Individual Counseling and Therapy: Skills and Techniques [3rd ed.] 9780415417334, 9780415415200, 9781315197654

Table of contents :
Cover......Page 1
Half Title......Page 2
Title Page......Page 4
Copyright Page......Page 5
Table of Contents......Page 6
Preface......Page 22
Acknowledgments......Page 24
1 Theoretical Frameworks......Page 26
Failure of Mutual Empathy in Clients’ Lives and How to Resolve It......Page 27
At the Core, Client’s Issues Are Utterly Interpersonal......Page 28
The “Self ” of the Therapist—The Key Instrument for Removing Clients’ Obstacles......Page 29
Looking at Repetition Compulsion in the Now......Page 30
Using Collaborative Empiricism to Restructure Clients’ Cognitive Distortions......Page 31
Using New Coping Skills and Mindfulness Techniques to Break the Reciprocal Circle......Page 32
A Focus on Bodily Felt Experiences......Page 33
Albee’s Formula of Human Suffering......Page 34
Solution-Focused Therapy and Narrative Therapy......Page 35
The Emotional Brain and Its Overriding Power......Page 36
Therapy Can Increase Neuroplasticity......Page 37
Becoming a Neurally Integrated Therapist......Page 38
Success Has Nothing to Do with Your Chosen Approach......Page 39
Clients’ Characteristics......Page 40
Clients As the True Engine of Change......Page 41
Honesty and Trust......Page 42
Hope and Expectancy......Page 43
The Therapist Factor......Page 44
Counselors’ Self-Disclosure......Page 45
The Trajectory of Treatment and Improvement......Page 46
Counseling Skills as Skills of Connection......Page 47
The Best Way to Hone Your Craft......Page 48
Stage 1: Precontemplation......Page 50
“Stages of Counseling” Model......Page 51
Stage 2: Awareness Cultivation (Middle Stage)......Page 52
The Recursive Nature of the Counseling Stage......Page 53
Seven Ineffective Response Styles......Page 54
For Your Own Reflection......Page 56
The Speaking Style......Page 57
Observe and Negotiate with Our Inner Critic......Page 58
The Triad Model of Peer Counseling and Its Working Principles......Page 59
Setting Your Own Pace of Self-Disclosure......Page 60
Ways to Enhance Reflective Practice......Page 61
Let Your Brain Grow in an Accelerated Fashion......Page 62
The Wisdom of Taoist Philosophy......Page 63
A New Client’s Vulnerability and Ambivalence......Page 64
The Bona Fide Agent of Change: The Therapeutic Relationship......Page 65
Through Therapists’ Empathy, Clients Learn Experiential Acceptance......Page 66
The Lost Art of Conversation......Page 67
Attending Behaviors: SOLER......Page 68
Stay Tuned into Our Own Inner Reactions......Page 69
Rapport and Assessment: The First Stage of Counseling......Page 70
1. Paraphrasing: Reflecting the Verbal Content......Page 71
Paraphrase the Key Points: No Details......Page 72
Don’t Focus on Cognitive Process Exclusively......Page 73
We Can Figure Out Clients’ “Reactive Emotions” Just by Imagining It......Page 74
Some Misconceptions about Reflection of Feelings......Page 75
Use Metaphors to Reflect Feelings......Page 76
Use “Normative Reflections” with Special Populations......Page 77
Cautions of Reflecting Feelings......Page 78
Universal Psychological Needs......Page 81
Check the Accuracy of Your Perceptions......Page 82
What to Affirm? What to Validate?......Page 83
Make Sure that Your Validation Comes Out Proper and Genuine......Page 84
Opening Summarization......Page 85
Cross-Session Tracking......Page 86
Advanced Empathy in Context......Page 87
Listen to the Hidden Feelings......Page 88
Listen with Our Eyes—To the Nonverbal Cues......Page 89
9. Reflecting the Implicit Meanings......Page 90
How to Reflect the Implicit Meanings......Page 91
Keep Your Observations in Mind! Withhold Confrontation!......Page 92
Rating Your Own Empathic Responding: Using BARS......Page 93
An Illustration of Poor Responding......Page 95
Two Illustrations: Pulling All the Empathic Skills together......Page 96
Exercises......Page 98
Assessment and Therapist Accountability......Page 100
Review of Past Records: Indirect Assessment......Page 101
Questions for Gathering Information......Page 102
Questions for Intake......Page 103
Questions for Revealing Formative Influences......Page 104
Use Open-Ended Questions: Avoid Closed Questions......Page 105
Nurture the Client’s Answers with Empathic Responses......Page 106
Second Assessment Skill: Focusing: Hone in on a Specific Area......Page 107
Third Assessment Skill: Clarifying Statements......Page 108
Exercises......Page 109
The Task of the Intake Interview......Page 111
Four Areas to Inform in Professional Disclosure......Page 112
Initiate the Intake Interview......Page 113
Determine the Presenting Problem......Page 114
Learn about Attempted Solutions......Page 115
Check Other Issues and Emotional Concerns......Page 116
Take the Family’s Mental Health History......Page 117
Help Clients Set Positive and Specific Goals......Page 118
Exercises......Page 119
Review Intake Summary and Progress Notes before the Session......Page 121
Invite the Client to Elaborate......Page 122
Identify Exceptions to the Presenting Problem......Page 123
Revisit and Break Down the Goals into Manageable Bites......Page 124
Our Discomfort with Silence......Page 125
Show Attentiveness During Silence......Page 126
Dealing with Unproductive Silence......Page 127
The Stress of Dealing with Resistance......Page 128
Client’s Behaviors May Make Complete Sense......Page 129
Accept Where Our Client Is in the Stages of Change......Page 130
The Martial Arts of Dealing with Clients’ “I Don’t Know”......Page 131
Frame All Negative Complaints into Desirable Goals......Page 132
Use the Skills of Allowing and Normalizing......Page 133
Deal with Our Countertransference......Page 134
Three Risks of Other-Focused Reflection: Avoid Them!......Page 135
Use Tracking to Increase the Client’s Awareness When She Rambles......Page 136
Don’t Confront Clients’ Intellectualization! Use Empathy, Instead!......Page 137
Deliver and Stop!......Page 138
Get Rid of Those Vague Responses......Page 139
Keep Your Talking to the Bare Bones......Page 140
Make Your Responses More Natural with Tentative “Lead-Ins”......Page 141
Stop Content-Focused Therapy......Page 142
Use Mirroring to Deepen Your Rapport with Your Client......Page 143
To Ward Off Performance Anxiety, Ask for Time to Think......Page 144
Admit Your Misunderstanding, Bias, or Lack of Knowledge......Page 145
Exercises......Page 146
Action-Oriented Techniques: Alive and Dynamic Sessions......Page 148
Inadequate-Regulation......Page 149
What Effective Affect Regulation Looks Like in Everyday Life......Page 150
What Is Emotion Regulation, Anyway? The Four Keys......Page 151
I. Body-Oriented Directives......Page 152
1. Attention Suggestion—Focusing on Visceral Experiences......Page 153
2. Body Awareness Exercise......Page 155
3. Breathing Retraining......Page 156
4. Experiential Acceptance Retraining......Page 157
1. Cognitive Defusion......Page 159
2. Restructuring Automatic Thoughts/Beliefs......Page 160
4. Socratic Questioning: A Collaborative Examination......Page 162
The Surprise Task......Page 164
Scale the Next Step......Page 165
Evocative Questions......Page 166
Differentiate Among Visual, Auditory, Kinetic, Visual, and Tactile Types of Media......Page 167
Awareness Homework......Page 169
Cognitive-Oriented Homework......Page 170
Solution-Focused Homework......Page 171
Action-Oriented Homework......Page 172
Exercises......Page 173
Heighten Clients’ Awareness during the Second Stage of Counseling......Page 175
Second-Level Case Conceptualization: Theme and Pattern Analysis......Page 176
It Takes Sharp Eyes to Find Common Themes......Page 178
Interpersonal Neurobiology and the Recursive Nature of Coping Patterns......Page 179
Our Relational Realities Co-constructed by Our Coping Behaviors......Page 180
Conscious Choices versus Unconscious Attempts......Page 181
Creating New Neuron Pathways to Replace Old Neuron Networks......Page 182
Deliver the Common Theme Tentatively......Page 183
Deliver an Entirely Different Theme: Clients’ Heroic Triumph or Resiliency......Page 184
II. Interpreting Coping Patterns......Page 185
The Obstacles to Growth and How to Remove Them......Page 186
How to Handle Client Reactions to Your Interpretation......Page 187
Examples of Pattern Interpretation......Page 188
Connect the Coping Pattern to the Common Theme......Page 189
Use Counselor Self-Disclosure with Well Thought-Out Intentionality......Page 190
Too Much Counselor Self-Disclosure Can Cause Problems......Page 191
1. Personal Disclosure......Page 192
Immediacy: A Therapist’s Best Friend......Page 194
Address The Elephant in the Room—In the Here-and-Now Relationship......Page 195
Disclose How You Feel During the Here-and-Now Relationship Talk......Page 197
1. Positive Feedback......Page 198
2. Constructive Feedback—Process Comment or Impact Disclosure......Page 199
Three Things Not to Do When Giving Constructive Feedback......Page 201
The Best Time to Give Constructive Feedback—Notice the Two Cues......Page 202
Five Principles of Giving Constructive Feedback......Page 203
Examples of How to Give Constructive Feedback......Page 204
VI. Triangles of Insight: An Interpretation Skill......Page 205
Help Clients Work through Emotionally Charged Relational Patterns......Page 206
VII. Challenge and Proper Confrontation......Page 207
When Not to Use a Challenge Response......Page 208
Principles of Using Challenge Response......Page 209
1. Challenging Clients’ Discrepancies......Page 210
2. Challenging Client’s Distortions......Page 211
4. Nudging Clients to Act......Page 212
Exercises......Page 213
Intervention Techniques in High Gear......Page 215
The Roots of Schemas......Page 216
Behavior Change First, Then Schema Restructuring Will Follow......Page 217
I. Life Skill Training......Page 218
1. Role Play......Page 219
2. Role Reversal......Page 220
II. Mindfulness Training for Schema Change......Page 222
How to Coach Clients to Use Mindfulness As a New Response Repertoire......Page 223
Consolidate New Responses......Page 225
Loving-Kindness Meditation for “The Child-Self ”......Page 226
Cultivate the Observer-Self......Page 227
1. Guided Imagery for Reprogramming Self-Schema......Page 228
2. Attending Your Own Funeral......Page 230
1. Self-Affirmation Training......Page 231
Symptom Prescription As a Treatment......Page 233
Similar to, Yet Different from Role Reversal......Page 234
Methods of Conducting the Interview......Page 235
How to Use Parts Dialog to Facilitate Integration of Splits......Page 236
VIII. The Empty Chair Technique: Mutual Empathy Training......Page 237
Develop Mutual Empathy with an Unavailable Person......Page 238
A Case in Point......Page 239
Get the Enactment Going......Page 240
Make Process Comments on Clients’ Deflected or Constricted Emotions......Page 241
Change to the Other Chair after the Emotions Have Waned......Page 242
Stay with the Ebb and Flow of Emotions until All Are Released......Page 243
Processing......Page 244
Reconnect to Those Internal Representations of Important Others......Page 245
Exercises......Page 246
The Tasks of the Termination Stage......Page 248
Discuss the Termination Process with Clients Prior to Termination......Page 249
How to Conduct a Productive Termination......Page 250
Track the Client’s Narrative Change: Pursue the Change Talk......Page 251
Help Clients Extend Their New Self-Narrative to the Future......Page 252
Create a Ritual of Saying Goodbye: Share Appreciation and Regret......Page 254
Exercises......Page 255
Types of Disability......Page 257
Avoid Diagnostic Overshadowing......Page 258
Seek Consultations and Open Ourselves to Learning......Page 259
How to Address Persons with a Mental Health Diagnosis......Page 260
Let Our Language Convey Respect for Our Clients......Page 261
Counseling Children with LD throughout the Four Stages of Therapy......Page 262
Counseling College Students with Learning Disabilities......Page 264
Animal-Assisted Therapies......Page 266
Dance and Movement Therapies......Page 267
Educate Ourselves about the Client’s Physical Disabilities......Page 268
Include the Family and Caregivers in Therapy......Page 269
Exercises......Page 270
Multiculturalism......Page 272
Understand the Person and His Issues within the Social and Cultural Context......Page 273
Be Sensitive in Our Use of Language......Page 274
1. Don’t Assume You Know How Your Clients Identify Themselves: Always Ask......Page 275
2. Acknowledge Differences between Counselors and Clients......Page 276
3. No Need for Matching Therapists’ and Clients’ Race, Ethnicity, or Culture......Page 277
4. Use Racially and Culturally Appropriate Intervention Strategies......Page 278
5. Be Open to Learn: Seek Referrals When Appropriate......Page 279
6. Be Creative in Choosing Your Techniques......Page 280
7. Understand the Universal Themes and also Recognize the Unique Differences......Page 281
Step Outside Our Comfort Zone: Experience the World of Our Clients......Page 282
Join a Network of Counselors and Therapists......Page 283
Exercises......Page 284
Your Impostor Cycle......Page 285
On Board to Meet Standard of Care......Page 286
Intake Summary......Page 287
Four Major Formats of Progress Notes......Page 288
Our Professional Hazard—Burnout......Page 289
Practical Suggestions for Therapist Self-Care......Page 290
Appreciate Our Privilege......Page 291
Appendix A: An Example of a Service Disclosure Brochure......Page 293
Appendix B: Intake Notes......Page 295
Appendix C: SOAP Progress Notes......Page 297
Appendix D: Discharge Summary......Page 299
References......Page 300
Index......Page 312

Citation preview

Individual Counseling and Therapy

Individual Counseling and Therapy, third edition, goes beyond the typical counseling textbook to teach the language of therapy from the basic to the advanced. Lucidly written and engaging, this text integrates theory and practice with richly illustrated, real-life case examples and dialogues that demystify the counseling process. Readers will learn how to use winning skills and techniques tailored to serve clients—from intake to problem exploration, awareness raising, problem resolution, and termination. Students have much to gain from the text’s depth, insights, candor, and practicality—and less to be befuddled by while they develop their therapeutic voice for clinical practice. PowerPoints, chapter test questions, and an instructor’s manual are available for download. Mei-whei Chen, PhD, is a professor at Northeastern Illinois University, where she teaches individual counseling, group counseling, theories in counseling and psychotherapy, mental health counseling, grief counseling, and stress management. She has received the Faculty Excellence Award three times and the Beverly Brown Award. Dr. Chen is also a clinical psychologist in private practice. Nan J. Giblin, PhD, is a professor emerita at Northeastern Illinois University, where she was a professor in counselor education for thirty years and served as dean of the College of Education and department chair. She received the Counselor Educator of the Year Award (2010) in Illinois. Dr. Giblin is also a clinical psychologist in private practice and specializes in supervision, grief counseling, and issues related to aging.

Individual Counseling and Therapy Skills and Techniques Third Edition

Mei-whei Chen Nan J. Giblin

Third edition published 2018 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2018 Mei-whei Chen and Nan J. Giblin The right of Mei-whei Chen and Nan J. Giblin to be identified as the authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. First published 2002 by Love Publishing Co Second edition published 2014 by Love Publishing Co Library of Congress Cataloging-in-Publication Data A catalog record for this book has been requested ISBN: 978-0-415-41520-0 (hbk) ISBN: 978-0-415-41733-4 (pbk) ISBN: 978-1-315-19765-4 (ebk) Typeset in Bembo by Florence Production Ltd, Stoodleigh, Devon, UK

Contents

Preface Acknowledgments 1

xxi xxiii 1

Theoretical Frameworks Relational–Cultural Therapy 2 Our Source of Pain—The Sense of Disconnection 2 Relationship Differentiation Thrives Only Through Longstanding Relationships 2 Failure of Mutual Empathy in Clients’ Lives and How to Resolve It 2 A Therapist’s Relational-Cultural Mindfulness—His Prime Resource 3

Interpersonal Psychotherapy 3 At the Core, Client’s Issues Are Utterly Interpersonal 3 Interpersonal Deficiency and Its Despair 4 From Interpersonal Deficiency toward Interpersonal Effectiveness 4 The “Self ” of the Therapist—The Key Instrument for Removing Clients’ Obstacles 4

Dynamically Oriented Therapy

5

Healing Comes from Corrective Emotional Experiences 5 The Client’s Fundamental Shift Through the Here-and-Now Encounter Looking at Repetition Compulsion in the Now 5 In-Depth and Intense Engagement between Therapist and Client 6 The Kind of Therapy for Therapists 6

Cognitive Behavioral Therapy

6

Using Collaborative Empiricism to Restructure Clients’ Cognitive Distortions 6 The Central Role Schemas Play in CBT 7 Using New Coping Skills and Mindfulness Techniques to Break the Reciprocal Circle 7

Experiential Approach of Therapy

8

The Dead-End in Talk Therapy and Its Solution 8 Through the Present Moment, We Work through the Past or the Future 8

5

vi Contents A Focus on Bodily Felt Experiences 8 Breaking Away from the Addiction to Experiential Avoidance

Strength-Based Therapy and Choice Theory

9

9

Using Choice Theory to Boost Clients’ Sense of Self-Efficacy Albee’s Formula of Human Suffering 9 Two Treatment Principles of Strength-Based Therapy 10

9

Constructionist Therapy 10 Solution-Focused Therapy and Narrative Therapy 10 No Predetermined Solutions: Only Curiosity 11 Small Changes Is What It Takes to Create a Snowball Effect

11

Interpersonal Neurology 11 The Emotional Brain and Its Overriding Power 11 A Shift in Therapeutic Approaches toward Bodily Rooted Emotions A New Level of Compassion for Clients’ Difficulty in Change 12 Therapy Can Increase Neuroplasticity 12 Becoming a Neurally Integrated Therapist 13

2

14

Common Therapeutic Factors Common Therapeutic Factors

14

Therapeutic Success and the Factors Contributing to It 14 Success Has Nothing to Do with Your Chosen Approach 14 Common Factors—The Heart and Soul of Therapy 15 What Constitutes Common Factors? 15

The Client Factor—The Engine of Change Clients’ Characteristics 15 Clients’ Inherent Resources 16 Clients As the True Engine of Change

The Therapeutic Relationship Factor

15

16

17

Winning the Client with a Good Therapeutic Relationship 17 The Therapist’s Theoretical Orientation or Charisma: No Bearing Honesty and Trust 17 Acceptance and Validation 18 Selfless Focus on the Client 18 Ethics: The Heart of the Healing Relationship 18

The Last Two Common Therapeutic Factors Hope and Expectancy 18 Specific Technical Expertise

The Therapist Factor

19

19

Gender and Ethnicity 20 Values and Life Experience 20 Emotional Well-Being 20

12

18

17

Contents vii A Good Match in Expectation 20 Counselors’ Self-Disclosure 20 Years of Therapist Experience 21 Competence Level 21

The Treatment Factor

21

The Trajectory of Treatment and Improvement The Cost-Cutting Trend in Treatment 22

Our Craft: The Skills and Techniques

21

22

Skills and Techniques Stand and Serve the Therapeutic Relationship 22 Counseling Skills as Skills of Connection 22 Skills and the Therapist Become One: A Vessel of Artistic Expression 23

Your “Self” As the Most Important Instrument Your Senses and Feelings 23 Your Intuition 23 The Best Way to Hone Your Craft

3

23

23

25

The Journey through the Jungle “Stages of Change” Model Stage Stage Stage Stage Stage

1: 2: 3: 4: 5:

25

Precontemplation 25 Contemplation 26 Preparation 26 Action 26 Maintenance 26

“Stages of Counseling” Model

26

Stage 1: Problem Exploration (Initial Stage) 27 Stage 2: Awareness Cultivation (Middle Stage) 27 Stage 3: Problem Resolution (Later Stage) 28 Stage 4: Termination 28 The Recursive Nature of the Counseling Stage 28

Effective versus Ineffective Response Styles

29

Seven Ineffective Response Styles 29 The Effective Response Style: Empathizer For Your Own Reflection 31

The Therapeutic Language—Our Craft The Therapeutic Language The Speaking Style 32

Overcoming Performance Anxiety

31

32

32

33

Worries that Increase Performance Anxiety 33 Observe and Negotiate with Our Inner Critic 33 Practical Suggestions for Overcoming Your Performance Anxiety

34

viii Contents Peer Counseling: A Gift for One Another

34

Experiential “Live Practice” As a Gift for one Another 34 The Triad Model of Peer Counseling and Its Working Principles 34 Allow Yourself to Experience the Exuberance of Being a Client 35 Setting Your Own Pace of Self-Disclosure 35

Reflective Practice: A Key to Your Professional Development

36

Engage in Reflective Practice 36 Ways to Enhance Reflective Practice 36 Allow Yourself to Experiment New Ways of Being 37 Let Your Brain Grow in an Accelerated Fashion 37

4

Empathic Responding Skills—The Skills of Building Connection The Soft Skills versus the Hard Skills in Counseling and Therapy The Wisdom of Taoist Philosophy 38 Cut Across the Surface Dualism of Yin and Yang

Why People Have Difficulty Opening Up

38

39

39

Premature Solution-Centered Talk Shuts People Down A New Client’s Vulnerability and Ambivalence 39

39

Empathy 40 The Bona Fide Agent of Change: The Therapeutic Relationship 40 Empathy As Validation 41 Agreement Is Not Empathy—Agreement Can Risk Triangulations 41 Through Therapists’ Empathy, Clients Learn Experiential Acceptance 41 The Client Will Internalize the Therapist’s Empathy 42 The In-and-Out Process of Empathy 42

The Lost Art of Attentive Listening

42

The Lost Art of Conversation 42 Listen to Two Levels of Message 43 Attending Behaviors: SOLER 43

What Does It Take to Respond Empathically

44

Suspend Our Own Needs Temporarily 44 Set Aside Our Own Agenda and Judgement 44 Stay Tuned into Our Own Inner Reactions 44

Level-One Case Conceptualization

45

A Triangle of Clients’ Private Experiences 45 Rapport and Assessment: The First Stage of Counseling

The Seven Basic Empathy Skills

45

46

The First Seven Empathy Skills: Basic but Not Simple 46 Basic Empathy Skills Cover a Wide Range of Therapeutic Responses 46

38

Contents ix 1. Paraphrasing: Reflecting the Verbal Content

46

Reflect Clients’ Verbal Contents or External Circumstances Paraphrase the Key Points: No Details 47

2. Reflecting the Thought Content

47

48

Thought Contents: How to Reflect Them to Convey Empathy Don’t Focus on Cognitive Process Exclusively 48 How to Reflect Clients’ Cognitive Contents 49

3. Reflecting the Feeling Content

48

49

We Can Figure Out Clients’ “Reactive Emotions” Just by Imagining It Emotions and Feelings Are to Be Accepted, Not Evaluated 50 Feelings, Thoughts, and Needs 50 Some Misconceptions about Reflection of Feelings 50 Name the Feelings 51 Use Metaphors to Reflect Feelings 51 Target Your Reflection on the Client, Not on Third Parties 52 Use “Normative Reflections” with Special Populations 52 Build Up Your Vocabulary of Feeling Words 53 Cautions of Reflecting Feelings 53

4. Reflecting Needs

56

Universal Psychological Needs 56 Reflect the Unmet Needs 57

5. Perception Checking—Checking the Accuracy of Your Empathy Check the Accuracy of Your Perceptions Respect Boundaries 58

57

57

6. Affirming/Validating 58 What to Affirm? What to Validate? 58 The Therapeutic Effect of Affirmation/Validation 59 Make Sure that Your Validation Comes Out Proper and Genuine Canned Comments Are Not Affirmations 60

7. Summarizing/Tracking 60 Opening Summarization 60 Closing Summarization 61 In-Session Tracking 61 Cross-Session Tracking 61

The Two Advanced Empathy Skills

62

Counseling As Peeling the Onion 62 Advanced Empathy in Context 62

8. Reflecting Deeply Seated Feelings

63

Listen to the Hidden Feelings 63 Listen with Our Eyes—To the Nonverbal Cues

64

59

49

x

Contents Use Nonverbal Cues to Tap into Deeply Seated Emotions Use Successive Approximations 65

9. Reflecting the Implicit Meanings

65

65

Something of Significance 66 Play Just to the Edge of Clients’ Awareness 66 How to Reflect the Implicit Meanings 66

Reminders for Empathic Responding Skills

67

Avoid Evaluative Listening 67 Don’t Try to Take the Client’s Side 67 Be Mindful of Your Nonverbal Invalidations 67 Keep Your Observations in Mind! Withhold Confrontation! 67 Calm Our “Monkey Mind”—Be Present with Our Client 68 Don’t Wait until You Have Something Perfect to Say 68

Rating Your Own Empathic Responding: Using BARS Illustrations of Empathic Responding

68

70

An Illustration of Poor Responding 70 Two Illustrations: Pulling All the Empathic Skills together

71

Exercises 73 5

75

Clinical Assessment Skills Assessment in Counseling and Therapy

75

Testing versus Non-Standardized Assessment 75 Assessment and Therapist Accountability 75 Assessment and Reassessment: A Continuous Process 76 Qualitative Assessment: Face-to-Face Clinical Interview 76 Behavioral Assessment 76 Review of Past Records: Indirect Assessment 76

First Assessment Skill: Probing Questions

77

Questions for Gathering Information 77 Questions for Intake 78 Questions for Revealing Formative Influences

Principles of Using Probing Questions

79

80

Warning: Questions Are Inherently Controlling 80 Revise Probing Questions into Clarifying Statements 80 Use Open-Ended Questions: Avoid Closed Questions 80 Avoid Stacking Questions or a Series of Questions 81 Nurture the Client’s Answers with Empathic Responses 81 Avoid “Why” Questions or Accusatory Questions 82 Avoid Strategic Questions or Leading Questions 82

Contents xi Second Assessment Skill: Focusing: Hone in on a Specific Area

82

Zoom in on a “Problem” 83 Zoom in on a “Feeling” 83

Third Assessment Skill: Clarifying Statements

83

Clarifying Statements As an Invitation Response 84 The Two Components of a Clarifying Statement 84

Exercises 84 6

86

How to Conduct the Intake Interview The Intake Interview

86

Kick Start a Continuous Process of Assessment The Task of the Intake Interview 86 The Value of the Intake Interview 87 Other Aspects of the Intake 87

Professional Disclosure and Informed Consent

86

87

Four Areas to Inform in Professional Disclosure 87 An Example of Professional Disclosure and Informed Consent

Conducting the Intake Interview in Style: Cool Head, Warm Heart Initiate the Intake Interview 88 Determine the Presenting Problem 89 Take the History of the Problem 90 Learn about Attempted Solutions 90 Check Other Issues and Emotional Concerns 91 Find Out Relationship Dynamics in the Family of Origin Take the Family’s Mental Health History 92 Take Notes on Personal Resources and Strengths 93 Help Clients Set Positive and Specific Goals 93 Final Summarization and Explanation 94

88

88

92

Exercises 94 7

Dealing with Difficult Situations in Counseling and Therapy Dealing with the Second Session Anxiety

96

The Second Session Anxiety 96 Review Intake Summary and Progress Notes before the Session 96 Reestablish Rapport by a Greeting and a Summarization 97 Invite the Client to Elaborate 97 Stay with the Topics! Track! Track! 98 Assess the Common Denominator of the Attempted Solutions 98 Identify Exceptions to the Presenting Problem 98 Point Out the Positive Pattern Underlying the Exceptions 99 Revisit and Break Down the Goals into Manageable Bites 99 Give a Take-Home Exercise 100 Inquire into the Client’s Personal Experience with You 100

96

xii

Contents Dealing with Silence

100

Our Discomfort with Silence 100 The Therapeutic Power of Silence 101 Develop a Positive Relationship with Silence 101 Show Attentiveness During Silence 101 Use Process Questions or Process Comments Afterwards Dealing with Unproductive Silence 102 Be Mindful of the Cultural Context of Silence 103

Dealing with Resistance and Ambivalence

102

103

The Signals of Resistance 103 The Stress of Dealing with Resistance 103 Two New Ways to Look at Client Resistance 104 Client’s Behaviors May Make Complete Sense 104 Don’t Focus on Change Too Fast 105 Accept Where Our Client Is in the Stages of Change 105 Stay Away From the Questioning Mode! Don’t Ask Leading Questions! 106 Don’t Assume the “Expert” Role. Instead, Take a One-Down Position. 106 The Martial Arts of Dealing with Clients’ “I Don’t Know” 106 Join Clients’ Perceptions of the Problem 107 Frame All Negative Complaints into Desirable Goals 107 Use Statements that Encourage Collaboration 108 Use the Skills of Allowing and Normalizing 108 Prevent Resistance in the First Place 109 Respect Clients’ Right to Resist—A Zen Attitude 109 Deal with Our Countertransference 109

Deepening Clients’ Awareness, Not Their Anxiety

110

Regularly Address the Client by Her Name 110 Use Client-Focused Reflection to Help Clients Self-Observe 110 Three Risks of Other-Focused Reflection: Avoid Them! 110 Don’t Ask “How Does that Make You Feel?” 111 Use Tracking to Increase the Client’s Awareness When She Rambles 111 Use Experiential Focusing to Help a Rambling Client Become Aware 112 Don’t Confront Clients’ Intellectualization! Use Empathy, Instead! 112

Removing Your Own Communication Barriers

113

Talk No More Than 30 percent 113 Deliver and Stop! 113 Be Assertive in Your Delivery 114 Get Rid of Those Vague Responses 114 Knock Out Those Discounting Reassurances 115 Break Away from Your Own Intellectualizing Tendency Keep Your Talking to the Bare Bones 115

Dealing with Your Own Doubts and Discomforts

115

116

Make Your Responses More Natural with Tentative “Lead-Ins” Manage Your Discomfort with Unlikable Clients 117

116

Contents xiii Stop Content-Focused Therapy 117 When in Doubt, Focus on Feelings 118 Use Mirroring to Deepen Your Rapport with Your Client 118

Taking Care of Yourself in the Session

119

Take Care of Yourself Even Before the Session 119 To Ward Off Performance Anxiety, Ask for Time to Think 119 Find Out What Is Expected of You 120 Admit Your Misunderstanding, Bias, or Lack of Knowledge 120 Don’t Think! Look! Look at the Process of the Session! 121 Expect Highs and Lows 121

Exercises 121 8

123

Basic Intervention Techniques Alive and Energetic Sessions via Intervention Techniques

123

Intervention Techniques versus Generic Counseling Skills 123 Action-Oriented Techniques: Alive and Dynamic Sessions 123 Intervention Techniques and Treatment Plans 124

Affect Regulation 124 Affect Regulation Difficulties 124 Inadequate-Regulation 124 Over-Regulation 125 What Effective Affect Regulation Looks Like in Everyday Life 125 Not the Same as Control of Negative Emotions 126 Not the Same as Keeping Emotional Intensity Low, Either 126 What Is Emotion Regulation, Anyway? The Four Keys 126 Counseling Skills and Techniques to Enhance Client Emotion Regulation 127

I. Body-Oriented Directives 1. 2. 3. 4.

127

Attention Suggestion—Focusing on Visceral Experiences Body Awareness Exercise 130 Breathing Retraining 131 Experiential Acceptance Retraining 132

II. Cognitive-Restructuring and Socratic Questioning 1. 2. 3. 4.

134

Cognitive Defusion 134 Restructuring Automatic Thoughts/Beliefs 135 Restructuring the Shoulds and the Musts 137 Socratic Questioning: A Collaborative Examination

III. Solution-focused Questioning

139

The Miracle Question 139 The Surprise Task 139 The “How-Do-You-Do-That” Question Scale the Next Step 140

140

137

128

xiv

Contents IV. Motivational Interviewing

141

Evocative Questions 141 Extreme Questions 142 Looking-Back Questions 142

V. Expressive Arts Techniques

142

Tap into Clients’ Favorite Ways of Self-Expression 142 Differentiate Among Visual, Auditory, Kinetic, Visual, and Tactile Types of Media 142

VI. Take-Home Exercises/Homework Assignments

144

Awareness Homework 144 Cognitive-Oriented Homework 145 Behavioral Activation Homework 146 Solution-Focused Homework 146 Action-Oriented Homework 147

Exercises 148 9

150

Influencing Skills Heighten Clients’ Awareness with Influencing Skills

150

Heighten Clients’ Awareness during the Second Stage of Counseling Blend the Influencing Skills into Your Empathic Skills 151 An Overview of the Influencing Skills 151

Second-Level Case Conceptualization: Theme and Pattern Analysis

150

151

A Good Case Conceptualization Can Keep Us from Getting Lost 153 Look for Repetition in Client’s Message 153 It Takes Sharp Eyes to Find Common Themes 153 What Are Patterned Coping Behaviors? 154 Interpersonal Neurobiology and the Recursive Nature of Coping Patterns 154 Our Relational Realities Co-constructed by Our Coping Behaviors 155 Conscious Choices versus Unconscious Attempts 156 Seeing a Vicious Circle Is Often an Eye-Opening Experience 157 Creating New Neuron Pathways to Replace Old Neuron Networks 157

I. Interpreting Common Themes and Resiliency

158

How to Find the Common Theme? 158 Deliver the Common Theme Tentatively 158 Deliver an Entirely Different Theme: Clients’ Heroic Triumph or Resiliency 159

II. Interpreting Coping Patterns

160

Case Examples of Coping Patterns Becoming Maladaptive 161 The Obstacles to Growth and How to Remove Them 161 The Best Time to Offer Your Interpretation of a Pattern 162 Principles to Follow When Delivering Pattern-Interpretation to Clients 162

Contents xv How to Handle Client Reactions to Your Interpretation 162 Examples of Pattern Interpretation 163 Connect the Coping Pattern to the Common Theme 164 Follow Up by Asking “The Question” 165

III. Counselor Self-Disclosure: Basic Level

165

Use Counselor Self-Disclosure with Well Thought-Out Intentionality 165 Counselor Self-Disclosure versus Self-Disclosure in Social Interaction 166 Use Counselor Self-Disclosure with Certain Populations 166 Too Much Counselor Self-Disclosure Can Cause Problems 166 A Table of Proper Counselor Self-Disclosure 167 1. Personal Disclosure 167 2. Self-Involving Disclosure 169

IV. Immediacy 169 Immediacy: A Therapist’s Best Friend 169 The Highest Level of Intimate Communication 170 Help Clients Talk Openly about Their Here-and-Now Experiences with You 170 Address The Elephant in the Room—In the Here-and-Now Relationship 170 Disclose How You Feel During the Here-and-Now Relationship Talk

172

V. Feedback-Giving 173 1. Positive Feedback 173 2. Constructive Feedback—Process Comment or Impact Disclosure 174 Constructive Feedback: Unusual Yet Effective for Client Transformation 176 Using “Impact Disclosure” to Give Constructive Feedback 176 Three Things Not to Do When Giving Constructive Feedback 176 The Best Time to Give Constructive Feedback—Notice the Two Cues 177 Package Your Interpersonal Feedback with Care and Acceptance 178 Five Principles of Giving Constructive Feedback 178 Examples of How to Give Constructive Feedback 179

VI. Triangles of Insight: An Interpretation Skill

180

Repetition Compulsion and Relational Schema Playing Out in the Session 181 Help Clients Work through Emotionally Charged Relational Patterns 181 Principles of Using the Triangle of Insight 182 Examples of How to Use Triangles of Insight 182

VII. Challenge and Proper Confrontation

182

What Client Behaviors Merit Your Challenges?

183

xvi

Contents You Can Challenge As Much As You Have Supported 183 Challenge Responses as an “Act of Grace” 183 When Not to Use a Challenge Response 183 Principles of Using Challenge Response 184 1. Challenging Clients’ Discrepancies 185 Be Respectful toward Culturally Conditioned Discrepancy 186 2. Challenging Client’s Distortions 186 3. Challenging Clients’ Disowning of Strengths 187 4. Nudging Clients to Act 187 5. Confronting Clients with Ignored Information 188

Exercises 188 190

10 Advanced Intervention Techniques Energize Clients with Higher Level of Change Actions The Problem Resolution Stage of Counseling Intervention Techniques in High Gear 190

Third Level Case Conceptualization

190

190

191

Schemas: Deep-Rooted Thought Patterns and Core Beliefs 191 The Roots of Schemas 191 Examples of Early Maladaptive Schemas 192 Behavior Change First, Then Schema Restructuring Will Follow 192

I. Life Skill Training

193

Life Skill Training via a Hands-On Approach 1. Role Play 194 2. Role Reversal 195

II. Mindfulness Training for Schema Change

194

197

Practice Mindfulness When Maladaptive Schemas Are Triggered 198 How to Coach Clients to Use Mindfulness As a New Response Repertoire 198 Consolidate New Responses 200 Loving-Kindness Meditation for “The Child-Self ” 201 Cultivate the Observer-Self 202

III. Guided Imagery and Therapeutic Suggestions

203

1. Guided Imagery for Reprogramming Self-Schema 2. Attending Your Own Funeral 205

IV. Experiential Teaching

206

1. Self-Affirmation Training 206 2. Reowning and Reclaiming Training

V. Paradox

208

208

Symptom Prescription As a Treatment Examples of Paradox Technique 209

208

203

Contents xvii VI. Interviewing “The Internalized Other”—A Narrative Therapy Technique 209 The Therapist Interviewing a Referred Person Absent from the Room Similar to, Yet Different from Role Reversal 209 Methods of Conducting the Interview 210

209

VII. Part Dialog: Working with Polarized Parts 211 Splits—Polarized Parts—and Internal Tension 211 How to Use Parts Dialog to Facilitate Integration of Splits

VIII. The Empty Chair Technique: Mutual Empathy Training

211

212

The Four Components of the Empty Chair Technique 213 Empty Chair Technique As a Monodrama 213 Unfinished Business 213 Develop Mutual Empathy with an Unavailable Person 213 Bring Closure and Healing to Unfinished Business 214 A Case in Point 214 Provide the Rationale for Use of the Technique 215 Set Up the Two Chairs and Seating Arrangement 215 Get the Enactment Going 215 Do Not Ask Questions! Just Make Process Suggestions! 216 Direct Clients to Change Global Complaints to Specific Resentment 216 Use Attention Suggestion to Direct the Dialog 216 Make Process Comments on Clients’ Deflected or Constricted Emotions 216 Foster Congruency between Verbal and Nonverbal Expressions 217 Support Full Affect Experience 217 Change to the Other Chair after the Emotions Have Waned 217 Evoke Empathic Responses in the Other Person 218 Feed the Person Some Sentences to Try-On 218 Bring on Heart-Felt Responses to Each Other 218 Help the Client Tell the Truth of the Internal Conflict 218 Stay with the Ebb and Flow of Emotions until All Are Released 218 Close the Empty Chair Dialog 219 Processing 219

Healing and Meaning—Reconstruction

220

Co-Construct a New Narrative of Life 220 Reconnect to Those Internal Representations of Important Others Reorganize the New Self-Narrative 221

220

Exercises 221 223

11 Termination Skills The Stage of Termination

223

Loss and Separation in the Termination Stage The Tasks of the Termination Stage 223 On Premature Termination 224

223

xviii Contents Principles of Terminating a Therapeutic Relationship

224

Never Terminate Suddenly Unless it is Unavoidable 224 Discuss the Termination Process with Clients Prior to Termination 224 Reassure an Intermittent Termination or Slowly Wean Them Off 225 Help Clients See Termination As a “Graduation” from Therapy 225 Embrace Separation As a Pathway toward Individuation 225

How to Conduct a Productive Termination

225

Process Feelings of Separation Prior to Termination 226 Use the Scaling Question to Assess Client Progress 226 Track the Client’s Narrative Change: Pursue the Change Talk 226 Help Clients Extend Their New Self-Narrative to the Future 227 Give and Receive Feedback 229 Make Referrals If Necessary 229 Create a Ritual of Saying Goodbye: Share Appreciation and Regret 229

Exercises 230 232

12 Counseling Persons with Special Needs Clients with Disabilities

232

Types of Disability 232 The Challenges of Living with a Disability 233 How Mental Health Therapists Can Help 233

Developing Cultural Competence in Working with Clients with Disabilities Avoid Diagnostic Overshadowing 233 Go Beyond Empathy! Challenge the Clients! 234 Seek Consultations and Open Ourselves to Learning

The Proper Language to Use

233

234

235

Avoid Labels that Diminish the Person 235 Put the Person First 235 How to Address Persons with a Mental Health Diagnosis 235 Avoid Making Generalizations about Persons with Disabilities 236 Avoid Blaming the Victim 236 Let Our Language Convey Respect for Our Clients 236

Counseling Children and Youth with Learning Disabilities

237

The Social and Emotional Challenges Endured By Children with Learning Disability 237 Counseling Children with LD throughout the Four Stages of Therapy 237 Counseling College Students with Learning Disabilities 239

Counseling Children with Autism

241

Animal-Assisted Therapies 241 Equine Therapy 242 Dance and Movement Therapies

242

Contents xix Counseling Persons with Physical Disabilities

243

The Challenge of Establishing Rapport with Persons with a Physical Disability 243 Tips for Counseling after the Initial Interactions 243 Educate Ourselves about the Client’s Physical Disabilities 243 Watch Out for Comorbidity 244 A List of Suggestions 244

Other Considerations When Working with Clients with Special Needs

244

Include the Family and Caregivers in Therapy 244 Provide Both Compassion and Challenges in the Therapeutic Relationship

245

Exercises 245 13 Counseling Persons with Diverse and Multicultural Backgrounds Diversity versus Multiculturalism

247

Diversity 247 Multiculturalism 247 Biases and Prejudices: Racism and Microaggressions

248

Building Your Competence in Working with Diverse and Multicultural Clients 248 Understand the Person and His Issues within the Social and Cultural Context 248 Be Aware! Our Clients Could Be Underdiagnosed or Overdiagnosed 249 Be Flexible in Our Counseling Style 249 Be Sensitive in Our Use of Language 249 Be Self-Reflective, but Don’t Be Worried about Saying the Right Thing 250

Seven Guidelines for Multicultural Counseling

250

1. Don’t Assume You Know How Your Clients Identify Themselves: Always Ask 250 2. Acknowledge Differences between Counselors and Clients 251 3. No Need for Matching Therapists’ and Clients’ Race, Ethnicity, or Culture 252 4. Use Racially and Culturally Appropriate Intervention Strategies 253 5. Be Open to Learn: Seek Referrals When Appropriate 254 6. Be Creative in Choosing Your Techniques 255 7. Understand the Universal Themes and also Recognize the Unique Differences 256

Increasing Our Cultural Sensitivity

257

Advocate for Social Justice 257 Step Outside Our Comfort Zone: Experience the World of Our Clients Seek Out Additional Multicultural Training 258 Join a Network of Counselors and Therapists 258

Exercises 259

257

247

xx

Contents 260

14 The Journey Forward—Into the Practical World Welcome to the World of the Imposter Phenomenon

260

On Board with the Feeling of Being an Imposter 260 Your Impostor Cycle 260 You Are at the Right Place Where You Need to Be 261 Embrace a Realistic Expectation—A Lifelong Learning 261

Welcome to the World of Documentation and Record Keeping

261

On Board to Meet Standard of Care 261 Case Notes—The Heart of Documentation 262 Intake Summary 262 Progress Notes 263 Four Major Formats of Progress Notes 263 Termination Summary 264

Burnout and Therapists’ Self-Care

264

Our Professional Hazard—Burnout 264 Practical Suggestions for Therapist Self-Care Take Care of Your Inner World 266

Appreciate Our Privilege

265

266

Appendix A: An Example of a Service Disclosure Brochure

268

Appendix B: Intake Notes

270

Appendix C: SOAP Progress Notes

272

Appendix D: Discharge Summary

274

References Index

275 287

Preface

In his book, The gift of therapy, Yalom (2009) speaks of his unyielding effort to eliminate the mystical veil surrounding the art of therapy. All these years since the first edition of this text, we have been on the same path as Yalom. But in this text—Individual Counseling and Therapy: Skills and Techniques—we focus our effort to uncover the mystical veil specific to the therapeutic language. Through our extensive teaching, supervision, and clinical experiences, we observed that counselor and therapist trainees often have a good grasp on a wide range of theoretical frameworks, assessment and evaluation, and the nature of clients’ struggles. However, when it comes to facing clients, they often feel inadequate in therapeutic dialogue. “What do I actually say to my client?” they often so nervously ask. This text is our effort to bridge the gap that exists between theoretical knowledge and actual clinical practice. Step by step, we break down the mystique of therapeutic language into numerous small palatable skills and techniques. Example by example, we illuminate how each skill and technique can be implemented in a wide range of counseling and therapy scenarios. Though much energy has been dedicated to crafting the precise ways in which therapeutic messages can be put into words, this book does not concern wording and phrasing alone. What’s more, it exerts most of its effort in elucidating the therapeutic intent behind each skill and technique. From our countless conversations with those who are actively using this text, it is clear that the skills and techniques in this text have made significant contributions to the growth of counselor and therapist trainees as they foray into the exhilarating journey of helping others. Through the feedback received from them, we learn this: when budding counselors read the skills and techniques illustrated in conversational words, they feel like a light bulb goes on; the abstract and foggy concepts that they have learned in the theoretical frameworks suddenly become tangible and clear to them. We rejoice in hearing that this text has had a myriad of positive impacts on so many novice counselors. Their growth reaps the greatest reward for us. As we stated in our first edition, we feel privileged to write this book. For us, words are magic. We have been drawn to the verbal profession—the counseling and therapy profession—because we believe in the healing power of words. When expressed in compassion and from our inner truth, our words have the power to heal, expand, renew, and empower our clients and ourselves. Like a parent feeling the excitement and wonder in watching his or her child grow and mature, we feel the awe of watching the advance of this text into its third edition.

xxii

Preface

So what is new in the third edition? In addition to expected updates and revisions, Mei adds an entirely new chapter—Chapter 14: The Journey Forward—Into the Practical World. This new chapter covers: • • •

The imposter phenomenon The demand for documentation and record keeping in the field practice Therapists’ self-care and burnout prevention

What’s more, Mei adds a lot of new materials into various chapters. The following list provides a glimpse of them: • • • • • • • • • • • •

Interpersonal neurology (in Chapter 1) Dealing with the second session anxiety (in Chapter 7) Dealing with silence (in Chapter 7) Dealing with resistance and ambivalence (in Chapter 7) Affect regulation (in Chapter 8) Process resistance, process comments, feedback, and reality testing (in Chapter 10) Healing and reconstruction of meaning (in Chapter 10) Principles of terminating a therapeutic relationship (in Chapter 11) Tracking the client’s narrative change: pursue the change talk (in Chapter 11) Avoiding diagnostic overshadowing (in Chapter 12) Go beyond empathy! Challenge the clients! (in Chapter 12) Diversity versus multiculturalism (in Chapter 13)

Despite the new addition and expansions, this text keeps the basic flow of the previous editions. That is, the skills and techniques are presented in parallel with the stages of the counseling process. It follows the path from the more basic and less intense, progressing toward the more complex and intense. Mei has also brought many enrichments to the areas of advanced skills, advanced intervention techniques, and case conceptualization. These three areas usually get little coverage in counseling skill related textbooks. This book strives to magnify each of them. This book draws heavily on our own experiences in counseling, teaching, and supervising. We have been careful to ensure the anonymity of the clients in those clinical examples illustrated in this book.

Acknowledgments

We wish to thank our students, supervisees, and clients who often teach us more than we teach them. Our thanks especially go to our publisher, Routledge, for affording us the privilege to share our insights with a broader audience. Most importantly, our earnest gratitude goes to the Senior Editor at Routledge, Anna A. Moore, for her support, feedback, wisdom, and outstanding decision-making capacity. Special thanks go to Nina Guttapalle, editorial assistant, for her patience, understanding, and responsiveness; to Chantelle Walker and her marketing department for their commendable marketing strategies; to our copyeditor, and finally, to Jess Bithrey and her production team at Florence Production Ltd, UK, for their meticulousness and attentiveness. SPECIAL ACKNOWLEDGMENT FROM MEI My warmest thanks go to my co-author, Dr. Nan Giblin. Although I write the bulk of this text, I would not be able to accomplish all if not because of Nan’s contribution to the following: scores of skill illustrations and case examples in various chapters; the exercise section at the end of each chapter; the expressive art therapy section in Chapter 8; the techniques of counseling persons with special needs in Chapter 12; the specific techniques of counseling clients with diverse and multicultural counseling in Chapter 13; as well as all the online materials including PowerPoint slices, test banks, and the instructor’s manual. Nan has a great sense of humor, a rich imagination, and a charming charisma. During her tenure, Nan had served, at various stages of her career, as the Dean of the College, the department chair, and the teaching faculty. Nan was also the recipient of Counselor Educator of The Year Award of 2010 in Illinois and other numerous awards. I feel honored that Nan accepted my invitation to be my co-author. From the deepest of my hearts, I want to thank Ed Porter, Annie Huston, and Sarah Cozzi for providing assistance in editorial and grammatical help for the third edition. Like gardeners, you guys meticulously go through each chapter to prune back my sentences and pull out grammatical weeds. Your linguistic sensitivity enhances the quality of my writing. As well, I want to thank Ana Ferraz-Castilho for helping me carry out researches needed for the reference update. Thank you, Ana, for doing such an outstanding job that requires painstaking attention to details. Without your help, I would have been bogged down by this task. I want to thank the various significant mentors throughout my clinical training. I wish to thank Dr. Paula Seikel for introducing me to the profound art of Narrative therapy and the amazing techniques developed by Carl Tomm. Her continuous support

xxiv

Acknowledgments

and faith in me is a gift that I can only pay forward to the next generation of new counselors and therapists. I also want to thank Dr. John Littrell for initiating my interest in brief therapy, solution-focused therapy, and the MRI group. I can certainly trace the way I conceptualize cases back to the root of social constructionist impact. My heartfelt thanks go to the faculty of Indiana University, Bloomington, especially Dr. Thomas Froehle, Dr. Rex Stockton, and Dr. Alan Bell, for rooting me on to a rigorous groundwork in the art and science of Counseling Psychology, and a blissful inception in the art of teaching and supervision. I cannot thank enough my extended family and my friends for their encouragement, support, devotion, and sacrifice during the long process of my composing this new edition. Lastly, I want to thank all the great therapists and theoreticians who have inspired me with the rich literature as well as theories and techniques of counseling and therapy. Without them, this text would not have been born. SPECIAL ACKNOWLEDGMENT FROM NAN I would first like to thank Dr. Mei-whei Chen, a three-time recipient of the Northeastern Illinois University Faculty Excellence Award as well as the Beverly Brown Award, for giving me the opportunity to be her co-author on all three of the editions of this book. Mei is an excellent writer who is able to structure material in a way that promotes student learning and understanding. Her ideas are practical while offering students the freedom to develop their own professional styles of counseling. Her understanding of the importance of clear language comes from her ability to speak and write in several languages. Mei has taken great care to insure that the language in this edition of the book is lively, specific in meaning, and culturally sensitive. Mei is passionate about her writing, clinical practice, and her teaching. Writing this book and then using it with graduate students has been one of the most rewarding experiences of my career. I am grateful for the students in each Individual Counseling class who have given me feedback on the strengths of the book and areas for improvement. A book of this kind is an evolving work which develops and improves with each edition. Special thanks to my husband, Walter, and my son, Daniel, who are always willing to discuss ideas and help with technical support. I would like to thank many individuals who contributed ideas and information on counseling persons with special needs in Chapter 12 as well as counseling clients with diverse and multicultural counseling in Chapter 13, including Dr. Beverly Otto, Dr. Don Catherall, Dr. Judy Sutherland, Dr. Frances Ryan, D.C., Dr. Rosemary Egan, Dr. Michele Kane, Dr. Sara Schwarzbaum, Dr. Saba Ayman-Nolley, Ms. Ebony Jimenez Lee, Dr. Shedeh Tavakoli, Dr. Michelle Marme, Ms. Dona Wisniewski, Ms. Jackie Johnson, Dr. Lee Beaty, and the many people who contribute to the Conferences on Art in Response to Violence at Northeastern Illinois University. I am especially grateful that I have the opportunity to work at Northeastern Illinois University in Chicago, where scholarly, creative writing is encouraged and supported. For many years, Northeastern has been named by U. S. World and News Report as the most diverse university in the Midwest. Working with faculty from diverse populations and teaching to a diverse student body has afforded me access to ideas that help me grow personally and professionally. Finally, thanks to the readers of this book, the students who are dedicating their lives to a profession aimed at helping people who are suffering as they strive to restore peace and balance to their lives, their families, and ultimately to the world.

