor. This was the most common response. Respondents commented:

I wanted to work with someone who would understand the limitations and restrictions which ill health cause......I thought that another disabled person would be able to relate better to these issues.

I felt working with someone who has a disability would have a better of understanding of the 'ups and downs' and practicalities of living with a disability.

Respondents also indicated (80%, or 28 respondents) that having a counsellor with experience of disability enhanced the counselling experience. Comments included:

They can understand what pain is, therefore they are on a level with me.

I felt she had more of an empathy with me, having faced the same kind of problems and prejudices.

I felt more comfortable talking about disability issues.

These results are an indication of the value inherent in training disabled people as counsellors.

Impact of impairment on ability to counsel

Disabled counsellors have a lived experience which helps them to understand the social conditions in which their clients operate to a greater extent than non-disabled counsellors. This can have a positive impact on the counselling relationship, particularly in the early stages.

This having been said, it is also true that a person's impairment can have an impact on their ability to counsel. As might be expected, this varies with each individual. The impacts can be broadly divided into two categories: those which mean that the counsellor might be unable to physically attend to the counselling relationship, and psychological impact.

Physical impacts

* Some impairments have little or no impact.
* Other impairments might have an impact only in particular circumstances: for example a person with a speech impairment may not be able to speak directly to a telephone client; a counsellor with a visual impairment would find it difficult to communicate with a learning disabled client who can only communicate through a pictureboard.
* Periods of illness in a counsellor can interrupt the counselling relationship.

It is important that the counsellors, supervisors and service manager continuously monitor counselling relationships where the counsellor is prone to absence due to illness to ensure that the work continues to be effective.

In this context, it is important to remember that disabled clients have experience of the impact of illness on their own lives, and an understanding of the counsellor's situation. However, during extended periods of illness in the case of a particular counsellor it may be necessary to make alternative arrangements for their client or clients.

Psychological impacts

* As with any counselling training, it is important for counsellors to have some understanding of significant personal issues prior to working with clients. One of these significant issues in the case of disabled student counsellors can be the impact of impairment on their lives.

It is particularly important for disabled student counsellors who have not already done so to address to some extent the impact of impairment on their lives and outlook during the course of their training.

* Progressive illness can have an impact on a person's cognitive capacity, and/or on their emotional and psychological make-up. This potentially means that a trained and qualified counsellor effectively becomes unable to counsel after a period of time. This possibility needs to be monitored by the counsellor themselves, and by their supervisor and the counselling service, and may result in the counsellor honourably retiring.

Impact on completion of training and future career

In discussing the overall impact of impairment on disabled people in counselling training and as counsellors it would be useful to briefly review LCIL's experience with the most recent training group.

Students were selected for the course by LCIL staff and trainers solely on the basis of their potential as counsellors. The prospective students were provided with information on the probable demands of the course in terms of attendance, workload, assessment processes, etc.

At the recruitment stage, they were provided with the opportunity to consider these demands, and whether they might prove excessive in the case of any individual, due to their personal circumstances. 'Personal circumstances' included family and other commitments, and also the students understanding of how impairment might have a bearing on their ability to complete the course.

On this basis, nine people undertook the COSCA Certificate in Counselling Skills over the course of a year, and all completed it successfully.

The probable demands of the Diploma course workload were made clear to the students, and they were invited again to consider these demands in the light of their personal circumstances. One of the Certificate group decided not to continue on to Diploma training for personal reasons, and two external people who had already achieved the Certificate were recruited at this stage.

Of the ten people who started the three year Diploma course, two people left; one in first year and the other in second year. Neither of these left for reasons directly attributable to impairment. The remaining eight people passed their Diploma assessment.

Two years after completion of the course, one person is currently unable to work as a counsellor because of the impact of impairment. Six of the remaining seven are or have been working as counsellors in other contexts.

Although this is a relatively small sample size, it illustrates three important points:

* No student ceased training for reasons attributable to impairment.
* After six years, only one person has ceased working as a counsellor because of the impact of impairment
* The training provided skills which allowed disabled counsellors to find both volunteer and paid work in other contexts.

It is also true that about half of the training group had periods of illness and recuperation lasting for periods of less than a week up to two months, during which time they were not working as counsellors.

Finally, it should be said that the students brought passion, commitment and determination to their studies and their work as counsellors. They continued to study and work through personal circumstances which were often difficult and on some occasions life-threatening.

Conclusion

The experience of LCiL's Peer Counselling Service has been that it is feasible to train groups of disabled adults to a professional standard in counselling, subject to funding, and that the opportunity to access a disabled counsellor is particularly appreciated by other disabled people with emotional, spiritual and psychological issues. The training also provided disabled people who became counsellors with skills which they subsequently used in wider society, including counselling in other contexts.

The PCS was part of LCiL, which is a user-led disability organisation. LCiL operates from the Social Model of Disability, focusing on removing the barriers within society which prevent disabled people from achieving their goals, rather than on the person's individual impairment. The PCS effectively removed these barriers for the groups of disabled people who trained as counsellors with the organisation, and provided a resource which was widely appreciated by health and social care organisations in Edinburgh and West Lothian.

The Future

The PCS has been awarded grant funding by the Scottish Executive which will allow it to start operating again as a national telephone counselling service for disabled people from winter 2007.

At the same time, LCiL intends to pursue funding to re-open the face-to-face service in Edinburgh. We are committed to restarting the face-to-face service if at all possible, as the phone service will mostly not be accessible for people with learning difficulties and people with communication issues.