Advice and Guidance – New Modern Paradigms

Part One: Defining Advice and Guidance

‘Advice and guidance’ refers to a very large spectrum of helping social activity and contact, of which there can be no one fixed definition. The historical context and texts covering the social conditions and practice of advice and guidance are in constant flux, particularly in the twentieth century.
There are formally trained, wholly dedicated professionals who proffer advice and guidance as the major function of their employment (for instance, careers guidance), and then there are informal contacts solicited or encountered in time-limited sessions, by practitoners whose personal skills are enhanced by guidance theories and skills. The role of a ‘counsellor’ is generally more attendant and concentrated on psychotherapy training, with an intervention conducted in a person-to-person fashion. Advice and guidance are tied to prospecting and negotiating along with the client, relations between the client and different social agencies and authorities, such as a probation officer mediates between the client and court.
The motivations of the adviser, guidance counsellor or therapy counsellor, and their differences, is important to note. Often among advice and guidance personnel “the motive to care is more likely to lead to a career in social work, whereas therapy requires a strong interest in making sense of the inner world of clients.” (McLeod 1993: 201). The theoretical intensity and generality of the latter, of making sense of the inner human world, is deliberately tempered by the person-centered approach increasingly used in advice and guidance (though clearly the person-centered approach to guidance does strike a medium, between advice as more neutral, strategic information and psychotherapeutic counselling). Counselling is more perceived as a fully fledged, professional, dedicated service related to the inner world of the client, whereas advice and guidance are never so predicated on subjective assessments either from the helper or client (as for instance, evidence based guidance practices imply, discussed later).
A counsellor and the advice and guidance helper diverge over the principal reference of the question of the client’s problems between self and authority. Whereas the counsellor usually constructs a speaking position between the client and the client’s past (classically, a past relating to the troubled or troubling interior authority of father or mother figures), the relationship offered from advice and guidance personnel is usually mediating between clients and exterior authority structures, structures with independent, pressing concerns affecting the material present. Legal and medical priorities promoted by highly trained, middle-class professionals, are generally maintained to “gatekeep” an impersonal authority in which the middle class has tremendous social investments, while often those who need advice and guidance are underepresented among such professional elites (McLeod 1993: 109). Advice and guidance is in many ways a matter of opening these gates, for fair access to legal and medical help, to the discriminated, disadvantaged and different in our society. A key skill of advice and guidance would include “developing a sensitivity to the impact of social divisions on clients’ lives” (Thompson 1991: 62).
Instead of counselling’s more private considerations, advice and guidance programs “need to be aware of the community and to extend their efforts out into it. Members of minority groups frequently are not nearly as verbal as their white counterparts, but they still need active help.” (Glanz 1974: 1). Culture plays a role in generating stress and help-seeking behaviour in distinctive ways, and the cultural context needs fully understood for advice and counselling to be effective. For instance, Cartwright and Anderson (1981) reported patients coming to doctors with stress had almost doubled in ten years (cited Alberto and Ogden 2005: 274), yet in inner city London, white British patients more consistently reported stress to doctors than their black Caribbean or black African counterparts (Alberto and Ogden 2005: 274). Advice and guidance centres would pay attention to such divergences in ways unconsidered and quite unamenable to counselling practices, yet not without sensitivity of counselling skills. In other words, active social research and outreach lift advice and guidance programmes into social policy considerations exceeding the individual identifying himself or herself, or identified as, in want or need of help or direction from social agencies and authorities.
Studt has pointed out that “in one sense the worker’s position seems to be that of a middle man in the authority system” (cited Parsloe 1967: 27). The difficult conceptual and practical difficulties of straddling subjective and personal matters, beside more objective, perhaps legal and medical contingencies, is the modus operandi of advice and guidance.
‘Guidance’ is traditionally help for the young “as they seek to make their way in the world and to become free and responsible” (Glanz 1974: 30). This would be a normative social practice, yet guidance and counselling have become specialities. Fundamentally, giving advice is the basis of most discussions on guidance and behaviour change, based on a logic surmising people lack information which, if received from a respected source, is sufficiently compelling to produce change. This method can be used in a more or less authoritarian style, but it relies on an essentially paternalistic […] relationship in which the practitioner tries to persuade the patient about the wisdom of considering a change of lifestyle. The main limitation of giving advice about lifestyle is that the evidence of its effectiveness is not very convincing.. with success rates of 5-10% not uncommon. Thus, while some patients seem to respond to advice, most do not. (Rollnick 1993: 188)
The concept of a person-centred approach, or the ‘service user’ in community care, are methods to address the problem of limited uptake of advice, whereby the advice and guidance is “to focus on the service user, not on the service. It therefore presents a challenge to the traditional role and culture of the social services department” (Department of Health cited Stevenson and Parsloe 1993: 9). The traditional role of social service was then a service-centred, versus person-centred, approach to problem resolution. ‘Modern’ advice and guidance theories and practices are taking up the challenge to traditional authoritarian practices of advice delivery.

Part Two: Purpose, Outcomes and Benefits of Advice and Guidance, with Illustrations.