1

Theoretical Frameworks

As those who have played chess know well, the game requires razor-sharp concentration. Not only must the chess player carefully contemplate the ramifications of each of his moves, but he also must respond creatively and strategically to the other player’s moves, which, at a moment’s notice, can overturn his meticulously thought-out plans. These challenges never fail to make each game dynamic and spellbinding. The practice of counseling and therapy is like the game of chess. Not that the therapist and client are opponents, each trying to win out the other. No, indeed, our goal in therapy is always to serve, not to win. But that, like the chess player, the therapist must stay on the alert for the ever-changing dynamics in the session, ready to respond creatively to what her client gives back in response. This delicate, intimate give and take between the therapist and the client is complex and unpredictable, making each session novel and transfixing. The practice of counseling and therapy is also like the art of a co-reaction. Each session requires the therapist to blend the ingenuity of the client and that of the counselor—an art of co-creation unfathomable to those from the outside looking on. Perhaps this is why Yalom (2009) states in his text, The Gift of Therapy, that therapy “consists of small and large spontaneously generated responses or techniques that are impossible to program in advance” (p. 35). If therapy sessions are “impossible to program in advance,” if the exchanges are complex and unpredictable—unfathomable to those from the outside looking on, like a chess game—then how do we prepare ourselves to become counselors and therapists? How do we learn the strategies, the trade, the craft, and the art of the therapeutic practice? This book takes these questions head-on, aiming to decipher the code of the therapeutic process—its strategies, intents, the “why” and the “how”. We will work to understand the small and large dynamics of a therapy session. Through the well-demonstrated examples in this text, you will learn the skills and the techniques to fine-tune your practice and to ground yourself in a solid foundation of the craft of our trade. You will walk into the room with your client confident that you possess the necessary knowledge base to help you brave the exciting unknown that is a therapy session. In this first chapter, we lay out the theoretical underpinnings from which the skills and techniques of this text are drawn. Counseling and therapy, in actual practice, are based on a synthesis of multiple theoretical approaches; it is only for educational purposes that we present each separately. Please note that since each approach is quite complex, an elaboration of each theory is beyond the scope of this chapter. Instead, we provide a basic introduction to each of these theoretical perspectives.

2

Theoretical Frameworks

RELATIONAL–CULTURAL THERAPY The first organizing framework of our text, Relational–Cultural Therapy (RCT) represents a new awareness of, and an antidote to, the prevailing disconnect that our society faces. Our Source of Pain—The Sense of Disconnection The major source of our stress and pain comes from a sense of disconnection that permeates every facet of our lives. This sense of disconnection is a natural offshoot of an unbalanced life wherein the cultural imperative asks each of us to mature into a fully functioning individual through the development of the separate or independent self ( Jordan, 2010). Consenting to this belief of a separate self, we measure our success and our acceptability using the yardsticks of autonomy, individuation, firm self-boundaries, independence, competitiveness, and logical thinking. We close our eyes to our innate needs of interdependence and interconnectedness. But men, women, boys, girls, regardless of age, gender, or race, are neurologically wired to need connections with others. Yet, the cultural imperative compels us to somehow pull off this unattainable goal of independence and to prove immunity to interpersonal yearning. Swimming upstream against our makeup, it is no wonder we find ourselves shackled with a sense of pervasive aloneness and shame. Relationship Differentiation Thrives Only Through Longstanding Relationships This sense of disconnection diminishes our capacity for long-lasting relationships. Relational–cultural therapists assert that each of us can grow to our full potential only through longstanding relationships, through a sense of connection. According to RCT, our growth manifests itself in two dimensions: • •

Our ability to embrace the complexity within our relationships Our capacity to be with others and to allow others to be with us in whatever capacity they have

Cultivating these two dimensions of relational growth to their full potential, we reach what Jordan (2010) terms “relationship differentiation”—a state of personal growth wherein we arrive at authenticity, mutual empathy, mutual empowerment, and interconnectedness—our true home. Without longstanding relationships as its fertile ground, relationship differentiation will never take root, let alone reach its full promise. Failure of Mutual Empathy in Clients’ Lives and How to Resolve It Much of clients’ suffering can be traced to a lack of mutual empathy in their lives (Comstock et al., 2008; Jordan, 2010; Walker, 2004). Mutual empathy is like the bread and butter of connection and longstanding relationships. Yet many clients seem completely unaware of it. They want empathic responsiveness “from” others, but they fail to demonstrate their own empathic responsiveness “to” others. As a result, they get none. To reverse human suffering, we need to resolve the failures in mutual empathy. There are ways. First, the therapist responds in a way that is so selfless, so receptive, that it diminishes the client’s sense of isolation, that it initiates the client into a path of vicarious learning—

Theoretical Frameworks 3 absorbing and mirroring the therapist’s relational empathic responsiveness. Second, the client becomes aware of how their past nonempathic relational patterns have prevented themselves from getting the empathy they want. A small change will happen organically as the client internalizes the therapist’s relational responsiveness, learns to reverse her own pattern of disconnection, and develops her own inner resources to connect with others. Though small, a change on the client’s part can kick-start a positive circle of mutual empathic responsiveness. The snowball of change then gains momentum, and the tyranny of empathy failure is eventually overthrown. A Therapist’s Relational–Cultural Mindfulness—His Prime Resource When working with clients suffering from a deep sense of disconnection, a therapist’s relational–cultural mindfulness prevails as his prime resource. Just like those clients who have been effectively turned around by practicing mindfulness—as in the new wave of cognitive behavior therapy called acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 2011)—therapists now need to practice mindfulness with their clients. For therapists, the only way to connect is to bring their own meditative presence into their sessions, to demonstrate a drastic departure from our culture of disconnect. As such, mindfulness practice affords both therapists and clients hope and tools to grow and thrive in connections. INTERPERSONAL PSYCHOTHERAPY As managed care relentlessly pushes for cost-containment, counselors and therapists have been increasingly called upon to conduct a kind of therapy that is both short-term and in-depth. To respond to this call, therapists increasingly need to find therapeutic methods that have an immense power to zoom into the heart of client issues (Chen & Rybak, 2018). For this, interpersonal psychotherapy fits the bill. It is thus the second organizing framework of this text. At the Core, Client’s Issues Are Utterly Interpersonal Entering counseling, clients often present a wide range of problems, ranging from weight issues, panic attacks, stress at work, anger management issues, insomnia, to loss and grief, just to name a few. Scrape beneath the surface, and we will find that their underlying core issues are utterly interpersonal, calling for a therapy that has the power to go beyond symptom reduction. Interpersonal psychotherapy, rooted in the interpersonal psychiatry of Harry Stack Sullivan (1968, 1971) and based on the attachment theory of John Bowlby (1977), has established itself as an effective treatment for depression. Believing that therapy should not stop at symptom reduction, it dives further into client’s real-life problems in interpersonal relationships—a primary source of depression. This focus represents an astonishing shift from Freud’s biologically based drive theory, which was the prevailing paradigm in Sullivan’s era regarding human behaviors, experiences, motivation, and accompanying clinical applications. Sullivan’s vision of interpersonally oriented therapy is so prophetic that it has spawned a lineage of interpersonal theory and study (Kiesler, 1982a; Strupp & Binder, 1984; Teyber, 2000; Teyber, McClure & Weathers, 2011).

4

Theoretical Frameworks

Interpersonal Deficiency and Its Despair Sullivan’s interpersonally oriented therapy has contributed enormously to our understanding of clients’ struggles. We are now able to track the reciprocal dynamics of interpersonal relationships that underlie most clients’ struggles—a give-and-take pattern between two people that usually fail to meet both parties’ fundamental needs. Yalom and Leszcz (2005), as part of Sullivan’s lineage, provide a constant reminder that most people seek counseling and therapy because they suffer from some fundamental deficiency in their relationships, that they have an inability to establish and maintain interpersonal relationships that mutually meet the needs of those involved. In due course, the grave despair that this deficiency creates brings them to therapy. From Interpersonal Deficiency toward Interpersonal Effectiveness Interpersonal psychotherapy focuses on how the client sees himself, how he is seen by others, and how he can reconstruct his interpersonal reality (Hirsch & Roth, 1995; Wachtel, 2011). Interpersonal psychotherapy hits the nail on the head because learning to reconstruct one’s own interpersonal reality is the essence of counseling and therapy. To reconstruct their interpersonal reality, according to Cozolino (2004), clients have to: • • • • • •

Examine their assumptions and beliefs Expand their awareness Increase their reality testing ability Confront experience that provokes their anxiety Modify their negative self-talk Develop a new adaptive life narrative

All of these will increase the client’s interpersonal effectiveness, turning their interpersonal deficiency into interpersonal fulfillment. The “Self” of the Therapist—The Key Instrument for Removing Clients’ Obstacles During the therapeutic process, both the therapist and the client inevitably bring their core identities and their established ways of being in relationships into the therapeutic encounter. Sooner or later, they will reactivate, in each other, familiar feelings from the past. Facing this challenging process, the therapist will have to rely on her “self ”—the most powerful instrument available to her, much more powerful than any skills and techniques—to facilitate clients’ learning regarding new styles of feeling, beliefs, and relating (Maroda, 2012). Yalom (2009) sums up the main tenet of interpersonal therapy with this profound insight: “Psychotherapy based on the interpersonal model is directed toward removing the obstacles to satisfying relationships” (p. 48). And the way to help clients remove their obstacles to satisfying relationships is through a relationship, albeit a therapeutic relationship—a special type of interpersonal interaction that endeavors to replace the old, ineffective interpersonal patterns with new, more adaptive ones—wherein the therapist has to summon all that is alive within his “self ” as the key instrument for client change.

Theoretical Frameworks 5 DYNAMICALLY ORIENTED THERAPY The next approach from which the skills and techniques in this text are taken from is dynamically oriented therapy, or so-called psychodynamic therapy—the approach most recognized for its concept of the corrective emotional experience (Alexander, 1980). Healing Comes from Corrective Emotional Experiences The concept of corrective emotional experiences has become the fundamental therapeutic principle of all counseling and therapy. Almost all therapists and counselors come to realize that mere cognitive reconstruction or intellectual insight does not suffice to create long-lasting change in the client. To heal the damages instigated by negative forces of the past, the client needs a corrective emotional experience. To begin with, the genuine and steadfast relationship between the client and the therapist provides a basic level of a corrective emotional experience. Moments, when the client might experience such a corrective emotional experience, may include but are not limited to the following: • •

Receiving genuine warmth and respect from the therapist—such as when the client receives a sincere apology when her comments are misunderstood. Experiencing the therapist as someone accepting her true self, her true feelings, and her true thoughts (Levenson, 1995; Summers & Barber, 2013).

The Client’s Fundamental Shift Through the Here-and-Now Encounter That said, a break-through level of a corrective emotional experience won’t happen until the client works through his resistance, learning to become attuned to his true feelings and learning to express them in the here-and-now of the therapeutic relationship. Such a here-and-now based interaction with the therapist can create a fundamental shift wherein the client feels as if something starts to dislodge—he has reached a tipping point in which he is able to leave behind his old way of being. The client’s behaviors outside therapy go through a transfiguration as well. As the client changes, people in his life begin to respond to him in new ways, treating him differently than in the past. It is a complete make-over, and the change is reciprocated by others in his life. Looking at Repetition Compulsion in the Now Without the corrective emotional experience, people tend to keep repeating in their present relationships those patterned behaviors, adaptive or maladaptive, that originated in the past—a tendency termed repetition compulsion (Summers & Barber, 2013). If we are unaware that a repetition compulsion is occurring, we, the therapists, can be jolted by the immediacy of our own emotional reactions to clients who unconsciously play out their patterns in the therapeutic relationship with us. To help clients break free from their repetition compulsion, psychodynamic therapy encourages therapists to: • • •

Explore the conflicts in the client’s current life; understand how these conflicts relate to the past. Search for recurring patterns. Look at how conflicts are repeated in the here-and-now with the therapist.

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Theoretical Frameworks

This venture provides the client and the therapist alike with profound insights as to why things happen in a certain way. This is an important step toward stopping repetition compulsion in its tracks. In-Depth and Intense Engagement between Therapist and Client Dynamically oriented therapy challenges therapists to show warmth and empathy to clients’ inner struggles and, at the same time, to remain vigilant for how clients’ old patterns replay themselves within the evolving therapeutic relationship. As a result, the therapeutic work tends to give priority to transference, countertransference, implicit meaning in the here-and-now, and the impact of early relationships. Such focus renders it possible to do in-depth treatment and to accomplish it within a reasonable amount of time. It does take intense interpersonal engagement between therapist and client, therefore, it might not be for the faint of heart. But if taken on, this kind of intense focusing has the power to reshape clients’ emotional learning in the most fundamental way (Levenson, 1995; Maroda, 2012; Summers & Barber, 2013). The Kind of Therapy for Therapists When therapists seek personal therapy for themselves, they tend to choose psychodynamic therapy, sensing that this approach proves most useful for them (McWilliams, 2004). This does not surprise us. According to McWilliams, therapists of this approach tend to base their practices on: • • • • • •

An attitude of curiosity and a sense of awe Respect for the complexity Empathy Respect for subjectivity and for emotions Appreciation of attachment Faith in the therapeutic process

It is no wonder that therapists seek out psychodynamic therapy for themselves. Receiving treatment from another therapist who emphasizes affect and intense inner experiences, therapists meet their own needs for clarity and resilience—a support much needed because the job they do, day in and day out, really demands a great deal of emotional resilience, especially when helping distressed individuals. COGNITIVE BEHAVIORAL THERAPY Another organizing framework of this text is cognitive behavioral therapy (CBT). CBT emphasizes that people’s negative interpretations and negative predictions of life events— known as cognitive distortions—cause their emotional disturbances. Using Collaborative Empiricism to Restructure Clients’ Cognitive Distortions To help clients overcome their emotional problems, cognitive therapy targets its interventions on clients’ cognitive distortions (Beck, 2014; Beck, Rush, Shaw, & Emery, 2003). Using collaborative empiricism, therapists help clients discover the inaccuracy and the maladaptive quality of their thoughts. In such collaboration, the therapist does

Theoretical Frameworks 7 not assume an expert role but rather works within the client’s frame of reference. She tries to see clients’ worlds through their eyes and, at the same time, help clients reach a conclusion about the validity of their thoughts. Thoughts that lack validity are treated as distortions. They are then replaced with more accurate, alternative ones. Often, short-term cognitive restructuring suffices to help people overcome their emotional difficulties; at times, however, when clients hold entrenched and elaborated thought patterns—something called schemas—these thought patterns won’t budge with short-term cognitive restructuring. The Central Role Schemas Play in CBT Schemas, often developed in childhood, represent our mental templates through which we process information or filter our experiences in life. These mental representations prove to be extremely self-perpetuating and resistant to change (Young, 1999). For example, children with a schema that assumes that if they don’t try to appease their caregivers they will be abandoned, usually do not question this assumption. Not even when they become adults. This abandonment schema—accompanied with maladaptive coping mechanisms that serve to prevent this abandonment from coming true— will lead to difficulties in relationships and much suffering in the client. So subtle, schemas often operate under cover, out of our awareness; so selfperpetuating, they often resist change under normal circumstances. Misled by their relational schemas, people may enter certain self-defeating relationships without much consciousness. It is only when a major life stressor hits that the ensuing intense negative emotions, thoughts, actions, and reactions will finally lead them to therapy. Working with clients’ schemas, a therapist must try to strike a balance between providing empathy to validate the clients’ pain and providing challenges to disconfirm their maladaptive core schemas. Anytime clients’ maladaptive schemas play themselves out in the counseling session, they must be addressed in the here-and-now. The skill of I-Thou Immediacy, covered in Chapter 9, can be employed to shed light on clients’ schemas, providing the first step toward emotional relearning. Using New Coping Skills and Mindfulness Techniques to Break the Reciprocal Circle Many behavioral techniques, when dovetailed with cognitive therapy, have the power to help clients change long-term behavior patterns. Meichenbaum (1990) believes stressors from external events have a reciprocal relationship with clients’ cognitive thoughts and behaviors. To break the vicious reciprocal circle, new coping skills— including relaxation techniques, self-instructional techniques, emotional self-regulation, and communication skills—can be taught to the client within the session, to initiate a beneficial feedback loop. For instance, a therapist may use role playing and role reversal (see Chapter 10) to help a client build better skills of self-expression. Processing how their self-expression comes across to others can vastly benefit clients with a reality check, a much-needed step before they apply the new behavior skills in real-life situations. Several mindfulness-based techniques, in Chapters 8 and 10 of this text, illustrate how to facilitate client change using mindfulness-based therapy (Harris, 2009). This mindfulness-based therapy is the third and most recent wave of behavior therapy.

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Theoretical Frameworks

EXPERIENTIAL APPROACH OF THERAPY Our next organizing framework—experiential therapy—provides a solution for the dead-ends that often happen in talk therapy. The Dead-End in Talk Therapy and Its Solution Talk therapy frequently stumbles upon a tribulation called “dead-end” (Gendlin, 1998). A dead-end arises when the therapist relies merely on reflecting, interpreting, and processing skills, without attending to the client’s bodily experiences. It also occurs when the client repeats certain themes and patterns, without being able to move deeper. Even though talk therapy does provide a certain degree of catharsis, when the deadend hits, the therapy loses its vitality and energy. The experiential approach provides an antidote to this very problem. It creates powerfully visceral and memorable experiences in the session, bypassing a dead-end type of discussion. For this reason, Chapters 8 and 10 present numerous experiential techniques, some basic, others advanced, each well-known for their capacity to help clients reconnect to their felt sense, moving them deeper and further into what’s alive within them. Through the Present Moment, We Work through the Past or the Future When therapy focuses on the client’s subjective phenomenological world, something usually emerges—be it an unfinished business, an awareness of feeling stuck, or a realization of certain interpersonal tasks that the client has to face (Nance, 1995). As these materials become accessible, clients then can choose to work on this unfinished business, stuckness, or interpersonal deficiency. Any closure achieved through this kind of work will lift clients’ energy and spirit, empowering them to make life-enhancing choices in their lives. Firmly grounded in the existentialism oriented schools of thought, experiential therapy has deep roots in Gestalt therapy. As Gestalt therapy focuses primarily on the present moment, so does experiential therapy. Indeed, it believes that the present moment is the only point in time through which the past or the future can be worked through (Nance, 1995). Often, a client comes into intimate contact with the present moment when a therapist guides her to focus on a directly felt sense. A Focus on Bodily Felt Experiences When we feel something in our bodies—perhaps a tightening in our throat or butterflies in our stomach—we are experiencing a direct sense. When a therapist helps clients stay with their direct sense as they are experiencing it in the moment; when a therapist invites clients to go further into the bodily felt experiences, amazing therapeutic results can emerge (Daldrup et al., 1988; Gendlin, 1998; Greenberg, Rice, & Elliott, 1996). Clients begin to gain access to emotions that have long been churning underneath. Emotions, as Greenberg (2012) states, function like “the captains” of our lives, and as such, they “need to be processed rather than avoided or controlled” (p. 698). When we gain access to those emotions, perceptions, memories, and thoughts originally buried within, deep changes start to happen—not just a new way of thinking or just a new awareness, but something more fundamental.

Theoretical Frameworks 9 Breaking Away from the Addiction to Experiential Avoidance Experiential therapy generates high energy and dynamism in the session, helping clients change more effectively. Even the third wave of behavior therapy has now shifted its interventions to focus on experiential therapy (Harris, 2009)—therapists have come to realize that it is experiential avoidance (Hayes et al., 2011) that causes human suffering. Experiential avoidance consumes so much of our energy, yet so many people are addicted to it because the moment we fall back on experiential avoidance, immediately we experience its soothing effect: our anxiety or sense of emptiness vanishes. For a short time, we feel better; still, something continues to churn under the surface, waiting for an opening to escape. When it does, it will require even more forceful avoidance strategies to achieve the prior effect of the suppression—more forceful strategies such as substance addiction or process addiction. Recognizing this long-term damage of experience avoidance, the third wave of behavior therapy now has focused highly on experiential therapy (Harris, 2009). This shift represents a noteworthy backing of the power of experiential therapy. STRENGTH-BASED THERAPY AND CHOICE THEORY Strength-based therapy, another organizing framework of this text, focuses on resilience in clients. It looks at client problems realistically and pragmatically, deeming them as possibilities and potentials for growth and change. With one eye on a client’s resilience and capabilities and another eye on the client’s underdeveloped parts of self, strengthbased therapy fosters an increased sense of hope, options, and self-efficacy (Sharry, Madden, & Darmody, 2003). Using Choice Theory to Boost Clients’ Sense of Self-Efficacy We cannot provide strength-based therapy unless we understand the concept of selfefficacy. Self-efficacy (Bandura, 1982) refers to clients’ sense of ability to mobilize whatever skills they need to deal with their environment. We cannot truly foster clients’ selfefficacy unless we help them see their responsibilities. Choice Theory (Glasser, 2001) enters into the picture when we address responsibilities. This theory emphasizes the following: • • •

Clients need to take responsibility for solving the problem even though they probably did not cause the problem in the first place. Clients’ behaviors are within their own choices and, therefore, within their control. By making more conscious choices, clients can learn to master their environment.

To communicate to the client these concepts of choice theory, we can look to Yalom (2009, pp. 139–140): Even if ninety-nine percent of the bad things that happen to you are someone else’s fault, I want to look at the other one percent—the part that is your responsibility. We have to look at your role, even if it’s very limited because that’s where I can be of most help. Albee’s Formula of Human Suffering Many factors have an effect on human suffering. These factors can be summed up in the following equation formulated by George Albee (1986, p. 13):

10

Theoretical Frameworks Organic Factors + Stress + Exploitation Incidence =

Coping Skills + Self esteem + Social Support

Simply put, mental distress results when the forces of stressors (the top half of the equation) engulf the resources owned by the person (the bottom half ). If the person’s stress level (organic factors, stress, and exploitation) accumulates to a high level while her resources (coping skills, self-esteem, and social support) stay low, mental distress ensues. Conversely, if a person has low stress while his resources abound, a state of well-being arises. What if a person’s stress level accumulates to a high level but her resources stay strong? Well, she, too, probably will not have mental problems. Conversely, a person with low stress and low resources can get by okay until some crisis occurs. In short, Albee’s model indicates that mental health conditions (such as depression) result from overwhelming external life circumstances paired with a lack of internal coping resources. Two Treatment Principles of Strength-Based Therapy With Albee’s concept of external stressors and internal coping resources in mind, therapists who embrace strength-based and choice-based therapy strive to follow two treatment principles: Externalizing problems: Placing the cause of problems outside of clients. This frees their energy from shame and guilt, enabling them to direct their energy outward toward solving the problem. As a result, they feel liberated and dignified. Internalizing coping resources and a sense responsibility: Although clients do not create their problems, they must take responsibility for changing their behavioral coping patterns, learning new inner resources, and building support systems. All of these are within a client’s control. These two principles speak of the essence of Glasser’s (2001) “Choice Theory.” Once clients engage themselves in new coping actions, others tend to respond positively to them, rendering these clients even more empowered to change. Such mutual positive response demonstrates the power of strength-based therapy. CONSTRUCTIONIST THERAPY Constructionist therapy, the next organizing framework of this text, consists of solutionfocused brief therapy (often abbreviated as solution-focused therapy or brief therapy), and narrative therapy. Solution-Focused Therapy and Narrative Therapy Solution-focused therapy and narrative therapy share much in common. Let’s first look at their roots. Solution-focused therapy grounds itself in two camps of ideas innovated during the past 50 years. The first camp originates from the hypnotherapist, Milton Erickson, who greatly inspired Steve de Shazer and Insoo Kim Berg. The second camp encompasses the group at the Mental Research Institute in Palo Alto, including Gregory Bateson, Paul Watzlawick, John Weakland, Jay Haley, and Richard Fisch (Guterman, 2014; Quick, 2008).

Theoretical Frameworks 11 Narrative therapy bases itself on social constructionist theory, which stresses that people co-construct or co-author their interpersonal reality in relationships (Neimeyer, 1996; White, 2007). Solution-focused therapy and narrative therapy share a common belief that the way a therapist inquires during a session can essentially shape the direction of the therapy. This realization drives both approaches to shift the focus of counseling and therapy away from talking about problems and toward investigating the exception to the problems as well as forgotten strengths; away from emphasizing the past and toward focusing on the present and future (Chen & Noosbond, 1999a; 1999b; Guterman, 2014; Sharry et al., 2003). No Predetermined Solutions: Only Curiosity Respectful curiosity stands as the hallmark of these two therapies. Even when a therapist uses a series of questions to invite clients to envision their preferred future, he does it gently and respectfully. The therapist will never take on an expert or authority position; nor will he use strategic questions to manipulate clients to arrive at a predetermined solution (Chen, Noosbond, & Bruce, 1998; Edwards & Chen, 1999). Small Changes Is What It Takes to Create a Snowball Effect These two schools of therapy also deem change as a given in life. Since change happens constantly, we therapists must take a proactive approach to it—to do something to tip the change into the desired direction instead of letting chance run its course. This something they do is to initiate a small change which, surprisingly, has the power to break the vicious circle of clients’ patterns. Though small, the change snowballs, and slowly but surely, a beneficial circle starts to take shape, eventually replacing the vicious one. INTERPERSONAL NEUROLOGY The field of interpersonal neurobiology (Siegel, 2015) has evolved enormously, thanks to the contributions of neuroscience. Though most concepts in counseling/therapy have been validated by interpersonal neurobiology (Fishbane, 2014), much remains to be learned about how to engage our clients’ brain to deepen therapeutic change. Interpersonal neurobiology helps therapists deepen our appreciation of the deeply interpersonal nature of the human being (Tootle, 2003). We, therefore, have relied on it throughout this text to organize our views and thoughts on counseling and therapy. The Emotional Brain and Its Overriding Power Interpersonal neurobiology has unlocked the mystery of the emotional brain—the limbic area of the brain—and in particular, the amygdala (Damasio, 2006; LeDoux, 2015). A primary part of the brain, the amygdala plays a critical role in the emotion regulation—and the lack of it (Tootle, 2003). Forces of natural selection have given more primacy to the emotional brain, due to it being more critical for survival than the cognitive brain. Emotions, then, have the ability to override intellect in moments when our survival is threatened. The primacy of the emotional brain shines through when comparing the number of axons: The axons extending from the limbic area to the prefrontal cortex double the number of those extending from other areas (Calvin, 1996; Damasio, 2006; LeDoux, 2015).

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A Shift in Therapeutic Approaches toward Bodily Rooted Emotions As the neuroscience revolution reveals the primacy of emotions in people’s striving to survive, counseling and therapy have also undergone a paradigm shift, away from treatment models favoring cognitive—top-down treatment—but towards models that lay emphasis on bodily rooted emotions—bottom-up treatment (Fosha, Siegel, & Solomon, 2011). What a paradigm shift! Some time ago, treatment focusing on emotions and bodily felt experiences was simply overlooked; now works focusing on emotion-based transformation are getting the respect they deserve (Fosha et al., 2011). A New Level of Compassion for Clients’ Difficulty in Change In counseling and therapy, all too common we have to deal with two conflicting forces within the client: to change or not to change. Clients’ resistance to change often prevails, leaving therapists to spend a great deal of energy tackling it. Now, with the insights from neuroscience, we can come to appreciate why change can be so difficult. According to Hebb’s Law, “neurons that fire together wire together” (Siegel, 2015, p. 49). Over time, the connectivity among those neurons transmitting the message associated with certain behavior starts to strengthen (Makinson & Young, 2012). In plain English, the more we do, think or feel something now and in the past, the more we will do, think, or feel the same in the future. Hence, much of our functioning becomes automatic and ingrained. Habits and personality characteristics formed early in life tend to retain dense brain wiring and, therefore, defy clients’ will to change. In fact, we can say that when clients experience resistance, they are actually, as per Hebb’s law, stuck in neuronal ruts. Trying to change, clients literally have to go against their neural wiring (Fishbane, 2014). This understanding of Hebb’s Law really gives us a new level of compassion for clients at the crossroads of change. Therapy Can Increase Neuroplasticity Fortunately, neuroscience has given us hope for the possibility of breaking free from the neuronal ruts. It shows that our brains do have the capacity to create new neural networks through a phenomenon called neuroplasticity, which tends to happen in an enriched environment wherein interpersonal stimuli are complex and motivating enough to expand learning (Makinson & Young, 2012). Counseling and therapy represent one form of an enriched environment in that clients learn to think differently, to feel what was previously blocked, and to make more conscious choices. Upon experiencing these gifts, something in the client’s brain happens—new neural connections strengthen, disconnected networks are linked back, and the neuroplastic process activates (Cozolino, 2010, 2016). As newly learned behaviors are practiced over and over, new neuronal connections will take root via Hebb’s Law, and these once new behaviors will begin to feel like second nature. Clients, then, will have successfuly changed their brain structurally and physiologically. With this, we can say that counseling and therapy literally rewire the way the mind works (Doidge, 2014; Makinson & Young, 2012). Neuroplasticity lays the foundation of change in therapy (Chen & Rybak, 2018).

Theoretical Frameworks 13 Becoming a Neurally Integrated Therapist Clients’ neural plasticity comes about, according to Cozolino (2004), only under the following conditions: • • • •

A safe and trusting relationship has been established. A moderate level of stress is present. Emotion and cognition are both activated. New meanings have been co-constructed for the clients’ life stories.

To be able to provide these conditions to clients, we, the counselors and therapists, must first become neurally integrated ourselves. That means our cognition is integrated with emotions, our empathy is integrated with challenges, our own emotions are regulated, and our responses are diverse (Siegel, 2010). This amounts to no small demand. Becoming a neurally integrated therapist is a lifelong process. And the journey must begin now if it has not already.

2

Common Therapeutic Factors

Look beyond the minutiae of the world and wade through the dizzying confusion before us, and we are likely to find an amazing simplicity at the core. Look beyond the intricate theoretical orientations of counseling and therapy, and we will find unity and coherence woven through the human psyche. It is then when we begin to realize this: the multitude of therapeutic commissions within the diverse theoretical orientations actually has more in common than meet the eye. In looking for common threads, we do not ignore the obvious difference between the different theoretical approaches, nor do we dismiss the necessary diversity of therapeutic endeavors. Rather, we try to find, throughout our field, the same overarching principles—a vision of what constitutes the therapeutic factors. COMMON THERAPEUTIC FACTORS To effectively serve our client, we need to know what factors lead to therapeutic success. This section seeks to uncover the factors contributing to therapeutic success. Therapeutic Success and the Factors Contributing to It The father of individual psychology, Alfred Adler, once said, “The first rule in treatment is to win the patient; the second is for the psychologist never to worry about his own success; if he does so, he forfeits it” (Adler, 1964, p. 73). Adler’s wisdom still speaks to us today. When we enter the consulting room, our “ego” is the first to go. Our ego tends to focus on the outcome of our performance and thus hinders our ability to be present. With that in mind, we cannot afford to ignore the factors that lead to the success of the therapeutic outcome; our clients’ well-being depends on whether we can be the catalyst to set these factors in motion. Success Has Nothing to Do with Your Chosen Approach Devotees of various theoretical orientations emphatically claim that their specific approach proves more successful and effective than others. Meta-analysis studies, however, reach a drastically different conclusion: There exists no difference of effects between numerous schools of therapy and their different intervention techniques (Asay & Lambert, 1999; Lambert, 1992; Norcross & Lambert, 2011; Glass, Smith, & Miller, 1980; Sprenkle & Blow, 2004; Wampold, 2010). This comes as a surprise to those who devote much of their career to certain theoretical approaches, especially evidence-based approaches. Evidence-based treatment, which is essentially data-driven treatment or empirically supported intervention, has become the treatment of choice by insurance companies

Common Therapeutic Factors 15 and practitioners alike. It stands opposite of effectiveness research (Gartlehner et al., 2006) which evaluates the effectiveness of real therapy used by practitioners in the real world with real clients and therefore, it cannot be empirically evidenced. People are easily led to believe that therapy without evidence-based research must not be effective. This is far from the truth. A therapy that is not evidence-based simply means this: it has not been studied for its effectiveness. Several reasons contribute to its not been studies yet: it takes longer to conduct effectiveness research, it can be more burdensome effort-wise; it requires more capital. And, finally, most academicians or researchers don’t have required resources to conduct real therapy based effectiveness research. Common Factors—The Heart and Soul of Therapy Meta-analysis studies reveal that the effectiveness of therapy actually relies on common therapeutic factors; all forms of therapy bank on almost identical common factors to produce positive client change (Asay & Lambert, 1999; Lambert, 1992; Glass, Smith, & Miller, 1980; Wampold, 2010). The finding of these studies led Wampold (2010) to claim “The common factors are indeed the ‘heart and soul’ of therapy” (p. 54). The knowledge of common therapeutic factors liberates many counselors and therapists from a strict adherence to any dogmatic theoretical systems. It emphasizes the value in taking an integrated approach where therapists make the most of the multiple models of psychotherapy. What Constitutes Common Factors? The analysis by Asay and Lambert (1999) shows a specific breakdown of the common factors and how they contribute to success in therapy: • • • •

Client factors 40 percent The therapeutic relationship 30 percent Hope and expectancy 15 percent Specific techniques 15 percent

Please see Figure 2.1 for a closer look at how each common factor functions in the therapeutic outcome. In the following discussion, we combine results from studies by Asay and Lambert (1999); Lambert (1992); and Glass, Smith, & Miller (1980). The intent is to increase your understanding of how to maximize your therapeutic success. THE CLIENT FACTOR—THE ENGINE OF CHANGE Accounting for 40 percent of the therapeutic outcome, the client factor stands out as the best predictor of therapy success. The question is: what exactly does the client factor entail? Clients’ Characteristics The first client factor involves the characteristics of the client, including client functioning level and client motivation. The more disturbed the client is, the less positive the therapeutic outcome. The more intelligent and open the client is, the better the therapeutic outcome. The more motivated a client is to change during therapy, the more positive the outcome.

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Common Therapeutic Factors

Figure 2.1 Factors Accounting for Treatment Success in Therapy. Data Sourced from Asay and Lambert (1999)

Please note, the motivation to change at the beginning of therapy is less predictive than the motivation to change during therapy. Many other factors increase client motivation to change and these will be described in a later section on the therapeutic relationship. Clients’ Inherent Resources The following have proven to be essential elements of the client factor: clients’ resiliency, ability to tolerate anxiety, and strength of the support system. As therapists, we need to tap into these inherent powers within the clients. In addition to resiliency, the client’s ability to identify at least one problem to work on in therapy significantly contributes to a positive outcome. Identifying a problem makes it possible to set a realistic goal to work toward. Finally, a client’s capacity to relate to others (and to the therapist) plays a part in the therapeutic success. To increase their capacity to relate to others, therapists will need to help clients cultivate their capacity for mutual empathy—an ingredient that often leads to an expansion of their core support systems. Please review the concept of mutual empathy in Chapter 1, under “Relational–Cultural Therapy.” Clients As the True Engine of Change Research of the common factor highlights the greatest truth of the clients—they are the engine of change. In the therapeutic platform, the client shines as the main character. Therefore, whether or not therapists get clients actively involved in the therapeutic process can make or break the therapeutic outcome (Bohart & Tallman, 2010). Anything we can do to encourage client collaboration in therapy, to get them engaged in the session, to get their minds involved, will greatly benefit the outcome of therapy (Duncan, Hubble, & Miller, 1997; Duncan, Miller, & Sparks, 2013). How can we effectively engage clients? The below text, and throughout the coming chapters, demonstrates the how-to. The basic ideas can be summed up as follows: • • • •

Show curiosity about the client’s frame of references and inner perceptions. Respond to the client’s private experiences with validation and acceptance. Learn as much as you can about the client’s view and assumption of change. Be flexible about your theoretical orientation, and try to adjust to the client’s assumption of change and special needs.

Common Therapeutic Factors 17 • • •

Make therapy a collaboration between you and your client as much as possible. Provide a validating atmosphere wherein clients can feel safe to participate, test ideas, and make mistakes. Get clients involved in actions in the session; make the session a workspace.

THE THERAPEUTIC RELATIONSHIP FACTOR Accounting for 30 percent of the therapeutic outcome, the therapeutic relationship is the second most important common factor (Asay & Lambert, 1999). Winning the Client with a Good Therapeutic Relationship Adler (1964) stated, “The first rule in treatment is to win the patient” (p. 73). Winning the clients pertains to developing a good therapeutic relationship. We have all heard the saying, “It’s the relationship that hurts, and it’s the relationship that heals.” What makes the relationship healing? A relationship that heals often demonstrates a strong connection—a special type of attachment with trust and a sense of safety—between the therapist and the client (SommersFlanagan & Sommers-Flanagan, 2015). However, the therapist alone cannot forge a solid therapeutic relationship; the client’s ability to establish an interpersonal relationship plays an important role. A therapeutic alliance, therefore, entails a mutual process and is never a one-way street. Glasser (1990, 2001) indicates: the quicker the therapist creates a therapeutic relationship with the client, the greater his ability to help the client, and the more efficient the client’s issues can be resolved. If a therapeutic relationship fails to take root, the therapy likely will not succeed. Thus, the training of a therapist starts with the development of the skill of connecting—empathic skills. The Therapist’s Theoretical Orientation or Charisma: No Bearing Regardless of how intellectually appealing it is, the therapist’s theoretical orientation has no bearing on the quality of the therapeutic relationship. Also, the charisma of the therapists has no influence on the quality of the therapeutic relationship, regardless of its initial appeal. For those prospective therapists with a quiet and unassuming inclination, this finding may calm your nerves. It turns out that you don’t need to be extroverted, charismatic, or anything other that your true self. It is more than possible to win clients over with your personal nature, as long as you hold the following traits and attitudes. Honesty and Trust Clients desire to work with a therapist providing them with complete honesty and care. Honesty rapidly wins the trust of clients (Glasser, 1990, 2001). Rogers (in Yalom & Leszcz, 2005) indicates that a trusting therapeutic relationship makes the following outcomes more likely: • • • •

The client feels free to express his feelings. The client becomes aware of previously denied or distorted feelings. The client’s self-concept becomes more congruent with his actual experience. The client begins to test reality, becoming more aware of his feelings and perceptions toward his experiences.

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Common Therapeutic Factors

Acceptance and Validation It is believed that all humans have three basic needs: the need to maintain and enhance our physical well-being; the need for positive regard—acceptance, love, and approval; and the need for self-respect. Emotional problems in life often stem from earlier experiences, suffused with judgment and invalidation. To heal, the deprived acceptance and validation must be repaired by a capable person—typically a therapist. It is worth repeating, “It’s the relationship that hurts, and it’s the relationship that heals.” Feeling accepted by the therapist and internalizing the capacity for self-validation, the client becomes more adept at transmitting that sense of acceptance in her relationships. Thus, the client is no longer trapped in the bottomless pit of seeking external validation. Selfless Focus on the Client Even though it is authentic, the therapeutic relationship cannot be symmetrical. As Rabinowitz and Yalom (2000) indicate, an effective therapeutic relationship features itself with the therapist’s selfless focus on the client. Entering the therapeutic relationship, the therapist holds no personal agenda. Her mind concerns only the best interest and the well-being of the client. She carries an open heart, accepting the client as a human— even when the client discusses things in the session that may be unappealing or not within the normal range of things. Hence, entering the therapeutic relationship, the therapist leaves her own needs and wants unmet. She demands nothing in return and wants only the growth and the fulfillment of clients—a selfless and generous act on therapists’ part. This unconditional love gives strength to clients. Outside of therapy, it is difficult to find a relationship with such selfless acceptance and focus. Ethics: The Heart of the Healing Relationship Ethics—at the heart of any therapeutic relationship—hold us to the highest standard of care. Not just providing the rules and regulations for risk management, ethics guide the way therapists think, feel, and respond when faced with the competing demands and responsibilities of helping another person (Birrell, 2006). In a world where value systems crumble around us and unprincipled behaviors abound in the national and international front, we as therapists become the holders of the highest standard of care and principled conduct. All prospective therapists and counselors need to become familiar with the code of ethics during training. Due to space limitation, we cannot list the details of the principles and guidelines. Please consult the code of ethics by American Psychological Association, American Counseling Association, and the National Association of Social Workers. THE LAST TWO COMMON THERAPEUTIC FACTORS The third and the fourth common factors land on hope and specific technical expertise, respectively. Let’s take a closer look. Hope and Expectancy The hope and expectancy factor makes a 15 percent difference in the success of therapy, according to Asay and Lambert (1999). What gives hope to clients?

Common Therapeutic Factors 19 First, simply being in therapy instills a sense of hope in clients—a hope that things will get better. Clients are motivated by their expectations of the outcome of their actions. To instill hope, we need to place the spotlight of therapy on resilience and resourcefulness in clients, even if they deny having these traits. This is not to brush away their presenting problems but, instead, to look at them realistically so as to discover open spaces and possibilities. At the same time we highlight clients’ resilience and capabilities, we also need to point out clients’ underdeveloped parts of self. Cultivating the development of the whole self can foster a sense of hope, reversing their hopelessness or despair. One caution: Research reveals that clients with extremely high or extremely low expectations toward therapy tend to not fare well (Goldstein & Shipman, 1961). Therefore, we should exercise caution to not foster false hope or to not mislead the client toward unrealistic expectations. Specific Technical Expertise The factor of specific techniques accounts for 15 percent of the difference in the success of therapy, according to Asay and Lambert (1999). Technical expertise generally refers to techniques and procedures unique to various specific treatment approaches. Some examples of specific techniques may include, but are not limited to the following: • • • • •

The miracle question in solution-focused therapy. In vivo exposure in behavior therapy. The triangles of insight in psychodynamic therapy. Socratic questioning in cognitive therapy. Externalizing the problem in narrative therapy.

These specific flashy techniques, touted by various new workshops or workbooks, can easily delude us into thinking they have a greater therapeutic power. In the end, though, all techniques deliver no more than 15 percent of the difference in the therapy outcome. Duncan, Miller, and Sparks (2013) further point out this reality by reporting, “The competition among the more than 250 therapeutic schools amounts to little more than the competition among aspirin, Advil, and Tylenol” (p. 51). At their best, intervention techniques create a favorable therapeutic environment wherein clients’ resources can be expressed. The therapist’s technical expertise can serve to channel a clients’ inherent abilities and skills toward achieving their goals. With more than 250 therapy models and copious numbers of techniques to choose from, we need not be overly enthused about or devoted to any given approach (Duncan, Miller, & Sparks, 2013). Rather, we ought to stay open, because different clients respond to different approaches and techniques. For this reason, this text adopts an integrated approach wherein each approach has a gift for building our clinical competency. Our clients will receive better services when we assimilate the best approaches and develop our own personal style, congruent to who we are as a person. THE THERAPIST FACTOR Besides the previously mentioned four common therapeutic factors, two factors indicated by Glass, Smith, & Miller (1980)—the therapist factor, and the treatment factor—have an impact on the outcome of counseling. To begin, this section discusses the therapist factor.

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Common Therapeutic Factors

Gender and Ethnicity When the therapist and the client share a similar ethnic background, it helps to eliminate the number of premature terminations. Much to our surprise, however, the ethnic similarity itself does not have much of an impact on the outcome of therapy. Furthermore, even though African-American clients tend to disclose more to AfricanAmerican counselors than to White counselors, at the end of the day, ethnicity similarity alone does not dictate therapeutic success. In the same vein, shared gender between the therapist and the client does not impact treatment outcome. Also, male therapists are generally just as effective as female therapists. Of course, some clients have a specific gender preference for their therapist, but that has more to do with personal reasons, and less with therapeutic outcomes. Values and Life Experience Shared values, lifestyles, and life experiences between client and therapist have a more positive impact on the outcome of therapy than a shared ethnicity. For example, if a therapist has experienced a recovery process herself, she would have a greater positive impact on a client struggling to recover than if she were to share the same ethnicity, but not the recovery process experience. This finding serves to confirm the notion that people with the same values and lifestyles tend to gravitate toward one another and open themselves to each others’ influence. Emotional Well-Being The therapist’s emotional stability and well-being have a positive correlation to a successful outcome. This implies two things: First, whenever possible, we seek personal therapy to resolve any unresolved business in our lives that might hamper our emotional stability and personal well-being. Second, we practice personal self-care on a regular basis. Any of the following examples can go a long way to nurture our well-being: contact with nature, good nutrition and diet habits, exercise, yoga, meditation, healthy relationships, and support systems. A Good Match in Expectation When the client’s expectation about counseling matches that of the therapist’s, treatment is more likely to succeed. Hence, therapists should communicate clearly with the client about the process of therapy and set a realistic goal that both can agree upon. Periodically, check with the client about the progression of therapy. Taking one step further, Yalom (2009) emphasizes that we always check in with our clients at the end of the hour, even when it has been a productive session. For example, he would say the following to his client, “Let’s take a minute to look at how you and I are doing today” (p. 72). Counselors’ Self-Disclosure Another surprise in the finding is: the therapist’s self-disclosure does not increase the effectiveness of treatment. Given this, clients’ disclosures take center stage in the session.

Common Therapeutic Factors 21 The therapists’ self-disclosure occasionally arrives on the scene, for the purpose of increasing transparency. One exception: When working with clients coming from cultural backgrounds different from our own, we strive to offer self-disclosure. As we all know, differences between two persons can easily lead to misinterpretations of intentions. The gap created by different perceptions can be bridged by an increased sense of transparency. Using self-disclosure within this context, therapists can enhance the development of trust which might otherwise be impeded by cross-cultural barriers. Years of Therapist Experience Highly experienced therapists do better than extremely inexperienced therapists. Yet, if we exclude these two extremes from the spectrum, then the therapist’s experience does not dramatically affect the success of therapy. This is good news for beginning therapists, who, having bypassed the “extremely inexperienced” status, are no longer edged out by experienced therapists based on the sheer number of years in practice. However, during the early sessions, a therapist’s experience does make a difference. Experienced therapists tend to establish the therapeutic relationship more quickly than an inexperienced therapist does. This lead tends to even out in later sessions as inexperienced therapists prove themselves just as effective as the experienced ones in securing the therapeutic relationship. The one area in which the therapist’s level of experience makes a significant impact on the outcome is treating difficult and intractable clients. Seasoned practitioners generally have better results when working with difficult clients. This often leads beginning counselors to seek the wisdom of the seasoned practitioner. Competence Level Chief among all therapist factors which impact the success of treatment is the therapist’s competence level. Like apples and oranges, competence level differs entirely from years of experience. Unfortunately, the competency of some therapists does not grow along with their years of experience. Competence covers a broad range of knowledge, skills, techniques, capacity for empathy, style of communication, and knowing when to do what. Expanding your competency level is the aim of this text. THE TREATMENT FACTOR Another factor which may impact the therapy outcome is the “treatment factor” (Glass, Smith, & Miller, 1980)—a factor currently challenged by the “cost-cutting” demands of our era. The Trajectory of Treatment and Improvement Client improvement tends to increase positively in a linear fashion from the first to the 26th session (Glass, Smith, & Miller, 1980). After 26 sessions, the improvement typically reaches a plateau. Though client improvement continues, the rate at which it occurs slows down considerably (Glass, Smith, & Miller, 1980).

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This trajectory does not mean that long-term therapy is useless. On the contrary, for clients who suffer multiple traumas or are under tenacious stress, long-term therapy may be essential in contributing to clients’ eventual recovery. The Cost-Cutting Trend in Treatment The cost-cutting mechanisms of managed care organizations have set a new trend in treatment—a trend that favors fast solutions, rapid implementation and application of intervention techniques, limited numbers of sessions, research-based and manually driven techniques, and the use of psychotropic medications to stabilize behaviors, emotions, and thoughts (Danzinger & Welfel, 2001). This trend tips us even more off balance in a society where the atmosphere is already highly competitive, time-driven, anxious, easily bored, desires quick fixes, and constantly searches for the newest fad, yet never feels quite fulfilled. We, as therapists, have to find ways to meet the cost-cutting demands of managedcare organizations. At the same time, we must nurture the client–counselor relationship, treat those in our care as clients rather than as patients, and respect the subjective and phenomenological experience of the individuals. Each of us will have to find our own answer through our unique trajectory of discovery and creative adventure. OUR CRAFT: THE SKILLS AND TECHNIQUES All artists have to work at their crafts, be they musicians, painters, sculptors, or writers. Therapy, as a type of art, has its own crafts, its own skills and its own techniques that are to be mastered by its artists. Skills and Techniques Stand and Serve the Therapeutic Relationship Skills and techniques cannot stand alone in therapy. Without a genuine therapeutic encounter, a therapy consisting of dazzling skills and techniques is a meaningless therapy. Existential psychotherapist Rollo Reese May (2015), puts it well: “Technique emphasized by itself, in the long run, defeats even technique” (p. 47). So what are skills and techniques for? We believe that skills and techniques exist to serve the therapeutic relationship. This resonates with the view by Sommers-Flanagan and Sommers-Flanagan (2015): the primary purpose of skills and techniques is to help build a responsive and sturdy therapeutic relationship. Counseling Skills as Skills of Connection Years after therapy has ended, clients probably won’t remember much of what the therapist has said, but they will remember the warm and genuine connection they had with the therapist. Through this connection, clients learn authentic ways to connect with others, thereby becoming able to fulfill their needs effectively through relationships. To build a solid and deep therapeutic connection, therapists use various skills and techniques as the cornerstone (Sommers-Flanagan, 2007; Sommers-Flanagan & Sommers-Flanagan, 2015). Just as a pianist needs the piano as the medium to express the music in her mind, the therapist needs skills and techniques as the medium to connect with clients. Through proper use of skills and techniques, the therapist plots a course of working through clients’ complicated life problems.

Common Therapeutic Factors 23 Skills and the Therapist Become One: A Vessel of Artistic Expression Many people wonder: How do skillful therapists build therapeutic relationships so much more quickly and successfully than others? The key to this mystery lies in their fluent use of a wide range of skills and techniques. Without the proper use of skills and techniques, you will not know when and how to work through various situations. In addition, you will be more likely to feel inadequate, lose motivation, and succumb to burnout. Counseling skills and techniques actually encompass a wide range of complex interpersonal skills, process skills, and intervention strategies. When used fluently and masterfully, these skills and techniques grow to be so natural and organic that they become invisible. The therapist and the skills become one, just like a pianist and the piano becomes one. Unified, they become one vessel of the artistic expression—the peak experience we dream of. YOUR “SELF ” AS THE MOST IMPORTANT INSTRUMENT As therapists, our most powerful instrument available in helping clients is our “self.” Our ability to use our “self ” relies primarily on our level of awareness about our own impact, and how we choose to make use of that impact. This section expounds on what constitutes this instrument. Your Senses and Feelings As therapists, we operate on two levels. First, the cognitive level: where we process the “content” of the discussion during the session. Second, the visceral level: where we sense the energies flowing between us and our clients; where we sense the acceptance or rejection, tension or ease, contentment or defensiveness, and so on. The second level of our “self ” offers critically important data: it tells us a great deal about how the client is perceived in their outside relationships. Though subtle, we must pay close attention to this particular type of information. Once we value the visceral side of our self, we then want to increase our comfort and skill level in putting our visceral senses into verbal expression. The more we are able to verbalize our experience with our client at any given moment, the more we have the leverage to help our client raise her awareness and increase her commitment to the journey of personal transformation. Your Intuition When facing clients’ complex challenges, we can become paralyzed by content analysis. What we might not realize is this: our intuition has gathered information instinctively all along, gathering data that is more valid than our objective analyses. Experienced therapists trust their intuition more than anything else. Having such a highly developed intuition allows for quick, effective, therapeutic decisions—something beginning therapists can take to heart. The Best Way to Hone Your Craft The message we send in the way we act has a greater influence than in the way we talk. Clients need us to walk the walk, not just talk the talk. Yalom (2009) states, “Therapists must show the way to patients by personal modeling” (p. 40). Specifically, we must be willing to face up to our own dark side and accept all human impulses and feelings.

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There is no better way to hone our craft—our “self ”—than to enter personal therapy. As stated by Yalom again: “To my mind, personal psychotherapy is, by far, the most important part of psychotherapy training” (p. 40). Entering personal therapy enables us to work through our own personal stumbling blocks, discover our own blind spots and biases, experience the many aspects of therapy from the client’s seat, and develop personal awareness and strength. What’s more, it helps us cope with the intensive emotional demands exacted on us in the practice of helping others.

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The Journey Through the Jungle

The acquisition of counseling skills and techniques exhilarates all who embark on this journey. For a long time, you yearned for the time when you would be the one to reduce the suffering of those in need. The time draws closer as you acquire these skills. If you allow it to happen, the skills will work in you, change you, permeate your being, and become a part of you. As with any new skills, however, there is a learning curve—a journey through a jungle (Barker, 2013). This chapter addresses the necessary adjustments this journey will require of you. Fine-tune yourself along the process to achieve effective response styles and therapeutic language, and you will see the clear sky at the end of the jungle. “STAGES OF CHANGE” MODEL Several models exist in explaining how client change happens in counseling and therapy. We will look at the two models most relevant to the themes of this text: • •

“Stages of change” model “Stages of counseling” model

The “stages of change” model bases itself on Prochaska’s transtheoretical model of behavior change (Prochaska, Norcross, & DiClemente, 2010; Prochaska & Norcross, 2013). The stages of change have a lot to do with the client’s readiness to change. It proposes that in making behavior changes, people usually progress through five stages of readiness. The stage of change model applies especially well to people recovering from their addictive behaviors, including smoking, drinking, eating disorders, weight problems, and health-related behaviors. The five stages are presented below: Stage 1: Precontemplation At the first stage, people do not believe that they have a problem. Therefore, they neither recognize the inherent risks of their behaviors nor have a desire to change. At this stage, they are operating based on the defense of denial. They suspect: even if a problem exists, that problem must belong to someone else. If a person at this stage does show up for counseling, it is typically someone else who has requested it—perhaps the court, the supervisor, the school, the spouse, etc. The dropout rate stacks high at this stage. Therefore, don’t take it personally if the client does not come back. If your client stays, don’t proceed with the standard counseling process. Instead, use motivational interviewing (see Chapter 8) to see whether the client might start to acknowledge that there exists an issue, and they might then move ahead to the next stage of change (Norcross, Krebs & Prochaska, 2011).

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Stage 2: Contemplation People at this stage begin to acknowledge that they may have a problem and allow the awareness to grow. Still, they feel ambivalent about change, lacking a commitment to therapy. This sense of ambivalence gets them “stuck” in the contemplation stage for a while—sometimes years—due to their “chronic contemplation” (Velicer, Prochaska, Fava, Norman, & Redding, 1998). If your client is stuck in the chronic contemplation stage, you can continue to use motivational interviewing and help them take only baby steps of change—steps so small as to bypass the clients’ defense of their minds. Stage 3: Preparation At this third stage of readiness, the client has developed a commitment to change and has begun to entertain the idea of overcoming the barriers to change. You will know when your client has entered this stage because you will begin hearing reports about small changes they have made and how these changes benefit them. In this stage, the clients need you to help them set realistic goals. Goals too vague or too high may set them up for failure. Stage 4: Action This stage involves the most active behavioral changes. Here, the client is highly motivated to do the work and to initiate tangible behaviors to change for the better. This stage, therefore, is also known as the reorientation stage (Stoltz & Kern, 2007). Not every deep issue will be resolved, which leaves room for occasional relapses. Even with occasional relapses, the clients’ efforts of change often allow others in their life to begin to respond to them favorably. After at least six months into the action stage, the client may be ready to move on to the next and final stage. Stage 5: Maintenance In the final stage, the client learns how to take cautious steps to prevent relapse. Even after the client has renewed her daily functions and has changed her relating styles, relapse may still occur. Typically, when under stress, people tend to revert to previous ways of coping. If your client is in this stage, you are likely to provide supportive counseling and stress management counseling. You want to help your client learn how to avoid triggers that might cause a relapse, how to continue her recovery and take preventive measures to maintain the gains made during the previous stage of action. “STAGES OF COUNSELING” MODEL While the “stages of change” model bases itself on the client’s readiness to change, the “stages of counseling” model bases itself on the therapist’s tasks and their skills to accomplish these tasks. Many variations also exist within the model of “Stages of Counseling,” each based on the clinician’s preference of conceptualization. Our clinical experiences lead us to conceptualize the process of counseling with four stages, each with its own unique tasks and required counseling skills.

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A key to increasing your effectiveness as a therapist is to have a continual awareness of where you and your client are in terms of the counseling stage. Beginning therapists often try to solve clients’ problems prematurely, even when rapport has yet to be established and the core issues have yet to be identified. Unfortunately, premature problem solving, driven by counselors’ performance anxiety and desire to help, often leads to defeat. . . . To keep on task, we need to ask ourselves the following question when we are with a client: “Have I completed the necessary tasks of the counseling stage we are currently in?” Stage 1: Problem Exploration (Initial Stage) The problem exploration stage of counseling might correspond to Prochaska’s contemplation stage. The tasks in this stage are: • • • • •

Conduct a thorough intake. Explain the counseling process to the client. Establish rapport (by focusing on the client’s experiences and emotions). Reassess the central problem (focusing on the client’s actions and failed problemsolving attempts). Look for the client’s resources and strengths.

To accomplish these tasks, the therapist uses at least two primary skills: •

•

Empathic responding skills—reflection of feelings, thoughts, needs, and values, paraphrasing, affirmation, perception checking, periodical summarization, and advanced empathy (see Chapter 4). Probing skills, including focusing, probing, and clarifying statements (see Chapter 5).

If the client proves ambivalent about change, use motivational interview techniques (see Chapter 8). Stage 2: Awareness Cultivation (Middle Stage) This stage might correspond to Prochaska’s contemplation stage or preparation stage. The tasks are: • • • • •

Help Help Help Help Help

the the the the the

client client client client client

increase his awareness of ineffective coping patterns. work through resistance. accept, own up to, and honor old patterns. recognize and draw on forgotten strengths. visualize what he wants out of his life.

To accomplish these tasks, the therapist uses a wider range of skills and interventions that focus on raising awareness, facilitating fuller expression, and enhancing emotion regulation. These skills include the following: • • •

Empathic responding skills (Chapter 4). Influencing skills which include identifying patterns, self-disclosure, caring confrontation, giving feedback, and immediacy (see Chapter 9). Basic and advanced intervention techniques (Chapters 8 and 10).

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Stage 3: Problem Resolution (Later Stage) The problem resolution stage might correspond to Prochaska’s action stage. The tasks of counseling at this stage are: • • •

Help the client reconstruct her schema by in-session training for new behaviors or skills. Support the client in integrating disowned parts of her experiences through experiential techniques. Empower the client to exercise her freedom of choice, and implement an action plan in her life.

In an effort to accomplish these tasks, the therapist has to use a wider range of skills and interventions including: • • •

•

Empathic responding skills. Influencing skills. Advanced intervention techniques, such as role playing, role reversal, mindfulness training, guided imagery, experiential techniques, part dialogue, empty chair technique (see Chapter 10). Other specialized techniques drawn from various theoretical approaches.

Due to the complexity and wide variety of intervention techniques that exist, most therapists need “continued education” through workshops, externships, or conferences. Continued education allows the therapist to expand upon their repertoire, in order to better serve their clients. Stage 4: Termination The termination stage does not correspond to Prochaska’s stages but might resemble the maintenance stage somewhat. The tasks of this stage are: • • •

Help the client evaluate his progress and transfer his learning to real life. Assist the client in anticipating future challenges and envisioning strategies for coping. Help the client bring closure to therapy.

The counseling skills used in the termination stage include all skill levels. The Recursive Nature of the Counseling Stage The above-presented pairing between counseling stages and certain counseling skills is not a fast and hard rule. It is primarily for training purposes. Skilled therapists do not restrict themselves to empathic responding skills and inquiry skills in the initial stage. Rather, they use a combination of basic skills and advanced skills, such as advanced empathy, self-disclosure, and directives. In addition, the stages of counseling are not linear in nature. Although the process might follow a noticeable progress, clients may actually move backward or forward in reality. For example, a client may have resolved a problem regarding her relationship with her husband and be ready to terminate counseling, when a new crisis suddenly erupts, propelling her back to the middle stage of counseling. Here, she is again faced with the challenge to examine her understanding and handling of the situation.

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EFFECTIVE VERSUS INEFFECTIVE RESPONSE STYLES The next element needed in the journey of acquiring skills and techniques involves response style or habit in communicating. As counselors, it is best if we become more selfobservant of how our communication styles have impacts on clients, and on those with whom we come into contact. Seven Ineffective Response Styles Long (1996) pointed out eight response styles that people commonly use in everyday communication. Of these eight styles, seven of them prove ineffective in the counseling setting. Be aware if you fall into any of these seven styles. Try to avoid communicating in these ways with your clients. Following are the seven ineffective response styles. 1. One-Upper One-uppers talk as if every conversation is a competition. If someone says they twisted an ankle, the one-upper says they have a broken leg. No matter what others say, the one-upper has to top it with something smarter, bigger, or more dramatic. “You had a bad day? Wait until you listen to this. . . .” When telling their stories, most people just want a sympathetic ear to listen to their personal experiences or feelings. But the one-uppers cannot simply listen. They budge in to one-up the other. If you often find yourself steering the spotlight back to yourself in social interaction, you may be a one-upper. You may just use the more dramatic story to convey a supportive message, thinking that misery loves company. Yet, your one-upping will not be well received. Most likely, the other person feels that you just steal the thunder from them. 2. Discounter A discounter dismisses others’ experiences and feelings with indirect put-downs, sarcasm, or reassurance. Why is reassurance a discounting response? It is because others can actually feel discounted when you give too much reassurance. Excessive reassurance makes others feel diminished. See the following examples: Put-downs: — “You need to learn to put things in a better perspective.” — “You are thinking too much. It is all in your head.” Reassurance: — “You are a very strong person, time will heal.” 3. Expert The expert gives out the aura of one in authority. The expert may talk to another person just like a parent to a child, a boss to an employee, a teacher to a student— appearing to know more than the other person does. If you talk as if you have an answer for every problem that another person is facing, your response style might seem patronizing. Examples are:

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— “I think you’re making a serious mistake by not considering your husband’s opinion.” — “You have a pattern of never letting yourself have what you want.” — “Don’t think that way! It’s going to slip into that downward spiral of depression.” 4. Advice Giver Advice givers operate from a position of a guide or a lecturer, using keywords such as “should” and “ought”—telling others what to do. Advice giving seems to be the most common response style in our society. While it is indeed a suitable communication style in teaching, if we use this communication style in counseling, we are likely to fall prey to rescuing—sparing clients from wrestling with their problems. In so doing, we inadvertently disempower them, despite our best intentions. Examples are: — — — —

“What you should do is be less apologetic.” “You ought to sit down and think about the pros and cons of your decision.” “You should not take the corrective feedback from your supervisor so personally.” “You must get a handle on your impulses.”

5. Cross-Examiner Cross-examiners ask question after question with the good intention of obtaining further information, in order to better understand the situation. Unfortunately, the response style of asking many probing questions often backfires. The person on the receiving end often feels uncomfortable, thinking, “What did I do to deserve this interrogation?” Worse yet is when the cross-examiner uses “closed questions,” allowing for only “yes” or “no” answers. Closed questions shut people off and make them feel defensive. Most of the following examples are closed questions: — “Were you surprised when she did come home? Did you ask her what made her change her mind?” — “Have you thought of confronting her? Did you tell her how you feel? What would she respond if you were honest with her?” — “Did you feel hurt by her action? Did you feel betrayed? Do you think she did it just for revenge?” — “Have you thought of why you’re always attracted to this type of women? Are you aware that the same things seem to repeat over and over?” 6. “Canned” Counselor Canned counselors talk as if they care, even though they are not emotionally present. All they supply is a phony veneer that hides their laziness or indifference. Regardless of what “right” words they use, their response does not convey true understanding. As a result, these responses don’t come across as authentic or honest. It’s easy to slip into this canned response style, possibly because it requires minimum effort. Examples are: — — — —

“So how does that make you feel?” “I understand how you feel.” “I’ve been there myself.” “I hear you.”

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7. Problem Solver Problem solvers feel responsible for analyzing others’ problems, as well as providing solutions. Similar to the advice givers and the experts, the problem solvers assume that others are unable to solve their own issues, therefore needing the problem solvers to offer solutions. Unfortunately, this deprives others the chance to build their own problem-solving skills. The problem solvers, as the old proverb goes, “gave others fish but didn’t teach them how to catch their own fish.” It is another form of disempowerment. Some problem solvers combine cross-examining and advice-giving when providing solutions. Examples are: — — — — —

“So, have you thought of going back to school to better your career choice?” “Have you thought of taking a long vacation to ease your stress level?” “The more introverted you are, the more often you have to go out.” “Helping others is the road to personal happiness.” “What have you done for yourself lately?”

The Effective Response Style: Empathizer Of the eight communication styles, only the empathizing style proves effective for interpersonal connection, as well as for counseling. The empathizer makes the effort to do the following in their communication, wherein the above-mentioned seven response styles go amiss: • • • • • • •

Strive to understand other people’s experiences and perspectives. Listen attentively, suspending their own opinions and judgments during the interaction. Put themselves in the other person’s place, feeling the other person’s world. Reflect what the other’s true struggles or feelings might be. Strive to nurture the ongoing dialogue. Help clients discover their own inner truth. Even when a question is needed, they ask open-ended questions or a reflexive question, and not a closed question. When the question is answered, they follow it up with another reflective response.

This response style requires mental presence and energy, but the empathizer willingly takes it on, and their respect, authenticity, and responsiveness shines through. Examples are: — “It sounds like you’re feeling lonely and wonder if that feeling will ever change.” — “You’re asking me what to do, and I can sense your sense of urgency to take back control of your life.” — “As I hear your story, I sense that you’re beginning to mourn the loss of your childhood and the dream of a loving family.” — “It seems as if you’ve come to a transition in your life where you want to move forward, but are afraid what might happen if you do.” For Your Own Reflection After reading these eight response styles, which types do you find yourself using most often? If your response styles tend to fit within the first seven types, some of the following questions might be worth contemplating:

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— “In what ways has my current response style prevented me from building a rapport with those I work with?” — “How can I alter my habitual use of the undesired style?” — “How can I cultivate a more empathic response when talking with others?” Many people can provide you with feedback regarding the first question. Listen to this feedback. The answers to the second and third questions are well related. When you learn a more effective response style, the undesired style will subside; the two cannot co-exist. All skills and resources in this book are designed to help you develop a repertoire of the effective response style. THE THERAPEUTIC LANGUAGE—OUR CRAFT All artists practice their craft. Musicians, painters, sculptors, writers, etc., all work to improve upon themselves in their specific craft. As well, the art of counseling and therapy has its own craft—the therapeutic language and the speaking style. To become skillful in our crafts, we all have to go through certain changes in our use of language. The Therapeutic Language The first element of our craft involves the therapeutic language. None of us are native to the therapeutic language. In social interactions, the language of expression varies widely. It can encompass smooth, entertaining, vague, evasive, self-promoting, opinionated, lengthy, competitive, intriguing, surprising, funny, chatty, small-talking, effortless, dominant, subjective, and more. These social languages are based on the speaker’s interest of the moment. Yet, in counseling, this kind of social language does not work. In counseling, the intent of expression is to understand, to convey understanding, and to bring about renewal. The language, therefore, must be empathic, specific, sensitive, effective, purposeful, respectful, and accountable. The shift of language from the social mores to the therapeutic is the most difficult challenge for beginning counselors. This is a shift often compared to learning a foreign language—it feels awkward and unnatural. If the empathic response feels unnatural and contrived, welcome aboard! Your discomfort is normal. In this learning curve, we all have to ascend our own “Mount Everest” from the base camp, with no short-cuts. In the end, it will prove to be a rewarding process, even though it requires a great deal of energy, self-monitoring, and conscientiousness. The Speaking Style The second element of our craft involves the speaking style. Beginning counselors tend to carry some of these past speaking styles, which often have a distracting quality: • • • • •

rambling using too many fillers circumscribing abstracting elevating tone at the end of a statement

• • • •

rehearsing speaking too fast using a monotonous voice intellectualizing

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Each distracting style has its own negative effect on the counseling process. Often, these speaking styles sneak up on us when we are nervous; when we do not have a sense of direction in the session. We will gain a sense of direction during a session by using a road map—case conceptualization. Various levels of case conceptualization will be presented throughout this book to give you a mental map. It will also equip you with a sense of direction at each step you take on the journey with your clients. OVERCOMING PERFORMANCE ANXIETY Facing the challenge of helping others resolve their complicated issues for the first time can be daunting. To a certain degree, all of us will experience this all-too-familiar phenomenon—performance anxiety. Worries that Increase Performance Anxiety As your clients present their problems to you, the following concerns may cross your mind: — — — — — — —

“How should I start?” “What should I say next?” “What should we do after the problem is presented?” “What if the client won’t talk?” “What if I say something wrong, the client gets offended and doesn’t come back?” “What if I don’t have any experience with the issues that the client talks about?” “What if the client finds out that I’m not as competent as he has expected?”

These are reasonable worries as we begin to see clients, but they do increase our performance anxiety nevertheless. Performance anxiety often ensnares us in an overwhelming sense of self-consciousness, which inhibits us from being completely in tune with our client’s world. Observe and Negotiate with Our Own Inner Critic Don’t try to fight your performance anxiety. Rather, hear its voice and look it in the eye. You will probably see that this is not something entirely new. You have lived with this critical inner voice for quite some time. Now is the time to understand what this voice is telling you. Does this voice come from pure judgment, or does it come from the intention to do the best for the client? As we learn to observe our inner critic, we are more likely to embrace particular sensations in our body: a queasy stomach, pain in the back, or a creepy, tingly sensation on the back of the neck. Our anxiety will become our assistant—these bodily reactions will clue us in as to how we are responding to our inner critic and how we are responding to a client’s communication style. Taking one step forward, you can negotiate with your inner critic. You can ask your critical inner voice not to judge you against the competence level of an experienced therapist. Ask it to focus on learning, instead of on maintaining the all-too-fragile selfimage. See whether this critical inner voice might improve its understanding of this new experience in foraying through the jungle.

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Practical Suggestions for Overcoming Your Performance Anxiety The following three practical suggestions work well in overcoming performance anxiety: • • •

Practice, practice, and more practice. Practice is the best antidote to performance anxiety. Try to really understand the intent of each skill and technique so you know why and what you are doing. Know case conceptualization thoroughly. Only when you learn to formulate the case can you truly build your sense of confidence. Case conceptualization gives us a road map through which we can navigate the complex landscape of clients’ problems and locate unique pathways to resolutions.

PEER COUNSELING: A GIFT FOR ONE ANOTHER The journey of acquiring counseling skills and techniques starts with something rather humble, something that requires intense supervision, due to the lack of a certificate or a license on your part. That something is peer counseling. This section presents concepts for you to consider in stepping into your peer counseling experience. Experiential “Live Practice” As a Gift for One Another Counseling skills can best be learned through face-to-face live practice. Through this experiential practice, you will learn to comprehend emotional tone, nonverbal cues, facial expression, and your interpersonal dynamics with your peer client, etc. All of these are priceless experiences that are rarely found in online training or mere role playing. Who are the willing guinea pigs for your live practice when you are just starting out? Your peers! The experiential live practice with your peers, therefore, becomes the gift that you give one another. This represents your first counseling experience. Your peer stands in as your first client. What a gift! You will never forget those of your first. The Triad Model of Peer Counseling and Its Working Principles In peer counseling, it takes three trainees to form a triad. Each member takes his or her turn in the lab to be the counselor, the client, and later, the observer. Please see Figure 3.1 for the Triad Model of Peer Counseling. The working principle of the triad lies in its turn-taking, which goes like this: • •

The client always becomes the observer. The observer always becomes the counselor in the transition.

Following this principle, after Judy finishes her turn as the counselor, Ann (the observer) will then become the counselor while Tom (the client) becomes the next observer and Judy the next client. Instead of immediately becoming the counselor, Tom switches to the observer role to cool off after being in the intense role of the client. This triad may be maintained throughout the process with the same threesome or the configuration may be changed somewhere. The benefit of maintaining the threesome throughout the process is that you, as the student counselor, get a chance to: • •

Witness the stages of counseling unfold before your eyes. Practice advanced influencing skills and advanced intervention techniques when the working alliance with your client is well established.

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Figure 3.1 The Triad Model of Peer Counseling

• •

Observe the depth and complexity of your client’s struggles. Experience the exhilaration of working toward problem resolution together with your client.

Allow Yourself to Experience the Exuberance of Being a Client When you are in the role of the client, you will be able to work on some personal concerns. Of course, being a client can provoke some anxiety, so some people begin by role-playing an imaginary client. Role-playing has its own place during the beginning of a training process, allowing trainees to ease into the client role. It, however, should not last for long. If left to continue, role-playing will deprive the trainees of genuine emotions and dynamics, denying them the opportunity to put themselves in the clients’ seat. Pretty soon though, you will need to allow yourself to be a client in peer counseling. Being a client can be an exuberant, albeit unsettling, emotional experience—you get to have the firsthand experiences of being vulnerable, of being understood, of being challenged. You may be enlightened with fresh perspectives; you come to appreciate some of the misgivings or apprehensions that clients often face in talking to a relative stranger about intimate details of their lives—what a gift for a prospective therapist. You should view peer counseling as a free opportunity to look at some concerns in your own life, especially those that may influence your effectiveness as a helper. Setting Your Own Pace of Self-Disclosure When you feel more comfortable and able to trust the triad and the supervision process, you are ready to work on real issues. Rest assured, self-disclosure is a voluntary act. Don’t disclose too much, too fast, too soon. Set a pace comfortable for yourself.

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Your self-disclosure should remain appropriate to the goals you set for yourself. Therefore, take care in choosing what you reveal about yourself. Prepare what you are going to say. Afterward, reflect on the impact of the session. These considerations will prevent you from revealing things about yourself that you would rather not. REFLECTIVE PRACTICE: A KEY TO YOUR PROFESSIONAL DEVELOPMENT The “self ” of the therapist is the most important instrument that determines the outcome of therapy. This section focuses on the cultivation of the self of the therapist. Engage in Reflective Practice Reflective practice—the most important tool (Atieno Okech, 2008; Bolton, 2010) in the development of any professionals—is at the heart of cultivating our inner therapist. Reflective practice asks that we critically examine our values, concepts, and assumptions (Bolton, 2010). As we engage in this kind of reflective practice, we widen our perspectives, develop our own personal voice, and clearly see our role, responsibility, and boundary. According to Zhang & Parsons (2015), two types of reflective practice matter the most to counselors and therapists: •

•

Reflection on practice: Looking back over the previous session and reflecting on what we did and why we did it, and what adjustment can be made for the following sessions. Reflection in practice: Attending to our own behaviors, moment-by-moment counseling decisions, and to the client’s response to these decisions, using the data to guide our adjustment to the dynamics occurring in the session.

Ways to Enhance Reflective Practice There are various ways to enhance your reflective practice. We will only discuss a couple in the following: •

•

Case conceptualization: Case conceptualization increases your therapeutic efficiency, and therefore stands at the center of your reflective practice. For beginning counselors and therapists, the data transpired during the session can overwhelm us much like seeing a puzzle for the first time. After the session, we can take a breather and put the pieces of the puzzle together by practicing case conceptualization. When done thoughtfully, case conceptualization provides us a road map, guiding our observations and interventions for future sessions. Throughout this text, various levels of case conceptualization will assist you in getting this kind of excellent reflective practice. Reflection journaling: Another excellent way to engage in reflective practice is by reflective journaling. Bolton (2010) emphasizes that all professionals in training regularly engage in reflective practice so that they can critically examine their values, concepts, and assumptions. This emphasis has a special bearing for therapists, as therapists “don’t deal in certainties, but in educated guesses, intuition, and gut feelings” (Cozolino, 2004, p. 70). To fine tune your intuitions and gut feelings so that they become reliable instruments to guide your moment-to-moment decisions in the session, reflective journaling is imperative.

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In line with the above notions, we suggest all beginning therapists use reflective journaling to gain greater clarity in our inner feelings, emotions, and cognition and to achieve more awareness about those of others. Journaling helps us dig into the depth of our self, discover our forgotten self, and create an inner richness that will deepen your interaction with others and with clients. Allow Yourself to Experiment New Ways of Being Many new therapists fear that they may make mistakes by saying the wrong thing or using the wrong skill—an anxiety that leads to a cautious and assiduous counseling style and a perfectionistic stiffness. Truth be told, there is actually no such thing as a perfect question to ask or a perfect skill to use. What really counts is what you use to meet the client’s needs at that particular moment. The more we engage in reflective practice, the more we realize that to tap into the power of the therapy process, the only thing we can do is to give our self to the process without any reservation. We must be emotionally present. We must take risks to be present. Without this dedication, we are not therapists—but mere technicians. When we take risks with new techniques, our first attempt may fail because of our lack of experience in its application and delivery. After several attempts, however, our delivery of the skill or intervention may become more sophisticated and effective. The new skill will eventually become second nature. Allow yourself to experiment with different skills and techniques—skills and techniques should NOT be outside of who we are; but rather be our new way of being. Experimentation is the only way to further our growth. Experimenting is not about using clients as guinea pigs. Rather, experimentation means that we constantly check how the client responds to our therapeutic methods and accordingly adjust those methods until they work. Let Your Brain Grow in an Accelerated Fashion The process of learning counseling skills can electrify and challenge us—it can challenge us by making us feel like we are traveling through a jungle: we doubt at times whether we will ever reach our destination (Barker, 2013). You probably will question, at times, whether you will ever feel confident about your counseling skills, and possibly will feel frustrated with the slow pace of your progress as well as with the lack of a shortcut. Know that this aggravation is completely normal. As much as you desire to get to the destination quickly, it is best to consider your process in terms of a journey. Take one step at a time. Fix your eyes on the scope of tasks within each present step. Eventually, you will see the clear sky at the end of the jungle. When you arrive at the end, you may not be able to recognize yourself—the new you. It is because, as Cozolino (2004) states, the stress of this early development as a therapist can actually “prime your brain to grow in an accelerated fashion” (p. 69)— so much so in fact, that you might have grown to such an extent that you cannot even recognize the new you—the budding therapist in the making.

4

Empathic Responding Skills— The Skills of Building Connection

Like climbers trekking up to the summit of Mount Everest, we now take our first humble step in our journey. The mountain stands proud in front of us, rising toward the clouds. Step by step, foot by foot, day by day, we trudge onward. With dedicated minds and positive attitudes, in due course, we reach the top of the mountain to enjoy its’ fantastic vista and celebrate our extraordinary strengths and growth. This chapter begins our expedition with that first humble step—the empathic responding skill. Humble, yet not simple. The chapter stretches quite long to cover a skill set broad and complex in nature. THE SOFT SKILLS VERSUS THE HARD SKILLS IN COUNSELING AND THERAPY Empathic responding skills seem “soft” and “passive” when compared to the passionate and powerful influencing skills (covered in Chapter 9) or the active and dynamic intervention techniques (covered in Chapters 8 and 10). But don’t be fooled by this impression. The Wisdom of Taoist Philosophy The ancient book of Taoist philosophy, Tao Te Ching by Lao Tzu—a timeless guide to the art of living, a book on the basic principle of the universe, translated as The Book of the Way (Mitchell, 2006)—opens our eyes to appreciate the intrinsic power of the soft, with the following verses: Nothing in the world is as soft and yielding as water. Yet for dissolving the hard and inflexible, nothing can surpass it. The soft overcomes the hard; The gentle overcomes the rigid. Everyone knows this is true, But few can put it into practice. (Lao Tzu, Tao Te Ching, Chapter 78) Like water—with its inherent power obscured by outwardly soft appearances—the empathic skills may not impress you with their force. Yet, in winning clients, in launching them safely into the challenging process of therapy, nothing in the world can surpass the effectiveness of the empathic skills.

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Cut Across the Surface Dualism of Yin and Yang Conveying the therapist’s responsiveness, understanding, receptiveness, and nurturing presence, the empathic skills embody the Yin principle of the natural world—the nurturing gentleness desperately needed by clients who are distressed, discouraged by their circumstances. In contrast, the influential skills and intervention techniques, featuring active, commanding, and ardent energy, correspond flawlessly to the Yang principle. This principle is best received when the therapeutic relationship has been characterized by sufficient trust and a solid foundation. The Yang power can overwhelm clients in distress, but is welcomed by clients ready to confront their own long-held, maladaptive patterns. The dualism between the Yin and the Yang stays only on the surface. Deep down, they flow in cyclical motion, complementing each other, reaching a constant harmony and balance of the universe. Like the Yin and the Yang, the soft skills and the hard skills actually flow back and forth; interconnected and interdependent in the consulting room. These two skills complement each other, working in tandem, integrated as one, to make the therapeutic encounter whole. This chapter dedicates its presentation to the most unassuming, yet restorative skills of empathy, laying the groundwork for the pyramid of your skill repertoire. WHY PEOPLE HAVE DIFFICULTY OPENING UP More than anything, people want to be heard, to be known, and to be understood. Yet, many of them have a hard time revealing their true thoughts, needs, and feelings. They recoil from opening up because those listening cannot hear them. The listeners cannot hear for the unfortunate reasons to be discussed in this section. Premature Solution-Centered Talk Shuts People Down Many listeners lack the skills of focused listening. As soon as people begin to peel off the first layer of their problems, the listeners first reaction is to offer “how-to-fix-it” answers. Though well-intended, this kind of response only serves as a quick shut-off valve. It shuts down the person revealing their problems because it renders them feeling unheard. In the same vein, many therapists and counselors in training surrender to the urge to solve clients’ problems. They feel the pressure to perform, to measure their performance against the yardstick of how the treatment outcome should look like. The truth is, when we focus on premature problem solving, we risk sending the client a subtle message that says, “How you experience your life doesn’t matter. It’s the outcome that matters.” A New Client’s Vulnerability and Ambivalence When they first enter the consulting room and begin to tell a stranger about their concerns, people cannot help but feel vulnerable. They often have these questions running through their mind: — “Is this counselor someone I can confide in?” — “Is this therapist someone who I can trust not to hurt me, not to manipulate me, but rather someone who can help me resolve my issues?”

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— “Is this therapist someone who will be considerate of my personal feelings, needs, and my vulnerable position?” Further, a sense of ambivalence often accompanies the act of seeking help: one part of them embraces the idea of entering therapy; another wants no part of it. One part of them looks for self-discovery; another part defends against any slight possibility of exposure. One part desires to let go of the old; another part holds dear to the sense of control. On top of this vulnerability and ambivalence lies the typical discomfort associated with coming to therapy: • • • • • •

Anxiety over an unfamiliar environment Fear of being judged Lack of words to express their experiences A sense of confusion, not knowing where to start Certain cultural barriers Language barriers

Not all clients experience these difficulties in the same way, but most new clients will experience at least one. To ease the discomfort associated with self-disclosure and helpseeking, something must take place to make clients feel safe. That something is empathy. EMPATHY Before we delve into the skills and techniques, let’s look at the central role that empathy plays in the therapeutic encounter. The Bona Fide Agent of Change: The Therapeutic Relationship When listening to client’s presenting problems, most beginning counselors preoccupy themselves with questions like: — “What should I do?” — “What should I say next?” These kinds of questions set off beginning counselors’ performance anxiety. It disconnects them from clients’ experiential reality. A more productive question, as indicated by Maroda (2012, p. 2), can take the form of the following: — “What has to happen in this relationship at this moment to meet this client’s needs? And what is the best way for me to facilitate it?” Why think about “this relationship right now”? Therapy is not really technique-driven or theory-driven, but “relationship driven” (Yalom, 2009, p. XVIII). It is the therapeutic relationship that drives client change. Another thing to keep in mind is the following: — “How do I go about maintaining the connection between myself and my client, so that the therapeutic relationship can slowly take root?” The answer boils down to the same element—empathy—the key building block for the priceless connection between you and your client.

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Empathy As Validation What is empathy? According to Koerner (2012), in empathy, we communicate our accurate understanding of the world from the client’s perspective, without any judgment. This communication implicitly validates the client’s experiences. So, is empathy the same as validation? Almost, but not quite. In validation, we, the therapists, actively convey that “the client’s perspective makes sense” (Koerner, 2012, p. 15, with italics added by us). In a way, validation goes one step further than empathy; it says that the client’s reactions seem sensible given the circumstance. We will talk more about validation later within this chapter when we present the empathic skill of affirmation. For now, let’s look at how empathy and validation may each sing a different tune: Empathy:

“Tom, sounds like you feel outraged when your friends tease you relentlessly.”

Validation:

“Tom, it certainly makes sense that you would feel outraged when your friends tease you relentlessly.”

Agreement Is Not Empathy—Agreement Can Risk Triangulations One thing to keep in mind: empathy and validation do not equate to agreement. When showing empathy and validating people’s reactions to their circumstances, we are not saying that we agree with their reaction. Agreement (to be avoided): “Tom, it is good that you are outraged and showed them your limit. These friends of yours are too insensitive. It’s a good thing that you let them have it.” This kind of agreement sounds like triangulations—the therapist oversteps his boundary by taking the client’s side and going against and judging the third parties. Through Therapists’ Empathy, Clients Learn Experiential Acceptance Experiential avoidance pervades our society. Starting at a very young age, children have been told to control their thoughts and feelings. Whether they receive punishment and reinforcement will depend on whether they can control outward signs of aversive emotional arousal. In due course, we all learn that successful living involves avoiding anything aversive—an avoidance made possible only by remaining in tight control of our thoughts, feelings, memories, bodily sensations, and behavioral dispositions (Blackledge & Hayes, 2001; Hayes, Strosahl, & Wilson, 2011). This control later becomes a problem in and of itself. Studies found that subjects who use thought suppression as a primary way to manage aversive effects have higher levels of depressive and obsessive symptoms than those who do not (Wegner & Zanakos, 1994). Likewise, clients who use deliberate control as their preferred way of managing aversive thoughts, feelings, and bodily sensations typically don’t fare well in life. Control is a short term solution. Before long, something almost always breaks off. The tighter the control, the more forceful the rupture of negative experiences. Ironically, many clients enter therapy thinking that their life is going poorly because they have failed to control their depression, anxiety, or other aversive feelings, and thoughts. They think that you, the therapist, will bring their control back.

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As an antidote to this kind of experiential avoidance, therapy strives to help clients accept those experiences that they desperately want to get rid of. A client can only learn to accept his own whole experiences through the eyes of a therapist—someone who demonstrates a nonjudgmental acceptance and empathy; who hears them out, and who acknowledges their thoughts and feelings. The Client Will Internalize the Therapist’s Empathy According to Miller (2013), the shame that people feel about themselves originates from a lack of parental empathy. The healing of that shame and the wound will come about through the therapist’s empathy. Hence, empathy shines as the North Star across the sky of all orientations of counseling and therapy. Each empathic response by the counselor works its magic in clients as they internalize it. As Teyber and McClure (2016) state, “It is the relationship that heals. The relationship between the therapist and the client is the foundation of the therapeutic enterprise” (p. 8). Empathy responding, therefore, towers over others as the first skill that a practitioner must master. The In-and-Out Process of Empathy Empathy, not as a static state of mind, involves an in-and-out process. For the “in”, it requires us to enter the client’s internal world, recognizing what the client is thinking, feeling, and longing. For the “out”, it requires us to step back, in an effort to retain our objectivity. We need that objectivity to see, with impartiality, clients’ illogical thinking, distortion, or maladaptive relational patterns (Wright et al., 2017). If any distortions, illogical reasoning, or maladaptive behavior patterns are detected to have contributed to the presenting problem, we keep this observation in mind and address these problems later—at a time when trust has been firmly established in the relationship. Please refer to Chapter 9 for influencing skills and Chapter 10 for intervention techniques, to review how to deal with clients’ maladaptive perceptions and behaviors. Empathy itself encompasses a heap of multifaceted skills. To make the complex simple, we can break it down into two actions: 1) attentive listening, and 2) empathic responding. Each of these two aspects will be discussed next. THE LOST ART OF ATTENTIVE LISTENING The first aspect of empathy involves our ability to listen deeply to the clients’ verbal and nonverbal messages. Listening, however, seems like a lost form of communication in our increasingly fast-paced society. As communication technology rapidly advances, people’s capacity to listen seems to recede. The Lost Art of Conversation In this era of digital communication, people pay little attention to what each other are saying, even when talking face-to-face; so little that the conversation is passed as an “alternating monolog”, a term coined by Cozolino (2004). Yet, the human desire for someone to listen to us does not disappear altogether with the advance of communication technology. Indeed, people now seek out counseling, in part, to fulfill their needs of being listened to.

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To listen attentively is to listen with the intention to understand. We achieve this by getting inside the other’s frame of reference along these following areas: — “What are the client’s core messages?” — “What themes are coming through in the stories?” — “What significance becomes clear in a certain aspect of the client’s story?” In other words, we listen to see, to hear, and to sense, from the client’s perspective. So seldom have clients been listened to in such a way in their daily experiences that a therapist’s attentive listening can move the client deeply. Listen to Two Levels of Message Attentive listening calls for us to concentrate on two channels of communications: verbal and nonverbal. •

•

Verbal communication: Listen carefully to people’s verbal communication, and soon we will find that people often bury their thinking, feelings, and personal needs within their own tangled stories. These stories are most likely “other-focused” narratives, involving many third-party antagonists. Only when we track carefully do we realize how their thinking, feelings, and needs have a powerful impact on their own behavioral reactions. This will be later demonstrated in detail in first-level case conceptualization of this chapter. Nonverbal communication: What people truly think and feel shows more readily through their subtle nonverbal cues—tone of voice, facial expression, and body movements. Tune into people’s nonverbal communication, and we will get a greater sense of what’s going on with them. We then can use that data to help them fulfill their needs. He who has his innermost feelings, thoughts and inspirations heard and recognized will rest at ease as a contented client. When using the advanced empathy skill, covered later in this chapter, we need to rely on our attunement to clients’ nonverbal messages.

Attending Behaviors: SOLER Just as the client’s nonverbal communication gives a sense of what’s going on with them, the therapist’s own nonverbal cues send signals to her clients about the quality of listening. We want our body language to convey a message that we take interest in them, and care for them. The therapist’s nonverbal cues are called the attending behavior. To become aware of your attending behaviors, learn the principle of SOLER: Square, Open, Leaning forward, Eye contact, and Relaxed. — Square: Sitting squarely to the client, but not direct to them—there should be no desk or table between client and therapist. Place chairs at a slight angle to make it easier for a client to disengage from eye contact when needed (Cozolino, 2004). This placement establishes an egalitarian relationship with the client. — Open: Sit in an open posture with your arms uncrossed. Arm-crossing speaks aloud a body language of defensiveness, resistance, self-protection, and judgment— something you want to avoid. In contrast, the open-arms posture conveys openness and acceptance; a message you want to convey. — Leaning forward: This posture indicates that you take an interest in what the client has to say; you are actively engaged in the interaction.

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— Eye contact: Eye contact conveys attentiveness. Your eyes say a lot about your internal experiences. Keeping eye contact shows respect and attentiveness to your client and gives you the opportunity to understand what the client is experiencing internally. If you constantly look away, it may send a message that you are disinterested, bored, or preoccupied. Eye contact does not need to be intense. Rather, keep it soft and steady. There is no need to stare or gaze. — Relaxed: While listening to the client, loosen the muscles in your jaw, eyebrows, forehead, lips, torso, and limbs. Allow yourself to be present; let go of your worries about the future and the outcome. Allow yourself to be in the present moment, with an unadulterated, genuine and selfless devotion to the client’s needs. When you are relaxed, your client will be as well. WHAT DOES IT TAKE TO RESPOND EMPATHICALLY The second aspect of empathy involves the ability to respond. We respond to express our understanding, to show that we accept clients as they are, without judgment. This is called empathic responding. The wider your range of responding skills, the more your clients will be receptive to your influence. Empathic responding is not a regular daily language, but a therapeutic language with a complex skill set. No one is born with the natural inclination to respond empathically. This section presents three ways to cultivate this special skill. Suspend Our Own Needs Temporarily First, temporarily set aside your own needs. Selflessly focus on the client’s experiences, and leave your needs and wants at the door. Even when we are going through a rough spot in life—and this inevitably will happen—we will suspend our personal needs when we are with clients. This dedicated focus on the client demands nothing in return, wanting only growth and fulfillment of those we serve. People seldom find someone in their lives capable of such selfless listening and responding. It is a profound experience for a client when their therapists provide them with such dedication. Set Aside Our Own Agenda and Judgement Second, abandon any agenda of our own—especially our agenda to change our clients’ feelings or reactions. Even when the client’s presenting problems seem unappealing or seemingly out of range, we must suspend our own judgment. We must restrain ourselves from wanting to immediately problem-solve. Accept the client ultimately as a human. See the person as separate from their maladaptive behaviors. See the human conditions that connect you and your client. Stay Tuned into Our Own Inner Reactions Third, don’t dismiss your perceptions and inner reactions, even as you set aside your needs. Rather, recognize your body’s own emotional signals. For instance, a tightening in our throat may tell us that something vital is happening at that moment. Perhaps the client is feeling a tightening in her throat as well. Or perhaps the client has said something that is triggering an emotional issue from your past.

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Whatever your internal responses are, be aware of them. Use those internal messages to understand the dynamics of what is going on between you and your client. If a client elicits frustration in you and causes your throat to tighten, they typically elicit the same reaction in other people as well. By paying attention to your own bodily reactions, you will gain firsthand information about how other people in the client’s life react to them as well. In the early counseling process, keep your perceptions and reactions to yourself. Only in later sessions should you consider using these insights for exploration. For example, to tackle these powerful yet elusive interpersonal issues in the consulting room, you will use influencing skills (Chapter 9), such as immediacy or feedback-giving. LEVEL-ONE CASE CONCEPTUALIZATION To avoid over thinking what to say next, we need to have a mental road map of clients’ inner self. The case conceptualization will provide you with a map, helping you to navigate through clients’ inner landscapes. Case conceptualization also guides treatment planning and helps us arrive at the problem resolution. In conducting a case conceptualization, a therapist usually tries to see the cause-effect recursive dynamics (how and why the client’s issues get perpetuated over time) through her theoretical framework (Cozolino, 2004). We will cover three levels of case conceptualization throughout this text, with their depth progressing incrementally. This chapter will cover the first level case conceptualization. A Triangle of Clients’ Private Experiences To make sense of clients’ subjective experiences, see Figure 4.1 which provides an image of their private experiences. Environmental stressors or external events can trigger clients’ thoughts, unmet needs, and emotional reactions—a triangle in which the various aspects of a client’s inner workings impact one another. These three inner processes contribute greatly to how a client reacts and copes with the situation. The ensuing coping reactions will be covered in detail in the secondlevel of case conceptualization in Chapter 9. For now, we will focus on the three inner processes, relying on them as our road map into the clients’ inner landscape. Rapport and Assessment: The First Stage of Counseling In the initial stage of counseling, when we do not have a clear idea of the client’s core issues and have yet to establish a solid relationship with them, we must give priority to establishing the much-needed rapport. At the same time, we must try to assess and understand the client’s central problems. Two skills are required to accomplish this task: empathic responding skills, covered in this chapter, as well as assessment skills, covered in Chapter 5. As you apply the empathic skills, keep the flow chart of Figure 4.1 in your mind. This will help you gain a sense of clients’ inner subjective experiences. Clients intrinsically want to be understood and seen, and their subjective inner experiences will help you make sense of why they act and react in certain ways.

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Figure 4.1 Level-One Case Conceptualization: The Subjective Inner Working of Clients’ Thoughts, Needs, and Emotional Reactions

THE SEVEN BASIC EMPATHY SKILLS Let’s now dive into the nuts and bolts of the empathy skills. As a whole, the empathic responding skill may seem like a mystery, but if broken down into the sub-skills or micro-skills, they are actually quite manageable. From our perspective, there are nine empathy skills, which can be further grouped into: • •

Seven basic empathy Two advanced empathy skills (to be covered later in this chapter)

The First Seven Empathy Skills: Basic but Not Simple Basic empathy skills—or called accurate empathy—lay a solid foundation for all the other skills. Basic does not mean simple. As shall become evident, basic empathy skills—such as reflection of thought content, reflection of feelings, and reflection of needs—actually take a great deal of mental energy and practice to become well versed in. We encourage you to take your time practicing these basic empathic skills, until they become second nature. Basic Empathy Skills Cover a Wide Range of Therapeutic Responses The seven basic empathy skills cover a wide range of therapeutic responses necessary to begin the therapeutic process. This is good news for you. Wright (2003) states, “In a relationship, the person with the widest range of responses will have the greatest amount of influence” (p. 31). In the sections that follow, we will detail each of these skills. Table 4.1 presents a composite look at the seven basic empathy skills. 1. PARAPHRASING: REFLECTING THE VERBAL CONTENT The simplest skill of empathic responding is paraphrasing. In paraphrasing, you leave out your own interpretation or perceptions. Instead, you simply restate the key points of a client’s verbal presentations.

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Table 4.1 The Seven Basic Empathic Responding Skills with Illustrations The 7 Basic Empathy Skills

Illustration

1. Paraphrasing 2. Reflecting thoughts

“Sounds like it is very frustrating.” “Sandi, you seem to believe as a fact that ‘No one really cares about my feelings.’ ” “I have the sense, Susan, that you feel angry at your mother (reflecting feelings) but you think to yourself, ‘It’s awful to feel angry at my parents’ (reflecting thoughts).” “Tom, it certainly makes sense that you would feel frustrated when your friends tease you relentlessly.” “Ed, I can see that deep down you have a strong need for connection with your son, but there is more and more frustration as time passes because your son hasn’t shown much interest in responding.” “Sam, I appreciate how hard it must have been for you to go through this. Your resiliency is commendable.” “I was wondering if leaving your husband is the plan you really want. I heard some doubt in your voice. Did I hear you right?” “It sounds like you are torn in two ways. On the one hand, you’re worried that your drug use is hurting your family, and that you are spending a lot of the money on the drug. On the other hand, you certainly don’t think of yourself as an addict, and you believe this assumption that ‘I can quit the drug anytime I want, without any bad effects.’ ”

3. Reflecting feelings

4. Reflecting needs

5. Affirming/Validating 6. Checking perceptions 7. Summarizing

Reflect Clients’ Verbal Contents or External Circumstances When starting to present their issues, most clients will lay emphasis on the external circumstances that life has dealt them. As you listen, you may naturally recap and reiterate the circumstances that they have just relayed to you—you have paraphrased already. Don’t confuse rote repeating for paraphrasing. Rote repeating is more like parroting— you are not demonstrating that you are listening attentively to the main message, nor are you creating a real interpersonal connection. Paraphrase the Key Points: No Details To paraphrase, start with sentence stems such as: — — — —

“Looks like you’re saying. . . .” “It seems that. . . .” “It sounds like. . . .” “Let me see whether I’m on the same page with you. . . .”

After a sentence stem, follow it with the main points of the difficult situations. In including the sentence stem, you will sound more natural. Remember, you don’t need to recap all the details, just the key points. Example 1 Client: “My feelings don’t matter to anyone; 1950s women don’t voice their opinion. Because I’m not providing an income, I can’t express my thoughts in my household.”

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Counselor : “Wendy, it seems the generation that you are from and being unemployed both have held you back from speaking your mind.” Example 2 Client: “My test scores were so low! I can hardly believe how low they are. And so much was riding on them. What will I do?” Counselor : “Sounds like your scores have really shaken up your confidence to the point that you’re starting to question your future. [Pause] It also sounds like you’re hoping that input from me may help you turn the tide.” Here are some more examples of paraphrases: — “Sounds like it is very frustrating.” — “Lili, it sounds like there is still some love in your relationship with him, yet, not enough to help you get along.” — “Correct me if I’m wrong, Joe, but it seems that you’re squeezed at both ends: Work is becoming more difficult, and your daughter’s problems and your wife’s poor health are becoming difficult for you to cope with.” — “From what I hear, Sharon, your son’s addiction problem is becoming increasingly difficult for you to deal with.” 2. REFLECTING THE THOUGHT CONTENT Reflecting clients’ thought content has a great advantage. It not only helps you convey your understanding but also helps reduce the anxiety clients’ feel about being in counseling. For those clients hindered by their feelings, your reflection on their thought content can help them hear their own thought processes, calm them, and trust your ability to understand them. Thought Contents: How to Reflect Them to Convey Empathy Clients’ thought content encompasses a wide range of cognitive process—assumptions, beliefs, inner voice, interpretations, and decision-making process. Whenever you sense that they may have made certain assumptions about themselves, others, or life in general, you can reflect those thought contents back to them. This shows your clients that you understand what they are thinking or assuming. Please remember that at this point, reflection of clients’ cognitive content only serves to convey empathy and understanding. You are not trying to change their thoughts or assumptions. But even just hearing someone reflect their internal dialogue back to them can stir the clients’ awareness. Later, when clients are ready, you may employ cognitive restructuring (covered in Chapter 8) to help them modify any mistaken assumptions. Don’t Focus on Cognitive Process Exclusively Though the reflection of clients’ thought content may calm them and awaken their awareness, it must be applied with moderation. When used exclusively without being balanced with other types of reflection, it may inadvertently strengthen a client’s pattern of intellectualization—a defense against emotions. Such a pattern often establishes its roots in the client’s family of origin wherein expression of feelings is discouraged, minimized, or even punished.

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How to Reflect Clients’ Cognitive Contents A client’s thoughts and cognitions often present themselves as streams of inner voice. When we reflect a client’s thoughts, we can allude to their inner talk in a first-person voice. This won’t be the exact quotation of what clients say, but rather our inference of the assumptions that cross their mind. How do we detect a client’s assumptions or their inner voice? By listening carefully to what they say. We put our self in the client’s position to feel that which they feel but cannot express. Soon enough, we will begin to see the kind of assumptions that run through the client’s head. The following examples illustrate how we can reflect clients’ assumptions or inner voices. They are purposefully put in italics and in parenthesis. — “Bianca, I can almost hear you thinking, ‘I should have it all together.’ ” — “Correct me if I’m wrong, Gus, but from what you said, I get the sense that you’re saying to yourself, ‘I will always fail so I should stop trying.’ ” [Using the client’s firstperson voice to capture his thought process] — “Mahari, it seems as though you think to yourself, ‘If I judge myself first, then no one else can hurt me.’ ” — “Nancy, it’s as if you’re thinking ‘My father doesn’t agree with me, therefore he doesn’t love me.’ ” — “Dan, it seems like you are saying to yourself ‘I’m worthless unless I get the approval of my father.’ If I were to entertain this kind of assumption, I probably would feel anxious about everything I do. I wouldn’t feel free to be my true self. [Pause] It certainly would be a difficult way to live if I had to base my self-esteem on others’ approval.” [Reflecting both thoughts and emotions, ending with an interpretation] — “So there’s a voice inside you like a broken record saying, ‘If I let myself have some of these feelings, I may lose control.’ Do I hear you correctly, Yingtai?” — “Mia, I seem to hear you say: ‘I need to make myself needed; otherwise people will leave.’ [Pause to let the client hear her own cognitive assumption] When was the first time you felt the dread of people leaving you?” [Segueing to the bigger picture] — “Willa, you seem to assume ‘No one really cares about my feelings.’ [Pause] When was the first time you had this belief?” [Segueing to the bigger picture] 3. REFLECTING THE FEELING CONTENT Feelings and emotions serve certain essential functions for humans—to influence others and to stimulate a response from them. Emotions and feelings produce an enigmatic yet powerful presence. They are meant to be received and responded to (Kemper, 2016). To receive and respond to such energy, the therapists simply reflect these feelings and emotions back to the client—the third skill that conveys empathy and establishes a connection. We Can Figure Out Clients’ “Reactive Emotions” Just by Imagining It We can easily sense the energy of clients’ “reactive emotions” (Greenburg, 2008; Greenburg & Pascual-Leone, 2006; Johnson, 2004)—the more accessible feelings, such as frustration, guilt, anger, discouragement, worry, anxiety, etc.—as clients talk.