Advice and guidance personnel are today trained in supplying help to clients in a manner adjusted to not treating persons as ‘cases’, and not taking ultimate decisions on their behalf; empowerment is the watchword of good advice and guidance provision. The institutional trap of assuming power ‘over’ those in need generates a failure to empower service users, whenever there is “a proliferation of professional helpers who exercise considerable power over those they profess to be helping” (Barnes cited Servian 1996: 10). The purpose, outcome and benefits of advice and guidance of course depend on the quality and relevance of the information supplied, but as Rollnick above suggests, plain, indiscriminatory information has proved more ineffectual than hoped for in transacting positive outcomes, and so alternative techniques and means of providing information are being devised and revised, often on an evidence based practice (EBP) basis.
Suboptimal uptake and results of various treatments on the NHS have been investigated for factors dependent on allowing patients choice and found to be of importance. In one systematic analysis of outcomes involving patients who suffered heart attacks and were offered cardiac rehabilitation therapy implemented either as hospital or home-based, it was found patients desire “specific advice, guidance and support from knowledgeable experts”, but patients’ own lifestyle choices, especially feelings over security in groups and transport mobility, were crucial arbiters in rehabilitation uptake and success (Wingham et al. 2006: 289).
At every stage of the advice and guidance process (either serial and formal, or variable and informal, or any combination), as an active and imaginative consideration, patient or client choice and sympathies should be solicited, developed progressively through information provision, and finalised in tandem with the client.
However, in the field of physiotherapy for instance, it has become increasingly clear that “proponents of self-management must recognise that clients may engage in strategies that run counter to professional advice” (Yoshida and Stephens 2004: 221). Advice may be given for the client to then pursue alternative strategies involving some trade-off, perhaps leading to extra pain later, pain judged worthwhile among the client’s own priorities for some person-centred benefit not effectively registered by professional considerations. Such strategies may “be seen as inherently ‘risky’ or ‘unsafe’ by health professionals, but are part of the everyday decisions” patients must take – the notion of ‘everyday strategies’ situated within the context of the client’s own worldview is becoming far more considered in the literature of professional advice and guidance for disability and chronic illness (Yoshida and Stephens 2004: 229).
If the client’s voice is nowhere allowed except to offer gratitude at the end of the provision of professional service (traditional professional structural imperatives also raise expectations of compliance and gratitude, and a stressed or vulnerable and so suggestible individual may too readily intuit and supply, disregarding his or her own feelings or perspective on the course of action decided), this should not count as providing the empowerment advice and guidance seek to offer.
Rather, in recent analyses of the problem for government policy and the concept of the ‘service user’, what advice and guidance should aim for in purpose and outcome, is perceived control by participants as well as perceived positive encouragement of participants (Seligman cited Servian 1996: 61); positive recognition within any group setting (Tajfel cited Servian 1996: 61); means for allowing the ‘voice’ of the individual to be heard, such as complaints procedures or elections within the group setting; meaningful and actual access to choice; meetings to take place that use open agendas and plain language; and power structures to be transparent and open to challenge (Servian 1996: 62). The outcome of such service provision is the empowerment of the individual, meaning responsibility and control rest more there than in the service provider, generating commitment and positive feedback in the entire process.
For instance, Coventry Mind is a registered charity and an excellent example of the new adaptation of advice and guidance services part-funded with significant public funds. Originally conceived as a support service for those with mental health problems, the centre has expanded to become a wide-ranging drop-in centre without an appointment system, conforming to a more person-centred standard of communication. Informality is empowering in a first contact situation, and specialist advice can be proffered at further sessions, including legal advice. The service user may access this network of advice by telephone, face-to-face sessions, or email, which ever is more comfortable – the medium and frequency is up to the user to plan. This arrangement is geared to the “involvement of service users in the planning and management of care… one of the ‘pillars’ of community care” (Macdonald cited Kelly 1998: 98). Helping activate and abetting the voice of the service user is key to advice and guidance practice.
Baggot considers that service user provision should include “greater emphasis on care and support in the home and mobilisation of the community itself” (cited Kelly 1998: 98), and Coventry Mind has concentrated resources in providing service users with advice in the provision and maintenance of their home. As for Baggot’s note towards mobilisation of the community, Coventry Mind has a Befriending Service, matching service users with regular one-to-one support from a selected volunteer from the community, to pursue some regular social activity together. The impressive range of advice and guidance offered by Coventry Mind and engendered in a personal fashion with befriending, does embody all of the collaborative nature of formal and informal helping, respect, advanced empathy and challenge, Gerald Egan advocates in The Skilled Helper (1998: 10, 51, 180, 197).