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As humans, we communicate largely through the energetic transmission of emotions, especially through our body language—tone of voice, facial expression, eye expression, etc. Even though some clients may keep their reactive emotions at bay when first revealing their issues, we can still figure out what their reactive emotions might be by using our own imagination; by putting ourselves in the client’s shoes. Emotions and Feelings Are to Be Accepted, Not Evaluated The evolution process has preserved human feelings because of their adaptive functions (Greenberg, 2012). All feelings are, in a sense, adaptive. Therefore, all feelings should be accepted, rather than evaluated. Unfortunately, some people have developed a lifelong practice of shutting down their feelings and emotions. By shutting down, they have lost their ability to recognize their own feelings, as well as those of others. If a therapist does this, she won’t have the ability to figure out how the client feels under the reported circumstance and may, therefore, leave the client feeling invalidated or uncared for. Fortunately, the majority of counselors and therapists have the ability to tune into clients’ feelings with ease. As they take one step further to reflect the emotional energy, clients often respond eagerly by disclosing at a deeper level. When their feelings are reflected back to them, clients often feel accepted, heard, and seen on a profound level. People in general, and clients in particular, yearn to have their inner feelings heard. Being on the receiving end of reflection of feelings usually liberates a person. The receivers feel lifted and relieved as if, for the first time in their lives, they are finally seen, and accepted. Feelings, Thoughts, and Needs Our feelings are intimately connected to our thought content and to the state of our psychological needs. Naturally, we may lump the reflections of thoughts, needs, and feelings altogether, as demonstrated by the following: — “Cindy, it sounds like you’re feeling hurt and sad [a reflection of feeling] because your need for recognition isn’t being met [a reflection of unmet needs]. Your mind says, ‘He only knows how to criticize me for trivial things and totally ignores my positive contributions.’ ” [Reflection of thoughts] As you reflect these inner experiences, the message you convey is, “I’m with you. I can sense the world that you’re feeling and perceiving.” Some Misconceptions about Reflection of Feelings Some counselors are hesitant to reflect clients’ feelings based on two misconceptions. First, if they reflect clients’ negative feelings, the client may then feel worse. Second, reflecting clients’ feelings is an intrusion of their privacy. The truth is, reflecting clients’ feelings does not make them feel worse unless you fail to follow it with other skills. Reflecting clients’ feelings also does not intrude into their privacy. In reality, clients long for someone to see into and validate their inner experiences. So, try to think of reflection of feelings as a way of demonstrating your acceptance of their feelings. If you fail to acknowledge clients’ emotions, you may come across as unresponsive, rejecting, or disconnected. This is not what you want.

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You can reflect clients’ feelings in two ways: 1. naming the feeling, and 2. using metaphors or analogies. Name the Feelings Don’t just say to your client, “I understand what you feel.” Rather, prove your understanding by naming the feeling. Simply naming the energy of the feeling can do more than you realize (Hanh, 2013). When you name a client’s feeling, he rewards you by opening up to a whole new level of intricacy; taking you to a new view of their inner experience. Consider the feelings named in the following example: Client: “The VCR in the school is missing. Well, two teachers came up to me and said, “What did you do with the VCR?” Counselor : “I can sense your anger, Barbara. You feel blatantly accused.” Following are a few more examples of how to name clients’ feelings: — “Your tears welled up when you talk about the loss of your pet, I can see how painful this loss has been for you, Ruth.” — “Your voice trails off when you talk about your engagement, it seems that you feel uncertain about it.” — “On one hand, you feel excited about moving out, and on the other hand, you feel guilty for leaving your Mom alone.” — “When you’re not in control, you feel restless or disturbed.” — “Mahukar, I have the sense that you’re angry at his failing to recognize your contribution, but you kind of tell yourself, ‘I shouldn’t be angry.’ Is that correct?” [Naming the feeling, then the thought] — “Tammy, it seems like you feel frustrated because you can’t express your thoughts and feelings to your husband. Your needs of being heard are left unfulfilled.” [Naming the feeling and the unmet needs] — “I have the sense, Bill, that you’re mad at your mother but you think to yourself, ‘A kid shouldn’t feel angry at his parents.’ ” [Naming the feeling, then the thought] — “I’m getting a sense, Sheri, that you feel hurt when he doesn’t call. This is something that’s uneasy for you to talk about, and I’m pleased that you’ve found a way to get to it.” [Naming the feeling, then affirming] Use Metaphors to Reflect Feelings According to our clinical observations, it is often helpful to use metaphors and analogies to help male clients link their inner experiences to a visual image; describing their feelings in a more tangible way. Men, in most cases, have a less-developed vocabulary for describing their feelings. However, they make up for it by having a highly developed visual faculty. When counseling male clients, consider the use of metaphors and analogies that link their inner experiences to visual images: — “It is as if all your efforts have been defeated, Jerry. Almost like you’re running into all walls.” (powerless) — “When your mother-in-law comes to visit, Joe, you feel pinned down . . . almost like a prisoner.” (strained and inhibited) — “You feel like you’re coming undone.” (losing control) — “You feel as if you’re on cloud nine.” (excited)

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— — — —

“It’s almost like you’re moving mountains.” (having great difficulty) “You feel like you’re walking on a tightrope.” (nervous) “You feel like you’re at the end of your rope.” (hopeless) “It feels almost like a pile of manure, doesn’t it?” (worthless)

Target Your Reflection on the Client, Not on Third Parties To help your clients experience and own up to their feelings, your reflection needs to focus on your clients. Even if your client is talking intensely about how others’ behaviors are having an impact on her, you must refrain from focusing on the third party. In other words, your reflection should be client-centered, not others-focused. Examples of others-focused responses: “I can’t believe he did that to you.” “Wow! She must have made you so mad.” Other-focused reflection can easily lead to story-telling or slip into the risk of taking sides with the client, and then into triangulation. Compare the two responses in the following examples: Example 1: Problematic: — “It sounds like she made you feel inferior.” [Other-focused reflection; reinforcing a victim mindset by blaming the third party—an act of triangulation] Improved: “Sounds like you feel irritated with some of the things she said.” [Clientcentered reflection; focusing on the specific triggers without blaming] Example 2: Problematic: — “I can see how he annoys you.” [Other-centered reflection, at risk of sounding like triangulating with the client] Improved: “It makes sense that you get annoyed with him after that unpleasant event.” [Client-centered reflection; focusing on the specific triggers without blaming] Example 3: Problematic: — “Everybody is kind of on the defensive since your new boss has come in, is that correct?” [Other-centered reflection, can lead the client to a story-telling mode] Improved: “You don’t enjoy the atmosphere in the office since the change of the boss.” [Client-centered reflection; focusing on the client’s reaction to the event] Use “Normative Reflections” with Special Populations Initially, openly discussing feelings and emotions may feel foreign for some adolescents or non-White clients, especially Asian/Pacific islanders. With these populations, we can use a type of reflection of feelings that we call “normative reflections”. Normative reflections acknowledge that others in similar situations often have similar emotional reactions to clients’ feelings, therefore, they are within the norm and natural. Normative reflections give these clients permission to bring their feelings and emotions into the open. They no longer feel alone or abnormal. With adolescents: Adolescents often feel self-conscious. To avoid intensifying their selfconsciousness, normative reflection may be in order:

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— “A lot of young people also feel uncomfortable when they have to discuss things like this.” — “That certainly explains a lot about why you would want to run away because it’s too much to endure for most people your age.” — “Many people at your age also face the same sense of anxiety, anger, and guilt, when their parents go through a divorce.” With non-White groups: Restrained feelings and reserved emotional expression are culturally sanctioned behaviors for Asian/Pacific islanders (Sue, 1990; Sue & Sue, 2016). Interestingly, a normative reflection actually helps these clients feel validated: — “A lot of people in this situation would feel insulted. Is this how you feel, too?” — “Most people would feel exploited if their boss treated them this way. I know I would. Is this how you experience the situation, too?” Build Up Your Vocabulary of Feeling Words A list of feeling words is offered here to help counselors who are more cognitively oriented build a vocabulary of feeling words. In Table 4.2, each list is presented in hierarchical order: lighter feelings on top and then descending with increased level of emotional intensity. When in doubt, use the words at the top of the list first. Cautions of Reflecting Feelings Please be mindful of the following when you reflect clients’ feelings: Don’t just reflect on feelings exclusively: Reflecting on a client’s feelings helps her feel heard and accepted, but it should not be the only thing a therapist does to convey empathy. Reflecting on feelings does not suffice to bring a sense of psychological visibility and a sense of being seen. Other aspects of what the client brings in with her, such as her cognitive contents, her world view, her needs, her value systems, and her strengths, etc., must be recognized and acknowledged as well. What you reflect on will lead the session in that specific direction: When you reflect on a client’s feelings in her presenting problem, the session will dive into that direction. Whereas, when you reflect on a clients’ cognitive content of the problem, the session will go in that direction. You should be intentional in terms of what you choose to reflect.

Table 4.2 Principles of Reflecting Client’s Message Things To Consider

Things To Avoid

Give yourself some time to think before responding Allow yourself to feel Use short responses Focus your reflection on the client, instead of on the others in the story Remain objective

Tucking reflections inside a closed question Cliches Interpretations Advice Judgment Minimizing Parroting Sympathy Taking sides with the client Agreeing

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Differentiate empathy from sympathy: A lot of people mistake sympathy for empathy; pity for sympathy. So how do they differ? Pity means feeling sorry for someone and looking down on her. Sympathy refers to a sense of sorrow for someone without looking down on them. Below are a few examples of sympathetic expression. — — — — —

“I feel so bad for you.” “It’s awful.” “Oh, that’s too bad!” “Poor you!” “I’m so sorry for you.”

Although sympathy sounds better than pity, people still don’t want to receive sympathy. They don’t want you to feel a sense of sorrow for them. Period. Indeed, sympathy increases the receivers’ feelings of being alone and isolated. In contrast, empathy conveys that you feel “with” the person. Empathy implies a more active process, requiring us to use our imagination and mental process to name others’ emotional reactions. Below are examples illustrating why empathy is a more active process. — “I can imagine how distressed you must feel to have such a financial challenge.” — “When my mother died, I had the same feelings of guilt, sadness, and emptiness that you’re feeling now.” As long as we are discussing sympathy and empathy, let’s expand the discussion to compassion. Compassion is understanding, plus a helping action. Compassion means that we not only empathize but also do or say something to help those who are suffering. For example, to offer compassion to someone who has experienced a recent loss, we might accompany him to a grief workshop, help him with a ritual, or provide him with some tangible support. Within the clinical setting, the best gift we can give is empathy; within our personal life, compassion. Don’t make the reflection into a question: Some beginning counselors make their reflection into a closed question, as a way to soften it up. The intent is good, but the method is problematic. Making the reflection a question, you would have driven your clients to think about how to answer your question. Here feelings are thus interrupted. If you really want to soften up your reflection, use a normative reflection combined with perception checking. Problematic: “Do you feel resentful when your needs are given low priority?” [Making a reflection into a closed question; not effective] Improved: “Many people feel resentful when their needs are constantly put at the bottom. Is this how you feel?” [A reflection of feeling + perception checking] Don’t convey judgments in your reflection: Try not to convey any sense of judgment in your reflection. Problematic: “So, you were self-centered and thought only of yourself on your first date when you were sitting there, waiting for him to show up for several hours.” [This reflection conveys a judgment. The client would feel scolded by this kind of problematic reflection] Improved: “If I were you and had to wait a long time for my date to show up, I would feel anxious. I would probably also fight with a voice of self-doubt saying ‘I am being

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dumped again.’ Is this how you feel?” [Reflection of feeling and thought content + perception checking] Don’t say “I know how you feel”: Some counselors use a pseudo-empathic response to convey understanding. They often say something like, “I know how you feel.” “I understand.” This kind of response is pseudo-empathic—no feelings are named to substantiate the declared understanding (Coplan, 2011). It sounds phony at best and it invites client defensiveness at worst. Remain objective about the bigger picture of themes and patterns: When we tune into the client’s inner experiences for too long, we risk losing our objectivity. Empathy is actually a constant in-and-out process, as stated previously. At one moment you tune in, feeling the client’s emotions and perceptions; the next moment you back out, looking at the bigger picture of the theme and patterns in his life. Table 4.3 summarizes things to consider and things to avoid in reflecting client’s messages.

Table 4.3 Feeling Words in Hierarchical Order Depression

Anger

Anxiety

discouraged blue down on yourself downhearted distressed depressed dismayed dejected hopeless helpless powerless miserable numb desperate

frustrated annoyed aggravated irritated upset insulted resentful mad angry furious enraged infuriated incensed wrathful

worried apprehensive anxious vulnerable nervous tense agitated startled afraid fearful frightened terrified horror-stricken panicky

Hurt

Guilt

Ambivalence

disappointed wronged offended insulted hurt injured wounded disheartened disillusioned demoralized shattered

responsible at fault to be blamed guilty guilt-ridden ashamed remorseful terrible mortified awful

confused uncertain unsure hesitant ambivalent perplexed bewildered disoriented baffled befuddled

Inadequacy

Stress

Mistreatment

doubtful of self insignificant inadequate

stretched too thin burdened stressed-out

unaccepted invisible unheard, unseen continued

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Table 4.3 Continued ineffective incompetent unqualified deficient unfit inept like a failure

exhausted overwhelmed overloaded burnt-out overpowered stifled oppressed

neglected judged rejected left out excluded put down discriminated mistreated accused cheated betrayed manipulated exploited violated

Happiness

Connectedness

Strength

glad hopeful satisfied content happy delighted blessed excited rejoiced elated ecstatic overjoyed exhilarated

warm appreciative touched moved in synch close supported respected treasured connected intimate loved attached

centered focused grounded resolute tenacious capable competent confident resourceful resilient strong powerful unshakable

4. REFLECTING NEEDS The fourth skill of basic empathy is to reflect clients’ unspoken needs. Our survival depends on fulfilling both physiological and psychological needs. Of the two, psychological needs often operate below the threshold of consciousness. Much of our interpersonal interactions are driven to meet our psychological needs. To reflect these needs constitutes an important part of empathy. Universal Psychological Needs Our daily decisions are often made subliminally, based on psychological needs. These decisions are later justified by logical thinking. Several key universal needs and longings seem to drive our interpersonal behaviors, including but not limited to the following: • • • •

Need Need Need Need

for for for for

acceptance love recognition freedom

• • • •

Need Need Need Need

for for for for

being heard safety worthiness being in control

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Reflect the Unmet Needs Most clients’ frustrations and sufferings involve their essential needs not being met. As you listen to the client, try to detect how their suffering might be connected to certain psychological needs being deprived. Seeing the connection will help us better appreciate clients’ intense reactive emotions. Often, a reflection of needs is combined with the reflection of feelings. Consider the following example. Client: “I just found out that my 52-year-old husband is having an affair with a 26year-old woman. I’m at a time in my life when I had hoped to retire and travel with him. Now I find that he plans to divorce me.” Counselor : “Sue, it sounds like your desire for enduring love and for growing old together has been shattered. And you’re wondering ‘how am I going to put my life back together?’ ” [Reflecting unmet needs and thought content] Some more examples: — “Ed, you have a strong desire to instill good values and work ethic in your son. But because he is only able to come over one day a week, there’s not much you can do to monitor his video game-playing behavior, which, you assume, is spoiling his work ethic. If I were you, Ed, I would feel out of control, just the way you do.” — “Ed, I can see that deep down, you have a strong desire to connect with your son, but your frustration and agony are intensifying because your son hasn’t shown much interest in response.” — “Because of the divorce, you can’t stop saying to yourself, ‘I’m a failure because I wasn’t able to make my marriage last.’ Jeff, I can see that you have a strong need to be in control and to be successful in making your loved ones happy. When these things don’t happen, you feel ashamed and hopeless.” 5. PERCEPTION CHECKING: CHECKING THE ACCURACY OF YOUR EMPATHY The fifth skill of basic empathy involves checking your perceptions. Our social conditioning encourages us to chatter onward, even to deliberately confuse meaning with innuendo, humor, irony, and metaphor. We rarely check with one another about the accuracy of our perception of others (Brammer & Macdonald, 2003). In counseling, the opposite must be in place; we need to use perception checking to ensure our communication with our clients is as clear as possible. Check the Accuracy of Your Perceptions To verify the accuracy of our understanding, we use perception checking. Perception checking prevents our own views from clouding the true meaning of what a client is trying to express; from projecting our own assumptions on clients. On a technical level, perception checking involves a combination of two separate skills, with the checking—a query—tagged at the end of an empathic response: • • • •

Paraphrase + checking Reflection of feeling + checking Reflection of thought + checking Summarization + checking

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The checking may sound like the following: — “. . . Is this correct?” — “. . . Am I right?” — “. . . Do I understand you correctly?” Respect Boundaries Perception checking expresses our empathy and, at the same time, shows a respect for a clear boundary between our self and the client. The client feels a sense of differentiation from us due to the checking query. This combination of empathy and a clear boundary allows a client to become even more comfortable opening up. — “If I understand you correctly, Dana, you seem to be saying, ‘I would be less anxious if my husband was more reassuring.’ Is this correct?” [Reflection of thought + checking] — “You seem to be very angry with your son, Markel. Am I right?” — “I was wondering if leaving your husband is what you really want. I thought there was some doubt in your voice. Did I hear you right?” — “José, I want to see whether we’re on the same page. You said that you’d like to live independently, yet in the last few minutes, you said that you can’t imagine leaving your elderly father alone. I detected strong contradictory feelings toward the move. Is this correct?” 6. AFFIRMING/VALIDATING The sixth basic empathy skill is affirmation or validation. In validation, we strive to convey that the client’s reaction makes sense under the circumstance. In affirmation, we strive to convey to clients that they have intrinsic goodness and inherent worth. What to Affirm? What to Validate? In general, we can affirm clients’ strengths and inner resources, including: • • • • • • •

Interests or passions. Inner strengths, such as creativity, open-mindedness, forgiveness, love of learning, spirituality, and appreciation of nature. Resourcefulness, such as social intelligence or relational skills. Ability to make a difference in their environment, such as problem-solving skills or leadership. Altruistic intentions, such as helpfulness or loving-kindness to others. Courage or the choice they make to come to counseling. Past accomplishments, positive relationships.

For clients whose emotions are dysregulated (see Chapter 8 about affect regulation), therapists need to validate the challenges and difficulties that they are facing. Such validation implies that their reactions toward these difficulties make sense. According to Koerner (2012), therapists can target their validation on the following: • • • •

The importance of clients’ problems. The difficulty of the task at hand. Clients’ emotional pain. The reason why they feel out of control.

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The Therapeutic Effect of Affirmation/Validation Our validation of clients’ experiences has a powerful effect on the client’s morale and on the therapeutic rapport, based on two reasons: Encouragement: Validation gives clients encouragement. According to Adlerian’s approach of psychotherapy, encouragement feeds on psychological health, whereas discouragement leads the road to mental health problems (Sommers-Flanagan & Sommers-Flanagan, 2015). When clients’ efforts and challenges are validated, such encouragement gives them further strength to endure difficulties in their lives, as stated below by Bromfield (2005, p. 15): The human spirit can bear all sorts of hardship and extremes, especially when its efforts and challenges are noticed. Conversely, there are few things that feel as maddening and unloving as having what we’re going through minimized or disregarded. Respect to clients’ resilience: Affirmation/validation focuses on clients’ strengths and specifies their inner resources, similar to strength-based therapy (Sharry, Madden, & Darmody, 2003). Not just for therapeutic bonding, the power of validation reverberates throughout all stages of counseling and therapy. It’s no wonder Yalom (2009) avows that it is the therapist’s affirmations and acts of support—not her interpretations or insights—that leave the lasting impression upon a client. Given this, whenever something adaptive surfaces in a client’s story, it is best to nurture this adaptive quality by gently amplifying and affirming it. Make Sure That Your Validation Comes out Proper and Genuine Affirmation must be done with care and moderation. If you overdo it, your client may think that you only want them to look at the bright side; that you are trying to minimize their issues or are not taking their problems seriously. See a personal reflection below by a novice therapist: It was called to my attention that I have a tendency to glaze over my clients’ sadness and pain, to focus only on their strengths. Upon some personal reflection, I realized that I had learned to endure my own sadness and depression in life, essentially by bulldozing through it. I had learned to say, “This is what life is; there is no recourse or relief. Suck it up and get on with it.” This type of militant attitude has enabled me to get through and overcome many difficult things in my life. Therefore, I was having difficulty validating my client’s pain. In not validating her painful emotions, I have, inadvertently, denied my clients the experience of being totally accepted by me. To avoid minimizing clients’ issues, there needs to be balance between reflecting on clients’ troubled feelings/thoughts and reflecting on their strengths (Cozolino, 2004). In so doing, our validation is delivered in a proper and more genuine way: — “Choi, I appreciate how hard it must have been for you to go through this nightmare. Your resiliency is commendable.” — “I think it’s remarkable, Darrell, that you want to feel better and that you’re willing to put forth the effort for change.” — “Erin, you’re certainly a person of courage to have been able to survive the trauma you’ve been through, without letting it tear you apart.”

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— “I’m awed to hear of all the stress that you are enduring. Your choice of coming to counseling demonstrates that you’re starting on the right path to better self-care.” — “I can see that you’ve made great strides from being shy to being totally yourself and open.” — “Nelia, I want you to know that what we have accomplished here is all due to your willingness to come in and put in the work.” — “Adalina, what a power and inspiration you have drawn from your spiritual foundation, a constant source of peace and reassurance. Your ability to tap into that resource has helped you stay grounded and remain empathic to others in need.” Canned Comments Are Not Affirmations Some new therapists confuse canned comments for affirmation. Canned comments diminish clients’ feelings and leave them feeling invalidated and insignificant. Effective affirmation, however, requires great effort and attention on the part of the therapist to articulate clients’ strengths. See the following examples of canned comments and how they resemble cheerleading and differ from affirmations. These must be avoided: — — — —

“Don’t worry. It will get better.” “Things are so bad that they can’t get any worse.” “Don’t worry—be happy!” “God never gives you more than you can handle.”

7. SUMMARIZING/TRACKING The seventh skill of basic empathy is summarizing. To summarize, the therapists track the key storylines of what the client has presented. We may use linking phrases, such as “on the one hand . . . on the other hand” or “at the same time” to tie together related issues. Tracking is one of the most pivotal and important counseling skills to master. A sense of coherence will emerge in the session when you use tracking skills and tie your clients’ materials in. Please note: When summarizing, try to track both cognitive and affective components of a client’s messages. Summarization may take shape in four ways: • • • •

Opening summarization Closing summarization In-session tracking Cross-session tracking

Opening Summarization When opening each session, you may track materials covered in the previous session. An opening summarization like this can provide a much-needed sense of continuity week by week. For example: — “May I recap some of the highlights of what we talked about last time? First, you’re concerned about the issues of Alzheimers because it runs in your family. You’re especially worried about having to take care of your parents with respect to Alzheimers and how it would take away your freedom to pursue your creative

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expression as a writer. Second, you’re concerned about how your dad’s alcohol issues might have affected you, especially because you are currently experiencing some anxiety issues. You have seen your dad use alcohol to cope with anxiety in his own life. Does that cover most of what we talked about in the last session?” Closing Summarization When closing a session, you may pull together what has transpired in the session. To summarize the entire session, you will have to decide what elements to include and what to leave out. Here’s an example: — “We have three minutes left. I’d like to sum up what we’ve covered today. First, you want to stay rooted in your fortress, but the location of your home isn’t safe for you and your wife. Second, your wife gets upset about the time and energy you’ve invested in trying to eliminate the gangs in your neighborhood and how this takes the attention away from her. On one hand, you really love and care for your wife, and on the other hand, you feel very strongly about fighting for justice in your neighborhood.” In-Session Tracking During the session, we need to track the themes of clients’ stories on a regular basis so as to stay focused. As a result of tracking, the texture of the session becomes richer. Consider examples below: — “It sounds like you are torn in two ways. On the one hand, you’re worried about how your drug use is hurting your family and how all of your money has been spent on drugs. On the other hand, you certainly don’t think of yourself as an addict and you assume that ‘I can quit the drug anytime I want, without any bad effects.’ [In-session tracking] If it’s okay with you, Joe, I’d like to find out more about how your drug use is hurting your family.” [The skill of focusing, to be covered in Chapter 5] — “Phil, I can see that you feel frustrated in two ways. First, you’re frustrated with the system for its inadequacy in preventing the theft from occurring. Second, you’re frustrated that you were accused of stealing, which you know you didn’t do.” — “Liz, I can sense a lot of pain and confusion in you through what you’ve just told me. Throughout your discussion about your marriage, your weight, and your new job, you’ve experienced feelings of failure in each of these areas.” — “Let’s see how the pieces fit together, Todd. Your mother has confided a secret to you and you can’t tell your father. You have a strong need to be loyal to both of your parents, and now you’re having a loyalty conflict. You feel stuck in the middle. Is that how you feel?” Cross-Session Tracking Cross-session tracking allows you to sum up the common threads that run through various sessions. Example 1 Client: “Whenever I start a new relationship, I feel really anxious. I just don’t have any confidence in myself about keeping the man I’m attracted to.”

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Counselor : “In previous sessions, you’ve talked about how your dad was never there for you, physically or emotionally. And just now you said you don’t have the confidence to keep the man you are attracted to. If I could sum it up, it seems like in both situations, you believe that men will not be emotionally available to you.” Client: “I never thought of that, but it makes sense.” Example 2 Counselor: (summarizing a theme that appeared several times previously): “In the past few sessions, we talked about your concerns about your relationship. Some of the following things seem to stand out. First, you’ve felt angry and resentful toward your ex-husband and father because of how they have been disconnected with you. Second, you feel disheartened and lonely at work. Third, you have difficulty expressing your needs and feelings, because whenever you talk about feelings that are unappealing to you, you laugh. I am wondering how all of the pieces fit together.” THE TWO ADVANCED EMPATHY SKILLS This section continues the skills of empathic responding, but focuses on using advanced empathy to reflect clients’ inner experiences that are most protected and hidden inside of the human psyche. Counseling As Peeling the Onion We often use the metaphor “peeling the onion” to depict the process of counseling. The skills of advanced empathy get beyond the outer layers and reach the inner layers of the onion. The outer layers of the onion: Three top layers are easiest to see: • • •

First layer: the content of the story (paraphrasing suits this). Second layer: cognitive content (reflection of thought process fits this). Third layer: the accessible feelings (reflection of feelings suits this).

Clients often feel safe to explore these first three layers and therapists can easily reflect their contents. The inner layers of the onion: Hidden deeper inside are the very tender and wellprotected layers: • •

First inner layer: the hidden meanings that the client attributes to the event. Second inner layer: the hidden feelings that the client cannot articulate just yet.

To reach these two inner layers, therapists need to use their intuition and intense listening. Advanced empathy aims to reflect on these two inner layers of client experiences. Advanced Empathy in Context Another way to look at the advanced empathy skills is to put them in the context of the various levels of empathy listed by Linehan and Dexter-Mazza (2008). • •

First level: listening and observing (this is the counselor’s internal process). Second level: accurate reflection (this is the basic empathy as illustrated in the seven empathy skills).

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Third level: articulating the unverbalized (this is the advanced empathy to be covered next). Fourth level: understanding the client’s behavior in terms of history and biology (this requires the therapist to understand the client’s special cultural and familial backgrounds, as well as their special needs. See details in Chapters 12 and 13 for working with diverse populations).

Since these advanced empathy skills are part of the empathy skill-set, they are considered the eighth and ninth of the skill set. Table 4.4 presents a quick look at the illustrations of these two advanced empathy skills. Table 4.4 The Two Advanced Empathic Responding Skills with Illustrations The 2 Advanced Empathy Skills

Illustration

8. Reflecting unspoken feelings “Although you didn’t talk much about your feelings, each time we discuss your mother’s verbal abuse, your head hangs down and your fist clenches, and I can sense a strong feeling of shame and tension inside of you.” 9. Reflecting implicit meaning “Nette, you have referred to the new you several times. I can almost hear the new Nette saying, ‘I am no longer just surviving, I am thriving.’”

8. REFLECTING DEEPLY SEATED FEELINGS Underneath the accessible emotions—reactive emotions—lies the vulnerable and deep-seated emotions. These are the primary emotions (Greenburg, 2008; Greenburg & Pascual-Leone, 2006; Johnson, 2004). They may include shame, unworthiness, loneliness, despair, etc. When we are able to detect what is hidden and reflect those deep-seated feelings back to the client, we reach the highest level of empathy—advanced empathy. Various means exist to help us reach these deeply rooted feelings: Listen to the Hidden Feelings Though hidden inside us, the primary emotions drive many of our behaviors. Consider the comparison in Table 4.5. Table 4.5 Examples of Surface Emotions and Behaviors and What Primary Emotions They Cover Surface emotions and behaviors

Hidden emotions

belittling behaviors frustrations anger (for men) hurt (for women)

jealousy inadequacy hurt or fear (for men) anger (for women)

Example A male client: “I got the raise but other White colleagues with less experience get a higher salary than I do. It drives me nuts just to think about this social system.” [Client expressing anger]

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Counselor : “You’ve succeeded in getting a higher salary, but still, you feel angry. Underneath the anger, I also hear some hurt. It hurts that as a minority, you have to work your tail off to earn a raise, while some people get the same results with little to no work.” [The counselor goes beyond anger and reflects the hurt that the client has yet been able to gain access to] Listen with Our Eyes—To the Nonverbal Cues What our clients actually say—the content—constitutes only 7 percent of their message; their tone of voice, 38 percent; their nonverbal cues, 55 percent (Wright, 2003). With these numbers in mind, we need to listen with our eyes; paying more attention to the nonverbal message than listening to the verbal content. In so doing, we are more likely to detect the hidden emotions behind the content of clients’ stories. As a rule of thumb, clients’ nonverbal cues do not always convey hidden messages. Only when we put the pieces of nonverbal cues together shall we attempt to see the bigger message. Regardless, body language speaks louder than the spoken word, perhaps because nonverbal cues cannot be controlled for too long by the conscious minds (Pease & Pease, 2016). When clients’ nonverbal cues appear more than twice or three times, we can feel confident that these cues contain certain feelings and messages that should be acknowledged. To our delight, Garner (1997) differentiates further: the message conveyed through the face begs to differ from that conveyed through the rest of the body. • •

The face conveys the kind of emotion, or the lack of it, that one is experiencing. The rest of the body reveals the intensity of the emotion conveyed by the face.

Thus, we may detect whether clients are feeling sad, angry, depressed, anxious, etc. from their faces. Then, we interpret how intense the specific feeling is through cues from the rest of the body. Please take the time and the patience to imagine possible emotions associated with the nonverbal cues in the following three categories: Facial expressions • • • • • • •

Tears in the eyes Dilated pupils Raised eyebrows Corners of the mouth turned down A tight jaw A stiff upper lip Lip pursed

• • • • • • •

Biting of lips Changed color in the face Facial tics Frequent blinking of eyes Not blinking the eyes Not looking you in the eye Wincing of the face

• • • • •

Fidgeting The body turned away Body slumped Shoulders dropped Arms crossed in front of the chest

Bodily gestures • • • • • •

Pulling the ear Biting fingernails Fist tightened Legs kicking Body shaking Finger strangling

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Nonverbal language linked with positive emotions • • • •

Eyes sparkling Face lit up Stronger voice projected Smiling

• • •

Body leaning forward Sitting straight Open body posture

Caution: Some nonverbal behaviors in non-White cultures convey very different messages than those in White cultures. For example, in Asians, especially in Japan, avoiding eye contact signals respect or deference (Sue, 1990; Sue & Sue, 2016). Without this knowledge, a well-intended beginning counselor may misread a Japanese client’s lack of eye contact as inattentiveness, rudeness, or low intelligence—a misinterpretation that will wreck the rapport with the client. This represents just one example of the cultural differences with which we should become familiar when dealing with clients from various cultures. Use Nonverbal Cues to Tap into Deeply Seated Emotions The following illustrates how to use nonverbal cues to tap into the deeply seated emotions: — “As you were sharing, I got a sense of despair in your voice—a feeling of carrying this burden for so long.” — “Although you didn’t talk much about your feelings, each time we discuss your mother’s verbal abuse, you hang your head and clench your fist. I can sense a strong feeling of shame and tension inside of you.” — “As you talk about your hurt, I hear the anger in your voice, Wendy. You feel like a sucker for being so giving and then being taken for granted.” — “Ruby, you said that you’re hurt by your husband’s indifference. I also hear the anger in your voice.” — “Tom, when you said that, you literally pulled yourself back as if you were hit in the chest by what your wife said.” — “Toby, as you talked about your anger, I also notice a fear in your eyes.” Use Successive Approximations When reflecting clients’ deeply seated feelings, try to start out with a less strong word and read the client’s reaction to it. If the client’s nonverbal feedback gives confirmation, then proceed to add the primary emotions. Successive approximation helps us get as far ahead as possible into clients’ underlying message, without arousing discomfort in clients. Client: “When my mother died, I was seven years old and I didn’t know that she had committed suicide. I did not find this out until one of my relatives told me that she had jumped off the roof of a bank building.” Counselor : “I can see that you felt surprised and shocked, even shamed in learning about the way your Mom died.” 9. REFLECTING THE IMPLICIT MEANINGS Reflection of meanings often comes late in the journey of counseling and therapy. Meanings often hide within convoluted stories, requiring a sharp mind to crack their codes.

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Something of Significance To understand clients’ implicit meaning, we need to sense how clients are interpreting the life events but not reporting; we need to unearth hidden messages that clients are only partially saying. These implicit meanings often carry a certain significance that has to do with what the client is troubled with (Young, 2013)—meanings that shape their self-identity or self-worth in a certain way. Reflecting the significance and the construed meaning for the client often helps her develop insights (Hepworth, Rooney, Dewberry-Rooney, & Strom-Gottfried, 2013). Play Just to the Edge of Clients’ Awareness We need to listen between the lines and trust our intuition to uncover the hidden meanings in the clients’ storylines. Clients who are more concrete in their information processing style may not immediately appreciate the abstract meanings. Therefore, Hepworth and colleagues (2013) suggest that we save the reflection of implicit meanings until the client is ready for deeper self-exploration. If and when the client is ready, we can reflect it back tentatively, playing just “to the edge of the client’s self-awareness” (Hepworth et al., 2013, p. 541). How to Reflect the Implicit Meanings In reflecting hidden meanings, we go beyond the details, the thoughts, or the feelings. We go deeper into the implicit; the hidden meanings wherein the client construes the matter at hand (Young, 2013). To get at the significance or the hidden meaning, we need to pay attention to the key phrases that the client repeats over time (Ivey, Ivey, & Zalaquett, 2014) and then ask ourselves: • •

What does the client believe this experience says about him or her (associated with his/her self-identity)? What message does the client express regarding his or her basic trust of life?

Consider the following examples: — “Simona, it seems like you interpret being compliant as the only way to keep people close to you. For you, to speak your truth means that people will leave you. And if people leave, to you that would mean that you are unlovable. So, to keep the close connection, you seal off the real you. Am I hearing it correctly?” — “Pippa, it seems like you take people’s disapproval of you as an indication that you were born flawed and worthless. This interpretation seems to come through when you talk about your father, your boss, and now your partner. Does this ring a bell?” — “Nette, you have referred to the new you several times, I can almost hear the new Nette saying, ‘I am no longer just surviving, I am thriving.’ ” — “As you talk about your brother, you start to lean forward. I can sense that he holds a special place in your heart.” — “Whenever you talk about your father, you light up. I can sense that he is a great inspiration for you.”

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— “Zelda, this seems to come up several times. It seems that, for you, love means agreement. If your husband does not agree with you, then it means that he does not love you. Am I hearing you right?” — “Yvette, I can understand how you would repeatedly ask yourself ‘Why does this happen? How can this be possible?’ When such a tragedy happened to such a good person as your father, life suddenly becomes unpredictable, unfair, and meaningless.” REMINDERS FOR EMPATHIC RESPONDING SKILLS To ensure that your empathic skills are the most effective, make sure to avoid the following: Avoid Evaluative Listening According to Egan (2013), a number of obstacles tend to block counselors and therapists from being able to respond to clients empathically. These obstacles include filtered listening, evaluative listening, being judgmental, having biases, pigeonholing clients, attending to facts, sympathizing and interrupting. These obstacles seem to cluster on evaluative listening. An example of evaluative responding is as follows: A new counselor said to a client who was venting over a frustrating event in her life: — “You are thinking too much!” — “You are too sensitive to people’s opinion of you.” These kinds of evaluative statements can harm your clients. Don’t Try to Take the Client’s Side Another obstacle that blocks counselors from being truly empathic is taking the client’s side and blaming the third party. For example: — “Your mom is a control freak and she just cannot let you spread your wings.” — “So this guy went from his parents to his roommates, to you. He definitely has certain dependency issues.” Be Mindful of Your Nonverbal Invalidations Your nonverbal cues or actions might create a barrier for your therapeutic empathy. Following are examples of nonverbal cues that indeed invalidate your client: • •

Taking a phone call during a session. Glancing over to check text messages.

Keep Your Observations in Mind! Withhold Confrontation! Listening to your client’s story, you may notice certain red flags: you may notice the way in which the client exaggerates, contradicts, or misinterprets reality. If you do, keep these observations in mind for later exploration. Don’t confront your clients at this point. Don’t interfere with the flow of dialogue.

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The right to confront must be earned. You earn the right to confront your client only after you have established a secure, trusting relationship. To prepare for later exploration, you may want to jot down your impressions of these contradictions or distortions after the session has ended. This is the situation in which process notes (see Chapter 7) come in handy. Calm Our “Monkey Mind”—Be Present with Our Client Our ability to be present with our client starts with our way of being—our way of being present. In behavioral terms, being present means the following: • • • •

Setting biases aside for the moment. Walk in the clients’ shoes. Calm your busy mind. Slow down to the speed of mindfulness. Being responsive, not listening passively. Being courageous enough to move gradually toward sensitive topics and feelings.

It is a privilege to be in a therapeutic encounter with our clients—an honor to be invited into their intimate, private worlds; to catch a glimpse of their beliefs, assumptions, thoughts, feelings and how they interpret the meaning of the events occurring in their lives. This is not something to be taken for granted. We can only reward our client by being totally present with them. Don’t Wait until You Have Something Perfect to Say Don’t wait until you get a perfect understanding of clients’ core messages. We can’t and won’t be accurate all the time about how clients feel (Teyber & McClure, 2000). Instead, use your imagination to guess at the client’s inner experiences. Even if we make mistakes, our clients will appreciate the effort. Our goal is not to be right, but to be caring, empathic, and emotionally available. Just reflect along the way. Our clients need to sense that we are making an effort to understand their personal world as they see and feel it. If your reflection is not on the right track, just say, “Ooops! Sorry, I misunderstood you there. Please help me understand.” Here is a reflection of a beginning therapist about his journey to overcome the need to be perfect: As I begin to let go of being perfect, I focus on reflecting. More specifically, reflecting feelings because it seems to connect the energy immediately. For me, reflection is a whole new way of being in the conversation. It becomes my life jacket when I am lost at sea. When I reflect back what has been going on with my client, she becomes aware of those parts of herself she has learned to distance. When I validate parts of her that she doesn’t accept, she starts to accept them too. Reflection becomes one of my favorite therapeutic tools. RATING YOUR OWN EMPATHIC RESPONDING: USING BARS The behaviorally anchored rating scale (Schwab, Heneman, & Decotiis, 1975)—also called BARS—is a Likert scale that many organizations use to provide job feedback to their workers. During training, we, as therapists, can use BARS to monitor our own progress in our empathic skills.

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Table 4.6 Behaviorally Anchored Rating Scale (BARS) for Empathic Skills: Designed for Peer Counseling Feedback or for Trainee Self-monitoring Point

Anchored Behaviors of Clinical Empathy

Check

1 (Lowest)

Failing to attend to the client’s feelings; sidetracked significantly from the clients’ sensitive experiences; jumping from topics to topics; asking poorly-timed questions. This is the lowest level of empathic response.

___

Somewhat derailed from the clients’ affective experiences and content; eventually coming back to acknowledge client’s distress after some time has passed; using cliché or jargon as a substitute for an empathic response.

___

Able to acknowledge the client’s obvious thoughts, feelings, needs, and perceptions, with a focus on creating comfort in the session.

___

Able to facilitate client’s self-understanding by providing appropriately-timed acknowledgment or reflection to the client’s less obvious distress, experiences, and thoughts.

___

Able to nurture the dialogue with the client at a deeper level by addressing the client’s unspoken feelings, embedded thoughts, deprived needs, and the meaning that the client has attributed to the critical incident. This is the highest level of empathic response.

___

2

3 4

5 (Highest)

BARS, as shown in Table 4.6, illustrates the best and the poorest empathic responses possible. Each point on the scale links to a behavioral anchor of empathy. The person in the observer role in the triad of peer counseling can use BARS to give feedback to the person in the counselor role about each of the counselor–client exchanges. This kind of feedback contains more value and usefulness. Otherwise, you can use BARS yourself to monitor your own skill development. The following scenarios demonstrate how various counselor responses might fare in the BARS scale: Client: “Last week my younger sister brought her boyfriend to visit our family for the Thanksgiving holiday. It totally ruined my holiday because they got all the attention. I couldn’t even get a chance to chat with her. It’s all about her boyfriend. And my family was all over him as well. It was disgusting.” (client hand-wringing and fidgeting) Counselor responses rated by the BARS: Level 1 (the lowest): — “How long did her boyfriend stay with your family?” [Ignoring the client’s feeling; asking a poorly timed question; the focus being shifted to the third party] Level 2: — “I know how you feel. All of this must be very upsetting.” [Using a cliché like “I know how you feel,” failing to name the client’s feelings. “Upsetting” is not a feeling, it is a reflection of the situation]

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Level 3: — “You felt frustrated that you didn’t get a chance to connect with your sister and family because they were preoccupied with her boyfriend. Would you like to talk a bit more about this?” [Able to reflect an obvious feeling. This is the basic empathy] Level 4: — “I can sense that you feel ignored by your sister over the holiday. It hurts. And I can also sense that your family’s exuberance toward your sister’s boyfriend touches a very sensitive spot in you.” [Reflecting unspoken/less obvious feelings. This is advanced empathy] Level 5 (the highest): — “I can sense that you’re hurt a lot because of being ignored during the holiday. I also sense some anxiety and a sense of shame as you were talking about your family’s reaction. We’ve talked about the difficulty you’ve had in establishing a lasting intimate relationship with a suitable partner. As an elder sister, you take it as if you’re being passed by in life. You feel inadequate in not being able to meet the expectations that you yourself and your family have for you.” [Reflecting both buried feelings and implicit meanings. This is the highest form of advanced empathy] These examples strive to give you a more concrete understanding of what the various levels of empathic responses look like. As you learn the complicated art of empathic responses, use BARS to assess your empathic presence for all of the critical exchanges with your clients. ILLUSTRATIONS OF EMPATHIC RESPONDING An Illustration of Poor Responding The following example illustrates how a counselor can inadvertently discourage a client by rushing in to focus on solution solving without showing empathy, acceptance, validation, or connection with the client. Client: “I can’t believe how fast my relationship with her went down. I’m totally lost. I thought it was a good one.” Counselor : “Are there any times when you don’t feel lost?” [No reflection of any kind whatsoever] Client: “I don’t know.” Counselor : “When are the times when the relationship does work?” [Bombarding the client with another question, even though it is a solution-focused question] Client [arms closed]: “Can’t remember now. Can’t feel anything now. I just feel so lost.” Counselor : “Suppose you’re not feeling so numb. What would you be doing differently in your relationship?” [Again, bombarding the client with another solution-focused question] Client [looking down, slouching into the chair]: “I don’t know. I feel like giving up, everything is so bleak.”

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Two Illustrations: Pulling All the Empathic Skills Together Example 1: The Case of Anna (The name is masked) Client [who had a miscarriage]: “Why me? Why did this happen?” Counselor : “Yes, it is so unfair, and it is so difficult when you don’t know why this happened.” [Validating the client’s difficult situation] Client: “Maybe it’s my fault.” Counselor : “It sounds like you are thinking, ‘There must be a reason why this happened, and if nothing causes it, then it must be me.’ ” [Reflecting the thought content] Client: “I just don’t understand. It’s not fair.” Counselor : “Anybody in your situation would feel angry at the injustice.” [Reflecting the reactive emotion, using normative reflection] Client (starting to open up): “Yes, I was angry at first, but now I’m just sad. I’m just very, very sad. It’s unbelievable how my life came to change so suddenly and my plans and hopes are all gone. Yesterday all of my emotions and sadness hit me like a freight train. I just miss being pregnant and miss the excitement that came along with it. My friends keep telling me, ‘Don’t worry. You can get pregnant again.’ They think it will make it all better just to replace this baby. No one understands how sad it is for me. I’ve been up crying because my baby is gone. . . .” Example 2: The Case of Janet (All names are masked) Counselor : “Janet, we have about 50 minutes together. Perhaps we can start with a question: What’s on your mind that you’d like to discuss?” Client [sitting cross-legged, holding her legs up to her chest; embracing them with her arms]: “My husband, Jeff, and I had a really rough year—circumstances and various things had happened. And we didn’t have a chance to mourn any of those things. There were really quite a lot of losses in one year. When Jeff reminded me of the losses, tears just welled up in me and I didn’t have any idea why. He said, ‘Do you think you have been able to mourn any of these things?’ And I just started weeping. So maybe there’s something to it that I haven’t thought about.” Counselor : “Sounds like you guys have gone through quite a lot this past year, Janet. It also sounds like you’re searching for a way to mourn the various losses.” [Paraphrasing, focusing on the circumstances + reflecting on the needs] Client [opening up]: “Yes. About a year ago, my husband’s parents were in a car accident, and his dad was killed, and it happened just four weeks shy from the birth of my second baby girl. As if that was not tragic enough, during an ultrasound, the doctor found an abnormality in my baby, caused by a cyst on one of her organs. After she was born, my baby went through four to eight weeks of straight crying. She had insidious pain caused by the cyst. I felt so heartbroken because my little baby had been in pain for so long. So I ended up bringing her to the emergency room and she had surgery. Another tragedy struck again. My husband’s grandma died on the same day my baby was undergoing the surgery to remove her cyst. After that, my husband and I jumped right back to work full time. We also had to travel back and forth to take care of my husband’s mom, who suffered some brain problems due to the car accident. So we’ve been handling all these.

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I feel like I kinda lost a lot of time just in survival mode. Amidst all these things, I came down with something that took me to the emergency room and I was in the hospital for five days. They misdiagnosed me. I actually had a perforated appendix, but because of the misdiagnosis, I had poison leaking into my abdomen that was so painful that it was unbelievable. After we went through all of that, all of a sudden my husband and I looked at each other and started saying things like, ‘Hmm, I don’t really like you’ to each other. We were in survival mode for so long, we just let a lot of little stuff build up. Yeah, there’s some stuff built up. I don’t know what to do with all that. It did induce this emotional reaction in me. So that’s the layout. It’s been only a year.” Counselor : “It must be devastating when after having endured all this enormous pain and suffering, you woke up to find out that you and your husband had literally become strangers to each other; misunderstandings have built up between you. A few minutes ago, Janet, you said that tears just welled up in you when your husband reminded you that you haven’t really grieved the many losses that you went through. I almost hear you crying inside, saying, ‘I’m coping as best as I can, but I’m scared about what’s going on between us.’ You feel really alone because your role in the family asks you to be strong and to keep plowing ahead, yet your intimate relationship requires you to be vulnerable and emotionally open. It’s like you feel alone and lost in the uncharted water. Am I hearing you right?” [Summarization, tracking the enormous amount of materials that the client just vented] Client: “Yes. When my husband brought it up, it was like, that was a lot. I don’t know what to do with all of that. He said, ‘Do you think you’ve mourned my Dad at all?’ And I was like, ‘I don’t know.’ I don’t even know how to answer that. Like I said, it did stir an emotional reaction in me.” Counselor : “I can imagine that the confrontation from Jeff was a bit difficult for you to take. Janet, would you mind talking a bit about the emotional reaction that occurred at that moment?” [Validating the difficult situation; using focusing skill (Chapter 5) to lead to a new area of discussion] Client: “It’s true that I didn’t really grieve the death of Jeff ’s dad because I’ve only known him for five years. We lived in a different location than his Dad. Though he certainly was, um [began to tear up], I feel like, well my Dad was an alcoholic and still is, but he’s not like an abusive alcoholic. However, I can never trust him. On the contrary, Jeff ’s dad really filled a void that my Dad could never reach. That’s the part of him that I really missed. There are times when I wish we could continue to benefit from his wisdom and support. He was really wise in terms of discerning through life in that way. I really miss having someone with that.” Counselor : “I am glad that your father-in-law was able to fill in the empty spot where your own father couldn’t. I may be wrong, but as I hear you talk about how you miss the presence of your father-in-law, I also hear some grief of the unspeakable loss of not having a steady father figure whom you could trust. I wonder if these two might be interrelated. Janet, as we start to work on resolving the built-up tension between you and Jeff, which seems to be what is worrying you the most right now, I wonder whether it might be also beneficial to explore, in the future, how your early loss, related to the emotional unavailability of your father, might have an impact on your ways of dealing with difficult emotions. Does it fit into what you are looking for?” [Summarization, tracking; goal-setting] Due to space limitation, we can only illustrate the first 20 minutes of the session.

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EXERCISES After each client statement, please write your response using the skill notated. 1. Paraphrasing Client (a mother): “I tell my kids to call if they need anything, but they never call. It’s been like this for a few years. I remember what it was like to be a teenager, but now I’m the parent—the noncustodial parent—and it doesn’t feel right.” 2. Reflecting thoughts, feelings, and affirming strength Client (a father): “Sometimes I’m too critical of myself. Because then I think that I should have done more for them as a father. I should have been closer to them when their mother died. I was just too wrapped up in my own grief to take care of them the way they needed to be cared for.” 3. Reflecting needs and feelings Client: (long pause) “Since fifth grade my family has moved around a lot. I was born in Cleveland. Then we moved to Pasadena, Seattle, Miami, Boston, and London. By the time I was 16, I had gone to seven different schools. It was hard to make friends. Now, at 25, I don’t keep in touch with any of the people I went to school with, and I also have difficulty in relationships.” 4. Reflecting needs and feelings Client: “I actually was enjoying just being there with her. We weren’t doing anything together or talking. She was sewing and I was watching the football game, but it was just nice to not be alone, to have someone with me, a companion.” 5. Reflecting feelings Client: “I think that I feel kind of bad and, even though I hate her, I sort of regret not being there for her.” 6. Reflecting feelings Client: “It’s hard for me because it just happened. I feel like I’m in a daze although I’m still doing the same things I always do. Although it seems like nothing has changed but everything has changed. My brain just hasn’t gotten the news.” 7. Reflecting feelings Client: “She never admits that she’s wrong. Instead, she turns it around and makes me seem like the bad guy. She says stuff like, ‘I’m so sorry that I disappointed you’ or ‘I’m so sorry that I can’t live up to your standards.’ Why is it always my fault?” 8. Reflecting feelings Client: “I never thought that kids would be so much work. We have four kids all under seven years of age. All I do is stuff for them. I know I should be happy, but it’s too much. I just want to run away, and that makes me a really bad person.”

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9. Reflecting unspoken feelings Client: “So, I’m going to get over this illness. I’ve entered myself in a 10K run in the fall. It’s out in the Quad Cities. I’m going to try to keep more contact with my friends who run these races and live healthily. You know, the guys who work out, or run, or do something like that. Your friends can make a lot of difference in how you feel.” 10. Reflecting unspoken feelings Client: “My husband and I have decided that we never want to have children. My mom says that when we get older that we will change our minds and then it will be too late.” 11. Reflecting feelings and needs Client: “My mom is just dumb and clueless. She is messing up my whole life. She just doesn’t get it.” 12. Reflecting feelings and affirming client’s strengths Client: “I just try to do what is right. My mom and dad raised us the right way and now I want to do the same for my own kids.” 13. Reflecting implicit meaning Client: “Last week someone stole my phone off the counter at school. This week someone broke into my house and took my television, and then I got sick. This seems like just too much happening to me. Am I attracting bad things to myself someway?”

5

Clinical Assessment Skills

When clients walk into your office, they most likely have emotional distress and associated symptoms—such as anxiety and/or depression—that they want to get rid of. You will try to figure out the root causes of these problems and flesh out a treatment plan for its resolution. Assessment will begin immediately. The purpose of assessment is discovery. To conduct a proper assessment, you need two predominant skills: • •

Empathic responding skills Assessment skills

Clinical assessment is a continuous process. This chapter presents the basic assessment skills—probing questions, focusing, and clarifying statements. More advanced forms of questions will be covered in Chapter 8. ASSESSMENT IN COUNSELING AND THERAPY Assessment—integral to the clinical interview—permeates every aspect of the counseling process, especially in the beginning stage of counseling and therapy. This section discusses the nature of assessment and the three basic types of assessment in counseling and therapy. Testing versus Non-Standardized Assessment Testing—a standardized assessment—measures psychological constructs through instruments that are developed under a rigorous process. Testing usually produces results that tell something meaningful about an individual in the context of a population (Gladding, 2012). Instruments—such as inventories that measure depression or anxiety, and personality tests—fit this description. In contrast, a nonstandardized assessment—or simply, assessment—gathers information without adherence to a strict set of rules as testing does. This kind of assessment is integral to clinical interviews. Counselors and therapists need to be competent in both standardized and nonstandardized assessment strategies, as both are required in their services to clients. Assessment and Therapist Accountability Assessment (non-standardized assessment) is not conducted just to provide a diagnosis. Rather, assessment strives to identify problems, discover personal strengths, and plan interventions.

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Through careful assessment, therapists can provide clients with needed services that otherwise may not be justifiable. Through careful assessment, therapists also meet the demand of accountability and effective practice. Assessment and Reassessment: A Continuous Process To repeat: clinical assessment is a continuous process, not a once-and-for-all deal. Clients’ issues constantly shift, are in a state of flux or are in need of constant redefinition. Like peeling an onion, when the outer layers of clients’ issues are removed, the inner core is revealed. As such, we constantly redefine clients’ issues and needs and accordingly adjust our interventions to address their most urgent needs. This section gives an overview of the three basic types of assessment as initially defined by Juhnke (1995): • • •

Qualitative assessment Behavioral assessment Review of past records

Qualitative Assessment: Face-to-Face Clinical Interview In counseling and therapy, qualitative assessment towers over the other two types of assessment as listed above. In sharp contrast to standardized tests, qualitative assessment involves face-to-face interviewing. During the interview, therapists use questions, such as those presented in this chapter, to uncover significant events in clients’ developmental histories. Through discoveries obtained in the clinical interview, therapists gain insight regarding what therapeutic direction they should launch into for helping the client. The assessment skills that this chapter presents focus on the qualitative assessment, mostly used in the clinical interview. Behavioral Assessment Behavioral assessment aims to find out the antecedent to the clients’ problem behaviors and the resulting consequences of said behaviors. This kind of assessment takes a broader effort. Not only do therapists interview clients, but they also talk to clients’ significant others to gather information. Though it goes beyond interviewing clients, the validity of the data gathered through behavioral assessment is still limited as it relies on selfreporting, which is often biased. Another method of behavioral assessment involves directly observing clients in settings (such as homes or schools) where the problems occur. This method may use behavioral problem recording systems to monitor the frequency, duration, and intensity of problem behaviors. Though this type of behavioral assessment provides more objective data, it consumes much time and requires intensive labor. Therefore, it does not suit the needs for the initial assessment in counseling and therapy. Review of Past Records: Indirect Assessment The third type of assessment involves reviewing a client’s records—reports from prior counseling, records from school, police, medical, or the military—which provide important information about the client. We call this an indirect assessment.

Clinical Assessment Skills 77 Through past records, we can identify patterns in a client’s life—such as self-injury, legal involvement—or other events that they may not disclose in face-to-face interviews. Reviewing records from past counseling sessions can provide us with details about the types of treatment previous therapists have attempted and whether or not they have been effective. Such findings can help us create new treatments accordingly. FIRST ASSESSMENT SKILL: PROBING QUESTIONS The first type of assessment skill to master for qualitative assessments during the clinical interview is probing questions. While Ivey, Ivey, and Zalaquett (2014) describe probing questions as an invitational response, we classify probing questions as an assessment skill. This seems to resonate with the position taken by Cormier, Nurius, and Osborn (2013). From our view, probing questions can be further categorized into three subgroups: 1. Questions for gathering information 2. Questions for intake 3. Questions for revealing formative influences Questions for Gathering Information The first type of probing questions is used to gather information. This seems to come naturally to most counselors, perhaps because it is an integral part of everyday conversation. Therapists are expected to be able to use probing questions to gather information for the following functions: Open a session or an interview — — — —

“What would you like me to know about you?” “What would you like to talk about today?” “What’s been going on? Could you tell me?” “The last time we met, we talked about the tension with your mother. How did it go this week?” — “Perhaps we could start by having you tell me: where you are now?” Pursue specificity and concreteness Example 1 Client: “Because I’m in the front desk part of the organization, it always feels like he ambushes me.” Counselor : “Would you give an example?” Other examples: — “Would you give me an example of what your wife does that triggers this sense of inadequacy?” — “What does she do specifically that brings out your anger?” — “What happened first (next)?” — “What was the result?” — “What did she say (do)?” — “What did you say (do)?” — “Would you tell me more about it?”

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Discover clients’ points of view — — — — — — —

“What do you mean when you say ‘depressed’?” “You say that he is domineering; Would you elaborate on what you mean?” “In what way is that a concern for you?” “How much does this issue concern you?” “What does all this mean to you?” [Discovering client’s cognitive assumptions] “Does this make sense to you?” [Same as above] “What do you tell yourself when this happens?” [Same as above]

Dive into clients’ internal experiences (feelings, thoughts, and doubts) — — — — —

“What’s the feeling behind your tears?” “How did you feel when it happened?” “How do you feel when your mother yells at you?” “Would you like to tell me what’s on your mind at this moment?” “If you had to ask yourself one question right now, what would it be?”

Look for clients’ strengths or resources — — — — —

“What qualities of yourself are you most proud of?” “What were some of your best traits as a child?” “Would you tell me a story about one of your childhood successes?” “Who in your life has encouraged you the most?” “What kinds of things that people do encourage you the most?”

Seek extra data — “What other important things are happening in your life right now that I should know about?” — “Is there anything else happening in your life at this time?” — “Are there any other things that might be contributing to this?” — “What are the ways you’ve tried to solve the problem?” — “What other information do I need to know to better understand this problem?” Trace pattern of connection — — — — — —

“Who else worries?” “Who do you think worries the most?” “Who do you imagine worries the least?” “What does he do when he worries?” “What do you do when she shows you that she’s worrying?” “What are other occasions when this pattern arises?”

Questions for Intake The second type of probing questions is used in the intake interview. The procedure involved in conducting an intake is demonstrated in Chapter 6. Here are some useful intake questions for extra consideration: — “What would you like to gain in counseling?” — “How long has this issue been going on?” — “Before coming to counseling, what have you tried to cope with this problem?”

Clinical Assessment Skills 79 — — — — — — — — —

“What role did you play in your family while you were growing up?” “What major losses have you had in your life?” “What major changes have been going on in your life in the last five years?” “Whom do you turn to when you need someone to talk to?” “What are the positive things in your life right now?” “What spiritual connection is important in your life?” “What are you most proud of in yourself?” “What changes do you think counseling can help you accomplish?” “What do you see happening when counseling is successful in helping you reach your goal?” — “How long do you think these behavioral changes will take?” — “What do you hope a therapeutic relationship in counseling will be like for you?” Questions for Revealing Formative Influences The third type of probing questions are questions used to uncover forces—familial, social, cultural, and spiritual—that significantly impact clients’ psychosocial development. Probing about influential people — “Who in your life has influenced you the most?” — “Outside of your family, which adults or teachers have made the biggest difference in your life?” — “Who in your life has given you the most encouragement and has boosted your self-confidence?” Probing about core beliefs — “What messages did you get about yourself from your parents’ arguments and eventual divorce?” — “How did the constant moving in your childhood impact the way you think about relationships?” — “What messages did you get from taking care of your chronically ill mother when you were growing up?” — “What did you learn about yourself when you finally stood up for yourself against the bullies in school?” Probing about cultural and social influence — “How has growing up in an immigrant family affected you?” — “How did the difficulty of not being able to speak the new language affect you?” — “How has moving from a small rural area to the Chicago metro area influenced you?” — “What impact has your Asian cultural background had on the way you see the world?” Probing about transforming experiences — “What life events have you been through that have changed the way you feel about yourself and life?” — “What experiences have you had that have changed the way you deal with the world?”

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PRINCIPLES OF USING PROBING QUESTIONS Before moving on to learning the other two assessment skills for qualitative assessments, we need to remember this: asking too many probing questions can be extremely detrimental to the counselor–client relationship. This section presents principles of how to use probing questions. Warning: Questions Are Inherently Controlling It is true: questions are inherently controlling. First, the one who asks the question garners all the power. Second, with the type of question you ask, you will wield the session into specific directions of your design. You must watch out for how you use this power of questioning. If you go overboard in your questioning, you risk overpowering or oppressing your clients. A better way to utilize the power of questioning is to carefully curate your questions as an intervention technique, in order to achieve specific therapeutic effects. Intervention oriented questions include those used in solution-focused therapy and cognitive therapy (Chapter 8). Revise Probing Questions into Clarifying Statements Unaware of the power differentiation in probing, beginning counselors tend to overuse questioning (Wright, 2003) perhaps because of their performance anxiety. To correct the mistake of excessive questioning, you may want to review your videotaped interviews, as suggested by Wright. Write down each question you asked, then revise the questions into clarifying statements (to be covered in the next section). Time-consuming as it may seem, this method has benefited many trainees in steering them away from the tendency toward overusing probing questions. In the following examples, the probing questions are revised into statements examples. You will notice that the statements come across as more supportive and yet inquire about the same issue: Question: “What are you angry about?” Revision into a statement: “I can see that you’re angry, and I’m curious about what your anger is about.” Question: “Why do you continue to use the drug if you are so concerned?” Revision into a statement: “I understand that you’re concerned about your drug use. Please help me understand what you like about using drugs and what the downside might be.” Use Open-Ended Questions: Avoid Closed Questions If you have to use probing questioning, use open-ended probing questions and avoid closed questions. Open-ended questions allow the client the most leeway to respond. Any question that can be answered with a “yes” or “no” is a closed (or close-ended) question. Because these questions require only a minimum response from the client, closed questions can curtail the flow of the session and therefore must be used sparingly. When you find yourself asking a closed question, stop and rephrase it. Change it into an open-ended question, a clarifying statement, or perception checking (to be covered in later sections). Following are examples:

Clinical Assessment Skills 81 Example 1 Close-ended question: “Have you ever thought of telling your mother how you feel about the curfew hour?” Open-ended question: “What do you think will happen when you tell your mother how you feel about the curfew hour?” Example 2 Close-ended question: “Are you frustrated or angry when your friends tease you about your weight?” Perception checking: “I get a sense that you’re frustrated, even angry when your friends tease you about your weight. Am I reading it right?” Avoid Stacking Questions or a Series of Questions Don’t allow yourself to ask stacking questions or a series of questions without a break. When used one after another, in a series, probing questions make clients feel like they are being interrogated and manipulated. Asking stacking questions provokes resistance in clients (Miller & Rollnick, 2012), causing them to become defensive. Remember that the information you gather from questions will not give you the whole truth, as Cozolino (2004) asserts, “asking a simple question is often not enough and what you are told isn’t always true” (p. 57). Beginning therapists sometimes fall into the habit of asking one question after another when they don’t know what to say. They feel safer by asking questions one after the other because it gives them a sense of control—albeit a false one. Notice how in the following interaction the counselor asks three questions in a series, which leads to the client feeling unheard, and eventually shuts down: Client: “I really don’t know how I feel about my husband anymore.” Counselor : “Lauren, are you thinking of divorcing him?” [Closed question; first question in a series] Client: “Well, I occasionally think about it, but not very often.” Counselor : “What situations make you think about divorce, Lauren?” [Second question in a series] Client (fidgeting): “Well, I don’t know. He never listens to what I say.” Counselor : “Lauren, what do you think could happen if you let him know what you need from him so you won’t look for what you deserve in another relationship?” [Third question in a series, and an inappropriate leading question] Client [Fidgeting, even more, neck getting red, arms crossed]: “I don’t know. Probably nothing will happen.” Nurture the Client’s Answers with Empathic Responses First and foremost, nurture each of the client’s answers by using empathic responding skills, as covered in Chapter 4. This will reduce your client’s sense of vulnerability, enhance trust, and strengthen the therapeutic relationship. It is only after you follow your client’s answer with an empathic response that you earn the right to ask another probing question: Counselor : “What’s your mother’s attitude about your marrying outside your race?” [Probing]

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Client: “She cut off communication with me.” Counselor : “You must have been disappointed and hurt by your mother’s response, Nancy.” [Empathic response, to show that the therapist hears the answer] Client: “Yes, I was devastated by her shutting me out.” Counselor : “What was your relationship like with your mother before this?” [Having given the empathic response previously, the therapist now earns a right to ask another probing question] Avoid “Why” Questions or Accusatory Questions Asking a “why” question can be perceived as a criticism or an accusation. The word “why” is interrogative in nature, perhaps because it demands that the other person justifies herself, thus creating an automatic defensive response in the receiver: Counselor : “Why do you continue to use drugs when you know that many people in your life have been harmed by your drug use?” Client [arms crossed, getting defensive]: “Well, it’s not really my fault that they’re unhappy. Nobody can make anybody happy.” Alternative counselor response 1: — “Would you help me understand some of the reasons you continue to use drugs?” Alternative counselor response 2: — “What are the possible reasons that make you think it’s okay to continue your drug use?” Avoid Strategic Questions or Leading Questions Some people might use strategic questions as a way of giving advice—albeit through the backdoor. In other words, they ask questions that strategically “steer the ship,” so to speak, in order to avoid resistance against their advice. This kind of strategic questioning is also called leading questions. As Young (2013) suggests, leading questions have “an embedded message” and are “a secret way of giving the client advice” (p. 93). Though some counseling approaches encourage followers to use strategic questioning to subtly sway clients to change, we suggest avoiding this kind of practice. Excessive use of strategic questions inevitably reduces trust and thus disrupts the therapeutic alliance. Therefore, try to avoid the following types of strategic questions or leading questions: — “Don’t you think you might be better off talking to him about your worries instead of turning to your kids for support?” — “Can you see how your withdrawal causes your wife to become frustrated?” — “What would happen if for the next week at dinner every evening, you suggest that he share some responsibility of parenting?” — “Have you thought of asking your wife to get some help?” SECOND ASSESSMENT SKILL: FOCUSING: HONE IN ON A SPECIFIC AREA The second skill to master for your qualitative assessment during the clinical interviews is focusing. When clients ramble or cite multiple problems, you can employ focusing skills to narrow down the problems or emotions related to a given issue. Focusing affords the assessment process a focal point, allowing you to become more effective in discovering areas that the client may gloss over.

Clinical Assessment Skills 83 Zoom in on a “Problem” Example 1 Client: “I want to call my sister and talk to her, but I don’t want to talk to the rest of the family. I don’t want to deal with the rest of the family right now. I’m angry with them about a lot of things.” Counselor : “Sam, I heard you say that you are angry at your family. Would you elaborate more specifically about which family member you are most angry with?” [Zoom in on a specific person in the client’s problematic relationship] Other examples: — “Sue, you just said that no one cares about you. When did you start to feel this way?” [Zoom in on an incident of the problem] — “You said that you worry too much, Joe. Can you give me an example of what worries you the most?” [Zoom in on a specific area of the problem] — “Amanda, I noticed that you mentioned “loss of self.” Can you say more about what you were thinking when you said that?” [Zoom in on an abstract expression of the client’s problem] — “John, earlier you said a couple of things about not having motivation. I’d like to go back and follow up along those lines with you.” [Go back and zoom in on a key phrase] — “Matt, you’ve been discussing many topics in the last few minutes. Could you tell me which of these concerns you most and elaborate on that?” [Zoom in on a specific concern from many] Zoom in on a “Feeling” When a client talks extensively about significant events in her life while glossing over feelings, it can be difficult to assess the impacts of the events on the client. In this situation, homing in on the client’s feelings might help her deepen her self-disclosure, and, at the same time, help you assess the circumstances more clearly. — “Laurie, we’ve been talking about the layoff that happened to you last week, but I haven’t heard you talk much about your feelings yet. Could you name a feeling you have right now?” [Zoom in on a feeling to assess more clearly the client’s circumstance] — “Just now I noticed that your expression changed, Brian. What are your feelings now?” [zoom in on the feeling behind the outer expression to enhance assessment] — “We’ve talked about your divorce, Dan, but we really haven’t explored how you feel about it. Could you name a feeling you have about your divorce?” [Zoom in on a feeling to assess more clearly the client’s circumstance] THIRD ASSESSMENT SKILL: CLARIFYING STATEMENTS To repeat: questions are inherently controlling. If you sense that you have asked quite a few probing questions already, shift to clarifying statements. This section introduces the third skill to master for your qualitative assessment during the clinical interview: the clarifying statements.

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Clarifying Statements As an Invitation Response Clarifying statements serve as an invitation response, encouraging the client to elaborate further. Through such an invitation, you will garner the information you need to suit the assessment purpose, but in a much more personable and gentle way. This is a more humane way to do an assessment. The Two Components of a Clarifying Statement A clarifying statement involves a combination of the following two components: 1. Empathic responding 2. Not-knowing position The first component, the empathic response, renders the client feeling heard; while the second component—the “not-knowing position,” a term coined by Anderson and Goolishian (1988)—represents a humble stance of naive curiosity, a polar opposite of an expert stance of certainty. This curiosity opens up, instead of closing down, the conversation in the consulting room (Chen & Noosbond, 1999b). — “I can see that you’re angry (a reflection of feeling), but I’m not sure what it’s about (not-knowing position).” — “I realize now that you get angry when your mother-in-law stays for more than a day (a reflection of feeling), but I’m still not sure what she does that makes you angry (not-knowing position).” — “I understand that you’re concerned about your drug use [paraphrasing]. Please help me understand what you like about using drugs and what the downside might be [not-knowing position].” — “I understand that talking to your family is stressful [paraphrasing], but I’m not sure what your family does that makes you feel so stressed and frustrated [notknowing position].” — “You said that your family is an eyesore in the community [paraphrasing]. I’m not sure whether you are saying that you’re embarrassed by your family or something else [not-knowing position].” EXERCISES After each client statement, write a counselor response using the skill indicated next to the number. 1. Focusing Client: “It’s frustrating because I don’t understand why people react the way they do. I never know where the anger is coming from. Things seem to be going okay, and then—wow—like it comes out of nowhere. Then her mother calls up and gets into the argument, too. Our finances are a mess. It just doesn’t make sense to me.” 2. Focusing Client: “When I was a child, I could do almost anything I wanted. Now things are different. It’s so different. I want to be back there again so I can feel more in charge. Everything is different.”

Clinical Assessment Skills 85 3. Probing question Client: “I think there’s a lack of desire for intimacy. It used to be all the time that we were making love, and now I can’t remember the last time we were even alone together, when we weren’t so tired that we just fell into bed exhausted.” 4. Probing question Client: “My father was the perfect role model for me. I always wanted to live up to how he was. If I could just be half as good as my dad, I’d be satisfied. Really. I just don’t seem to be able to make my wife and children happy.” 5. Probing question Client: “It’s the cat thing. She loves them more than she loves me. All the time, she’s paying attention to them, and thinking of them. They’re just dumb animals, but I wouldn’t want to be around if she had to make a choice between them and me. I know who’d get to stay—and it is not me!” 6. Probing question Client: “My mom called me yesterday, and the day before. In fact, she’s called me every day since I left home to go to college. Sometimes I don’t mind, but the calls just seem to go on and on. When they’re finally over, I just feel terrible about myself.” 7. Probing question Client: “So last night I just sat around the house. I know I should be doing something, but everything is such an effort. Why should I bother to do anything anyway? I just get up, come home, and go to sleep, and get up and go to work again.” 8. Clarifying statement Client: “And for him, it’s kind of hard saying, okay, right now you’re my sister’s boyfriend. Right now, you’re my friend. I don’t get in the middle. If they come over and ask me for help, then I do help, but this being caught between them doesn’t work. I learned that a long time ago.” 9. Clarifying statement Client: “I never thought my life would turn out this way. Things were going one way for most of the time. Then, overnight, everything blew up. Now I’m wandering around in a new world.” 10. Probing question Client: “I think that my girlfriend is going to leave me. It isn’t really what she says; it’s more the unspoken stuff. She seems to be drifting away from me. She doesn’t even look at me much anymore.” 11. Probing question Client: “My boss keeps telling me to focus on work more but I think that I have ADHD, which makes focusing really hard. I start on one project, and then I find myself reading my e-mail. Before I know it, it is 11:00 A.M. and I still haven’t made a dent in the project that I started when I came into work. It is very frustrating.”

6

How to Conduct the Intake Interview

The therapist gets a bird’s eye view of the client and their background through the initial assessment—the intake interview. Information garnered through the intake will enable you, the therapist, to see the forest, not just the tree, and have the wide-angle lens to view the entire vista of a client’s life. This chapter details the stepwise procedures and skills necessary to conduct the intake interview. THE INTAKE INTERVIEW A client’s first interaction with a helping professional is through the intake interview. During this initial contact, you will use your assessment skills in order to appraise the nature of the client’s issues. This paves the way for you to create a personalized treatment plan for the client. Kick Start a Continuous Process of Assessment The intake interview will not be the only assessment through which you obtain essential information about clients. Rather, it serves as the starting point of a continuous process to obtain vital information about the client. As the course of therapy continues, additional critical information will emerge to provide a more comprehensive view of the nature of the clients’ issues. As therapists, we must maintain a curious attitude so as to remain open to new observations and information throughout the course of therapy. The Task of the Intake Interview The general goal of the intake is to get as much information from clients as possible before offering treatment to them. Of course, what constitutes an intake interview varies depending on the setting. In Adlerian centers, it involves taking elaborate family histories. In other settings, it involves obtaining an array of crucial information from the client and establishing the basis for a good working alliance (Morrison, 2014). At the bare bone, an intake interview shall garner the following information: • • • •

Presenting problems History of presenting problems Family background Clients’ coping skills

• • •

Functioning level Strengths Goals of therapy

How to Conduct the Intake Interview 87 The Value of the Intake Interview An hour spent in the initial assessment can save several hours of a bottleneck in the course of therapy. Intake prevents therapists from seeing the clients too narrowly or diving into clients’ presenting problems too quickly, without considering the context in which the clients are operating. Without the broad information gathered during the intake, therapists may see the tree and miss the forest because they don’t have the wide-angle lens to view the entire vista of a client’s life. If done well, the intake offers rich data for later review during the course of therapy, saving the therapist from going around in circles in the landscape of the clients’ problems. Other Aspects of the Intake We need to know several other things about intake. First, you may ask the clients to come in 10 minutes early to fill out a preliminary information form to collect clients’ demographic information. This information gives us a preview of clients’ concerns. Second, when conducting the intake with diverse clients, we need to exercise caution on certain aspects. As Sue and Sue (2016) point out, diverse clients may approach the intake interviewer with vigilance. They may not feel safe to self-disclose until the intake worker self-discloses first. Please read Chapter 13 for more details about how to interact with clients from diverse or multicultural backgrounds. Third, whether the intake interview is conducted by a specially trained staff or by therapists, the results of the intake must be documented. Results should be kept within the client’s chart, and secured in a safe office cabinet, available for later review by counselors and therapists. PROFESSIONAL DISCLOSURE AND INFORMED CONSENT Before therapists proceed to the intake interview, they are required by ethical codes to provide a professional disclosure to the client (Corey, Corey, Corey, & Callanan, 2014). This section discusses the topic of professional disclosure. Four Areas to Inform in Professional Disclosure Clients have the right to know about all areas of therapy that will be provided before they can make an informed decision to enter therapy. The four areas of the disclosure are: • •

•

•

Information about yourself—your beliefs, counseling style, and counseling skills, as well as your titles, licenses, and educational background. What process will be involved in therapy, the expected duration of therapy, what modes of therapy are available, how long each session lasts, how the therapist can be reached in an emergency, and how an appointment can be canceled. Your fee schedules, insurance information, and cancellation policy. Specifically, clients should be informed of the cost for each appointment, the time fees are to be paid, and what happens if the bill is not paid (Zuckerman, 2012). What kind of records retained, what kinds of people are allowed to read these records, and under what conditions the counselor may breach confidentiality.

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An Example of Professional Disclosure and Informed Consent Professional disclosure is an integral part of our overall effort in fulfilling the ethical code of informed consent. We must provide it to the client and since it involves a plethora of information, the professional disclosure is often done via a printed statement. After clients read the disclosure statement, they sign the informed consent sheet, indicating their consent for counseling (Keel & Brown, 1999). The signed form is an official document that should be kept in the client’s chart. See Appendix A for an example of the professional disclosure statement and informed consent form for new clients. CONDUCTING THE INTAKE INTERVIEW IN STYLE: COOL HEAD, WARM HEART The intake interview necessitates a “cool head, warm heart” style. Warm heart—empathic responses blended with our questions. Cool head—objective assessment regarding the nature of the client’s issues. The combination of cool assessment and warm empathic responses will allow trust and comfort to develop during the intake process. It also reduces clients’ sense of vulnerability as they reveal personal and sensitive information to you, a relative stranger. At the end of the intake, the therapist needs to write up an intake summary. Please see Appendix B for an example of Intake Summary. Initiate the Intake Interview To initiate an intake interview, a few things need to be taken care of: • • • •

•

•

Before meeting the new client, read any information you have about the client (e.g., front-desk survey, case notes from other professionals). When you first meet the client, introduce yourself and use the client’s name, extend your hand, and indicate the seating arrangement. (Be sure to pronounce your client’s name correctly!) If you have to be late, acknowledge this with an apology. Avoid small talk because small talk won’t put the client at ease. Get to the heart of the business (Morrison, 2014) after your self-introduction. If you feel compelled to engage in small talk, ask a question that requires more than a yes/no response. For example: “How was the traffic coming here?” For a first time client, inform them what the intake will be like—how much time it will take, what sorts of questions the counselor will ask, and so forth. Convey some ideas about the sort of information you expect from the client. “We have about 45 minutes together today. This is an intake session, so I won’t be doing actual counseling with you today. Instead, I’ll be asking you a lot of questions to gather basic information that will be helpful in counseling. Some of the questions may be very personal. Please feel free not to answer any questions that you don’t feel comfortable with.” Convey confidentiality and its limits: “I understand that it takes a lot of courage to come to counseling. I assure you that what you reveal in the course of counseling will be kept strictly confidential. There are some limitations, though. For example, if you tell me that you’re going to harm yourself or someone else, or if you tell me about incidents of child abuse, I am obligated by law to notify the proper authorities. Do you have any question about this?”

How to Conduct the Intake Interview 89 •

•

•

If you will be taking notes, say something along the lines of: “I’m going to jot down some basic information that you share with me. Otherwise, I might not remember everything you tell me. I’ll put this information in your chart and it will be kept confidential. Is this okay with you?” Try to keep note-taking to the minimum, limited to only keywords. This way you can maintain proper eye contact with your client, allowing more astute observations of his behaviors and expressions. If you want to record the session, ask: “Do you mind if I record our intake session? It will help me serve you better. Again, the information shared will be kept confidential. If you don’t feel comfortable, I’ll honor your request not to record the session.” If a client resists, comply with their wishes and transcribe from your memory later. The goal is to complete the interview, not to establish power. Try to create a comfortable and safe environment that gives the client as much control as possible. In short, record the session only if the client has willingly granted you permission.

Determine the Presenting Problem After the above has been completed, you can now proceed to ask about the presenting problem. Specific areas to gain information: • • •

The problem that brings the client to counseling. Its specific impact on the client’s life and emotional distress. The frequency of these distresses.

Questions used to determine the presenting problem might include the following. Remember to follow the clients’ reply with your empathic responses: — — — — — —

“Okay, now can you tell me what brought you in to see me today?” “What caused you to decide to enter counseling at this time?” “How does this problem affect you personally?” “How does the problem affect you physically?” “Could you give me some examples?” “How long have you been experiencing these distresses?”

Examples Counselor : “Okay, Ann, with the informed consent covered, we can now move on to taking a look at your needs. Perhaps we can start by going over the concerns that bring you here.” [Invitation to present problems] Client: “Well, I recently quit my job because work was causing me too much stress after 11 years. I had to move back in with my parents because I’m not receiving unemployment checks and only a small amount of child support from my ex. For the rest, I’m financially dependent on my boyfriend, and this doesn’t make me feel good.” Counselor : “It sounds like you have a lot on your plate right now. How do all these stresses affect you personally?” [Paraphrasing + probing question] Client: “They’re making me very nervous. If I was by myself, it wouldn’t be as nervewracking, but with two kids, it’s hard.”

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Take the History of the Problem After you get a sense of what the problem is, finding out the history of the problem is helpful. You might ask: — — — —

“When did the problem start?” “How long has it been happening?” “What usually sets off the problem?” “Have you ever had this problem before in your life?”

Examples Counselor : “How did all of these stressful events start?” Client: “It all started with the divorce. My ex gives me only 300 dollars a month, but I don’t always get it, so I can’t always count on it. He knows I’m not working, and he doesn’t offer to help with the kids in any other way at all. I feel bad for my kids, but my daughter defends him and doesn’t really see things for what they are. I think she deserves to know the truth. I mean it might be hurtful, but it’s kind of necessary to explain things to her.” (hands and feet fidgeting) Counselor : “I can sense that you’re hurt, Ann. You feel unsupported by your exhusband. The anxiety of not having steady child support when you need it the most is eating at you. On top of that, you worry that your daughter isn’t aware of what’s actually going on with her father.” [Reflection of feelings + summarization] Client: “It makes me really angry because he’s very quick to point out things that he thinks I should be doing on a daily basis, but he’s not around the kids every day. And he’s not doing things that he’s supposed to be doing that are his responsibility. And he likes to tell me what I should be doing.” Counselor : “Ann, I can see that you’re angry. The snowballing effect of not receiving payments on time, not having a job, and having to take on pretty much the full parental responsibilities, have compiled themselves into stresses that really hurt.” [Reflection of feelings + summarization] Client: [seeming to slow down and appears more relaxed] “Absolutely.” Learn about Attempted Solutions Next, inquire about any attempts that the client has made to solve this problem so far: — “What have you tried to solve the problem?” — “How do you cope with the distress this problem causes?” Watch out for habits that clients have relied on to deal with their distress. The following is a list of common maladaptive habits that clients use to cope with emotional or physical distress: • • • • • • • •

Alcohol and/or substance abuse Caffeine addiction Compulsive shopping Compulsive working Nervous habits (nail biting, facial tics, hair-pulling, foot-tapping, finger-drumming) Overeating Being overly responsible (busy taking care of others but neglecting oneself ) Smoking

How to Conduct the Intake Interview 91 • • • • •

Withdrawal Passivity Victim thinking (blaming) Inactivity Self-injury

Examples Counselor : “With all the stress in your current life, how have you been coping with your stress? What kinds of things have you tried to help manage your stress?” [Probing questions about coping] Client: “Ummm. You know, I usually keep myself so busy that I don’t . . . you know, I do relax at night once the kids go to bed. I watch TV or have a glass of wine, but during the day, I’m usually so busy that unless something specific happens that makes me think about it, I just try to block it out.” Counselor : “So you distract yourself from your feelings because they’re too much to deal with every day.” [Summarizing client’s coping habits. The counselor notices the client’s use of keeping busy and a possible alcohol use, and files this data away in her mind] Client: “Mmmm hmmm. And I don’t feel like with my ex there’s really any way to resolve the issues with him because I’ve tried talking to him and it doesn’t go anywhere. I kind of feel like at this point it’s pointless to keep worrying about it, but then when something happens, I blow up because it makes me really, really angry.” Check Other Issues and Emotional Concerns Find out if the client has other issues or concerns that have not yet emerged. You may ask: — “Are there any other things going on in your life that I need to know about?” Examples Counselor : “So one of the main issues you’re facing right now, Ann, is being extremely angry at him and at the situation. How does this affect your kids?” [Assessment extending to the kids though they are not present] Client: “Well, ever since the divorce three years ago, the situation worsened. We couldn’t get along at all, to begin with, and it’s actually a relief to finally break it off. But it’s still difficult. I’ve tried to distance myself from him as much as I can so it doesn’t affect the kids. I really don’t speak to him unless I have to because usually when I do, it just makes me angry. So the kids talk to him and are free to talk to him, but I try not to unless I absolutely have to, because usually, he’d say something to aggravate me. This is hard because I want the kids to have a nice relationship with him and I’ve tried to get him more involved with the kids, to be more supportive of them. But it’s gotten to a point where I can’t control every situation, so I just try to step away from it.” Counselor : “You seem to have a good awareness that you can’t fix everything. You’ve learned to give up control and allow the relationship between your kids and your ex to grow at its own pace so you don’t stress yourself out.” [Summing up the client’s strengths]

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Find Out Relationship Dynamics in the Family of Origin Relationship dynamics concerning clients’ family of origin can provide therapists with remarkable insights. These might involve: • • • • • •

Attachment patterns. Roles played in the family of origin. The way the family handles emotions. How the individuation process is managed. How conflicts are resolved or stay unresolved, any cut-offs. How the family functions under stress.

When possible, explore the relationships between family members and the impact of different family members on the client’s current life. Given that this line of inquiry may tap into something highly personal, counselors must reassure the client that they need only reveal what they are comfortable sharing at this point. Questions you may ask include: — “I’ve got a sense of how your problem is bothering you. Now I need your help to understand a bit of your family background. Do you mind if we shift gears to cover the family you grew up with? Some of the questions I’ll ask may be very private. Please feel free to not answer any questions that you consider to be too personal.” — “Could you tell me a little bit about each of your family members?” — “Could you describe each of your family members in one sentence each?” — “Which of your family members do you talk to the most? Which do you talk to the least?” — “Who in your family do you like the most? Who in your family would you miss the least if that person were to move away?” Examples Counselor : “Now I need your help to get me to understand a bit of your family background. Do you mind if we shift gears to cover the family you grew up with? This information will help me see the bigger picture. Some of the questions I’ll ask may be a bit private, so please feel free to not answer any if they’re too personal for you at this point.” [Inquire about family of origin] Client: “No! Not a problem. Actually, I’m glad you asked. Well, my parents are still together, and, as I said, my kids and I are now living with them—another layer of stress that I have to deal with. Okay, when I was growing up . . .” [Client starts to give the background of her family-of-origin, revealing several conflict-laced interaction patterns and cut-offs. The intake interview continues] Take the Family’s Mental Health History A history of mental health in a client’s family can shed further light on the client’s current struggles. Areas to be explored in detail include: • • • • •

Alcohol and/or substance abuse in the family History of emotional disturbance in the family History of neglect Sexual behavior, especially in children and adolescents Disciplinary practices

How to Conduct the Intake Interview 93 • • • • •

Past diagnoses from charts and medical records Hospitalizations, surgeries Number of family moves, significant losses Cultural and religious values and beliefs History of receiving mental health counseling

Mental health history may be explored with questions such as: — “Have any members of your family been seriously depressed or had other mental health problems?” — “Have any members of your family been hospitalized for mental illness?” — “Do you recall hearing any stories of people in your family who might have had mental health problems?” — “Did any of your family members die in any unusual way?” Obviously, these are highly sensitive questions. Proceed as gently as you can, and stop if the client shows any sign of discomfort. Due to space limitations, we won’t provide more counselor–client dialogs here. Take Notes on Personal Resources and Strengths A bright spot in the intake interview is to discover clients’ talents and resources that will be of help in mobilizing them to resolve their problems. These resources can be determined by asking questions such as: — — — — — —

“What are some things about yourself that make you proud?” “Are there any people in your life who are a positive influence on you?” “What are things you do well?” “What support systems do you have in your life?” “What did you do in the past that has proven to be effective in releasing stress?” “What talents do people say that you have?”

Help Clients Set Positive and Specific Goals Near the end of the intake, we typically begin to work together with our client to define goals for therapy. Clearly defined goals help set up success for therapy (Haley, 1991). Further, at the conclusion of counseling, clearly defined goals help both the therapist and the client assess whether the goals have been achieved. If the client phrases her goal in negative terms, help her flesh it out in positive terms, instead. Heed the following warning by Barker (2013, p. 67): Many people come to therapy with negative goals. They want to feel less depressed, or to stop eating so much, or to stop smoking. Or they want their children to stop fighting, or their teenage daughter to cease refusing to eat the food they provide. These are all good reasons for seeking professional help, but they are not adequate as outcome frames. Therapists should help the client set a goal that gives a comprehensive picture of how they want things to be (Barker, 2013). To turn a negative goal into a positive goal, you might ask the following questions: — “If you don’t want to feel depressed, how do you want to feel?” — “What will replace smoking (or eating too much) in your life?” — “What will your children be doing if they aren’t fighting?”

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Even when clients’ goals are stated in positive terms, they may be vague and ill-defined. For instance, clients may say that they want to “feel happier” or “have more energy” or “be able to decide what I want to do with my life.” Barker (2013, p. 68) pointed out the pitfalls of such vague goals: Such statements are all right as starting points for discussing treatment goals, but they are not in themselves adequate outcome frames. What does ‘feel happier’ mean? Happier than what or whom? Under what circumstances does the person feel happier? How will the client and the therapist know that the desired degree of happiness has been achieved? The point is clear: We should try to get the client to describe, as specifically as possible, how things will be when counseling has concluded successfully. To clients who said they want to feel happier, for example, we may ask: — “When you feel happier, what will you be doing differently?” — “When you have more energy, how will you act differently than you do now?” — “When you’re able to decide what you want to do with your life, what will your life be like?” In short, therapists have to guide clients to state their goals in behavioral and realistic terms. In this way, the client’s and the therapist’s energy can be channeled into a welldefined focus. Final Summarization and Explanation To conclude the intake interview, you may summarize the major points the client has presented and explain the next step in the counseling process. This is also a good time to verbalize respect for the client. Examples — “Our time will run out in a few minutes, so let me summarize what we just covered today. . . .” — “Thank you for sharing with me the pain you’ve been through. I respect your courage to come into counseling. The next session will be the first actual counseling session, where we’ll start the process of working on achieving your goals. Sometimes goals change as the counseling process deepens and this is to be expected. During the week, if any thoughts occur to you relating to what we have talked about today, please jot them down and bring them to share with me.” EXERCISES 1. Acknowledging client’s feelings and apologizing Scenario: Counselor arrives 5 minutes late for an intake interview with a client. The client is waiting and looking anxious. Client: “I thought maybe I had the wrong time. I was starting to get worried.” 2. Explain confidentiality to the client Scenario: Counselor and client meet for the first time.

How to Conduct the Intake Interview 95 Client (32-year-old male): “I’ve never been to counseling before. I’ve heard that you have to keep what I say a secret. Is that right?” 3. Ask the client to talk about the problem that caused her to seek counseling Scenario: Counselor and client meet for the first time for the intake interview. Client: [silent] 4. Ask more about the presenting problem Client: “I came to counseling because the judge said that I had to or she would take my license away. I need my license to keep my job.” 5. Transition from client’s problems to finding out about relationships in her family of origin Client: “I got 2 DUIs in a row because I was stopped by the police. I don’t think that I was drunk. I had control of the car. I really don’t see the problem. People drive buzzed all the time.” 6. Change goal statements into positive goals Scenario: During the goal setting portion of the intake interview, the client states her goals. Client: “My goals are to feel less depressed and to stop eating so much.”

7

Dealing with Difficult Situations in Counseling and Therapy

After the intake interview, the journey of therapy begins. Through a series of sessions, you and your client will traverse the uncharted seas, trying to find the way to the other side of the shore. In the process, the two of you will form a close connection unlike anything else. How to go about this journey with your client? No format has ever existed, but many tools stand ready to assist you. These tools will be presented in future chapters. For now, let’s look at some difficult situations that may arise in your sessions and the skills you can use to deal with them. Learning these management skills will increase your success in the initial stage of counseling. DEALING WITH THE SECOND SESSION ANXIETY The second session presents the utmost challenge for both clients and therapists. A great sense of uncertainty and anxiety permeates the second session wherein both the therapist and the client anticipate to begin the real work of therapy, yet they have to tread carefully as the therapeutic relationship has yet to be firmly established. So how are you to make the transition to your second session smoothly? This section attempts to provide tools for you to walk into your second session with confidence. The Second Session Anxiety Many therapists experience “the second session anxiety”. Truth be told, in comparison with the second session, the intake session is easier due to its being so structured and having predesigned topics to cover. Facing the second session, however, many therapists feel the pressure to “perform” and to produce “results”. If the intake has uncovered the tip of the iceberg, the second session embarks on a journey to discover the mass of the iceberg, hidden underneath the surface. Facing this unknown, we feel a sense of uncertainty, anticipation, and an inevitable anxiety. Please remember: the second session is not intended to solve the client’s entire problems. No, the second session is intended to “start small.” Getting a handle on a small portion of the client’s problems can lead to improved client confidence. To manage your second session anxiety, please consider the tips below. Review Intake Summary and Progress Notes before the Session The first tip: Review your intake summary (see Appendix B) before going to your second session. And review your SOAP notes/progress notes (see Appendix C) before going to any of your subsequent sessions. While reviewing your case notes, look for the following:

Dealing with Difficult Situations 97 • •

Any patterns in the client’s overall history. The client’s attachment styles with people in his life.

As you review these notes, try to keep an open mind. Do not go overboard to the extent of making premature interpretations about your client. Unless you know your client well, stay away from pigeonholing your client. Let your notes inform you, but not constrain you. Reestablish Rapport by a Greeting and a Summarization Whether or not you are the one who did the intake, try to reestablish rapport with your client when you enter the second session (Hepworth & colleagues, 2013). This will ease both you and your client into the session. A brief warm greeting does not hurt, but then follow it with a summarization of the major points covered in the intake. This serves two purposes: • •

Summarization reestablishes your rapport with your client by showing that you really have heard him out and that you care about his concerns. Summarization acts as a catalyst, ushering you both to go to the root of the client’s concerns without skirting around the surface.

Here is an example of an opening summarization for the second session: — “I want to start our session, Jeff, by recapping some of the issues that we talked about in the intake. First, you’re concerned about the Alzheimer’s that runs in your family. Second, you’re especially worried about having to care for your mother, who’s showing mild signs of Alzheimer’s, and how this would take away your freedom to pursue your writing aspirations. Third, you are concerned about how your dad’s past use of alcohol to cope with anxiety might have affected you, particularly because you’re currently having some anxiety issues yourself. Does this cover most of the ground?” Invite the Client to Elaborate After the summarization, don’t start to ask a series of questions. As stated previously, questions are inherently controlling—the one who asks questions will inevitably dominate the conversation, disempowering the other. This is why Gerber (2003) cautioned therapists not to overpower the client with too many questions or to direct clients into solving their problems prematurely. Cozolino (2004) also reminds beginning therapist that questions, however good they are, will not really get you to the heart of clients’ issues. Instead of asking questions, you can zoom-in on one focus and invite the client to elaborate. For example, — “As you can see, we have a few domains here to attend to, Jeff. Let’s start with the most recent one. You expressed your concerns regarding the anxiety that you are currently experiencing. Perhaps we could go into the details of how this anxiety is affecting your life. Would that be agreeable to you?” If the client’s story is vague, such as saying, “I’m not happy with my life,” you can invite the client to provide more concrete examples: — “If it’s okay with you, D’Angelo, would you start with something specific that you’re not happy with right now in your life? This will help us get started.”

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Stay with the Topics! Track! Track! As clients start to unfold their current stressors, don’t try to venture into unnecessary details. Try to stay on course with the topics that they bring up. Use all the basic and advanced reflective skills to track what your client is talking about. As you track, you will be able to listen with a sharper ear. What can you track? Here are some suggestions: • • • •

Repetitive keywords Recurring actions and reactions Repeated feelings Recurring perceptions

If you find that your session crisscrosses all over the place, fiddling with this and that in a hit-or-miss fashion, it means that you or your client have changed topics one too many times. Slow down and find a focus to stay on. Track! Learning to track will boost up your ability to keep the session on course. Assess the Common Denominator of the Attempted Solutions As the session proceeds, you may ask the client about what solutions they have attempted for the problem. In so doing, you will know what dead ends to avoid. It helps you save time, and it helps you stay off the beaten path. — “What you have tried to solve your anxiety and sleep disturbance so far, Jeff?” If several attempts have been made, find out what these solutions have in common— in other words, what is the common denominator? Inside your mind, you might ask yourself silently, “Among these attempted solutions that have failed to work, what do they have in common?” After you discover the common denominator, offer it to your client: — “So, downing the booze, watching TV, Facebooking, all of these fail to relax you. In fact, you find yourself even more and more agitated, losing clarity of mind. It seems like the thing in common among these three solutions, Jeff, is that they all serve as an escape from what’s in your mind. And the more you try to escape from them, the more they take hold of you.” Identify Exceptions to the Presenting Problem Somewhere in the client’s life lies a key to the ultimate success of counseling—the exceptions to the client’s’ problems. Clients may overlook or forget exceptions unless we ask for them. Though the second session is still at a very early stage of counseling, identifying exceptions will instill, in the client, a sense of hope. — “As you look back on your life, was there a time when you didn’t experience the anxiety? What are some moments when you were able to find confidence in your writing?” — “And what was unique about that time? What was happening at that time that made a difference?”

Dealing with Difficult Situations 99 Point Out the Positive Pattern Underlying the Exceptions Give your client enough time to ponder your exception questions. You want as many details as possible. Once you get the picture of how the exceptions work, try to find the positive pattern underlying the exceptions. According to solution-focused therapy and narrative therapy (Guterman, 2014; Neimeyer, 1996; 2001; White, 2007), these positive patterns serve as your allies in helping clients arrive at their desired outcomes. — “So, from what you said, I got a sense that during all the times when you were free from anxiety—when you slept well and when your writing got a boost—all of these times are associated with periods when your relationship with your partner was going well, without many conflicts. Does this sound correct to you, Jeff?” — “OK, I see, thank you for the extra details. So when the relationship with your partner is going well, you are more open to him, and you feel you are accepted as the person you are, and that gives your self-esteem a lift.” Revisit and Break Down the Goals into Manageable Bites Near the end of the second session, revisit the goals your client stated in the intake. Just for your information, there exist two types of therapeutic goals: • •

Outcome goals: the client’s desired outcome for therapy. Process goal: the therapist’s intention to establish a trusting therapeutic relationship with the client.

You don’t need to discuss with your client your process goal, but you do need to revisit with your client her outcome goals. The client’s outcome goals may go through a series of changes. Whenever new awareness emerges, clients tend to modify their original goal to something more specific. With each modification, clients come closer to meeting their needs. These changes should be included in the client’s chart because outcome goals constitute a part of treatment planning. Even though the client’s outcome goals will evolve several times, at the end of the second session, try to help her break them down into several manageable bites (Cozolino, 2004). Smaller, more manageable goals tend to increase client motivation and hope of success. Consider the following examples, — “Jeff, your goal, as stated in the intake, was to deal better with the stress of handling your father’s health issues. As we talked more today, it seems like improving the quality of your relationship with your partner will give you strength, support, and the oomph to better deal with the stress of your father’s disease. Would it be safe to say that this would be your modified goal?” Later, — “Great! Now, to increase the success of you reaching your goal, let’s break it down into a few smaller, more manageable bits. From what I remember, it sounds like you want to spend some quality time with your partner; participate in some recreation activities together; clear out the misunderstandings that have piled up between you; open up, rather than shut down, to him about the challenges that have taken your mind away from joy; and communicate more clearly to him about

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Dealing with Difficult Situations your fears, insecurities, and dreams. We can make these wishes your new goals. All of these small pieces will improve your relationship with your partner, and help you reach your ultimate goal of dealing better with your current stress. Does this fit with what’s on your mind?”

Give a Take-Home Exercise At the end of the second session, try to give something for the client to take away— a new awareness or an experiential exercise. Chapter 8 “Basic Intervention Techniques” provides a variety of exercises or homework assignments for you to consider. The exercise that you give the client should closely relate to the client’s concerns and their new goals. You don’t need to name it as a homework assignment, as this label may not work well with some clients. Consider the following example: — “I’m thinking, Jeff, that during the week before we meet next time, it might be helpful for you to write down the times when you start to shut down. In your notes, also write down what you are thinking just before you start stonewalling yourself. The purpose is to catch your thinking so we can see how it impacts your reactions. When we can catch your thinking and assumptions, we will be able to work together to come up with alternative ones that serve you better in your communication with your loved ones. Would you be interested in doing that?” Inquire into the Client’s Personal Experience with You Before ending the second session, try to ask your client how he experiences the session and how he reacts to you (Cozolino, 2004). Yalom (2009) also encourages therapists to ask their clients how they experience their work together at the end of the session. We believe that this kind of intimate talk gives clients a chance to tune up their personal voice, helping them get used to more personal communication with the therapist. So at the end of the session, you might want to say, — “Jeff, we only have a few minutes left, I wonder how you think we’re doing together today?” Or — “Before we leave, Jeff, I wonder how you experience our session today?” DEALING WITH SILENCE Silence in the session towers as one of the highest challenges in counseling and therapy. We ought to learn to manage this powerful force and develop a good relationship with it. This section gives tips on how to do that. Our Discomfort with Silence Silence provokes a great deal of anxiety for many beginning therapists and for good reason. Our modern world allows so little room for the silence that its presence fills us with anxiety, stirring up all types of catastrophic imaginings. To cope, we fill the void of the silence with words. And this coping habit inevitably sneaks into the consulting room. Ten or so seconds of silence can feel like an eternity that we will do anything to escape from (Cozolino, 2004). To escape, we will ask a series of questions, often not well thought out, with the hope of getting the client to talk again.

Dealing with Difficult Situations 101 A therapist’s intolerance of silence, unfortunately, will rob the client of processing time (Meier & Davis, 2011), taking away the clients’ opportunity to muse about their own thoughts and feelings. The Therapeutic Power of Silence Know the therapeutic power of silence, and we will be eager to make it our first response when listening to the client. There are two kinds of silence: (1) the therapist’s silence, and (2) the client’s silence. Each has their own unique power. A therapist’s silence has the power to: • • •

Encourage the client’s self-exploration. Encourage the client to “carry the burden” of the conversation. Allow the therapist to collect her own thoughts.

A client’s silence has the power to: • • •

Allow himself to make sense of his own feelings or thoughts. Allow his feelings to slowly churn up. Allow memories of certain events to break the surface.

Will we allow silence to work its magic? Can we step back and permit it to deepen the level of contemplation in the therapeutic encounter? Develop a Positive Relationship with Silence We can if we develop a better relationship with silence. From our experience, the following ways help to improve our relationships with our own silence: • • •

Taking time to contemplate what you might want to say. Deliberately inducing a silence in the middle of the conversation, passing the responsibility of carrying it on to the client. Purposefully choosing not to respond when you see that your client might be on the edge of a new realization.

Also, try to understand what might be happening when clients are in silence: • •

In silence, the client is taking extra time to absorb an insight or to deepen his exploration. Lapsing into silence, the client is approaching a new awareness.

With these ideas in mind, try to allow your client’s silence to linger just a bit longer. Don’t use questions or statements to interfere with the client’s internal processing. Here is a beginning therapist’s reflection about her use of silence: “Before reading about the therapeutic power of silence, I didn’t think that silence would help my client accomplish anything. Now, I see clearly that the time when I deliberately let the silence linger is the only time that my client gets into personal reflection.” Show Attentiveness During Silence When sitting comfortably in silence with your client, do the following: • •

Remain centered inside yourself. Maintain your attentiveness to your client.

102 • • •

Dealing with Difficult Situations Show warm interest with your eyes. Let the silence continue as long as the client is comfortable. Wait for the client to break the silence.