Part Three: Compare and Contrast Two Guidance Models

The central hypothesis to Rogers’ ‘person-centred approach’ can be briefly stated as believing that the individual has within himself or herself vast resources for self-understanding, for altering his or her self- concept, attitudes and self-directed behaviour – and that these resources can be tapped if only a definable climate of facilitative psychological attitudes can be provided. (Rogers 1990: 135)
Roger’s positivism over the efficacy of his approach, always based on the particular, i.e. the individual in a network of social relations, does bode for a heady co-operative spirit being entirely achievable. Within a permissive atmosphere, and when responsibility is genuinely placed with the individual or group, and their capacities are respected, then responsible and adequate analysis of the problem is made; responsible self-direction occurs; the creativity, productivity, quality of product exhibited are superior to other comparable methods; individual and group morale develop. (Rogers 1951: 63-64)
One of the main benefits of such self-actualised health is how the individual would be “less frustrated by stress, and recovers from stress more quickly”, and Rogers goes so far as to say if “certain attitudinal conditions exist, then certain definable changes will occur,” including potentially a “new field of human relationships” (Rogers 1967: 36-37).
Rogers’ practical concern was to develop an approach which was effective, instead of labouring under theoretical speculation – against psychodynamic propositions describing the person as a highly complex structure of conflicted speech, the conceptual apparatus of the person-centred approach is an “insubstantial scaffold” (McLeod 1993: 67). Altogether there is a utopic belief in the power of genuine openness and co-operation, but surely those seeking advice and guidance may not well be capable of the sort of communication and knowability Rogers implies is possible, even with expert, kind intervention? Rogers did defend the research applicability of his own person-centred method, but the constructs of “self-concept, or the need for positive regard, or the conditions of personality change”, which Rogers claims “all have application to a wide variety of human activities”, is surely to say everything and nothing about helping others (Rogers 2004: 246). Such constructs based on the “emerging self” may well have limited application to significant lasting change given the ego’s capacity for fiction-making especially before authority figures (or equally, the self’s disappearance as an object at moments of “little self-conscious awareness”, or sublimity, as Rogers describes in an idealised therapeutic situation (1967: 147).
However, Rogers did recognise that the “person of the therapist was a significant part of the therapeutic relationship”, not only by role and function (Tudor et al. 2004: 42), and that the client’s perception of the therapy process overrides every other condition of the therapist’s intention, such as unconditional empathy (Rogers 1967: 145-151).
Motivational interviewing (hereafter MI) is a guidance technique for promoting changes in behaviour first developed for the problem of addiction. MI has an integrationist philosophy to advice and guidance, and its patient-centred approach and focus on empathy and strong reflective listening skills are principally drawn from the client centred therapy of Carl Rogers and his belief in the “force of life,” the natural self-actualising tendency of healthy people. (Welch et al. 2006: 5).
One main benefit of MI is how there is evidence for example that “motivation for change in problem drinking can be affected by relatively brief interventions” (Miller and Rollnick 1991: 31; Miller et al. 1993: 455). In terms of implementing training programmes and time-enhanced results, MI has strengths in terms of cost and simplicity over traditional counselling techniques.
According to its design instigators, MI was an “approach designed to help clients build commitment and reach a decision to change” (Miller and Rollnick 1991: x), a description later refined to ” a directive, client-centered counselling style for eliciting behavior change by helping clients to explore and resolve ambivalence”. (Miller and Rollnick 1995: 325). Ambivalence is a simultaneous attraction and repulsion, as problem behaviours could well be described as eliciting in clients, and “not wholly rational” (Miller and Rollnick 1991: 47). MI does encounter the irrationality of the inner, human world of the client without prevarication, and indeed uses irrationality as a “force of life’ to be addressed and redirected.
For instance, MI has been gathering support in areas of advice and guidance traditionally using a rationalistic, “hard-hitting, directive, exhortational style intended to overwhelm robust defense mechanisms”, such as in probation work and addressing problem drinking (DiCicco cited Miller et al. 1993: 455). In fact, such ‘rational’, confrontational styles increased client resistance to behaviour change (Miller et al. 1993: 458).
In MI, ambivalence is fundamentally overcome by eliciting “self-motivational statements… to increase awareness of the discrepancy between one’s goals and present actions. The greater this discrepancy, the greater the motivation for change” (Miller and Rollnick 1991: 87). Therefore, MI would reverse a client’s troubled behavioural relationship with personal goals and authority (the irrational discrepancy) into a standing contradiction. Other more preferred personal goals (and also a personal form of authority), are seen to be contradicted by current behaviour, in the client’s own speech, making ambivalence diminish, though it usually does not disappear (Miller and Rollnick 1991: 87).
MI “steers clear of the both the hard and soft approach”, either being overly-directive and strongly representing the court’s authority, or defending the probationer even when court order violations occur (Clark et al. 2006:43). Fundamentally, MI has no concept of “unconditional empathy”, but instead forces an ‘improving contradiction’ on the client, through his or her own analysis.
The evidence-based practice (EBP) of MI, along with a MI Skills Code for assessing educators and in particular patient-educator interactions, places the concept of MI itself on a more empirical basis, with the testing of good practice an intrinsic merit. As well, having EBP as a central tenet places MI within the management culture of the NHS (and the dominant political culture), meaning MI may graft more readily to the NHS rather than a more tendentious ‘person-centred approach’, without EBP feedback processes. Indeed, “a systematic review and meta-analysis of randomised controlled trials show that motivational interviewing in a scientific setting outperforms traditional advice given in the treatment of a broad range of behavioural problems and diseases.” (Rubak et al. 2005: 306).