In your attentive and tranquil presence, your client will either deepen his reflection or share a new realization to explore together. Use Process Questions or Process Comments Afterwards If the client remains quiet after a long silence, you might want to use processing questions to draw out the inner experiences that arose for the client during the silence: — “I wonder what went through your mind in this moment of silence, Jeff.” — “What’s it like for you to sit here quietly?” If you notice something worth exploring in your client’s nonverbal cues, you may make some process comments (similar to advanced empathy) like the following: — “It looks like you’re feeling sad about something we just talked about. It looks like you are in touch with some pain that you still have.” If your client does not come up with any words, you may acknowledge his struggle: — “There seem to be no words that can convey what you’re thinking or are feeling at this moment. Sometimes it’s difficult to find language for the pain that we’re experiencing.” This kind of processing shows that you are completely present with him and are interested in his inner experiences, moment by moment. This will encourage him to pick up more of the responsibility of deciding the direction of the therapy (Cozolino, 2004). Dealing with Unproductive Silence Not all silence will be therapeutic or productive. Indeed, some clients—perhaps due to their lack of practice with self-reflection, their social anxiety, or their limitation in cognitive functioning—may have recurring silences and may not respond to your process questions or process comments at all. At times, we need to provide clients with some education about how to embrace silence so that they can get in touch with their inner experience. For example, — “Sometimes in the session, we may have a moment of silence. Don’t be worried about that. It is actually good to just sit quietly in the moment and let whatever come to your mind. It is just like free association. And then you can just say whatever comes to your mind.” Some clients believe that it is the therapist’s job to provide answers and solve their problems; that all they have to do in therapy is to listen. If this is the case, then a process discussion of what therapy is about should ensue. For those clients who have cognitive limitations, it is even more necessary to give them extra time to respond. But don’t expect them to arrive at a place of deep reflection during moments of silence. Adjust your expectations.

Dealing with Difficult Situations 103 Be Mindful of the Cultural Context of Silence In some non-White cultures, especially Asian, silence is not a floor yielding behavior. Nor is it boredom or a painful struggle. Rather it’s a signal, indicating “a desire to continue speaking after making a particular point” (Sue 1990, p. 426). If you read this signal erroneously, you may mistakenly fill the pause by jumping into the conversation. This will frustrate your minority client as it prevents him from elaborating further. Most often, silence in Asian clients is a sign of politeness and respect, a thoughtful restraint from appearing overbearing and self-important. This kind of self-restraint should be affirmed as strength. It would be a mistake for the Caucasian counselor to misinterpret it as a sign of ignorance or a lack of motivation. DEALING WITH RESISTANCE AND AMBIVALENCE Resistance is a phenomenon that compels our attention. If swept under the carpet, it will grow and grow until it, like a volcano, violently erupts. Managing resistance to therapy, therefore, is a critical skill. However, as therapists, we want to go beyond just merely managing it. We want to transform resistance into a force for client growth. This is an art form, subtle and multilayered. Due to the complexity of this subject, this section is best read when you are not rushed and have a quiet time for reflection. The Signals of Resistance We know clients are stalling or slipping into resistance, not by guessing, but by paying attention to the following signals sent by clients: • • • • • •

Repeating the same stories. Body language showing distance, such as pulling back, crossing arms over the chest, slouching in the chair, etc. Chronically arriving late. Not following through with recommendations and homework. Dodging the issues that they need to work on. Shutting down feelings or intellectualizing away the session time.

In the face of these signals, the unsuspecting therapists tend to get frustrated but try to hold back the frustration. After a while, their energy starts to slump, tension starts to rise, muscles start to contract. Eventually, it leads to fatigue and discouragement. The Stress of Dealing with Resistance However subtle, client resistance can leave all therapists feeling dispirited. To cope, we work harder to reel them back, only to find even tougher resistance. We then carry the tension home and, in due course, feel stressed out by our work. Boiled down, the stress of dealing with resistance comes from the combination of: • •

Our high expectations of the treatment outcome. Clients’ negligible progress.

Indeed, both the therapist and the client contribute to the stress (Mitchell, 2009). To reduce our stress and burnout, we need to look at both ends of the equation.

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Two New Ways to Look at Client Resistance Resistance does not arise from clients’ personality issues or lack of motivation to change— as conventional thought would have us believe. Let’s instead take a crack at it from two new perspectives. First, neuroscience tells us: Repeated neural firing and wiring will strengthen certain behaviors. As a result, these behaviors become ingrained in us. Resistance to change is just the effect of our neural wiring (see Chapter 1 of this text). Second, social interaction theory states that resistance stems from the interaction style between two persons (Patterson & Forgatch, 1985; Strong & Matross, 1973). This notion helps us realize that it is our interaction style with our client that creates his resistance. Both above perspectives remove the blame from the client and put the responsibility of resolution squarely on our own shoulders. In particular, social interaction theory challenges us to consider the potential dynamics, such as the following, that might be contributing to client resistance: • • • •

Perhaps the client does not feel that he has the kind of control that we think he does. Perhaps we are zooming into solutions too fast in an effort to change his feelings or behaviors. Perhaps we are too preoccupied with our own expectations of how the client should progress. Perhaps our expectations do not match the client’s readiness and available resources.

With these potential dynamics in mind, we can start to adjust ourselves and be more in sync with our client’s reality. Client’s Behaviors May Make Complete Sense The first adjustment to make: stop labeling any client behaviors as resistant. Because once we label it, we get stuck in that limiting point of view and lose our ability to truly see the client’s perspective. Letting go of labeling, we free our minds and eyes to truly comprehend and see the microcosm of our clients’ lives. We then may find that our clients’ resistant behaviors make complete sense. For example: • • •

• • • •

The client does not want to be here because someone else demands it. The client does not want to open up because she does not know how to open up to a stranger (you), or how to look inside. The client does not want to go deeper because she does not know whether you would judge her or shame her just like some people in her life have when she has tried to authentically express herself previously. The client does not want to take risks because she has already been exhausted by past failure, and trying something new might subject her to another failure. The client does not believe in therapy because she has had bad experiences with therapy in the past. The client does not want to talk because he does not want to become too vulnerable, or he does not want to cry. The client does not want to do what you suggest to him because he treasures his own sense of independence and individuality.

Dealing with Difficult Situations 105 •

The client closes herself off because she does not feel heard, validated, accepted or understood.

Don’t Focus on Change Too Fast The next adjustment: completely let go of your own agenda of changing the client (Mitchell, 2009). Trying to go too fast is the perfect recipe for resistance. Hence, put the change on the back burner for a while. Don’t fixate on outcomes just yet. Instead, simply listen to the client and focus on understanding the client’s world. Simply focus on how to improve your interaction with your client: • • • • •

Do whatever you can to validate the clients’ experiences. Applaud their decision to seek counseling. Start off with less sensitive topics. If your client’s body language shows resistance, don’t comment on it directly; wait until he trusts you. Consistently offer your empathic understanding and acceptance.

Taking care of the dynamics in these ways will release your clients from the need to resist or defend. Accept Where Our Client Is in the Stages of Change Prochaska’s transtheoretical model of change (Prochaska, DiClemente, & Norcross, 2010) indicates that not all clients are in the contemplation stage ready for a change. However, many new therapists assume that as long as people show up in therapy, they must be ready. In fact, these people might still be dwelling in the precontemplation stage. They come to therapy perhaps because of pressure from others, and even though they do have issues to work on, such clients resist or at least feel ambivalent toward therapy. Please remember: Defiant as they are, they are right where they need to be. Facing such clients, a therapist will be making a big mistake if they push for client progress. Alternatively, we should spend as much time as needed to build trust. Don’t discuss their problems until you can do it in a hassle-free manner. Don’t even confront them about their lack of self-awareness or progress. If your client is in the precontemplation stage, wherein he feels a sense of ambivalence, make sure that you don’t push for any “change talk” for now. Get to know your client’s daily life and interests. Consider the following: — “I know that you don’t think you have any problems to solve at all. I completely respect your position. Since we are here together today, perhaps you could talk about what gives you the determination to get up every day, to go out there and make it?” This approach is much more effective than trying to explain to them why they have a problem. If at any point, the person starts to talk about a problem he does have, you may use some curious statements to coax more self-disclosure: — “I am curious about how this is a problem for you.” Later, — “I see, so this is a problem for you because it gets you a bad review at work. I am curious, what are other reasons that make this is a problem for you?”

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Stay Away from the Questioning Mode! Don’t Ask Leading Questions! Excessive use of questions is the fastest way to brew client resistance. Many therapists have a habit of using questions to pry open a client, and of course, they get stuck, without knowing why. Mitchell (2009) explains the reasons questions are therapists’ worst enemy: • •

Questions are, indeed, micro-confrontations in nature. And confrontation you should avoid like the plague when a client is trying to defy treatment. Questions put your client in a “one-down” position which will foster opposition even more.

The worst types of questions are “leading questions” (Mitchell, 2009)—questions that direct the client to certain solutions, answers, or conclusions. If you have a habit of naively asking question after question or ask leading questions, try to make an adjustment so that you don’t attract even more client opposition. Don’t Assume the “Expert” Role. Instead, Take a One-Down Position. Another way to prevent resistance is to stay away from assuming the role of an “expert” —too much of an expert stance will elicit the “Yes, but . . .” game from the client (Mitchell, 2009). Instead, you can take a “not-knowing”, one-down position of genuine curiosity. To take the “not-knowing”, one-down position, we can use the “I wonder” sentence stem in our statements (as covered in this Chapter 5). Do make sure that your nonverbal language matches your “not-knowing”, one-down position of curiosity. That is, our tone of voice, facial expressions, and body posture need to convey our unassuming attitude. The Martial Arts of Dealing with Clients’ “I Don’t Know” When a client is not invested, he may resort to saying “I don’t know”—a behavior that certainly ruffles a great many therapists, leading them to feel that they are “not getting anywhere.” Even though we know the client is avoiding something, the best way in dealing with this behavior is by joining the client (Duncan, Hubble, & Miller, 1997; Duncan, Miller, & Sparks, 2013). How to join the client? That we actually can learn from the martial arts. In martial arts, instead of meeting force with force (meeting the blow with a block), the martial artist meets the force with yielding. By yielding, he first allows his opponent’s force to continue its direction, then, with a twist or a redirect, he turns the opponent’s force into his own advantage. Now the opponent is rendered off balance. In the same vein, when a client gives you a blow with his “I don’t know” rhetoric, rather than confront it, you can take the wind out of his sails by radically accepting it with empathy. Consider the following examples: — “Yes, Jeff, I can see that you are really stumped by this situation.” — “Yes, Margie, you say “I don’t know” because you really don’t know. You are saying, “I don’t know you well enough to tell you something so personal.” I want you to know that it’s okay to be reserved, and you can set the pace of how much and how soon you open up.”

Dealing with Difficult Situations 107 — “Yes, Sebastián, it is very difficult for you to make sense of why the same thing happens again and again.” — “Yes, Judi, it is difficult to actually say the truth aloud.” — “Yes, Jeronimo, it’s really uncomfortable for you to face this aspect of your life.” — “Yes, Varinka, you are reluctant to tell me the details because you worry that I might judge you or disapprove of you.” Join Clients’ Perceptions of the Problem A close relative to the “I don’t know” is clients’ perception that their sufferings stem from others treating them wrong, that it’s all others’ faults. We know this to be a partial distortion, but we should not confront it at the early stage of therapy. Rather, we need to join the client’s perception until we have earned the leverage to influence her in recognizing her own part in her problems. We can join the clients’ perception by showing that we understand how they think and feel about their real life experiences. We reflect back to them their perceptions about oppression, rejection, unreasonable demands, control, etc. (Wubbolding, 2013). We accept their points of view. Remember, our reflection of clients’ thoughts and perceptions does not mean that we agree with them—only that we understand that this is how they perceive their external circumstances. Once we pass the test of trust, then we earn the right to help them examine whether or not their actions actually achieve what they want or need. As we focus on those options within the client’s control, we help them meet their needs. In other words, we help them self-evaluate (Wubbolding, 2013). Frame All Negative Complaints into Desirable Goals Often, clients present their problems with negative language. If we continue to discuss issues in such terms, we are not helping clients get unstuck. To get out of the negative focus, try to reframe clients’ negative complaints into desirable goals. Consider the following exchange between a therapist and a client: Client [focusing on negativity]: “No one cares! No one understands. It is just useless to talk about it!” Counselor reframing: “So, Carlos, you would like to feel that you really matter to your family. You would like the pain that you sustained throughout these ordeals to be acknowledged somehow.” [The counselor framed the same event in terms of what the client would like, rather than what others fail to do] Client: “Yeah, right.” Counselor : “So if anyone in your family could say something to you about what you have gone through, rather than just stay quiet, it would mean a lot to you.” Client: “Yeah, it would be cool. But you know it’s never going to happen.” Counselor : “In your mind, what will be the thing that they could say to you that would mean the most to you?” [The counselor continues with the positive inquiry] Client: “If anyone, especially my Dad, could say something like, ‘You really have a strong backbone to get through this.’ I think it would mean the world to me.” [The client is responding to the positive inquiry]

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Counselor : “So if your father is right here and could say to you, ‘My son, I am so proud of you and your courage’ then the whole experience would be transformed into something that has real meaning for you.” [The counselor started to plant the seeds of a positive dialogue between the father and the son] Client [smiling]: “Well, it would be a dream come true. I have always wanted to know how he sees me, how he feels about me. But . . .” Counselor : “There is so much for the two of you to learn about each other. Why don’t we try an experiment . . .” [The counselor went on with an empty chair exercise with Carlos. See Chapter 10 for the technique] Use Statements that Encourage Collaboration If you are working with young clients, you may need to do something to bypass their suspicion of you as an authority figure on a mission to “fix” them. An inviting statement such as the following is a good idea: — “I know this might not be the most comfortable place for you, Steve [validating the discomfort]. I just want to say that I’m not here to tell you what to do or to push you to change. If there’s any decision to be made, Steve, it will be something that we’ll figure out together [emphasizing collaboration]. How does that sound?” — “Margi, if there is ever any time that you do not understand why we are talking about something, or if you are uncomfortable with anything that I ask you to talk about, please stop me and express your discomfort.” Use the Skills of Allowing and Normalizing When working with young clients, be straightforward. Don’t try to be too sweet or charming. Sincerity and genuineness in your desire to understand them will go a long way in winning their trust. Young people crave such an encounter. As Bromfield (2005) states, “My experiences with patients, family, and friends suggest there is no more moving (and loving) experience than feeling understood by another person. And no one craves such understanding more than adolescents” (p. 12). For young people, the feeling of being understood and accepted can be amplified when a therapist applies the following two skills: 1. The skill of allowing: Counselor [inviting statement]: “If you want to talk about anything that happened today, Dan, I’m all ears.” Client [staring at the floor. Silent]: Counselor : “Dan, feel free to take as much time as you need to gather your thoughts about the things going on in your mind.” [Skill of allowing] 2. The normalizing skill: Counselor [inviting statement]: “If you want to talk about anything that happened today, Jes, I’m all ears.” Client: [silent] Counselor : “Many young people struggle with the same confusion about how to present the ideas in their mind when they come here. They sometimes find it helpful to take it slowly.” [Normalizing skill]

Dealing with Difficult Situations 109 Combining the two skills together: Counselor : “Many people find it difficult to talk about things that are of concern to them for the first time [normalizing skill]. I want you to know, Dan, if this time doesn’t feel right to you, we don’t need to talk about this right now” [skill of allowing]. Prevent Resistance in the First Place When it comes to resistance, an ounce of prevention is worth a pound of cure. To prevent initial resistance, take heed of the below don’ts: • • • • • • •

Don’t interrupt. Don’t offer a cliché. Don’t go the way of sympathy, such as “I’m sorry,” because it can be taken in the wrong way as pity. Don’t try to make clients feel better through an automatic expression of reassurance. Don’t give advice. Don’t try to take over and fix things. Don’t change the subject.

Respect Clients’ Right to Resist—A Zen Attitude To attain inner peace in dealing with client resistance, we take a “Zen attitude”—let go of what we can’t control; focus on what we can control at the present moment; treat the event with equanimity. While we do not have control over our clients’ reactions, we do have control over our own style of working, our own behaviors, our own delivery of skills and techniques, and our own way of engaging clients. If they so choose, clients have the right not to accept help, whether we like it or not. They have the right to avoid dealing with their problems, the right to keep others at arm’s length, and even the right to suffer. We have to respect these rights. As much as we care about our clients and feel obligated to turn their situations around, we must accept that they have the ultimate choice regarding their healing process. Our responsibility is to face the situation with care and compassion, to complete the tasks of each stage in the process, and to be as genuine as possible. We use supervision, consultation, and referral intelligently. Then we sleep peacefully and awaken with hope. Deal with Our Countertransference We therapists, as humans, can have our own buttons pushed when a client resists. A sense of being rejected, a sense of inadequacy, and a sense of unworthiness, all can be stirred up. Countertransference kicks in. In dealing with this kind of countertransference, try to remember this: all clients, including those who resist, have the same needs as we do—to be understood and accepted the way they are. If you have done everything you can to prevent resistance, and the client still resists, then it mostly stems from his having to face the difficulty of change. It is most likely not about you. If clients’ resistance does have something to do with us, then we shall seek out the proper supervision and consultation.

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DEEPENING CLIENTS’ AWARENESS, NOT THEIR ANXIETY As therapists, we want to deepen clients’ awareness and experiences without arousing too much of their anxiety, just like a dentist wants to drill deep to clean-up the bacteria in a cavity without touching the nerves of the tooth. This section provides some considerations for how to go about doing that. Regularly Address the Client by Her Name There is something inherently powerful in hearing our own names. When we hear our names, we become tuned into the conversation, almost like a reflex, and at the same time, connected to our inner self. Given this, throughout the session, we might want to address our clients by their names regularly. This is particularly needed whenever we want our client to hear a special message. Going one step further, to increase the effect and clients’ anticipation of what is to come next, you may want to subtly pause briefly after saying the client’s name. This will definitely get your client’s full attention (Mitchell, 2009). Use Client-Focused Reflection to Help Clients Self-Observe Self-observation soars above the rest as the most important skill in achieving selfawareness and affect regulation. Without the ability to self-observe, people cannot learn how to examine what’s going on inside them. Many clients obviously lack this skill, leading to a pervasive disconnect in their lives. As modest as empathic responding skills seem, nothing has more power in increasing clients’ ability to self-observe than these skills. When you reflect back what you perceive to be the clients’ experiences, unmet needs, perceptions, and feelings, your client can finally: • • •

Hear herself out and see her inner experiences as if reflected back by a mirror. Reconnect to her inner reality and fine-tune her reactions in daily life. Observe and reflect on her own life outside the session, leading to better regulation of her emotions.

Three Risks of Other-Focused Reflection: Avoid Them! Some therapists spend a lot of time reflecting back those experiences and reactions of the third parties in clients’ stories. This is called “other-focused reflection.” Regardless of how accurate your empathic reflection for the third party is, these “others” cannot benefit from it—they are not in the room. Three risks are involved in other-focused reflection: • • •

It derails the client from self-awareness or self-observation. It reinforces a blaming or complaining behavior. It will create an atmosphere of gossip, as you two talk about others who are not in the room.

Consider the difference of the following two different reflection orientations: Client: “My mom calls me all the time. It’s so annoying.” Counselor using other-focused reflection: “It seems that your mom is overly protective and even a bit intrusive.” [The reflection focuses on the Mom, the therapist is risking triangulation with the client against the Mom]

Dealing with Difficult Situations 111 Counselor using client-focused reflection: “I can sense that you feel frustrated, even irritated when your mom calls you more often than you want. You feel like you are back to being a little child.” [The reflection focuses on how the client reacts to her Mom. The therapist helps increase the client’s awareness of the source of her reactions] Don’t Ask “How Does that Make You Feel?” — “How does that make you feel?” This is a question perpetuated by the media, and unfortunately, misconstrued by many beginning therapists as a standard probing skill. This bogus probing creates many problems: • • • •

It implies that the client is a victim and is “made to feel” a certain way. It reinforces the notion that the client does not have the ability to regulate or control their own feelings, and that he is under the forces of other people and circumstances. It disempowers the client, stripping away the client’s sense of self-agency. It sounds canned, inauthentic, and disconnected.

If you really want to know how your client feels, just ask, — “How do you feel about. . . .?” Or, better yet, simply guess at your client’s feelings, then reflect them back. Your intuitive guess will come across more caring and warmer than a question: — — — —

“You probably have felt . . .” “I imagine that you might feel . . .” “Anyone in your situation would feel . . .” “If I were in your position, I’d feel . . .”

Use Tracking to Increase the Client’s Awareness When She Rambles When your client swamps you with details, adds comments tangential to the issues, or cannot stop talking, you have a problem at hand: A client who rambles (Schloff & Yudkin, 2011). According to Martin (2016), most of the time, rambling serves as a defense against: • •

The fear of engaging in real contact with another person. Painful feelings and thoughts.

Rambling certainly blocks one from self-awareness and self-exploration. To deal with client rambling, keep a mental map of the central issue, and track how the details connect to the central issue. Your connecting the dots will help your client increase her awareness: — “Jess, let’s stop for a few minutes to see if I understand what you’ve just told me. I think this elaborate story that you’re telling me right now about your father’s childhood seems to parallel what you were talking about before—that your father’s lack of presence in your early life seems to stem from his own father’s emotional absence when he himself was a child. Is that what you’re trying to get me to understand?” — “Simone, let me see if I can pull together some of the stories you’ve been talking about. It seems that fear of abandonment runs through all of your experiences, like a common thread running through a piece of fabric. Would you agree?”

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Use Experiential Focusing to Help a Rambling Client Become Aware Sometimes a client rambles as an escape from getting in touch with what is alive inside them—a form of experience avoidance (see Chapter 1). In this case, we can intervene by using a basic technique called experiential focusing (detailed in Chapter 8). Experiential focusing helps the client slow down and become aware of the present moment. In experiential focusing, you direct clients to pay attention to their breathing, voice, bodily sensation, subtle feelings, etc. Focusing in this way helps clients become more aware of their deeper self and become more grounded. — “Janis, I can see that this is a difficult topic for you to get a handle on. Let’s stop a moment. Try to pay attention to your breathing right now. Try to feel the soothing breaths as they come in and out. Let’s stay with them for a moment.” [The therapist then sits quietly with the client for a moment] After the client is more connected to herself, you may follow up with a processing: — “OK. Let’s see what you’re becoming aware of right now?” Don’t Confront Clients’ Intellectualization! Use Empathy, Instead! The most effective defense against feelings is intellectualization—a coping habit for escaping undesirable emotions. You know your clients are intellectualizing when you see them do the following: • • • •

Talking with impressive, abstract intellectual words. Talking in general terms. Constantly interpreting their experiences. Talking about experiences without feelings.

Allow a client to continue intellectualizing, and he will never get into what really matters to him—he may even never truly receive the benefits of therapy. We, the therapists, can easily be seduced into adopting a similar style. Without being alert, we can be tempted into intellectualizing away the session. The cure for intellectualization is empathy. When clients intellectualize, don’t confront! Just provide modeling of empathy—accepting his human feelings and emotions. This helps the client gives up their defense. Intellectualizing client: — “Our marriage fits the description of increased isolation as outlined in existential theory. This is an example of the existential vacuum as described in Viktor Frankl’s writing.” [The client talked about the problem, using impressive and abstract terms to avoid revealing any inner experiences] Ineffective/Confrontational counselor: — “There you go. You’re intellectualizing again. Why don’t you tell me how you feel instead of constantly interpreting your situation?” (The client may experience this confrontation as a direct criticism.) Effective/Empathic counselor: — “Even though you’re married, deep down you feel increasingly lonely and empty.” [The counselor acknowledges the feeling that the client was unable to reach]

Dealing with Difficult Situations 113 REMOVING YOUR OWN COMMUNICATION BARRIERS Many difficult and stagnant moments in therapy result from barriers in the therapist’s communication style. We can all benefit from knocking down our own communication barriers. Talk No More Than 30 Percent Words, used sparingly, fuel the power of therapy. However, words used too copiously set up communication barriers. Similarly, just the right amount of questions sharpen the focus of therapy. Too many questions cut off the client’s feelings. The time of a therapy session actually belongs to the client, not to the therapist. To benefit from therapy, a client has to have the luxury of time for self-exploration and self-discovery. Like a Zen monk, a therapist does not say much. When he does, he reverberates the essence of the client’s message. He brings it to life. If you talk more than 30 percent of the session time, it might be that you are nervous and trying to fill the time. Try to tackle this issue head on, be it through supervision or through personal therapy, so that it is fair to your client. Then you can truly enjoy helping others. Deliver and Stop! Get quickly to the point of your message. Then, stop. Period. In so doing, our clarity, brevity, and accuracy, combined with the silence that follows, will increase the impact of our message. A proven method to improve your delivery style is to carefully listen to your recorded sessions. Whenever you hear a long-winded response, pause the recording. Revise the response in your mind. Make it more concise. Practice the brief alternative response aloud or on paper. Following are examples for you to compare and contrast so that you can see how you can deliver and stop. Example 1 Client: “I really don’t think that I want to get involved with Frank again. After we got divorced the first time, I promised myself that I would never go back to a relationship with him because he abused me so badly. I even had a court restraining order against him. But last week he came over to my house and apologized, brought me flowers, and promised to be a good husband to me and a good father to our kids. I know I should tell him to go away, but my life is so empty without him.” A wordy response from a therapist: “So, Apunda, you were first married to Frank a number of years ago, but he abused you and you even had to get a court restraining order. You feel that you really should keep him out of your life but he has come back, is treating you nicely, and is promising to be a good husband and father. All the bad memories just melt away when he shows up with such nice gestures. Although you feel that you should not forget about the past, that you should not trust him so easily and should continue to keep him out of your life, you’re torn and are thinking about the attractiveness of his offer—that it might not be too bad to get back with him because you would feel less empty having someone to share life and parenting responsibilities with.”

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A concise response from a therapist—Deliver and stop: “Apunda, although you’ve ended your relationship with Frank because he was abusive, you’re now feeling torn between your longing for companionship and your desire to keep your resolve to stay away from him.” Example 2 Client: “So here’s how my day goes. I get up on Saturday, and I know I should be going out and having some fun. But instead, I go to the computer and print out a list of all the things that need to be done around the house. I have these things arranged so I can print them out by how much time they take, how much they cost, or how I’ve prioritized them in order of need. I determine what I’m going to do; then I have a drink and go shopping at the hardware store. I worked until eight o’clock at night on Saturday. Then I hate myself for blowing the whole day with work. I usually drink a bottle of gin and think about what a waste my life is.” A wordy response from a counselor: “So, Isabella, on Saturday you got up and consulted your computer concerning how you should spend your day. You decided that you’d get some of your house projects done. So you chose your project by cost, time, or need. Then you had a drink and went to the hardware store to purchase the needed items. Then you worked all day. Although you accomplished what you planned for, at the end of analysis you got angry at yourself for spending the whole day working. You wanted to have some fun at the weekend originally but ended up working all day. Then you drank a bottle of booze to soothe your selfcontempt but ended up feeling worse. When you look back, it feels painful because you haven’t gotten to where you want to be.” A concise response from a counselor—Deliver and stop: “Isabella, it sounds like you are unable to relax on your days off. There’s something inside that can’t be soothed by accomplishments. And you drink to numb the angst.” Be Assertive in Your Delivery On the other end of the spectrum are those therapists who suffer in not being able to get their words in. They struggle because: • • •

They don’t know what to say. They worry that anything they say would not sound intelligent. They don’t feel comfortable interrupting a talkative client.

If you suffer from an inability to get your words in, try the following: • • •

Practice over and over, until your skills become second nature until you build up your sense of confidence. Use hand gestures to get these clients’ attention, signaling that it’s your turn to talk. Don’t wait until you’re sure of the exact right thing to say. Getting actively engaged will serve your client better than saying something wise. Most clients long for the therapist’s emotional presence and connection.

Get Rid of Those Vague Responses A particular communication barrier is a vagueness. Though convenient and fitting for all clients in all circumstances, vague responses convey no substance, no personal presence,

Dealing with Difficult Situations 115 and no personal investment from the therapist. Worse yet, they reinforce a client’s sense of feeling unseen, unheard, and invalidated. The following list presents frequently used vague responses. Avoid them at all costs even when you can’t think of anything to say. Notice how impersonal these vague words—it, that, what—sound: — — — — — —

“I guess you’re pulled in different directions about that.” “I understand what you mean.” “I understand how you feel.” “I hear what you said.” “That’s something!” “It’s mind-blowing.”

Knock Out Those Discounting Reassurances With real substance, reassurance can provide comfort and relief. Without substance— you can call it empty reassurance—it discounts clients’ feelings. The following presents what discounting reassurance sounds like. Since these phrases do not convey validation to the client at all, we can expel them from our repertoire: — — — — — — — — —

“Don’t worry about it.” “You’ll get over it in time.” “That’s not so bad.” “Life will go on.” “Time will heal.” “This is nature’s way.” “Everything happens for a reason.” “There’s something to be learned from this.” “There’s always light at the end of the tunnel.”

When you don’t know what to say, say nothing! Silence is as good as gold (Meier, 1983), while empty reassurance is as worthless as dirt. If you do want to say something, use empathic responses. Break Away from Your Own Intellectualizing Tendency Previously, we discussed how to deal with the intellectualizing tendency of some clients. Here we will look at that tendency in some therapists. Therapists with an intellectualizing tendency may display two types of behaviors: • •

They focus on diagnosing, analyzing, assessing, interpreting, disputing, questioning, and so on. They use complex and abstract language to converse with their clients.

These kinds of intellectualizing behaviors do not benefit clients. Instead, they cut clients off from exploring their more in-depth experiences (Martin, 2016). Granted, therapists need to conceptualize their cases, but case conceptualization should happen in the therapist’s head, not in the communication with the client. Keep Your Talking to the Bare Bones If you have a tendency to intellectualize, take to heart what Cozolino (2004, p. 25) states here,

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Dealing with Difficult Situations The things that most people need to learn in therapy are related to attachment, abandonment, love, and fear. These emotional processes are organized in primitive parts of the brain, and the language associated with these emotions is very basic.

In therapy, clients experience their most powerful moments when the therapist uses bare-boned language—basic and to the point. The bare-boned language touches on the cores of human needs and emotions. Compare and contrast the following examples. Example 1 Client: “I’m a total loser. My family would be better off without me.” Response from a therapist with an intellectualizing style: “Your verbal expression certainly fits the description of a depressed person. In addition, depression is always anger turned inward, which, as you know, is often not expressed in a direct way.” A therapist with language kept bare-boned: “You’re feeling like a failure for falling short of your family’s expectations. I can pick up a sense of anger, and even shame, in your voice.” [The bare bones language often touches on humans’ most primary emotions] Example 2 Client: “I’m overwhelmed with everything I have to do. There’s no way that I’ll ever get through it.” A counselor with intellectualizing tendency: “You’re stressed out. Stress, however, is an internalized reaction to the external demand that you perceive in your environment. And your internalized reaction can indeed become biochemically triggered.” A counselor with the language kept to the bare bones: “It sounds like you’re overloaded and anxious. You feel bogged down.” DEALING WITH YOUR OWN DOUBTS AND DISCOMFORTS Empathy rests firm and humble as the cornerstone of all session management skills. Yet, none of us are born with it. When we first start out, we often perceive our empathic responses as unnatural, fake, or awkward. We often doubt ourselves. How can we deal with our own doubts and discomforts in practicing skills new and complex? How can we develop our neuron pathways so that these skills became a natural part of who we are? This section tries to help you address these challenges. Make Your Responses More Natural with Tentative “Lead-Ins” To make your empathy sound natural and more comfortable, consider using a tentative lead-in. When what you say is tentative, clients tend to open up, instead of closing down. Skillful tentativeness also gives clients the freedom to correct what you’ve said (Martin, 2016). You can achieve a sense of tentativeness in your statements by including some “leads-in” in your sentence stems: — “I guess you interpret it as if . . .” — “You seem to believe that . . .” — “I sense that maybe you are longing for . . .”

Dealing with Difficult Situations 117 — — — — — — — — — — —

“You feel as though . . .” “It’s as if you . . .” “You must have felt . . .” “Kind of feeling . . .” “Sort of like . . .” “It sounds like . . .” “I guess you mean . . .” “I guess you’re saying . . .” “I’m picking up that . . .” “If I’m hearing you correctly . . .” “To me, it’s almost as if you are saying . . .”

Manage Your Discomfort with Unlikable Clients As therapists, we may face our own discomfort with clients we find unlikable. Dolan (2014) tells a story of a novice seeking the advice of a seasoned therapist for her discomfort with an unlikable client. The seasoned therapist replied that there’s always something about a client that we can love, and the love of that little something can grow into an acceptance and appreciation of the whole person. He told a story of his own (p. 46): Like this guy I saw a week ago. He was unwashed, unkempt, hostile, he smelled bad, and I thought, “There’s got to be SOMETHING.” I sat there looking at him, and after a few seconds, I noticed that he had only one tooth in his mouth. Only one, but at least he had one tooth. I thought, “This guy has one good tooth, and I can at least appreciate that!” The seasoned therapist confirmed that his feelings of appreciation began to spread from the one good tooth to the rest of the guy. He became curious about the kind of life or the tragedies that the guy must have had that led to this current shape of health; about the love and grief the guy might have experienced. He repeated: something is always there if we just let ourselves connect with the person wholeheartedly. This story gives us encouragement to mine our inner compassion and to find something good in a client, no matter how small it is, in order to gain access to their inner person. However, if you are working with a client with whom you are unable to remain competent, then think referral. For example, if you are unable to work with a sexual perpetrator because of your aversive reaction to him, you should refer him to another therapist. In the same vein, if you have difficulty helping a client work through a decision about abortion, you should make a referral. Stop Content-Focused Therapy Some therapists feel as if they are swimming upstream when it comes to identifying feelings and needs. They cope with the difficulty by focusing on the contents of client discussion. Content-focused therapy tends to lead to clients’ storytelling, which can bog down our sessions. To advance to a deeper or more meaningful exploration, we need to be able to tap into clients’ inner world of assumptions, feelings, and needs. Among these, attachmentbased feelings are at the heart of counseling and therapy. Move past the content-focus, and enter your clients’ experiential worlds. As Meier and Davis (2011) stress “an ability to recognize . . . feelings in clients is a sign of progress in the beginning counselor” (p. 17).

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When in Doubt, Focus on Feelings Whenever you sense that your session is going in circles, that the client is lacking progress, that you are becoming bored, or that you should do something to bring depth to the session, whenever you are in doubt, focus on feelings! Why? First, it is more difficult to detect clients’ thoughts and assumptions, while it is easier to detect clients’ feeling. Feelings, as a type of energy, can be easily detected through clients’ nonverbal cues. Second, feelings often feel overwhelming and unmanageable to clients. Entering therapy, most clients need to have their feelings heard, so that they can start to manage them. Third, tapping into these overwhelming feelings, which are usually attachmentbased, we then arrive at the heart of counseling and therapy. Hidden under the feelings and emotions are deeply universal human needs that seek recognition and fulfillment. Be prepared for many clients to use vague words such as “upset,” “bad,” “not too good,” or “under the weather,” to describe their emotional experiences. Some even feel disentitled to their emotions, communicating no emotions at all, keeping their feelings bottled up until they explode (Meier & Davis, 2011). No matter how they obscure their feelings, these clients still long for you to recognize what they experience inside. Don’t wait until you have a perfect sense of what the client’s feelings are. Your reflection of feeling does not need to be perfect; all that clients need is for you to convey your acceptance of their inner experiences. Use the tentative lead-ins to increase your comfort in conveying empathy to your client. Use Mirroring to Deepen Your Rapport with Your Client Mirroring comes naturally when two people develop deep rapport (Dolan, 2014). When in love, people tend to mirror each other’s body language and speech pattern! Deep rapport fuels the chemistry of love. In therapy, therapists and clients develop a deep connection through mirroring. As you mirror your clients, their receptiveness to your therapeutic interventions increases, while their resistance decreases (Dolan, 2014). Several easy ways of mirroring are suggested here for your consideration: Verbal Mirroring Verbal mirroring equates to reflective/empathic responding skills. Verbal reflection deepens the rapport between a therapist and her client. Please review Chapter 4 for details. When it becomes your second nature to verbally reflect your client’s inner states, the following two types of mirroring will come easily. Mirroring your Client’s Facial Expressions Feeling comfortable with verbal mirroring, now you can advance to the mirroring of your client’s facial expressions. When a client expresses positive emotions, you also look happy; when your client communicates sadness, you also show sorrow in your face. Let yourself be so in tune with your client that your face is like a mirror, reflecting back your client’s inner experiences. On a side note, try to avoid the following three facial expressions: •

Avoid no facial expression: A face with no expression conveys to your client that you are not interested in your client’s experiences.

Dealing with Difficult Situations 119 • •

Avoid a continuous smile: A continuous smile indicates that you are not in touch with your clients but are faking your presence. Avoid a frequent frown on your forehead: A frequent frown signals to your client that you are disapproving of what she is saying. However, occasional frowns can be used to communicate that you did not follow what your client is talking about at that moment.

Mirroring Your Client’s Nonverbal Signs To mirror your client’s nonverbal language is to subtly match your own body language with that of your client’s (Robbins, 2015). When your client tilts her head, you follow suit gently. When your client shifts his weight, extends his foot, leans back in his seat, softens his voice, you subtly do the same. As Dolan (2014) exemplifies, “The therapist might swing her left leg in synchrony with the client’s leg and simultaneously match the tone and volume of the client’s voice” (p. 67). When you are so in sync with your client’s nonverbal cues, it creates a robust rapport between the two of you. Cautions: Not all nonverbal cues are worth matching. Some clients’ nonverbal behaviors—such as rapid and shallow breathing—are not the best target for mirroring. If you want to mirror client’s nonverbal communication, choose those that do not contain negative energy. TAKING CARE OF YOURSELF IN THE SESSION This may come as a surprise, but we have to take care of ourselves within the session, instead of waiting until we go home. Truth be told, when we take care of our “self ” in the session, we are honing our own instrument and will do a better job of serving our clients and dealing with challenging moments. Take Care of Your Self Even Before the Session The quality of our therapeutic work starts even before the session. Always allow extra time to get to your office so that you do not begin the session with strain (Cozolino, 2004). Make sure you have five minutes before each session in which you can center yourself, read your case notes, and even do a mini meditation. Here is a reflection from a new therapist about how he learns to take care of himself even before the session starts: I want to let go of trying to be ‘amazing’ in a session. Instead, I want to relax, trusting myself and my client. To this end, I try to ground myself before each session, taking a moment before stepping into the counseling room to become present in my own body. I do a mini meditation, asking the Universe to help me be of help, be of service, be present for my client. To Ward off Performance Anxiety, Ask for Time to Think Performance anxiety sneaks up on all therapists at various times. It sneaks up on us when clients are demanding a result or when we feel over-responsible. We may not be able to completely get rid of our performance anxiety; still, we can take steps to take care of our self, letting go of the pressure to perform on the spot.

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Here is a key step for in-session self-care: asking for time to think through a client’s statement or demand. For example, if your client throws you a curveball by saying something unexpected or asking you for advice, you might say something like: — “Please give me a moment to think through what you’re saying.” — “I’m feeling worried about what you’re describing. I need more information to understand this further. Would you help me?” — “I don’t know about this. I’ll have to give it some thought.” Hastening an answer does not lead to therapeutic effect. But after taking a moment to collect your thoughts, your response always sounds better because it is always in the client’s best interest. If you have no answers at all, don’t hesitate to honestly say “I don’t know.” Find Out What Is Expected of You Taking one step further, find out just what is expected of you from your client’s point of view. Different clients have different preferences as to what the therapist’s role should be. Some might want their therapists to be “change facilitators”; others, problem solvers; and still others, cheerleaders. When you find out your client’s expectation, discuss his expectation and make a clarification. If necessary, conduct your session in a way that complements the client’s expectation. For example, I (Mei) had a client who specifically expected me to conduct CBT to help her increase her success of in vitro fertilization (IVF) treatment that she had been undergoing. I gratified her expectation. When her goal was met, I then integrated other approaches to the therapy. See the following examples by Duncan, Miller, and Sparks (2013) of how to inquire about clients’ expectations of you: — “How do you see me fitting into what you would like to see happen?” (p. 74) — “What role do you see me playing in your endeavor to change this situation?” (p. 74) Admit Your Misunderstanding, Bias, or Lack of Knowledge Another way to take care of yourself in the session is to admit your misunderstanding or ignorance and your desire to learn. You may think that your admission might be interpreted as incompetence. As Cozolino (2004) states, clients most likely will experience your admission of ignorance and your desire to learn as your being interested and caring. Consider the following examples: — “I think I really misunderstood you there. Maybe you could tell me again so I could try to get it clear.” — “I admit that I know very little about your culture and how your people handle tension within the family. I’m going to do some research about this so I can serve you better. Right now, if you have anything you can share with me, I’ll be happy to be a student of your culture.” — “I had a feeling in the last session that we were stuck and that we weren’t working in synchrony. So I’ve given a lot of thought to that session and looked over my notes from previous sessions. And I just realized that I’ve been missing the boat.”

Dealing with Difficult Situations 121 — “As you may have noticed, I’ve been feeling lost in grasping some important points that you’ve tried to make. I’ve reflected on a few things that I had overlooked, and I’d like to share these ideas with you.” Don’t Think! Look! Look at the Process of the Session! Sometimes we need to take care of ourselves in the session by looking at the process of the session, instead of the content of the discussion. As Austrian British philosopher, Ludwig Wittgenstein, declares: “Don’t think! Look” (Duncan, Hubble, & Miller, 1997). When in a difficult spot, thinking about the content of what the client has said and what we have said will get us stuck in a place of superficiality, and our own anxiety will undoubtedly skyrocket. To avoid this trap, we need to look at what is happening in the here-and-now of the session. Chapter 9 offers several here-and-now skills to help you break through such blocks. Here, let’s just look at one example: Client (a young man longing for independence and having difficulty achieving his goal): “I really don’t have much to talk about today. (pauses and glances out the window) Not much happened this week. I chatted with my mom about finding a place of my own (glances outside the window). We had a long talk (sips on coffee). It was a good talk.” (Fidgets and looks down at the floor.) Counselor : “Matt, from the way you move, I get the sense that you’re having difficulty today in telling me what happened. Can we talk about what’s getting in the way? If it’s related to anything in our interaction, I’d like to resolve it.” Expect Highs and Lows A big step in taking care of yourself is to expect highs and lows as normal parts of the ebb and flow of the therapeutic process. We have seen so many new therapists feeling perplexed when in one session they and their clients are working steadily and making strides on some deep issues, then in the following session, the clients are withdrawn, the session feels like a drag, and the therapists feel inadequate and defeated. Highs and lows are to be expected when the client is working on profound—often painful—issues. After diving deep, the client naturally wants to take a breather from something painful. It is normal to withdraw for a while in an effort to regroup. Knowing the natural ebb and flow, you can alleviate your own frustration and critical self-evaluation. Patiently accept the ebbs. Gently take your time, as if waiting for a turtle to stick its head out of its shell. In the near future, your patience will be rewarded as soon as your client once again rides those high tides. EXERCISES 1. Give the client a homework assignment to help with their problem Client (Tyler): “I just can’t seem to get anything done. It seems like I’m always doing things, but I never get my homework done or do my violin practice. I want to do these things but something is always stopping me.” 2. Ask Tyler [above] about exceptions to her problem That is, ask for some examples of when she was able to get these things done

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3. Respond with a statement that shows respect for the client’s right to resist Client (Allen) was mandated to counseling by the court because he had 3 DUIs. Allen begins with, “I don’t want to be here. Counseling is a waste of my time and yours. I can quit drinking anytime I want.” 4. Correct the following counselor response Client (Maria) is a 34-year-old single mother of five children. She comes to counseling because her youngest child was just diagnosed with leukemia. Client: “I don’t think that I can deal with the chance that my Bobbie may die.” Counselor : “God never gives us more than we can handle.” 5. Change the following other-focused counselor response to a clientfocused one Client (Bob): “All my boss does is criticize me. He finds little mistakes in my work and then blows them up into huge things.” Counselor (being other-focused): “It sounds like your boss is a control freak.” 6. Correct the following counselor response Client (Alice): “She just stood there and told me that I was stupid.” Counselor : “How did that make you feel?” 7. Try to respond with a nonintellectual response Client (Sam, intellectualizing): “I think that the feelings that I have are very much like the modern day depression that I read about in magazines. They interviewed Aaron Beck about the existential mire that many people, including me, live in.” 8. Change the following intellectualizing counselor response into a nonintellectualizing response Client (Stella): “I’m very upset about the results of the election. Actually, I’m terrified about what might happen. Everything will change. My world is totally bleak.” Counselor : “I recently heard a speech by a Social Psychologist who was talking about his theory of the balance of political thought. He says that the election results are just a normal political correction.” 9. Ask for more time to learn about the client and to process the situation Client (Gregory, very agitated): “What do you think is wrong with me? Why do I keep going back to awful men? What could have happened to make me want to do this? All I want to do is meet a nice man who loves me for who I am.”

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Basic Intervention Techniques

Like a chef sprinkling spices into a dish to bring some zing to the taste, we need to begin to sprinkle into our nurturing empathic responding skills some active intervention techniques. These will give our sessions a sense of zest, energy, and forward movement. This chapter presents six intervention techniques of the basic level. These techniques, dynamic yet straightforward, can enliven the counseling process, especially during the first stage (problem exploration) and the second stage (awareness raising). ALIVE AND ENERGETIC SESSIONS VIA INTERVENTION TECHNIQUES Starting with the second session, we can inject more life into the counseling through the active techniques this chapter aims to introduce. What are intervention techniques? How do they differ from counseling skills? Intervention Techniques versus Generic Counseling Skills Intervention techniques are action-oriented in nature. Each therapy approach has its own uniquely designed intervention techniques intended to put their own distinctive concepts of therapy into action. On the other hand, generic counseling skills—empathic responding skills (Chapter 4) and influencing skills (Chapter 9)—are, in essence, interpersonal communication skills. All approaches of therapy rely on these interpersonal communication skills, as the vessel to carry their messages. Most therapists today combine generic counseling skills with intervention techniques in a seamless fashion. On the outside looking in, you will have difficulty telling the two apart. Further, most therapists draw on an array of intervention techniques from multiple approaches; rarely do they use techniques from only one single approach. Because of the trend toward multimodal integration nowadays, intervention techniques are virtually cross-fertilized. At times it’s almost impossible to determine which technique belongs to what approach. Action-Oriented Techniques: Alive and Dynamic Sessions Intervention techniques live, breathe, and enliven as a catalyst of change, however small that change might be. And though small, any change can quickly snowball, transforming a client’s life. A small action, something the clients rarely think of doing on their own, can be injected into the treatment plan. This small action, during the session or after the

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session, is all that is needed to render you and your client more alive; and the session, more dynamic. This action-orientation brings a balanced energy to any talk therapy. Intervention Techniques and Treatment Plans Therapists working in mental health agencies often have to write treatment plans to be accountable to their funding sources—insurance companies, grants, and governments— about progress in therapy. Generally speaking, a treatment plan consists of the following components: • • • •

Presenting problem: The major issues or complaints. Goals of therapy: The long-term goal and the short-term goals to be achieved. Methods: A list of the intervention techniques to be used to achieve the goals. Timetable: An estimated length of time needed to complete the treatment.

When writing a treatment plan, a therapist goes into detail on intervention techniques and methods, while leaving out generic counseling skills. Why? As stated, generic counseling skills are like the vessel that carries the medicine of therapy. We need to detail the remedy, not the vessel. The insurance companies couldn’t care less what interpersonal communication style you use throughout the session to build a trusting therapeutic relationship. Your clients, however, place a great deal of weight on your interpersonal communication style. Though left out from the treatment plan, a therapist’s generic counseling skills determine whether or not treatment will succeed. These skills could make or break your interventions and treatments. The contents of a treatment plan tell you nothing about what the session actually feels like. As we start to collect intervention techniques in our toolbox, never forget about the vessel—the empathic skills and influential skills. AFFECT REGULATION All therapists’ interventions aim at one prize—increasing clients’ affect regulation. To gauge whether or not therapy has been a success, all we have to do is to check whether or not “clients learn to experience, understand and regulate emotion” (Cozolino, 2004, p. 31). This section discusses the keys to client emotion regulation. Affect Regulation Difficulties Many people—who are born with biosocial vulnerability or live under exceedingly distressing or invalidating circumstances—have difficulty in modulating their emotions (Chapman, Gratz, & Brown, 2006; Koerner, 2012; Whiteside et al., 2007). When one struggles and then fails to regulate one’s emotions, dysregulation happens. In a state of dysregulation, a person’s emotions get off kilter, out of balance. They slip into one of the two extremes: either inadequate-regulation or over-regulation (Lapides, 2011; van Dijke et al., 2010). Inadequate-Regulation When a client swings to the extreme end of inadequate-regulation (sometimes called under-regulation), often her sympathetic nervous systems flip to a state of overdrive—a state of hyper-arousal. As she remains in this state of overdrive, she becomes exceedingly vulnerable to some of the following tendencies:

Basic Intervention Techniques 125 • • • • • •

Hyper-vigilance Anxiety Easily triggered emotions A sense of being overwhelmed Sensitivity to rejection Certain psychomotor agitation

A sense of being out of control, a sense of being overwrought, may permeate her being. Over-Regulation When a client swings to the other extreme end of over-regulation, often she becomes emotion-phobic (Koerner, 2012). She excessively regulates or over-regulates her emotions to remain in control. Her sympathetic nervous systems flip to a state of hypo-arousal. Under this state, she becomes unreceptive to her own emotions. In addition, she may show some of the following tendencies: • • • • •

Emotionally unavailable to others. Detached from inner experiences. Affects being overly inhibited. Shutting down. Disconnected from her own body.

Be it in the state of inadequate-regulation or over-regulation, as long as the client’s affect is dysregulated, the following are likely results: • • • •

She will not be able to balance between her thinking and her feeling. She cannot effectively articulate her experiences. She cannot read others accurately or respond effectively. She does not have the tools to communicate her inner experiences; therefore suffers an inadequacy in intimate relationships.

What Effective Affect Regulation Looks Like in Everyday Life When a client recovers from affect dysregulation, she returns to a state in which she can modulate her feelings, thoughts, communications, physiological responses, and emotion-related actions. If her healing goes deep enough, this capacity can persist even when she is under stress. What does this look like? From the outside looking in, her everyday life, according to studies (Gratz & Tull, 2010; Linehan, 1993; Melnick & Hinshaw, 2000), will show that she has the capacity to: • • • • • • • •

Recognize, accept, and articulate the emotions that she is experiencing. Notice and accept the emotions that others are experiencing. Tolerate negative feelings without acting out. Hold back from impulsive behaviors. Withstand certain pressures without being crushed. Work at one’s own goal even when experiencing negative emotions. Accept and calm his own emotions when distressed or overwhelmed. Wait out uncertainty or stomach the delay of attainment.

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Not the Same as Control of Negative Emotions Some people misunderstand emotion regulation as control of negative emotions. This is a classic error. To control, suppress, or avoid negative emotions would imply that negative emotions are inherently bad and thus need to be dampened (Gratz & Tull, 2010). But emotions, positive or negative, serve an evolutionarily adaptive function in our lives, providing important information about the environment, and guiding our actions (Gratz & Gunderson, 2006; Linehan, 1993). Control of emotions should never be our agenda, even when they are negative. In fact, studies indicate that controlling or suppressing negative emotions can actually exaggerate their frequency and severity (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Salters-Pedneault, Tull, & Roemer, 2004). Not the Same as Keeping Emotional Intensity Low, Either Another mistake is to believe that emotion regulation equates to keeping emotions at a low intensity—a belief based on the idea that intense emotions create problems and, therefore, prove inherently defective. It might be true that some people who are emotionally more intense may be at greater risk for emotion dysregulation (Flett, Blankstein, & Obertynski, 1996), but the intense emotion itself does not necessarily lead to emotion regulation difficulty. In fact, people with great passion tend to feel things intensely, but they are not emotionally vulnerable—they are not easily overwhelmed or triggered. However, people with low emotional intensity cannot always keep themselves on an even keel. What is Emotion Regulation, Anyway? The Four Keys The keys to affect regulation can be boiled down to four elements: acceptance of emotions, mindfulness, flexible modification, and interpersonal effectiveness (Gratz & Tull, 2010; Koerner, 2012; Linehan, 1993): 1. Acceptance of emotions: Emotion regulation involves accepting one’s internal experience, tolerating undesirable emotions, acting compassionately toward oneself and being able to self-soothe when experiencing negative emotions. As such, emotions are fully experienced and humanely allowed, but with no need to act on them. 2. Mindfulness: Emotion regulation requires us to observe and articulate our emotions, as well as to participate in activities of the present moment, even when we are under undue distress (Linehan, 1993). These above two keys—acceptance of emotions and mindfulness—seem to be the common denominator of the following treatment models: • • • • •

Dialectical behavior therapy or DBT (Linehan, 1993) Acceptance and Commitment Therapy or ACT (Hayes, Strosahl, & Wilson, 2011) Mindfulness-Based Cognitive Therapy or MBCT (Segal, Williams, & Teasdale, 2002) Mindfulness-Based Stress Reduction or MBSR (Kabat-Zinn, 2005) Acceptance-Based Behavioral Therapy or ABBT (Roemer, Orsillo, & SaltersPedneault, 2008)

All of these are innovative treatment models conceived during the past few decades.

Basic Intervention Techniques 127 3. Flexible modification: Emotion regulation involves being flexible enough to modify the course of action when circumstances call for it (Berking et al., 2008). This requires that one’s emotions and one’s cognitions work together to verify the facts, to come up with alternative responses, and to create realistic strategies for problem-solving. As a client’s responses become more flexible and adaptable, she will trim down her emotional vulnerability (Koerner, 2012). To be a flexible and creative problem solver really requires “the integration of affect and cognition where the brain is able to interconnect neural networks for these two functions” (Cozolino, 2004, p. 32). This integration is at the heart of all approaches in counseling and therapy. 4. Interpersonal effectiveness: Emotion regulation also involves having interpersonal skills of expressing our feelings and opinions, acknowledging others’ feelings and opinions, asking for what we want, helping others to get what they want, and negotiating alternatives when encountering obstacles (Koerner, 2012). All therapies aim to enhance this interpersonal functioning in clients. Counseling Skills and Techniques to Enhance Client Emotion Regulation As we can see, it takes rich internal resources for a person to achieve emotion regulation. Most people fall short in one way or another. In addition, pervasive misunderstandings exist among people about how to get their lives back when under distress. Some people believe that the only way to regulate their overwhelming feelings is to shut them down. Others believe that the way to do away with their overwhelming feelings is to selfmedicate (such as through substance abuse) or self-harm (Cozolino, 2004). Neither ways are how emotions deserve to be treated. According to Greenberg (2012) emotions act as the carriers of our personal meanings, informing us of what matters to us and what does not. We must honor them as the captain of our lives. What do we do to bring client emotion regulation into shape? We need to enlist the whole of the client to help them arrive at optimal emotion regulation, including their body, cognition, emotions, and their relationships. We also need to utilize all the skills and techniques within our reach to help clients accept and tolerate their emotions better. With the empathic skills already in our toolbox, we are now ready to add six basic intervention techniques into the mix. I. BODY-ORIENTED DIRECTIVES The technique of “directives” stands as the primary basic intervention to help clients optimize emotion regulation. Originated from the experiential therapy approach, the technique of directives is now widely employed in all therapies. In directives, you use respectful suggestions to direct the client, albeit in a collaborative manner, to focus on something immediate and intimate within themselves in the present moment. This section introduces four basic directives techniques, leaving the more advanced directives techniques for Chapter 10. You will find these four easy to apply in any of your sessions: 1. 2. 3. 4.

Attention suggestion (experiential focusing) Body awareness exercise Breathing retraining Experiential acceptance retraining

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1. Attention Suggestion—Focusing on Visceral Experiences Many people who have unprocessed emotions tend to have pent-up energy that seeps out through their somatic senses. Since emotion regulation involves mindfulness and awareness, we need to help our clients become more observant and aware of the messages that their visceral experiences are giving them. This awareness-enhancing technique is called attention suggestion, also known as experiential focusing. In the technique of attention suggestion, you guide your client, in a gentle yet firm way, to pay attention to their present visceral experience, including the following: • • • • • •

Breathing Voice qualities Tears Unspoken feelings Nonverbal movements, such as hand gestures, clenched fists Bodily sensations

Follow the Three Principles of Attention Suggestion To increase your success in attention suggestion, consider the following three principles: • •

•

Start your directives with a verb: To make your directive a real directive, you will need to start your sentence stem with an action-oriented verb. Let your voice be soft and clear: The softer and more gentle your voice is, the more effective it will be in leading your client’s attention inward. Make your voice clear so that your client can hear it. Allow the client time to stay silently with the felt sense: Whenever you notice any bodily reaction in your client, stop talking immediately. Allow the client adequate time to silently pay attention to the felt sense (Gendlin, 1998).

In the following examples, observe these three principles in action: Client: “I was never abused or anything like that, but my parents rejected me . . . everybody would be celebrating something and they would just forget that I wasn’t there. It was not any sort of big rejection . . .” Counselor : “When you said that, you looked like you were back at that young age. It seemed like the young part of you is saying I’m hurt here”. [Advanced empathy] Client (looking at the counselor and nodding, contemplating what was has just been said): Counselor : “Close your eyes. Concentrate on how you felt when you were younger. See if you have a sense of how you feel about this young and little version of you.” [Softly and clearly directing the client’s attention to her visceral experiences] Client: “I feel like the young and little me feels unnoticed” Counselor : “Feeling unnoticed [paraphrase]. OK. Stay with that feeling. See what comes up.” [Soft and clear directives] Consider more examples: — “Turn your attention inward and see what comes to you.” (Greenberg, Rice, & Elliott, 1996, p. 128) — “Take some time to hear what you just said. Don’t move on; just stay with it for a while.” (Daldrup, Beutler, Engle, & Greenberg, 1988, p. 60)

Basic Intervention Techniques 129 — “Vic, let’s stay with that sensation in the chest! Try to concentrate on it! (Pause for 1 or 2 minutes.) When you’re ready, please tell me what you’ve noticed.” — “Colleen, as you describe the fighting between your parents, and ‘the mediator’ role that you took on to help the family stay together, pay attention to the tremble in your voice. Let’s stay a bit longer with the emotions behind that tremble and see what comes up!” — “Take some time to reflect on the meaning of what you just said, Mike. Stay with it for a moment!” — “Okay, Cassie, let’s try to see whether you can stay with the sad feeling a bit longer.” — “All right, Carlos, try to see whether you can pay attention to your breathing pattern as you tell me this.” — “Bess, as you speak, try to pay attention to your hand gestures.” — “Joe, try to stay with that angry feeling for a moment. Later we’ll try to make some sense out of it. But for now, just focus on it.” — “As you talk about your father, Tyler, try to pay attention to your clenched fists.” — “Megan, as you speak, pay attention to how you clench your fists and how your breathing begins to speed up.” — “As you’re talking, Cole, try to pay attention to the sadness in your voice.” — “Judi, observe where you feel the anxiety in your body. Stay with that body sensation for a moment!” — “Okay, Asa, try to listen to the quiver in your voice for a moment as you speak.” — “Anne, let your tears have a voice. Let them tell you about what they’re trying to say.” Avoid the Two Mistakes of Attention Directives Two mistakes that you want to watch out for in carrying out attention directives: Don’t make a directive into a question: To soften the intensity of their directives, beginning therapists sometimes deliver the directive in the form of a question. For example, they will start the directive with “Would you please . . .?” or “Can you . . .?” This is a classic mistake. Questions tend to lead the client to “the head,” instead of to the bodily sensation. Doing so only defeats your original purpose of helping the client connect to their bodily sensation. As stated in Chapter 4, emotions and feelings are meant to be received and responded to (Kemper, 2016) with respect, instead of retreating to the more cognitive arena. See the following illustrations of what to avoid: The crossed-out words indicate that what are delivered are actually probing questions. Avoid them: — “Melissa, what do you think the quiver in your voice is telling you?” [The crossed out words indicate a probing question, far from an attention directive] — “Melissa, can you hear the quiver in your voice and what it is telling You?” [This is a closed question] — “Melissa, would you like to slow down and hear the quiver in your voice and what it is telling you?” [This is another closed question] Instead, say: — “Melissa, try to listen to the quiver in your voice. See what it is telling you.” [These are attention directives]

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Don’t say “I want you to . . .”: To reflect a collaborative atmosphere in your directives, avoid using phrases such as “I want you to” “I need you to” “I would like you to.” These phrases put too much weight on you and your agenda. Hence, get your “I” out of the way. Keep your directives as straightforward as possible: Don’t say: — “Judi, I want you to observe where you feel the anxiety in your body. Then I would like you to stay with that body sensation for a moment!” Instead, simply say: — “Judi, try to observe where you feel the anxiety in your body. Stay with that body sensation for a moment!” 2. Body Awareness Exercise For clients who are disconnected from their body or their feelings, body awareness directives can help them gain access to their feelings, which otherwise may prove inaccessible. Body awareness directives bypass human languages that can sometimes stand in the way, preventing clients from being in tune with their inner aliveness. As clients get in touch with their inner aliveness, their affect regulation improves. Body awareness techniques have been used in Eastern spiritual practices for thousands of years. Herbert Benson popularized it in the United States with his book, The Relaxation Response, wherein Benson laid the foundation for the various forms of systematic relaxation (Benson & Klipper, 2009). Body awareness techniques have been effectively used to treat phobias and anxiety, including panic attacks (Mehling et al., 2009; Mennin, 2006). Body awareness techniques consist of a series of attention suggestion directives (as presented above). After you get a handle on attention suggestion directives, you will feel at ease with the body awareness intervention. The following example was provided by Smith (2001), with our annotations in parentheses and our italics showing how each sentence stem starts with a certain verb. Notice how no questions or conversations are involved, just straight directives: • •

• • •

Close your eyes and just relax for a few moments. Breathe comfortably. (Pause) Check out your body to see what you find. Notice anything in your body which calls attention to itself. Just monitor your body, inch by inch, from the tips of your toes to the top of your head and down to the tips of your fingers. In particular, notice any hot spots, cold spots, tight or tense muscles, pains, tingling, or anything happening in your body. Don’t try to edit or change anything. Just be aware and note what is happening. Take your time. (Pause for a minute or 2) When you are finished, open your eyes. (Wait until the client opens her or his eyes) (p. 107)

After the exercise, you can process with your client what stood out for him during the exercise. Never leave the client without helping him reflect on the experience of doing the exercise. For example, you may say: — “Tim, thank you for trying this exercise. What did you notice the most during the exercise?”

Basic Intervention Techniques 131 3. Breathing Retraining Many clients who have emotional problems also have a chronic disturbance in their breathing, for examples, restricted breathing, shallow breathing, and habitually holding one’s breath. Restricted breathing can lead to hyperventilation, which then can lead to anxiety attacks. Shallow breathing and habitually holding one’s breath can lead to fatigue and mental fog, which then leads to depression (Hendricks, 1995). What do clients with these chronic disturbances in their breathing need? Breathing retraining (Hazlett-Stevens & Craske, 2009). As they breathe better, they may start to regulate their emotions effectively. Studies (Davis, Eshelman, & McKay, 2008; Field, 2011) show that diaphragmatic breathing has the following benefits that improve mood and reduce stress: • • •

Lower the stress hormone, increase serotonin and endorphins—the two feel-good hormones. Increase blood flow to the brain, leading to better mental focus and concentration. Change brain waves from the more stressful beta wavelengths to more relaxing and healthier alpha and theta ones.

So effective, deep breathing techniques, as indicated by Brown and Gerbarg (2005), can even be a stand-alone substitute for conventional medical treatments for problems, such as depression, anxiety, stress-related disorders, eating disorders, and obesity. Breathing retraining basically involves diaphragmatic breathing or belly breathing. In principle, when you direct your client to do belly breathing, you should do it yourself at the same time, so that your rhythm is not too fast. Some therapists guide the process in such a rush that it actually creates more stress for clients. This is something to be mindful about. The following are the steps of breathing retraining. Step 1. Explaining it — “I am glad that you are interested in knowing how to do it, Emilia. By itself, it is very simple as a concept, although it will take some practice to make it natural. First, about the count. For one breath, we will inhale for 4 counts, holds for 3 counts, and exhale for 7 counts. The counting can be done silently. When you get good at it, you can increase the count to any number you feel comfortable. Second, about the belly. When we inhale, let our bellies rise up to take in as much fresh air as possible; and when we exhale, let our bellies sink all the way in, so as to squeeze out all the air. So we are engaging the belly, instead of the chest. Third, about the hand. It is helpful to place one hand on the lower abdomen to feel the belly rising up and sinking in. When you are very good at it, you will feel the movement of the belly without engaging the hand. So all together, there are just three components. Got it?” Step 2. Clarifying it — “That is a good question. If you are in a situation not convenient to counting the breaths, then you can just focus on the exhalation, making it really slow, and you don’t need to engage your hand. It will have the same effect. Any other questions, Emilia?”

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Step 3. Illustrate it — “Perhaps I could show you how to put it all together. [The counselor starts by putting her right hand on her lower abdomen] Inhale . . .” Step 4. Doing it together — “Any questions? Okay, let’s do it together while I count silently. Ready? Inhale! [Counting silently for 4 counts] Hold! [Counting silently for 3 counts] Exhale! [Counting silently for 7 counts]” — “OK, that is one breath. Let’s do it together for another 9 breaths. Inhale . . .” — “How are you doing?” — “You are doing very well, Emilia! It will be a good idea for us to try the second method together as well. Just to review, we will focus only on the exhalation part of the breath, feeling the movement of your belly without engaging the hand, and making the exhalation really slow. Let’s go for 3 very slow exhalation cycles.” Step 5. Processing it — “OK, that is belly breathing. How did you experience this exercise? How do you feel right now?” Step 6. Taking it home — “As you practice more, it will start to come naturally to you, and eventually you will be able to do it even in stressful situations. Here is a take-home exercise for you to do during the week: spend 3 minutes in the morning and another 3 minutes before going to bed to practice the belly breathing. When you come back next week, share with me your experiences of the take-home exercise. Would you like to try it?” 4. Experiential Acceptance Retraining Experiential avoidance is a pervasive phenomenon in our society (see Chapters 1 and 4). We have learned successfully to avoid anything adverse, ranging from our thoughts and memories to our feelings and bodily sensations (Blackledge & Hayes, 2001; Hayes et al., 2011). One of the common but unconscious tactics of experiential avoidance is self-distancing or disowning, especially in the use of “You” statements when, in fact, one is really describing personal “I” experiences. This lack of ability to own up to one’s own experiences, or to express them directly, is one of the prevailing problems of many clients. Here is an example wherein a client, Bohai, displays this kind of distancing or disowning “you” statement: — “When no one is hearing what you have to say, you just sort of shut down.” Upon hearing it, most people will understand what Bohai means, but they will feel like there is a wall between them. They have to get past that wall in order to enter into his world. His use of the self-distancing “You” statement creates that wall. This distancing “You” statement allows him to play it safe, reducing his sense of vulnerability. However, the price tag will soar very high if he uses it too frequently.

Basic Intervention Techniques 133 His authority over his own experiences will be undermined, his own authentic voice will be lost and his relationships with others will be hampered; all by this wall. So, what’s the alternative? Use the “I ” statement. Let’s see how Bohai can change to an “I” statement: — “When no one is hearing what I have to say, I just sort of shut down.” This would have had a completely different effect on the listeners; they would have felt drawn into his inner world, his sense of agony of being unheard, and his loneliness. There would have been more immediacy and intimacy between him and the listeners. Assertiveness Training within behavioral therapy (Wolpe, 1991) has used “I” statements, with a lot of success, to retrain their clients. In acceptance commitment therapy (ACT), experiential acceptance receives a grand recognition as well (Gratz & Tull, 2010; Hayes et al., 2011). When clients change their habits of experiential avoidance to experiential acceptance, their quality of life improves, as does their emotion regulation. As well, experiential retraining uses a series of directives to achieve the retraining. See the following examples: Example 1 Client: “But when you don’t have unconditional love in your youth, you’ll always try to find it or search for it, and you always don’t have it, so you keep on searching for it.” [The client appears rather detached] Counselor : “John, what you just touched on is very much at the heart of your struggle, but you said it in a way as if it was someone else’s story as if you’re totally removed from it. Let’s do an experiment that’s actually pretty easy to carry out: Try to say what you just said out loud again, but this time, simply change the word ‘you’ to ‘I.’ See how it feels!” [The counselor uses a series of directives to retrain the client] Client: “Okay. Well . . . umm, since I didn’t get unconditional love at a young age, umm, I’ve always tried to fill the void inside me by looking everywhere for it. And the more you try . . . umm . . . okay, the more I try, the more I don’t get it, so the saga continues.” [The client is visually affected by his own experiences when he states them in this new way] Counselor : “Marvelous, John! You did a very good job, and you even corrected yourself midway. Now I wonder, what is it like for you to speak up for your experience in such a direct way using this kind of ‘I’ language? How does this new way of speaking change the energy in your body?” [Processing and encouraging client selfreflection] Client: [reporting a shift in consciousness] Example 2 Client: “Sometimes it’s frustrating because you thought this was your plan, this is what you wanted and it didn’t happen the way you wanted it so you’re like, ‘Oh, why is God testing me, why couldn’t He have just made it a little bit easier, and just let me get to the next part of life?’ But at the end of the day, you have to go back and realize you don’t know why this happened, it’s for your best interest, He’s not gonna take you this far and just let you go. He’s not going to tease you.” [The client is describing something significant yet uses distancing language to play down her emotions]

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Counselor : “I can sense there is a great amount of resilience in you that has helped you cope with the many challenges you faced during your medical school training. But I noticed that you sort of distance yourself by using the ‘you’ statement in all of your expressions. Let’s try to repeat some of the things that you just said, but this time, change them to ‘I’ statements.” [The counselor validates the client’s experiences and, at the same time, retrains her to use a more personal language] II. COGNITIVE-RESTRUCTURING AND SOCRATIC QUESTIONING Emotion regulation involves flexible modification of cognitive and emotional responses (Berking et al., 2008) wherein our emotions work together with our cognitions. When emotions and cognitions unite, we gain the ability to think flexibly, to problem solve creatively. Our emotional vulnerability naturally cuts itself back (Koerner, 2012). Many cognitive errors contribute to clients’ emotional difficulties, including: • • •

Cognitive fusion Automatic thoughts The shoulds and musts

This section introduces four intervention techniques of cognitive restructuring, known for increasing client’s cognitive flexibility, modifying their faulty thinking, and returning their emotions to health. In cases where cognitive distortions are rather entrenched and elaborated, the therapist will need to use advanced intervention techniques, such as schema rescripting, covered in Chapter 10. 1. Cognitive Defusion The first cognition-restructuring technique is cognitive defusion—used to counteract a cognitive error called cognitive fusion. Cognitive fusion happens when a client believes that her thought represents the reality (Blackledge & Hayes, 2001). In this error, the client is unable to see thoughts as thoughts, but rather she so attaches herself to her interpretations and thoughts that she believes her thoughts to be fact. This, of course, can create a great deal of suffering. To deconstruct this kind of cognitive fusion, therapists must defuse it. This is a process used frequently in ACT (Gratz & Tull, 2010; Hayes et al., 2011). In cognitive defusion, rather than let our clients blindly assume the validity of their beliefs, we actively help them counteract them. Examples of cognitive defusion follow: Client: “I look at all the mistakes I shouldn’t have made all my life and think to myself, ‘It is me, I am the only common denominator in these events, therefore, I am stupid. I am just no good.’ ” Cognitive defusion technique—Option 1: — “Barak, that is an interesting thought, but I am not sure how true it is. So let’s try to do something to find out. Close your eyes, put this thought that you just had . . . put it in a cloud bubble, watch it floating in the sky of your mind. Just watch. See what happens.” Cognitive defusion technique—Option 2: — “Barak, that is an interesting thought, but I am not sure how valid it is. How about this? Try to hold that thought in your mind and, at the same time, look

Basic Intervention Techniques 135 back to the history where you came from, look into the details of all the circumstances that you went through. Look at them like a detective. See what you find out.” Cognitive defusion technique—Option 3: — “Barak, that is an interesting thought. Close your eyes and stay with the thought you’re having. Accept it. Thank it, but don’t give yourself over to it unless it proves itself worthy of your time. Let’s see what will happen.” Processing the believability of the thought: — “OK, Barak, let’s see what you got. On a scale of 0 to 10, with 10 being the highest level and 0 being the lowest, where are you in believing that this thought is true?” [The scaling technique will be covered later in the following section of Solution Focused techniques] — “So you got a four. What does this mean to you? And where do you go from here?” [Continually processing to get to the client’s new cognition] 2. Restructuring Automatic Thoughts/Beliefs Most emotional difficulties have to do with some automatic thoughts or beliefs that are repetitive, like a broken record, and almost impossible to shut off (Leahy, 2017). For example: — — — —

“Everyone is judging me!” “Nothing I do will ever please her.” “I should never be angry.” “Something is wrong with me.”

These automatic thoughts are distorted because they have their bases on incomplete information. However, they possess such power as to shape clients’ perceptions about themselves, others, and their lives. For example, depression, according to Beck’s cognitive triad of depression, stems from clients’ automatic negative thoughts about self, negative interpretations about the world, and negative predictions about the future (Beck, Rush, Shaw, & Emery, 2003; Craske, 2010). What we need to keep in mind is that clients typically do not report their automatic thoughts. These automatic thoughts are elusive and flash through the mind at enormous speed, so fast that clients are unable to notice them. A surefire way to determine whether certain automatic thoughts or beliefs are occurring is to look for any tinge of strong emotions. When emotions are detected, we can take several steps aimed specifically at restructuring automatic thoughts and beliefs. The example below illustrates several case-specific steps. For other ways of cognitive restructuring, please go to the Socratic Questioning section (covered later in this section). Client: “My doctor told me that there’s a potential that I might not be able to have children. When I was in my first marriage, I didn’t want to have children at all, but the guy I’m with currently definitely wants to have his own children. So I start to go, like, are we a good fit? It’s constantly, sort of, looming out there. I’m afraid that he will be bitter and resentful. . . .”

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Step 1. Reflecting the thought Counselor : “Erin, I can almost hear the voice in your head constantly telling you, ‘I’m not good enough for my partner if I can’t have children. You feel terrified by this thought of not being good enough for your partner.” [The counselor demonstrates empathy, understanding, and acceptance] Client: “I think it’s just expectations. Everyone comes into it with some type of expectation of what you want to see happen and, yeah, it brings up emotions for me. I think that’s probably tied to some stuff from my past . . .” (Client starts to open up deeply about the hurt in her past that is triggering her current fear). Counselor : (continues to reflect the client’s thought and feelings associated with the past) Due to space limitation, client responses will not be included in the following exchanges. Step 2. Looking for supporting evidence — “Erin, with that background in mind, now we can slow down. Try to look at any pieces of evidence that support this thought of yours, ‘I’m not good enough for my partner if I can’t meet his expectations.’ When you get some, let me know.” Step 3. Looking for opposing evidence — “Erin, that makes sense that this evidence would lead you to think that way. Now, let’s take one step further and look at any pieces of evidence that prove that this thought is not true. Look back at all your experiences and see whether any would prove this thought to be invalid. When you find an experience or two, please let me know.” Step 4. Looking for how the thought and emotions are connected and how they are serving the client — “So there is evidence that supports your thought and evidence that invalidates your thought. That is good news, Erin, because we now know that this thought is not an absolute truth. Let’s take another step further. In what way might your thoughts be based on feelings rather than facts? And in what way might this thought and its associated emotions serve you?” Step 5. Looking for the effect of the thought and emotions — “Erin, when you get so scared of abandonment and get caught up by the thought of your not being good enough, how does it impact your partner?” Step 6. Looking for the pattern of interaction and the alternative — “From what you said, Erin, it seems that to protect yourself from being abandoned, your mind serves you with this thought so that you can back away, and then your partner sort of picks up the vibe from you and he starts to build his own walls. It is almost like a vicious circle. What might be an alternative that will soothe your fear without creating a vicious cycle in your relationship?” Step 7. Processing — “It looks like you’ve had an ‘aha’ moment. What is happening within you right now?”

Basic Intervention Techniques 137 Step 8. Give Homework Assignment See section XI: Take-Home Exercises. 3. Restructuring the Shoulds and the Musts People often have “shoulds” and “musts” regarding how life works. These “shoulds” shape the lenses through which people interpret their life events. By targeting clients’ “shoulds” and “musts”, therapists can help clients put their unarticulated assumptions on the table for examination and restructuring. This eventually helps them regulate their emotions better. Example 1 Client: “I feel horrible. I’m going to end up with a B in one of my courses. No matter what I do, I just can’t seem to shake the humiliation of it.” Counselor : “Dan, you seem to say to yourself, ‘I should get all A’s; otherwise something is terribly wrong with me.’ You feel humiliated when you can’t measure up to these rules.” [The counselor first reflects the should in the client’s thinking, then follows through with other steps to help the client restructure his faulty thinking] Example 2 Client: “I don’t know why my wife is making me come here. She’s the mother. She’s the one who’s with the kids all the time. She’s the one who’s having problems controlling them. I work hard all day, and the last thing I need when I get home is her getting on my case about every little thing that went wrong with her day. Coming here is a waste of my time when what’s really wrong is her inability to control the kids.” Counselor : “Sounds like in your view, Chris, the rule of parenting goes like this: ‘Parenting responsibilities should be a mother’s only.’ And given your own responsibilities at work, you feel it’s a burden to come here to discuss problems that you see are not yours.” [The counselor first reflects the should in the client’s thinking, then later follows through with other steps to help the client restructure his faulty thinking] Example 3: Counselor : “Tami, perhaps you can help me understand what’s causing you to feel down. Would you please complete this sentence, with the first thoughts that come to your mind: ‘I feel sad because I think that. . . .’ ” Client: “I feel sad because I think that ‘I’m such a failure. I should be at the place where everybody at my age is, but I’m not.” Counselor : [first reflects the should in the client’s thinking, then follows through with other steps to help the client restructure his faulty thinking] 4. Socratic Questioning: A Collaborative Examination Socratic questioning, a regimented questioning, constitutes the heart of the cognitive restructuring technique. Through Socratic questioning, the therapist helps clients examine the validity of their thoughts and learn to dispute them (Dryden, 2009).

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The unexamined life is not worth living. The Greek philosopher Socrates (c. 470 BC– 399 BC) originated this famous statement, and he truly lived his life by this credo (Vlastos, 1991). To guide his students to get to the truth, Socrates designed a disciplined style of questioning, now called Socratic questioning. Widely adapted in education, business, consultation, and therapy, Socratic questioning enjoys the standing as the most celebrated method to stimulate critical thinking Used properly after rapport has been developed, Socratic questioning can help clients challenge the validity of their automatic thoughts, their unchecked assumptions, their shoulds and musts. As a result, they can replace these unfounded thoughts with more accurate and functional ones. The key to Socratic questioning is collaboration. From a curious and respectful position, the therapist puts forward a question, gently drawing out clients’ internal thoughts, without ever appearing to know the answer already. Most therapists don’t use Socratic questions exclusively in a session, though. Rather, we sprinkle Socratic questions into the mix of many other skills and techniques. Beck (2011) groups Socratic questioning into the following subgroups. See the examples that we provide below to illustrate how to use each subgroup of Socratic questions. Evidence Questions — “Lillian, what evidence do you have that supports this idea that no one cares about you? And what evidence do you have that contradicts this idea?” — “From what I hear, Jasmine, you seem to be assuming that if you don’t speak perfect English, you’re nobody. What evidence supports this assumption? And what evidence contradicts this assumption?” — “Keith, what evidence do you have to verify or squash this assumption—that if people get to truly know you, they will reject you?” Decatastrophizing Questions — “Keith, what will be the worst result, if your nightmare does come true if after getting to know you, some people decide to reject you? How would you cope with this worst-case scenario?” Impact Questions — “Ramon, you said that you just knew that others were judging you, so you got angry. How does this assumption about others have an impact on your reactions to them?” — “Meg, you said that it’s better to keep everything to yourself. How does this relate to the relationship difficulties we’ve been talking about? And how does it have an impact on others in your life?” Alternative Questions — “So, Terry, if it is not true that people will reject you if they come to know the true you, then what might be another way to explain why people shy away from you? Why else does it happen?” — “So, Meg, now we have established that when you keep everything to yourself, people in your life feel frustrated, they feel walled off. What is an alternative that allows you to protect yourself yet also allows others to get to know some parts of you?”

Basic Intervention Techniques 139 New Awareness Questions — “Terry, now that we have established a new assumption that people shy away from you because they are afraid to make you even more nervous, how could you use this new assumption to help you make a different choice in your social life?” — “Meg, how would you use this new way of self-expression to help you become closer to the people in your life?” III. SOLUTION-FOCUSED QUESTIONING Social constructionism emphasizes that both the counselor and the client actually coconstruct the reality in therapy (Neimeyer, 1996; White, 2007). For example, the kinds of questions that we ask in the session can shape the direction the therapy goes. This realization drives both solution-focused therapy and narrative therapy to use a series of questions to steer the session into more productive directions. Caution: Asking too many questions can backfire. Do it gently and respectfully. Never overwhelm your clients with a barrage of questions. This section presents four solution-focused questioning techniques: • • • •

The miracle question The surprise task The “how-do-you-do-that” question Scale the next step

The Miracle Question The miracle question can help clients envision how their future will differ when the problem no longer exists. You have to roll out the miracle question slowly, observing clients’ nonverbal cues to inform you whether or not the clients understand your question. Asked in a rush, the miracle question will only get an “I don’t know” answer from the client. So allow the client time to fully take in the question. A traditional version of the miracle question would go like this: — “Andrew, suppose when you go to sleep tonight after a day of hard work, and in the middle of the night, while you’re deep in sleep, a miracle happens and the depression issues are solved just like that! Since the miracle happened when you were deep in sleep, you obviously don’t know that it’s happened. But when you wake up the next morning, you do sense that something is different, and you are no longer depressed. What do you observe to be different in you? What do you do that is different from the past when you were depressed? What things do you notice?” The Surprise Task “The surprise task” is used often in strategic therapy (Guterman, 2014), a predecessor of solution-focused therapy. Its purpose is to get the client to do something different, to break out of an old pattern. This may initiate a positive outcome in the clients’ life. Here is how it can be done: — “Ginny, we’ve talked about how you feel taken for granted by your live-in boyfriend. Between now and next time we meet, I’d like you to do at least three things that you believe will surprise your boyfriend. Of course, don’t tell him about the surprise,

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Basic Intervention Techniques but let him try to figure out what the surprises are. Do at least three surprises, because one surprise could easily slip past him without notice, but three definitely will stir his curiosity. Be sure not to discuss the surprises with anyone until we meet next time. We’ll discuss them in our next session.”

The “How-Do-You-Do-That” Question In stressful moments we tend to forget about our inner resources. The “how-do-youdo-that” question draws out the very resources that clients previously haven’t noticed. But this question only works when you show genuine curiosity and admiration of clients’ strengths. If done with wholehearted inquisitiveness, this kind of question has the potential to gently challenge clients’ problem-saturated self-concept. — “Ned, I can see that things in your life have been really volatile, yet it occurs to me that, in spite of all that’s going on, you manage to get up each morning, get your kids to school, go to work on time, and even get all the reading and homework done for your classes. How do you do that?” — “Jean, I can see that the trauma you went through early on really broke your heart, yet I’m struck by the fact that, in spite of the hurt, you manage to trust people, to give them the benefit of the doubt, to devote your time and care to your neighbors, and to go out of your way to connect with people. How do you do that?” Scale the Next Step Scaling questions represent a frequently used and versatile technique in solution-focused therapy. You can use a scaling question to help clients see the progress they have made toward their goals or to help them focus more on their strengths. Most importantly, we can use the scaling question to identify the next small step that clients can take to move toward change (Guterman, 2014). Consider the following examples: Step 1. — “Joe, on a scale of 1 to 10, where the number 1 represents the worst that things have been and 10 the best, at which point would you place yourself today?” Or — “Joe, if you were to ask your wife, where would she place you on the scale, today, in terms of reaching your goal?” Step 2. — “Okay, four. That’s a pretty impressive place! What things have you been doing that helped you get to four?” Step 3. — “Joe, what would be the first sign that shows you that you’re moving up one notch on the scale?” — “Who else would notice that you’ve moved up one notch on the scale? What would they notice?”

Basic Intervention Techniques 141 IV. MOTIVATIONAL INTERVIEWING Some clients are highly motivated to work hard in therapy, including those who are in acute distress or emotional pain and those who enter therapy voluntarily. For others, especially those mandated to enter therapy or those whose problem behaviors have become second nature—such as those with addiction problems—motivation tends to be low. Motivational interviewing (Miller & Rollnick, 2012) is the choice intervention when facing these unmotivated clients. It is an offshoot of a client-centered approach, yet, it is directive. It focuses on assessing and resolving clients’ sense of ambivalence toward change, particularly mandated clients and addicts who are in “the contemplation stage” of change (see Chapter 3). Motivational interviewing combines reflective skills and Socratic questioning (discussed in the previous section) to motivate those who are ambivalent toward change. The Socratic questions used in motivational interviewing can be grouped into the following three subtypes: 1. Evocative questions 2. Extreme questions 3. Looking-back questions When using motivational interviewing, therapists must follow four principles: • • • •

Empathy Accepting reluctance to change as natural Helping clients realize discrepancies between values and behaviors (Socratic questions are used for this principle specifically) Encouraging self-efficacy

To reiterate, therapists must integrate empathic responses with Socratic questioning. Don’t just ask loads of questions. With each client’s answer to your Socratic question, reflect it back to show your empathy and acceptance. Evocative Questions Evocative questions are designed to evoke clients’ concerns about their own problems or to evoke clients’ vision about change. These questions have the capacity to stir up clients’ desire for change. Here are some examples: — “How has your use of tranquilizers stopped you from being who you want to be?” — “In what ways do you think your drinking takes away from the closeness between you and your loved ones?” — “How much does this complication concern you?” — “What do you think will happen if you don’t make a change?” — “What makes you think that you might need to make a change?” — “What would be some advantages of making a change?” — “What do you think would work for you if you decide to change?” — “If you could wave a magic wand and change yourself, what would you change?”

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Extreme Questions Extreme questions cause clients to examine the most dreadful possibilities and scenarios. Through these questions, you guide clients to confront what they have tried to deny. And what they try to deny is often reality—the effects of their behaviors: — “What complication concerns you the most?” — “What are your most dreaded fears about what might happen if you don’t make a change?” — “What do you suppose are the worst things that might happen if you keep going the way you’ve been going?” Looking-Back Questions Looking-back questions motivate clients to change, not because they trigger nostalgic feelings but because they help clients remember how much better their lives were before they allowed problems to control their lives. Consider the following examples: — “What were things like before you started drinking so heavily (or before you started binging/purging regularly)?” — “Tell me how you two met each other, and what attracted you to each other back then?” — “What are the differences between the Mike of ten years ago and the Mike today?” — “How has the use of drugs (or violence) stopped you from growing into the person you’ve dreamed of becoming?” V. EXPRESSIVE ARTS TECHNIQUES Increasingly, therapists are infusing expressive arts techniques into talk therapy. This is not surprising because expressive arts techniques can help clients bypass their difficulty of putting their thoughts and feelings into words, helping them find an alternative way of self-expression (Degges-White & Davis, 2011). Regardless of your theoretical framework, you can find many ways to use expressive techniques to help your clients open up and dive into the heart of their issues. This section illustrates numerous expressive arts techniques—created by the second author, Nan—to help clients find alternative ways of expressing themselves. Tap Into Clients’ Favorite Ways of Self-Expression Many ways exist to integrate expressive arts techniques into therapy. Among them, the easiest way is this: as you listen to clients, pay attention to their interests and skills— their possible love of music, dance, art-making, theater, plays, or some other creative activity. Once you notice a particular interest, you can tap into it, using it as the medium through which clients can explore their unspeakable inner experiences (Allen, 2014; Giblin, 2011). Differentiate among Visual, Auditory, Kinetic, Visual, and Tactile Types of Media If clients don’t show a particular interest in any form of expressive art, listen to the words they use. Try to detect which types of information processing they use: Are they visual, auditory, kinetic, visual, and tactile? Your client will be more ready to

Basic Intervention Techniques 143 move into a specific media of expressive art if the media of your suggestion matches their information processing and self-expression type (Rogers, 2000). The following example from Nan illustrates the steps you can take to carry out an expressive art technique: Client (a 10-year-old girl whose parents are getting a divorce. Her grades in school are falling and teachers report on her inability to concentrate): “Things are scary at home. My parents are fighting all the time. When they fight, I just hide in my room.” Counselor : Initiation step: “Danielle, it must be lonely and scary when you hide in your room. I am wondering if you would draw a picture of your family so I can understand better. Here are some crayons and paper if you would be willing to draw.” Client: “Sure.” (Danielle takes the crayons and a sheet of paper. She quickly draws the picture and pushes it in front of the counselor.) “There.” (The drawing shows two very large figures yelling at each other. Huddled in the corner of the paper is a small figure.) Counselor : Processing step: “Danielle, please tell me about your picture.” Client (pointing to the large figures): “Here are mom and dad yelling at each other.” Counselor : Processing step (pointing to the small figure in the corner): “Who is this little person in the corner.” Client: “That’s me.” Counselor : Processing step transitioning to exploration step: “What does the little girl in the picture say?” Other examples of the initiation step are: — “Abdalla, I remember that you’re interested in birds. Here’s a gourd. I’m wondering if you’d like to try this? Draw a few things about your life on this gourd. Then make the gourd into a birdhouse.” — “Todd, you’re saying that you feel like a piece of furniture. Could you try this? Pretend to be that piece of furniture and show me what it would look like. If this piece of furniture could talk, what would it say?” — “Kirby, I have a box of pastels of different colors here. I wonder if you’d be willing to do this: Choose the color that most fits how you feel today. Then, take that pastel and draw a line. Pretend that the line is alive, and follow it where it goes as if you’re taking a walk with the line.” — “Zeke, would you be interested in doing this? Cut some pictures out of these magazines. Glue them onto this poster board. Let the pictures go together in any way. Then tell me about your collage.” — “Rusty, I notice that you like to take videos on your phone. Would you like to do a small experiment? During the week, make a video. Just take pictures of whatever you think would help me understand you and edit them up into a video.” — “Rick, thank you for bringing in these old pictures of your family. Now help me match up faces with their names. OK, now, arrange them on this desk in the way you’d like to see them in real life.” — “Here are some puppets, Annabel. Would you try this? Choose two puppets and have them talk to each other, just like the way you did with your brother.”

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VI. TAKE-HOME EXERCISES/HOMEWORK ASSIGNMENTS Therapists of almost all approaches give homework to their clients. Some therapists call it a “take-home exercise” to avoid the sense of authority associated with the word “assignment.” Homework has the power to extend the therapist’s intervention beyond the session. Why? Because they possibly could: • • • •

Accelerate the therapeutic process. Engage clients’ minds and energy beyond the therapy hour. Reduce their acting-out maladaptive coping behaviors during the week. Enhance their emotion regulation.

When the homework is completed, the therapist can process in the following session with the client about her self-knowledge uncovered through the exercise. If clients fail to follow through, then their feelings surrounding this failure will have to be explored thoroughly. Of course, don’t show the slightest hint of reproach when processing their resistance to the task. This section presents five types of homework: 1. 2. 3. 4. 5.

Awareness homework Cognitive therapy homework Behavioral activation homework Solution-focused homework Action-oriented homework

Awareness Homework Awareness is the pivot point in counseling. It can manifest itself as insight, self-acceptance, a sense of responsibility for one’s choices, knowledge of one’s relationship with the environment, and an understanding of one’s role in the process of change. In ACT, awareness is enhanced through mindfulness practice. In regular therapy, awareness can be awakened through homework. There exist many ways to give awareness homework. Most approaches use writing and observation to increase awareness. In giving awareness homework, therapists use directives to suggest that clients pay attention to the connection between events, thoughts, and feelings during the week. Consider the following examples: — “Giovanni, perhaps you can continue this mindfulness that we talked about today by doing something really simple during the week. It is this: Find a time when you can stop your busy activities, sit quietly for 5 minutes, follow your breath, and observe the thoughts that float through your mind. If you start to get too involved with a thought, let it go, and return to your breath. See if you could do this for 5 minutes every day, and see whether you observe any difference in how you feel about the day.” — “May I give you a suggestion, Sherrie? During the week, write down what you’re doing and thinking when you get depressed.” — “Here’s a little assignment for this week, Jed. Whenever you get that scared feeling, write down what’s going on in your mind and in your environment so you can be clearer about it.” — “Liz, during the week, pay attention to the event that happens directly before your panic attacks. Also, pay attention to how you keep the feelings inside that are triggered by the event.”

Basic Intervention Techniques 145 — “Ishmael, during the week, be really aware of the negative statements you often make about yourself.” — “Gail, during the week, pay attention to your negative thoughts about social interaction that lead to your fear and social withdrawal. Also, ask yourself what experiences taught you to think this way.” — “During this week, June, pay attention to the social contacts leading to your binging.” — “Terri, during this week, work on the letter-writing exercise where you write down your feelings toward your mother. You don’t send the letter, just keep it for yourself. You can decide whether or not you’d like to share it with me next week.” — “Joel, during the week, write down the situations and experiences in which you become angry. Ask yourself the reasons for your anger, and describe how you expressed or suppressed your anger.” — “Pam, during the week, make a list of coping techniques you’ve used in the past that have successfully helped you overcome your fear.” Cognitive-Oriented Homework In addition to the cognitive restructuring techniques illustrated previously, cognitive therapy uses special homework assignments to help clients examine the validity of their maladaptive thoughts. This fits its principle of collaborative empiricism. Give cognitive therapy homework only when sufficient trust has been established in the relationship, and only after clients’ core issues have become clear. Always follow up on homework assigned the previous week. This is a way of conveying a message that the homework is important. Consider the following examples: — “Would you be interested in doing an experiment, Lee? It goes like this: During the week, write in your journal whenever a situation triggers your depression. In the first column, describe the situation that triggers your depression. In the second column, jot down your first interpretation about the situation. In the third column, write down some alternative interpretations about the situation. Please try to generate as many alternative interpretations as possible. In the next session, we’ll work together to determine which of the alternative interpretations has the most supportive evidence.” [This is the three-column technique] — “Anita, during this week, find a quiet time and write down evidence for and against your belief that ‘I’m a total failure.’ Make two columns. In the left column, list evidence that supports this core belief. In the right column, list the evidence against it.” [This is the two-column technique] — “Sam, during the week, list five ways that your addiction has negatively impacted your health, relationships, self-esteem, work, and family relations. Then list five ways that your recovery from the addiction may impact your life positively.” [This is the list technique] — “During this week, Cheryl, try to journal your catastrophic thinking whenever it occurs. After that, try to replace your fear-producing thoughts with thoughts that are more realistic and positive. Please bring your journal to our next session for discussion.” — “James, to help you become more aware of how your thoughts affect your feelings, I’d like to suggest a homework assignment: during the week, when you notice that you’re having a troublesome feeling that you just can’t shake off, write down that feeling in the left column. Later, write down the thought that goes with that

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Behavioral Activation Homework When it comes to treating those who are severely depressed or low-functioning, who are incapable of or unwilling to exert the considerable effort that cognitive restructuring requires, who have minimal capacity to examine and break free from the loop of ruminating on depressing thoughts and feelings—when it comes to these cases, Beck suggests beginning the treatment with a technique called behavioral activation (Beck et al., 2003). Beck discovered that when given the simplest behavioral tasks as homework, the clients may become more active and may improve enough to be capable of progressing later into other forms of therapy, such as cognitive restructuring. When designing behavioral activation tasks, we need to target behaviors that the client enjoys, something that matches the client’s values. If clients show hesitation, then explore with them what obstacles are preventing them from engaging in these tasks. Work together to try to come up with a plan for overcoming those obstacles! — “Cicely, to help you get better, we need to help you get active. I understand that right now you feel it’s impossible to get around in any shape or form, and you just want to wait until you feel better before doing anything. The problem is that if you continue to wait, it may be a long time before you even get out of bed. Once you get moving, you’ll feel much better. So let’s try a small experiment: during the week, spend five minutes a day on straightening out a small area of your living room. Can you foresee yourself carrying out this assignment?” — “Tom, I have a clear picture about how hopeless you feel in terms of your not being able to banish the gloom-and-doom thoughts from your mind. To help us progress in therapy, I’d like to suggest a small exercise: During the week, go for a walk for five minutes each day and come back next week to discuss how it went. Do you see any difficulty in doing this?” — “Afua, I understand that you feel as if you don’t have any energy to do anything right now. To benefit our treatment, please try this tiny experiment: During the week, spend a few minutes a day washing your dishes. Jot down how many minutes each day you do it and how you feel after doing it. Can you foresee yourself doing this during the week?” Solution-Focused Homework Instead of focusing on problems, solution-focused therapy focuses on exceptions to problems as well as on forgotten strengths. As explained in Chapter 1, change happens constantly in life, so we ought to make use of it, to tip the scale in the desired direction instead of letting it happen by chance. With that in mind, we can design homework in a way that directs clients to attend to things that will accelerate the therapeutic process. — “Here’s a little take-home exercise for this week, Laurie: During the week, observe and describe in detail what you’d like to see continue in your life.” — “Chuck, during the week, pay attention to what you do during occasions when you cope effectively with your anxiety.”

Basic Intervention Techniques 147 — “Bonnie, during the week, whenever you have a chance to change to a new way of interacting with your daughter, make sure that the change is so small and so slow that it’s almost undetectable.” [A paradoxical technique] — “Ben, your circumstances are indeed tough. Between now and next week, pay attention to why the situation isn’t even worse. Observe what’s there that’s holding you together so well. When you come back next week, I’d like to hear what you observed.” — “Fran, between now and next time we meet, observe what’s happening in your life that you’d like to see continue. Jot down your observations. We will discuss your observations when we meet.” Action-Oriented Homework Actions are something more external and more concrete than feelings, needs, and thoughts, which can often be elusive. Actions are something we can more readily observe, monitor, and get a handle on. We can make the best use of this feature by giving clients action-oriented homework to help break the vicious circle associated with their old behaviors, in the hope of initiating a new, positive feedback loop. Consider the following examples: — “Dan, during this week, please make a list of your essential needs that are not being met. Next to each unmet need write down some things that you can do to help yourself meet those needs. When you get a chance, try to do just one of these actions at a time within your power. In the next session, I’d like to know what comes of it.” — “Folami, how about trying this little experiment? After you get home, make a list of small things that you used to like. Then, choose to do one little thing, every day, that you enjoy doing. Let’s talk about how your experiment turns out next time we meet.” — “Sandy, during the week, whenever something triggers you to become angry, instead of acting out or suppressing your anger, try to speak truthfully about your anger, the reasons for your anger, and your needs. Use ‘I’ statements, instead of ‘you’ statements. Focus on self-disclosure instead of focusing on the other person, so the other person can hear you better.” — “Eric, when you go home this week, try this experiment: Write a letter of apology to the person you harmed. Try to own up to your behaviors in the incident, and suggest how you could have done things differently. The draft of the letter is meant for you. If you decide to send or email the letter to him, please do bring the letter here for me to take a look first. Okay?” — “Beth, how about this? During the week, write a letter of forgiveness without sending it. You’re writing this letter for yourself instead of for the other person. In the letter, describe how the pain inflicted by the other person has had an impact on your life and on your ability to trust. Also, write about the reason you’re choosing to begin the process of forgiveness toward this person. Please bring your letter to our next session for discussion.” — “Here’s a little exercise for this week, José. Find a quiet time and write down a list of affirmative messages that help maintain your self-esteem. Review this list once a day before bedtime.”

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— “Tina, try to find some time during this weekend to visit your brother. You’ve avoided seeing him for a while, and even though you established an email relationship with him three months ago, it might be time for a personal visit now, in order to convey your sincere desire to reconnect with him.” EXERCISES After each client statement, write a counselor response using the skill indicated next to the item number: 1. Directives Client: “I have this really big project for school and I don’t know where to start. I’m supposed to write a story with seven different characters in it. The stupid thing is supposed to be at least 10 pages long and it’s supposed to take place in our high school and the people’s homes. This is the dumbest thing we’ve ever had to do. It’s due on the last day of the semester. Maybe I should just quit school now and be done with this.” 2. Directives Client: “I’m so depressed that I can’t get out of bed and get to work on time. They said if I’m late one more time, they’ll fire me. What can I do?” 3. Homework exercise Client: “My house is totally full of junk. My friends won’t come in the door. And my kids won’t have their friends over because they’re too embarrassed. I don’t know where to start, and I don’t have the energy to throw stuff out. Besides, everything I have is something I want—something that means a lot to me. A bunch of the stuff came from my friends. How would they feel if I got rid of the stuff they gave me?” 4. Homework exercise Client: “I’ve got this lump growing under my arm, and I’m really scared about it. It’s probably nothing, but I think about it all the time. What if it’s cancer? I’m just too scared to get it checked out.” 5. Body-oriented technique Client: “I keep getting these attacks where I feel like I can’t breathe. I’ve been to the doctor, and he says I’m okay, so it must just be nerves. What do you think might help?” 6. Body awareness technique Client: “I can’t seem to focus on anything. My mind is going a mile a minute. At meetings, I can’t even hear what they’re saying because I’m too scared and uptight. Last week at a meeting, my boss asked me if I was okay. That’s scary. What if I get fired?”

Basic Intervention Techniques 149 7. Expressive arts technique Client: “The only thing that shuts off the noise in my house is when I have my iPod and I’m blasting my music. At least for a while, I can’t hear them screaming at each other. My music is my world.” 8. Expressive arts technique Client: “At night when I try to go to sleep, my head just plays all the tapes from the day. Stuff I have to do . . . stuff I gotta do tomorrow . . . people who are a pain . . . bad things that can happen. I just can’t get to sleep . . . ever . . . until about three o’clock. Then I have to get up at six o’clock, and I fall asleep at school.” 9. A surprise task Client: “My mother keeps asking me when I’m going to give her a grandchild. I tell her that it is not going to be for a long time but she keeps nagging me.” 10. “How-do-you-do-it” question Client: “Ever since my husband walked out on me, things have been really rough. I have to get my three kids ready for school, drop them off, and get to work on time. Then I have to stand on my feet for 8 hours at my job. Then I pick the kids up at school, cook dinner, help with their homework, and start my own homework. I’m taking an on-line course to try to finish my college degree.” 11. Scaling question Client: “I’m having a lot of pain from my knee operation. It is really dragging me down.”

9

Influencing Skills

To influence is to inspire, to tap into people’s visions for themselves beyond just their current wants and needs, to enter their hearts and minds, and to lead with confidence. In therapy, influencing skills, as advanced generic communication skills, exist to achieve these effects. If the empathic skills are to understand, to mirror, and to follow, then the influencing skills are to arouse, to stimulate, and even, sometimes, to challenge. Blending both the empathic skills and the influencing skills together, you provide your clients with balanced mental nutrition; you nurture them to become strong and resilient. Arriving at such a healthful state, they can then access the unknown potential they have yet to realize in their lives. This chapter presents seven subgroups of influencing skills through which you can plant the seeds of personal transformation in clients’ awareness, inspiring them to reach their utmost potential of being. HEIGHTEN CLIENTS’ AWARENESS WITH INFLUENCING SKILLS Influencing skills, as a set of advanced communication skills, are what you need when you and your client enter the second stage of counseling—the awareness-raising stage. Heighten Clients’ Awareness during the Second Stage of Counseling The second stage of counseling aims to build up clients’ awareness—about the choices they make and about the roles they play in maintaining their problems, even if that amounts to only a small part of the total picture. We cannot truly foster clients’ selfefficacy unless we help them see their roles and their responsibilities. To demonstrate this point, it is worth repeating the message below which Yalom (2009) regularly communicates to his clients: “Even if ninety-nine percent of the bad things that happen to you are someone else’s fault, I want to look at the other one percent—the part that is your responsibility. We have to look at your role, even if it’s very limited because that’s where I can be of most help” (pp. 139–140). Entering the second stage of counseling, your goal is to help clients: • • • •

Develop an emotional awareness of ineffective coping patterns. Own up to, accept, and honor old patterns. Become aware of the impact of their coping patterns on others. Recognize their own strengths, utilizing them to accelerate the change process.

Influencing Skills 151 Blend the Influencing Skills into Your Empathic Skills Influencing skills command more intense energy and intricate thoughtfulness than empathic skills. To illustrate, let’s compare them: Empathic Responding Skills Empathic skills (as covered in Chapter 4) have an amazing soft power; they help you demonstrate unconditional positive regard to your clients, accepting their true self, true feelings, and true thoughts. Empathy acts as the catalysts that leads to a genuine and steadfast relationship that in its own right is a corrective emotional experience for many clients. In a sense, empathy is really the embryo of therapy. However, empathy alone is not sufficient to bring about in-depth change. Influencing Skills To bring about in-depth change, therapists have to penetrate clients’ defenses and blind spots. Through the use of influencing skills, therapists can get through to those clients who have developed entrenched and intricate relational patterns since childhood. Clients come to therapy because they are stuck. Something isn’t working. Something has to be changed. Influencing skills have the power to influence clients to face these barriers. Influencing skills, indeed, are the most exhilarating interpersonal communication tools that you, as a therapist, can muster to engage clients in the complex process of understanding and discovering themselves. Blend the Two Together When applying influencing skills, try to blend them in with your empathic skills. As Dolan (2014) cautions, “Each lead should be followed by several instances of additional pacing behavior. This will ensure that rapport is maintained” (p. 69). When you blend the influencing skills (the leading skills) into your skills (the pacing behaviors), you will reach uncharted territory previously imagined to be unattainable. An Overview of the Influencing Skills Before getting into the specifics, we provide here an overview of these skills with illustrations in Table 9.1. SECOND-LEVEL CASE CONCEPTUALIZATION: THEME AND PATTERN ANALYSIS Before we get into the depth of clients’ hearts and minds, we need a roadmap. The second level of case conceptualization provides us the very roadmap that we need. This level of case conceptualization requires that we apply theme analysis, or thematic analysis, which consists of three general components: 1. The common theme 2. The coping patterns 3. The vicious circle

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Table 9.1 Influencing Skills and Illustrations The Seven Influencing Skills

Skill Illustrated

I. Identifying Themes and Resiliency Mapping out the common theme

“Joyce, I may be wrong here, but I see a common thread running through several stories that you’ve shared. In an earlier session, you mentioned that you feel neglected by your husband. Today you compared your husband to your emotionally unavailable father. The pain of being neglected by an emotionally unavailable male seems to be a theme in your significant relationships.” “Rob, you’ve carried a tremendous burden of responsibility ever since you were little. In spite of all the difficulties all these years, you’ve gritted your teeth and done it.” “Correct me if I’m wrong, Erica. I’d like to share a pattern that I observed in our sessions. You have a tendency to talk a lot about what you think and glaze over what you feel (interaction pattern). Perhaps this loss of touch with feelings is making it difficult for people in your life to support you when you most need it, which in turn convinces you that no one really cares to be there for you (the vicious circle).” “Roger, now that you’re aware of the vicious circle that you get into whenever you use this blaming strategy with your sister, the question is: What will you do with this vicious circle?” “As I listen to what happened to you in your childhood, Leslie, I’m moved to tears.” “When I was a kid, Monica, I was also bullied in school. It was very painful, and it took me a long time to rebuild my trust in others and my confidence in myself.” “Chris, you’ve just stood up for yourself by disagreeing strongly with me. I’m wondering whether you’re afraid of how I might respond.” “Laurie, I wonder if the power struggle with your husband that you’ve been talking about may also show up between you and me here in our session. Where do you see the issue of control popping up in our relationship?” “Jeff, there’s something that I’d like to share with you. If I’m wrong, please feel free to disregard it. While we’re talking, it seems to me that you keep asking me for help, and when it’s offered, you keep saying, ‘Yes, but . . .’ I feel pushed away when you do that (impact self-disclosure). Do you think my reaction might tell something about why people tend to keep distant from you?” “Kate, I may be wrong here, but you seem to qualify yourself and smile a lot when you want to make a point. I wonder whether it’s possible that you’re struggling to assert your own voice here in our relationship, just like you did with your boss, and sometimes with your stepfather. In all these occasions, you seem to struggle with the same fear—being afraid of offending or appearing stupid in front of your father when you were little.” “I may be off target, Glenda, but even though you say ‘yes’ with your words, I see ‘no’ in your body language.” “Josh, correct me if I’m wrong. You’ve talked about your trouble relating to male authority figures and your desire to relate to them more realistically. Yet, I notice that now you put your supervisor on a pedestal and then write him off when he makes mistakes.”

Acknowledging clients’ heroic triumph or resiliency II. Identifying Maladaptive Patterns Identifying patterns

Asking “the question”

III. Counselor Self-Disclosure Self-involving disclosure Personal self-disclosure of a thereor-then nature IV. Immediacy “I-thou” relationship immediacy talk (process disclosure)

V. Feedback-Giving Giving interpersonal feedback (impact disclosure)

VI. Triangles of Insight

VII. Confrontation Confronting discrepancy Confronting distortion

Influencing Skills 153 A Good Case Conceptualization Can Keep Us from Getting Lost Cozolino (2004) is on target when he says that skills and instinct are not enough to navigate us through therapy. We must have a case conceptualization to prevent us from getting lost. A case conceptualization will help us understand the process of therapy and to focus on what is really important from session to session. Case conceptualization becomes imperative during the second stage of counseling when progress tends to become slow and difficult. At this juncture, if we can have a good case conceptualization, if we can revisit it and revise it regularly, we will have better clarity in terms of how to navigate this complex and intricate stage of counseling. This process of case conceptualization can be illustrated with the following reflection by a burgeoning therapist under my (Mei’s) training: Case conceptualization is to me like being in the middle of an endless fog, shapes and figures emerge, going past me, and I think, ‘This is it! This is the answer!’ But before long, these early forms of ideas go quickly past, and something deeper and truer emerges. Yalom (2009) writes of ‘a gradual unfolding process’ (p. 4), and this is exactly what I have experienced. My understanding of my client gradually enriches and becomes more subtle as the sessions go on. Since many beginning therapists are not familiar with case conceptualization, we will devote more space here to detail the methods of case conceptualization. Look for Repetition in Client’s Message Research shows that the more you devote your session to a central focus, the more effective your session becomes (Roth & Fonagy, 2006). Having one central focus, as opposed to having many problems all over the place, the session can bring a sense of hope to clients (Cozolino, 2004). So the more you are able to zoom-in on the client’s theme, the more you will succeed in helping clients come “out of the woods.” To zoom-in on a theme is to look for repetition in the client’s verbal and nonverbal messages. Whatever the client repeats simply represents a common theme in the client’s difficulties. It Takes Sharp Eyes to Find Common Themes A common thread is like a strand that runs through a piece of clothing. Look at the major events that your client has talked about, and you will find this common thread woven throughout your clients’ stories—in the way clients perceive things, in certain unrelenting feelings, or in certain needs that are left unmet. For example, you might find that a feeling of abandonment runs through various relationships in your client’s life and creates tension, pain, and loss of trust. A theme often hides beneath the surface of clients’ stories, and you must keep your eyes peeled to find it. The following common themes, observed in our clinical experiences, shall help you identify a theme more easily: • • • • • •

Feeling invisible, unseen, unheard Persistent feeling of disconnection The insidious feeling of isolation Obsessive need for control Fear of abandonment Suppressed anger and rage

154 • • • • •

Influencing Skills The sense of unworthiness The feeling of emptiness Fear of rejection Inability to trust Enmeshed boundaries

The experience of finding the common theme can be illustrated by the reflection of the same burgeoning therapist above: I tried to look for situations that repeated or mirrored my client’s family dynamics. Essentially, I tried to ask myself, ‘What keeps coming up?’ I was pleasantly surprised to find that most of the seemingly disconnected stories my client brought to the sessions indeed had a common thread: her need of being needed, something that originated in her family. I also trained myself to listen for repeated coping mechanisms. What Are Patterned Coping Behaviors? Coping behaviors serve to defend or protect us against inner tension—pain, anxiety, and other undesirable feelings. When repetitively used to deal with inner tensions, a coping behavior becomes patterned and becomes a form of memory. Whenever a perceived threat or a tension crops up, this patterned behavior automatically kicks in. In this way, our brain has learned to adapt and survive. Originally, the coping behavior rewards us by helping us escape from tension and perceived threats, thus it is considered adaptive for the time being. But when the behavioral response becomes habitual and rigid, it becomes maladaptive, starting to do us a disservice. For example, a neglected child may learn to use detachment to reduce his psychic pain and increase his survival; however, when repeatedly used in a habitual manner to deal with disappointments, detachment can create barriers to interpersonal intimacy and to fully living in the present moment. Patterned coping behaviors may turn up in the form of overeating, over-exercise, drug abuse, extreme weight management, etc. These behaviors take place repetitively to do away with the inner anxiety and undesirable emotions associated with certain underlying issues. What intrigues us is this: most of the time, clients do not appear aware of their coping patterns. Having become so ingrained in their memory and their lives, these actions have evaded the watch of their conscious minds. Please take a look at Table 9.2 for the most frequently used and patterned coping behaviors. Interpersonal Neurobiology and the Recursive Nature of Coping Patterns Hebb’s Law—“neurons that fire together wire together” (Siegel 2015, p. 49)—explains why certain behavior gets strengthened over time (Makinson & Young, 2012). When strengthened, coping behaviors become habitual and rigid, and they eventually carry a certain price tag—certain relational and social consequences. People in clients’ lives have feelings and needs, too, and they often react unfavorably to clients’ maladaptive coping patterns. As these people’s feelings and needs are frustrated, they themselves resort to their own protective measures, which in turn push the client’s vulnerable spots.

Influencing Skills 155 Table 9.2 Most Frequently Used Maladaptive Behavioral Coping Patterns Patterns of Numbing

Drinking too much Using drugs Smoking Engaging in promiscuous or unloving sexual acts

Patterns of Minimizing

Ignoring Joking Martyring Being chronically busy Therapizing

Patterns of External Control

Blaming other people Attacking others, verbally or physically Throwing temper tantrums Manipulating others Being late for appointments Withholding sexuality in loving relationships Failing to meet obligations (being passive-aggressive) Lying Making sarcastic remarks Complaining, nagging

Internal Coping Patterns

Anticipating negative results Holding back honest feelings Creating false limitations Blaming oneself Dwelling on past hurts Intellectualizing Rationalizing

Extracted and edited from original materials in “Self-Defeating Behaviors,” by Cudney and Hardy (2016). We only selected those most frequently observed in clinical settings.

In the end, both resort to distancing behaviors. Strain in relationships results in more tension in the client. This, in turn, drives the client to rely even more on the coping strategy to reduce the pain. Thus, a vicious circle takes shape perpetuating the problem. Not one single person is to blame, but rather the cause lies with the recursive nature of the dynamics. For example, a client, Myla, who uses shutting down to cope with disappointment, will frustrate significant others in her life, especially her husband, Justin. In response, Justin withdraws to deal with his own frustrated feelings and needs. Justin’s emotional withdrawal now creates more disappointment for Myla, which leads her to shut down even more. Thus, a recursive chain effect is solidified in their relational dynamics. Please review the flow chart in Figure 9.1 depicting the vicious circle. The client’s behavioral impact on the other can be seen on the lower left side of the figure where there is a reversed triangle. Our Relational Realities Co-constructed by Our Coping Behaviors Through the second level of case conceptualization, the complex and multidimensional nature of our client’s issues reveals itself in front of our eyes. It helps us see our client in a relational context, giving us a broader and more enlightening view.

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Figure 9.1 Second-Level Case Conceptualization: The Recursive Chain Effect of Coping Patterns on Interpersonal Relationships

Each vicious circle reminds us of a cause-consequence chain effect. But each vicious circle represents only a small sample of the web of interconnectedness—a concept originating in Buddhism—in which phenomena exist only because of their relationship with other phenomena. Everything in the world comes into existence in response to causes and conditions. Nothing arises of its own accord; everything exists in a vast web of interconnectedness. This concept of interconnectedness implies that our lives are constantly developing in recursive dynamics. Each of us contributes, however small, to the co-creation of our own relational realities. Buddhism’s concept of interconnectedness pulsates at the heart of social constructionist theory—a theory emphasizing the ways we co-construct or co-author our interpersonal realities (Neimeyer, 1996; White, 2007). As previously discussed in Chapter 1, this concept of the co-construction of interpersonal reality is a central tenet of narrative therapy. Conscious Choices versus Unconscious Attempts The concepts of interconnectedness and social constructionism uplift our spirits. Since we co-construct our own relational phenomena, we have the power to deconstruct

Influencing Skills 157 and reconstruct it. Each of us cannot be reduced to a pawn in the game of life. Each of us must live up to our promise as a key player. Through this lens, choice theory by Glasser (2001) makes even more sense. To repeat what we discussed in Chapter 1, choice theory emphasizes that we choose and control our own behaviors, not those of others. Unfortunately, many people have difficulty knowing where their control ends and others’ begins. When trying to get their needs met, they unknowingly step into the minefield of trying to change others’ behaviors, instead of changing those of their own. This inevitably leads to heartache and misery, which in the end, creates more vicious circles. The following provide examples of how people meet their needs by unconsciously trying to change others: • • • • • • •

Getting what they want by complaining, Ensuring love by testing others, Earning love by over-compensating with others, Earning respect by one-upping others, Gaining a sense of self-worth by dominating others, Helping by taking over others’ responsibilities, Keeping love by keeping a tight leash on others.

Seeing a Vicious Circle Is Often an Eye-Opening Experience Seeing the recursive nature of dynamics is often an eye-opening experience for a beginning therapist. This is reflected in one novice’s journal: I think that the thing that helped me understand my client the most was when I saw the circle of behaviors and patterns drawn out on paper, and how certain interactions between people can keep playing themselves out, over and over, with no end in sight, unless intervened upon. On the other side, when helped to recognize a vicious circle, clients often experience an “aha” moment. It’s as if their blinders have suddenly been taken off. They can now see the whole picture and can finally own up to their roles in creating their interpersonal reality. With this new realization, they begin to make more conscious and effective choices in their relationships. Creating New Neuron Pathways to Replace Old Neuron Networks Counseling and therapy, as discussed in Chapter 1, can increase neuroplasticity by providing an enriched environment (Makinson & Young, 2012)—an environment wherein clients learn to think differently, to feel what was previously blocked, and to make more conscious choices. This is Alexander’s notion of corrective emotional experiences in action (Bridges, 2006). What a privilege it is that we are given this task of increasing clients’ neuroplasticity, helping them create new neuron pathways in place of the old ones, and experiencing that precious corrective emotional experience. What an honor! The following sections present six subgroups of influencing skills. Please practice them with care, use them to inspire, to tap into your clients’ vision for themselves, to enter their hearts and minds, and to heighten their awareness of their roles and their power of choice.

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I. INTERPRETING COMMON THEMES AND RESILIENCY To heighten clients’ awareness, the first order of business is to help them recognize the common themes in their lives and the resiliency within. This section explores how to recognize the common theme, how to communicate that recognition to clients, as well as how to acknowledge clients’ resiliency. How to Find the Common Theme? Experienced counselors find the theme in a client’s stories naturally as they listen along the way. Beginning counselors, however, usually have to collect their thoughts after a session during a quiet time in which they can concentrate on mapping any themes out. To begin with, we will have to connect the dots of unconnected parts, to see the inherent relevance among the seemingly irrelevant parts. Obviously, it takes profound concentration and deep listening to achieve this. But most of us will get better and better as we practice more. Following is a reflection by a beginning therapist about finding a common theme in his work with his client: The theme analysis exercise really helps me put things into perspective. In the session, insights into my client’s situation would often come to me in flashes. It is only when I write out the common themes, then I can organize my thoughts, coming up with a game plan as to how I could best tackle my client’s situation. Deliver the Common Theme Tentatively Once you find the common theme, try to communicate it to clients so they will understand how they might play a role, however small, in contributing to their relational reality. To increase your client’s ability to hear it, try to deliver your interpretation tentatively and kindly by including a phrase like “I may be wrong” in your statement. This phrase softens your message and gives the client some space for consideration. Consider this case: Kenna, a young woman, reported that she will take anything she can get from men because of the severe lack of foundational relationships with her father and brothers. She said that she has had a series of relationships with men who easily connect with her on a physical level, but not an emotional one. Eventually, all of these encounters result in her feeling unworthy of being totally loved by a man just for who she is. Client: “When I did go out, I would end up dancing dirty with this one guy. And I knew in my head, that’s not who I am. These are not the things I want to do, this is not who I am. But when a guy shows any interest in me, I cling to it and I need it. And I know that’s probably, in some way, related to being rejected by my dad and by my brothers.” Counselor : “Kenna, I may be wrong but as I listen to you, a theme seems to emerge wherein this guy, or guys in general, become sort of like a drug or an escape for you [client nodding; with one hand covering mouth], a kind of momentary euphoria [client nodding], but then the damaging effects last [client nodding and raising eyebrow], and then you have to pay the price for that later on.” [Communicating the theme to the client]

Influencing Skills 159 Client: “Yeah, like today, feeling like shit because ‘why did I do that last night?’ [Shaking head; arms crossed with hand on chin] That’s not who I am. That’s not what I want to do. I feel gross and ashamed and stuff like that. The truth is: I value purity for myself. And part of the reason I have not been in a relationship or at least actively seeking a relationship is because I know if I get with somebody, I am going to sleep with them and I don’t want to do that because sleeping together tends to become what the relationship is all about.” [Client starts to own up to her own part of responsibility] Following are more examples of common theme interpretation: — “Kelly, I may be wrong here, but I see a common thread running through several stories that you’ve shared. In an earlier session, you mentioned that you feel neglected by your husband. Today you compared your husband to your emotionally unavailable father. The pain of being neglected by an emotionally unavailable male seems to be a common theme in your significant relationships.” — “Jed, let me share with you a theme that I found throughout your stories. You said you started assuming the adult male role in the family in your teenage years because there was no adult male around. You literally became your mom’s father and your sister’s protector. Now, as an adult, you find no one in the neighborhood to keep the gangs away, so you feel like you’re called upon to do this. I may be wrong, but the theme of your life seems to be that you take on the mission of being a rescuer when there’s a need.” — “I wonder if this fits or not, Hallie. I notice a similarity in the way you reacted to your grandmother’s death, your confrontation with your boss, and your reaction to your friend’s moving. I may be wrong, but in all these situations, you seem to keep your inner emotions from surfacing when faced with these events, for fear of having to confront the sense of loss.” — “I may be way off, but from what you said, Ken, it seems like you’re on bad terms with your father, your boss, and your professor. I might be wrong, but the theme seems to be that you have a hard time maintaining relationships with authority figures.” — “Please disregard this if I’m wrong, Barbara, but I see a common thread running through our last few sessions. The unresolved guilt and anger you carried from the relationship with your mother are spilling over into the relationship with your daughter.” Deliver an Entirely Different Theme: Clients’ Heroic Triumph or Resiliency Another entirely different theme may emerge as you listen to clients’ stories—a theme of heroic triumph despite all odds. This theme of heroic triumph represents clients’ resiliency. Resiliency embodies the edge wherein a client seems ready to transform a painful area of her life into a growth opportunity. The question is: How can we be vigilant for the potential growth edges? Usually, clients’ stories are problem-saturated. Let them continue the “problem talk,” and no amount of insight will get clients out of the woods. But if we focus on the emerging growth edge of the client’s experiences, their heroic triumphs, we will find exceptions to the problem-saturated stories—exceptions that can help turn the tide.

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In narrative therapy and strength-based therapy, therapists focus to a great extent on clients’ forgotten resources, unique outcomes, or exceptions to problems (Freedman & Combs, 1996; Sharry, Madden, & Darmody, 2003; White, 2007). More than just offering affirmations (see Chapter 4), narrative therapists search for “sparkling events” (Freedman & Combs, 1996). In so doing, counselors allow clients’ forgotten strengths and resources to shine through. To communicate clients’ heroic triumph or resiliency, we carry out two actions: • •

Describing the client’s difficulties. Pointing out the client’s signs of triumph over those difficulties.

Consider the following examples: Example 1 Client: “My dad has had Parkinson’s disease for the past eight years. I have to take care of my family because Mom died when I was five. I have to do all the work around the house, take care of Dad, and still, go to school. It’s like I have no life of my own.” Counselor : “Judith, you’ve carried a tremendous burden of responsibility ever since you were little. In spite of these difficulties all these years, you’ve gritted your teeth and done it.” Example 2 Client: “I’d like to move up in administration at my university, but I’m terrified of public speaking. The higher up you go, the more public speaking you need to do.” Counselor : “Rick, even though public speaking scares you, you still long to take up a leadership role and realize your potential.” Following are more examples of how to acknowledge clients’ heroic triumph or resiliency: — “Janet, you stated that it’s hard for you to change and try new ways of acting, yet it seems that in spite of all the difficulties, you’ve chosen to come to counseling. It’s a step in the right direction and reflects a lot of courage on your part.” — “Despite all that’s been put on your shoulders, Andrew, you’re able to find a way to get it all done well.” — “Maureen, you’ve come very close to exploring the fear underneath your hectic lifestyle. It would have been much easier to hide behind your shield and not face your fear, but you have chosen to meet your fear head-on. I feel inspired by your strength.” — “Darla, you stated that you have difficulty feeling worthy enough to take care of yourself. But by discussing this issue with me in counseling, you’re stepping in the direction of taking control of your life by taking care of yourself.” II. INTERPRETING COPING PATTERNS The trend of brief therapy demands us to quickly zoom-in on a central focal point and stay on track. Charged with this call, therapists inevitably have to face clients’ recurrent behavioral patterns, especially in cases where problems are more elaborate (Levenson, 1995). Therapists of most psychodynamic approaches unremittingly look for a coping

Influencing Skills 161 pattern, probably because the pattern sets the vicious circle in motion, perpetuating clients’ distress. And hitting the nail on the head—identifying the coping pattern—will quickly get the job done, meeting the time restraints of brief therapy. Case Examples of Coping Patterns Becoming Maladaptive Coping patterns, as stated previously, are behaviors used originally to defend against inner tension. These behaviors become maladaptive when their use becomes habituated without discretion. The following two case examples illustrate these points: The Case of Jackie As a girl, Jackie learned that cutting herself helped her gain back a sense of control and reduce the built-up tension inside her—an inner tension that found root in her family dynamics. Because the sense of release and control was so rewarding, she turned to this control measure again and again whenever she felt panicky or empty, even though this behavior has severe consequences. As Jackie turned to this control measure over time, and as certain rigidity sets in, it became her tool of choice for her affect regulation (see Chapter 8). Gradually, the coping pattern started to dampen down her emotional maturity and relational capacity. The Case of Charles Since his youth, Charles coped with his parents’ chronic illness by stepping up to be the competent one, becoming the emotional caretaker of the family. Being competent at a young age is quite an adaptive behavior, to begin with. But the over-development of his competent side and the suppression of any vulnerability slowly became rigid. Charles’ strength became his liability. This coping pattern cost him emotional and relational balance. It became the very obstacle to his growth. The Obstacles to Growth and How to Remove Them In his book The Gift of Therapy, Yalom (2009) proposed that each of us has an inner propensity toward growth and self-actualization; remove the obstacles blocking our paths, and each of us will naturally develop into a fully realized person. Hence, the therapist is to first identify what those obstacles are and to then remove them. Maladaptive behavioral patterns represent the biggest obstacles to growth. No wonder therapists across therapeutic approaches pay much attention to these patterns. Once we spot a pattern, we have the therapeutic responsibility to remove these obstacles by kindly communicating to the client our observation. If clients appreciate our insights, they may move to the next stage—the “reorientation” stage or the action stage (see Chapter 3, Prochaska’s transtheoretical model of behavior change). If not, then no sweat. These clients may just need more time—more empathy and validation from us—before they are ready to brave the challenge of change. Following is a reflection about pattern-interpretation by another beginning therapist under my training: My study of coping mechanisms proves to be instrumental in understanding my own blockages with family and friends, as well as some of my client’s blockages. I had countless epiphanies related to the understanding of coping patterns alone. As Yalom (2009) states, therapy is a mechanism of increasing awareness of the blind

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The Best Time to Offer Your Interpretation of a Pattern Interpreting a client’s pattern is like calling her out on her actions. It requires delicate handling on our parts. On the one hand, we should not treat clients as too fragile to hear our insights into their patterns; all approaches to counseling and therapy make it their fundamental task to offer their clients certain insights into their behavioral patterns. On the other hand, we must consider the timing because your insights could be a powerful jolt to your client. The best timing arrives when trust has been established, when you have a firm grasp on the picture of the vicious circle, and when the client has the capacity to hear it. In other words, we offer insights after having followed a client’s stories for a period of time, and after a strong therapeutic alliance has been put in place. When stressors dominate clients’ lives, delay your interpretation until they have the capacity to hear it. Principles to Follow When Delivering Pattern-Interpretation to Clients To increase the success of the delivery of your interpretation to your client, please observe the following action principles: • • • • • •

Wait until the behavioral pattern shows up for the second or the third time before offering your interpretation of the behavioral pattern. Wait for the best timing. Try to include your client’s own words or phrases in your interpretation. Present your interpretations as hypotheses. Use nonevaluative and nonpathologizing language. Speak from a one-down position, including “I may be wrong” in your statement. Allow room for clients to agree or disagree with your observations.

How to Handle Client Reactions to Your Interpretation Pattern-interpretation, as stated previously, may give your client a powerful jolt. Your client can have three possible responses to this jolt: receptive, no reaction, or rejection. Your Client is Receptive In this case, you may explore further to consolidate their awareness. Your Interpretation Is Rejected First, don’t take the rejection as a personal failure. Accept the fact that your observations may not always be on target. Second, if you believe that your insight has some validity but your client is not ready for it, back off from it for now, and come back to the insight sometime later when your client is more ready. Your Client Has No Reaction Even though your client might not show any reaction, oftentimes he does have one— it’s just happening out of awareness, way in the back of his mind. Your interpretation

Influencing Skills 163 has planted the seeds of change quietly. File this in your mental notes. Come back in a later session to check client awareness. I really like the following analogy by one of my beginning therapists—applying the technique is like taking buses: — I like to think of delivering themes and patterns like taking buses or taxis. Although I may miss one bus, another one will inevitably arrive in due time, at which point I will be able to hop on that bus, in order to address what clearly needs to be explored by the client. Thinking of it this way really encourages and enables me to stay present, in the here-and-now, during the session. — Previously, I had a tendency to think about what I was going to say next, how I was going to say it, and how I was going to address the patterns at hand. Now, I am actively working on reminding myself that a seemingly lost opportunity to address an issue is actually not lost at all—there will be another bus coming by very shortly. Examples of Pattern Interpretation The following examples illustrate how to bring a behavioral pattern to clients’ attention after observing it. Example 1 Counselor : “Lilly, correct me if I’m wrong, but from the several events you’ve shared, it seems that you have a pattern of letting other people make decisions for you.” Client: “But once they do, I’m usually dissatisfied, although I don’t let them know.” Counselor : “So people in your life just keep coming to your rescue and making decisions for you, and you just keep your feeling of dissatisfaction within yourself. Then they just keep on making decisions for you. The question is: What will you do with this pattern?” Example 2 Counselor : “Steve, I have an observation about your increased anxiety and fatigue. Please tell me whether it fits or not. From what we’ve talked about so far, it seems that you stretch yourself very thin by working full-time and attending school part-time when you have a family of four to take care of. In addition, you feel compelled to compete hard with others and to stay on top of the game at all times. It seems like you’re so used to this pattern of over-functioning that you don’t know any other way. But it’s taking a physical and emotional toll on you, leading to increased anxiety and fatigue, and on top of that, it’s alienating people in your life. The question is: What will you do with this pattern?” Client: “Now that you say it, it makes sense. It’s come to a point where it’s not working for me anymore. I really need to do something about it before it becomes too big.” Following are a few more examples: — “Jessica, correct me if I’m wrong, but throughout our conversation, it appears to me that you seem to seek external approval to reassure you that your feelings are okay. The more this happens, the more people feel frustrated or pushed away. This leads to even more self-doubt for you and drives you to seek even more outside approval. And so on. I wonder whether you see a pattern here or not?”

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— “Manuel, I wonder whether there might be a pattern here, but you seem to avoid communicating your feelings whenever someone upsets you. In the end, no one knows how you actually feel. This leads to your feeling more and more invisible and lonely, which in turn leads you to avoid communicating your feelings even more. I am not sure whether I am on target, but do you see an avoidance pattern here?” — “Correct me if I’m wrong, Tina, but I’d like to share a pattern that I observed in our sessions. You have a tendency to talk a lot about what you think and to glaze over what you feel. May be this loss of touch with feelings is making it difficult for people in your life to support you when you most need it, which in turn convinces you that no one really cares to be there for you. Do you see this spiral effect here?” — “I wonder if this makes sense to you or not, Aaron, but there seems to be a pattern where you manage your fear of failure by anticipating that negative things will happen and then you over-prepare yourself to compensate for the impending disaster. Even to mundane, daily challenges, you respond as if they are like climbing Mt. Everest. Sometimes this pattern of overcompensation seems to make things better for you, but other times it builds a wall and takes away your presence. This leads to distance and lack of connection in your relationships. The more this happens, the more guarded you get. Do you see this pattern here?” Connect the Coping Pattern to the Common Theme After communicating with clients about their coping patterns, we might go one step further to connect the behavior coping pattern to the common theme. For example, a therapist finds a common theme—fear of rejection—underlying the stories of her client, Bella, who also struggles with a behavior pattern of food addiction. The therapist might connect the food addiction to the theme of fear of rejection by saying something like the following: — “Bella, we’ve been talking about your tendency to use food as a drug to soothe your emotions. Actually, I’ve been wondering about what source might serve as the food trigger. I remember you saying that you really wish to be able to speak with your mother about your decision regarding Tom, but you’re afraid that if you speak up, she might reject you angrily. This is just one of the examples. It seems like you’re really caught between your desire to be your own person and your fear of rejection. The inner tension created by this conflict is too much to bear, so you turn to food to soothe your anxiety. Does this sound like how it’s triggered?” Another example: — “Gabe, we’ve talked about how you tend to fall back on the ‘take-charge’ behavioral pattern to deal with your emotional stress—a pattern that frustrates your partner. I’m wondering how this pattern might be connected to your fear of not being needed. I remember you said that your parents’ divorce left a scar on your psyche. You constantly worry about relationships not working, about people not needing you. It seems to me that the fear of people leaving you tends to trigger you to take up a ‘take charge’ behavioral pattern because it gives you a sense that you’re valuable, that people will always need you and not leave you. How does this sound to you?”

Influencing Skills 165 Follow up by Asking “The Question” After offering the client insight about his behavioral patterns, if the client seems receptive to the insight, then the next step would be to apply “the question”—a kind of choice question commonly designed to create an imbalance within the client’s cherished old identity. Imbalance propels people to enter a new stage of readjustment, a realization of new choices. The use of “the question” puts clients in a spot where they cannot help but examine whether the old pattern is still working to get them what they desire. Most of the time, clients realize that they are ready to shift gears and make better choices. This leads them to the reorientation stage of therapy. Putting the client in a spot of self-examination resonates with the motivational interviewing approach (Miller & Rollnick, 2012) wherein the counselor uses the creative tension produced by the discrepancy between clients’ deep needs and their current behavior pattern. This tension gives us a leverage to help our clients arrive at a tipping point in the therapeutic journey. Consider the following examples: — “I guess if I were in your position, Wanda, where I got no recognition in my family while growing up, I probably would act defiantly and be a rebel to assert my own existence. And I probably, like you, would get into all kinds of conflict with people in authority and even with the law. The question is: How does it serve you to continue to act this way at this stage of your life? What has to happen for you to get what you really want in your life?” — “Jim, now that you’re aware of the vicious chain effect that you get into whenever you use this blaming strategy with your brother, the question is: What will you do with this vicious circle?” — “Irene, I am glad that you see the pattern clearly. The question is: What do you want to do with this over-accommodation feedback loop?” III. COUNSELOR SELF-DISCLOSURE: BASIC LEVEL Self-disclosure prevails as the hallmark of emotional intimacy. When we, as therapists, reveal our inner intentions, reactions, assumptions, and emotions, we can amplify our genuineness and transparency, which deepen a genuine relationship with our clients. The client, through our self-disclosure, perceives us to be human, approachable and egalitarian. Thus, this skill moves the interpersonal process with clients up a notch. Of course, we have to walk a fine line regarding what and how to disclose. Use Counselor Self-Disclosure with Well Thought-Out Intentionality Therapists only disclose with the intention to benefit the client’s well being. As Zur, Williams, Lehavot, and Knapp, (2009) state, “Appropriate, ethical, and clinically driven self-disclosure are intentionally employed with the client’s welfare in mind and with a clinical rationale” (p. 24). According to Yalom (1983), our intention in self-disclosing should meet the following two purposes: • •

To provide modeling of openness and risk taking for clients. To increases clients’ trust in us that we are people with whom they can reveal their human condition.

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Counselor Self-Disclosure versus Self-Disclosure in Social Interaction Counselor self-disclosure differs from self-disclosure in social interaction. Self-disclosure in Social Interaction Here, self-disclosure is expected to be symmetrical; people disclose to each other at about the same pace, proportion, or depth (Garner, 1997). Counselor Self-Disclosure In a therapeutic setting, counselors self-disclose only when the disclosure can help the client. As Yalom (1983) put it, “Self-disclosure must be in the service of the primary goal of therapy” (p. 162). Use Counselor Self-Disclosure with Certain Populations Lack of counselor self-disclosure can prove detrimental when you are working with certain populations: Minority Clients Minority clients, in particular, prefer that we, the therapists, disclose ourselves, especially about our awareness of potential personal biases, or about our lack of knowledge of clients’ cultural values and customs. If we can meet their expectations through well-thought-out self-disclosure, they will know where we stand in our own awareness of the cultures involved. This will help our relationship with them. Adolescent Clients When working with adolescent clients, we will be better off to disclose our inner intentions, reactions, assumptions, and emotions. Adolescents usually have difficulty trusting adults due to their perception that adults often judge and/or and patronize them. Our self-disclosure can help adolescent clients feel honored and respected, leading to the development of trust between us (Egan, 2013; Sue & Sue, 2016). Too Much Counselor Self-Disclosure Can Cause Problems Some therapists disclose their problems and concerns frequently to their order to reassure them of two things: that it is a human condition to have and that the therapists really understand the clients’ struggles. However, in their problems and concerns in such a frequent manner, they can cause the two problems:

clients in concerns; disclosing following

Role-Reversal Therapists who divulge their personal experiences risk putting the clients in a rolereversal where the clients have to listen to the therapists or even feel compelled to take care of the therapists’ emotions.

Influencing Skills 167 Blurred Boundary Excessive self-disclosure about our own selves or our own struggles can blur the boundary between the therapist and the client, leading down the slippery road of unprofessional conduct. If you find that you are talking excessively about yourself, it’s an indication that you possibly have unmet needs in your own personal life that may require personal counseling (Wright, 2003). A Table of Proper Counselor Self-Disclosure We need to walk a fine line when it comes to our self-disclosure. To ensure that our self-disclosure does not cause role-reversal or blurred boundaries, we will have to take heed of the proper types of self-disclosure. Please see Table 9.3 for the four types of proper counselor self-disclosure, which we can further categorize into two levels. Table 9.3 Four Types of Counselor Self-Disclosure Types

Disclosing

Personal disclosure (of a there-or-then nature)

To disclose a fact about yourself upon the client’s request, or a there-or-then meaningful experience for the purpose of normalizing clients’ experiences. To disclose a within the session inner experience that you are having, related to the client’s situations. To disclose what you sense from clients’ metacommunication and its implication about the relationship between the two of you. (This will be covered in a separate section) To disclose the impact that the client’s behaviors have on your feelings and your relationship with the client. Then connect your reactions to the reactions of others in the client’s life. (This will be covered in another separate section)

Self-involving disclosure Immediacy (“I-Thou” relationship disclosure)

Feedback-giving (Impact disclosure)

•

Basic Level Counselor Self-Disclosure – Personal disclosure (there-and-then disclosure) – Self-involving disclosure

•

Advanced Level Counselor Self-Disclosure – Immediacy (I-Thou relationship communication) – Feedback-giving (impact disclosure)

Please note: The two advanced level counselor self-disclosures are more complex and will be detailed in separate sections. This section will only focus on the two types of basic level counselor self-disclosure. 1. Personal Disclosure Personal disclosure should take place only sparingly, even if you are doing it to normalize clients’ feelings. Use just a few sentences, without occupying too much of the session time. In what circumstances may we engage in personal disclosure? There are three provisions.

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a. Personal disclosure serving to normalize client’s feelings The best way to apply personal disclosure is this: use it to normalize clients’ feelings. Clients often feel alone because they assume their emotions are abnormal or illegitimate. In working with these clients, your personal disclosure can remove these erroneous assumptions, helping them to accept their own feelings. Client: “I don’t know how other Asian families are, but in my family, we don’t express much emotion. I want to be able to express more with them, and I’m thinking maybe my first step will be to show my feelings to them so I can move on. But it’s so hard to start, and I’m thinking I’ll never be able to do it because it’s just so painful, so hard.” Counselor : “Yes, Deshi, it takes great pains to change. As a White male in this society, I’ve been expected to be assertive and to speak what’s on my mind, and I haven’t been that way. When I was younger, I was very much the introvert. I wouldn’t initiate. It took a lot of pain, hard work, and practice for me to get to where I am now.” More examples of counselor personal disclosure serving to normalize clients’ feelings: — “Rimma, when I first moved to America, I was 18 years old. I left all my friends and my family to come here. I remember I also felt lost, alone, and isolated.” — “When my friends don’t ask me about myself as often as I’d like, I also feel lonely.” — “Andy, as a therapist, I feel the pressure to be competent and strong all the time, too. Sometimes I yearn for someone to accept my human frailty just like the way you feel around your family and friends.” — “When I was your age, Pete, I was also confused about not having a clear direction of where to go.” — “Lynn, I experienced those same emotions of sadness, guilt, and loss, too, when my dad died.” — “Ben, when I was a kid, I was also bullied in school. It was very painful for me and it took a long time for me to rebuild my trust in others and confidence in myself.” — “I, too, lost my mom to cancer. I remember feeling scared, anchorless, and relieved all at the same time.” — “When I was in college, I also felt like just another number.” b. Physical condition disclosure When you are under physical strain, take the liberty to disclose it to your client. This will prevent your clients from taking your limitation personally. Consider the following examples: — “I want to let you know that I’m not feeling that well today. I had a sinus problem last night and didn’t sleep well, so if I seem a bit out of sorts in our session today, that’s why.” — “I was on call last night. I got only two hours of sleep. If I appear fatigued today, that’s the reason.” — “I want to let you know that I have a migraine headache today, and if I seem a little different, it’s because I’m taking medication.”

Influencing Skills 169 c. Personal disclosure upon client’s request Clients sometimes may ask you about some facts about yourself, such as your training, professional experiences, where you come from, marriage status, whether or not you have children. Your clients do have rights to know about these aspects of you. You can just respond plainly and naturally. Client: “Are you married?” Counselor : “Yes, I’ve been married for two years.” Client: “Have you ever been divorced?” Counselor : “I’ve never been divorced, but I’ve had many losses in my life.” If clients’ questions seem to be charged with indirect messages that make you uncomfortable, then use the skill of immediacy (detailed in a later section) to address these indirect messages in a productive manner. 2. Self-Involving Disclosure The second form of basic counselor self-disclosure is self-involving disclosure. Though easy to use, self-involving disclosure boasts high therapeutic value. Here, you reveal how you are feeling and reacting to client’s situations—not to the client—as if you were involved in the situation. Your self-involving disclosure conveys to your client a strong sense of your personal presence. When you share your own emotional reactions to the client’s situation, it models for clients that feeling reactions are okay and justified (Meier & Davis, 2011). It then can “increase clients’ experience of their feelings” (Meier & Davis, 2011, p. 17). Consider the following examples: — — — —

“As I listen to what happened to you in your childhood, I’m moved to tears.” “As you spoke about your uncle, I felt angry and sad.” “I feel sad as I hear you talk about your loss.” “I feel my stomach tighten right now as I hear the way your step-mother treated you.” — “My chest tightened right now hearing that your loneliness in childhood was so deep that you wanted to die.” IV. IMMEDIACY Immediacy—centered around the here-and-now relationship between you and your client—is the fourth type of influencing skill that can heighten client awareness. It is also an advanced level of counselor self-disclosure. Immediacy is sometimes called “I-thou” relationship talk. We use both interchangeably in this text. Immediacy: A Therapist’s Best Friend Talking with your clients about what is happening between the two of you can further fuel the engine of therapy. However, like learning a new language, immediacy rewards you and, at the same time, challenges you. For Carkhuff (2010) immediacy boasts the richest means of communication available, one that reflects the life force within both therapist and client. But, what do we mean when we say life force?

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The life force within you is what is alive within you—how you feel, how you are moved, how you are drawn to the other person or shut out, how you regret what did not happen, how you feel alarmed, etc. When we are able to communicate what is alive within us and invite our client to do the same, the session often becomes mesmerizing. As Yalom (2009) states, “Therapy is invariably energized when it focuses on the relationship between therapist and patient” (p. 64). In our clinical work, we often witness this: when therapists bring up what is going on between them and the clients, the energy in the room instantly picks up, characterized by depth, intimacy, and transparency. It is no surprise that Yalom (2009) endorses immediacy, or here-and-now relationship talk, as “therapists’ best friend” (p. 46). The Highest Level of Intimate Communication Talking about what is happening between the two of you may prove foreign for both clients and therapists alike; perhaps because this kind of intimate communication is rather rare in our daily interactions. I-Thou relationship communication ranks as the highest level of human communication, according to Vienna philosopher Martin Buber (1937/2003). It is an indepth personal engagement where our “I” encounters the other person, the Thou (Watson, 2006). To make an “I-Thou” relationship with your client, you need to lay bare how you feel in this direct encounter with him, relating to him in a congruent and transparent way (Knox, Wiggins, Murphy, & Cooper, 2012). This intimate communication brings a deep richness to your session. Help Clients Talk Openly about Their Here-and-Now Experiences with You When your clients detach themselves from the here-and-now experiences in the session, this is a good time to shift gears—to change to the immediacy, the here-and-now. Consider the following examples: Example 1: Client (crying for the first time in counseling) — “Tell me, Wanda, what was that like for you to give in to a sob for the first time in our sessions together? How did it feel to let down barriers here, to allow me to see your tears?” Example 2 — “Dan, this is the first time that you’ve cried in our sessions. I feel that a deeper level of trust has developed between us. I wonder, what has it been like for you to let your guard down like this with me?” Address the Elephant in the Room—In the Here-and-Now Relationship Sometimes a client gives you an indirect message that concerns you about their experiences in therapy. Sometimes they act out their coping patterns with you in the therapeutic relationship. If you don’t address these behaviors, they will become the

Influencing Skills 171 elephant in the room—a tension felt by both but avoided in communication. This is the major reason why sometimes a therapy stagnates. Whenever sensing an elephant in the room, address it. Shift your conversation to immediacy—here-and-now relationship talk. Consider the following examples: Example 1 Client (a middle-aged divorced woman who finds herself in the presence of a young male counselor): “I feel a little nervous about discussing my problem with you. How much do you know about women and marriage?” Counselor : “Sandy, because I’m an unmarried young man, you’re wondering whether or not I can really understand your problems, and whether or not I have enough experience to be able to help you. Your feelings are legitimate. Before we go any further, let’s discuss a bit more about this so that both of us can be in a good place with any decision we make.” Example 2 Client (a woman client told a male counselor that she had a hard time opening up, especially to men, because she often felt misunderstood or unheard.) Counselor : “Thank you for sharing these concerns, Rozalia. I’d like to check with you to see whether you ever feel unheard when you are talking to me?” Client: “Most of the time, I feel that you do hear me, and there were several times when I did feel like you might be judging me or something.” Counselor : “I will never judge you or anything that you share with me here, Rozalia. I do want to apologize for shutting myself out a few times in our previous session when I felt stuck. That might come across as me judging you.” Client: “That was exactly what happened in the past with some men. I would like to know exactly what I did to cause people to disconnect from me?” Other examples: — “Terri, I’m aware that you’re wringing your hands right now. I can sense that you’re nervous about telling me what’s on your mind. I’m wondering whether you’re worrying that I might judge you for what you say.” — “I might be wrong, Kostadin, but it seems that you’re wondering if I—an inexperienced counselor in the very first year of my practice—could possibly untie all the tangled causes of your problems when other more experienced therapists have had little success with doing this in the past.” — “When you talk about these pains, Abby, you start laughing. You told me that you use your comic persona to deal with others when you’re in pain, to cover your vulnerability. And I sense that you do that with me here, too.” — “You’ve just stood up for yourself by disagreeing strongly with me, Ed. I’m wondering how you experience it. Were you afraid of how I might respond?” — “Cheryl, I wonder how the power struggle you have with your husband that you’ve been talking about may also get going between you and me here in our session. Where do you see the issue of control playing out in our relationship?” — “A couple of times last week, Amy, you alluded to some incidents about which you didn’t yet trust me enough to tell me. Today I noticed that you again seemed to worry about what I’d think about you. It seems that you worry that I might judge you or not accept you if you were to share certain information with me. I’m wondering how you view our relationship here, and the scope of our trust.”

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— “Tony, I was born in this country and I still have to struggle to fit in. But I get the sense that you’re wondering if I can really understand what it’s like for you to still feel like a ‘blind explorer’ after having immigrated here almost eight years ago.” — “You seem a bit uneasy today, Jean, and frankly, I feel the same. Let’s process what may be causing this feeling.” — “Eli, I’m sensing some tension between us and am wondering what has led to it.” Disclose How You Feel during the Here-and-Now Relationship Talk The skill of immediacy, as discussed previously, is actually an advanced level of counselor self-disclosure. In dealing with here-and-now relationship dynamics, your best bet is to disclose your feelings, intentions, and positions. When you self-disclose, your transparency will inspire your client to share with you what they did not originally feel comfortable revealing. Notice, in the following examples, how counselors use self-disclosure in their “I-Thou” relationship communication. Example 1 Client (a client with dependency issues): “I did all the things you suggested last week to reach out to people, and it worked out pretty well. But I still feel lonely, and I need you to tell me what to do about it.” Counselor : “Todd, it seems that you’re asking me to tell you what to do, and I’m afraid that if I do, it will produce the very problem for us in therapy that you’re having with your mother at home. So my intention is to refrain from telling you what to do, and instead, to help you look into what is going on for you when you face a problematic situation.” Example 2 Client (continuing her weekly saga about her longstanding difficulty in relationships with family members and her husband, without having any eye contact with the counselor) Counselor : “Perhaps we can stop for a moment here, Jill. You mention that it’s harder for you to let men get close to you than it is with women. I want to share with you that at this moment that is exactly what’s happening. I feel like I’m not able to get close to you, and as a result, I feel like I’m not a good enough counselor for you.” Client: “Well, in my brain there’s a very quick voice that goes, ‘He’s a man, and he’s probably thinking that what my husband said is right.’ ” Counselor : “So, in your mind, Jill, you say to yourself, ‘My counselor is a man, so he’s going to automatically take my husband’s side of the argument.’ Am I hearing you correctly?” Client: “Yeah . . . But I think the next question you’re going to ask me is where this mistrust of men comes from. Right?” Counselor : “You’re way ahead of me, Jill. But, you see, we have just bypassed what I was trying to bring to your attention—the difficulty I feel in connecting to you. Can we stay with it for a moment? So, you assume that since I’m a man, I would automatically side with your husband. Let’s slow down a bit so we can explore this. I would like to know: Have you ever felt unheard by me? Have you ever experienced that I sided with another person since we started working together? If you do, then I would like to know so that I can make it right for you.”

Influencing Skills 173 Other examples: — “Liam, I notice that you’re glossing over what’s happening inside you right now. I’m having difficulty paying attention to your stories. Can we talk about this a bit?” — “I’m concerned that you’re seeing me as your problem solver, Lynette.” — “I’m sorry, Jessica, but I don’t feel comfortable meeting you socially outside of therapy.” V. FEEDBACK-GIVING To help heighten client awareness, the fifth skill you can use is feedback-giving. There are two types of feedback: • •

Positive feedback Constructive feedback

Between the two, constructive feedback especially is a not a skill for the faint of heart; it requires you to disclose your feelings, in an authentic way, about the impact that the client’s behavior has on you. It takes a therapist a tremendous amount of courage to apply this skill; but if done with sensitivity, it has enormous transformative power for clients. 1. Positive Feedback Positive feedback resembles the skill of affirmation (Chapter 4) but adds something— you add your own positive feelings about or reaction to the client’s progress. Whenever you notice clients’ progress, including their exhibited strengths, successes, healthy coping, and the growth they have made, go ahead and express your feelings about their progress. This kind of positive feedback boosts clients’ morale. When done sincerely, it builds hope, motivating the client to change. Positive feedback can be considered the backbone of strength-based therapy (Smith, 2006). Principles of Giving Positive Feedback First, positive feedback must be genuine and must be given judiciously. You must not give positive feedback just to put a band-aid on clients’ wounds or to enable them to avoid exploring their anger, despair, depression, anxiety, hopelessness, or any other important subjects that may be uncomfortable for them to discuss (Wright, 2003). Second, do not use positive feedback excessively or too often. If you do, you may appear insincere or as if you are trying to please your clients; your positive feedback will sound phony and will not be believed by your clients. Use “I” Statements When Giving Positive Feedback In positive feedback, you use “I” statements to describe your warm reactions to clients’ progress. The following examples illustrate how to use “I” statements in describing your feeling reactions. — “Lee, I’m excited that you’ve come to this new level of insight about the pattern repeated in your life.” — “Zamir, I am happy to see how self-aware you are about the part you play in your relationship’s difficulty. This is a strength that will help us to eventually achieve the outcome you desire for this relationship.”

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— “Sherrie, in spite of the many difficulties you are going through, you accomplish more than could ever be expected. I am very proud of your accomplishments.” — “Anjali, despite your grief over the loss of your daughter, you’ve reached out to help others who have needed support. I just want to let you know how touched I am by your strength and resiliency.” — “I’m proud of all the hard work you did in this session, Joel.” — “Tina, I’m really pleased with how you owned up to your anger and guilt today.” — “Jim, I’m impressed that you’re not defensive in talking about this issue.” — “Kate, I’m happy that you’ve been able to communicate your anger to your husband and your mother without being blaming or hurting their feelings.” — “Ryan, I am inspired to hear you tell yourself, ‘It’s time to stop blaming other people and to start taking charge of my own life.’ I’m so excited for your growth.” — “Pam, I see how hard you’ve been trying to use the skills you learned in assertiveness training. I’m very proud of you.” 2. Constructive Feedback—Process Comment or Impact Disclosure When a client plays out his misperceptions or distorted schemas in the here-and-now of therapy, we, the therapists, need to seize the moment to disclose our reactions to their actions, so that they can come to the awareness of their own schemas. This kind of disclosure is called impact disclosure or process comment (Meier & Davis, 2011). Constructive feedback—identical to the above-mentioned impact disclosure or process comment—provides the client with an opportunity for emotional re-learning. It equips the therapist with the tool to deal with clients’ process resistance or with other impasses in therapy. Process Resistance and Impasses You know your client is engaging in a process resistance when your fine work suddenly comes to an impasse, and the therapy is stuck. Process resistance can take the shape of the following behaviors: withdrawing, shutting down, changing subjects, deflecting, dancing around a certain subject, arguing, becoming sarcastic, coming to the appointment late, missing appointments, or even terminating prematurely. Other variations of process resistance may include the following: clients unexpectedly becoming upset with you, telling you that you are “too young or old, too white or black, too gay or straight to understand or to be of any help” (Cozolino, 2004, p. 113). You can be sure that you are running into process resistance when “your personal attributes, credentials, or abilities are questioned” (Cozolino, 2004, p. 114) by the client out of the blue. Process Resistance as a Form of Communication Process resistance basically serves as a defense against anxiety (Cozolino, 2004)—anxiety toward change, toward interpersonal intimacy, toward a perceived sense of vulnerability, etc. Cozolino (2004) takes one step further in stating that whatever the client resists is exactly what her core issues are and where her anxiety stems from. From this perspective, we can have a greater appreciation of the client’s process resistance. As we look at the client’s emotional challenges in her history, we will come to appreciate her vulnerability and reactivity as well as her reason for resisting.

Influencing Skills 175 Hence, process resistance is no more than a form of the client’s communication: she is cluing you in about something that causes her anxiety, something that she cannot express explicitly. Process Level versus Content Level of Communication Teyber and McClure (2016) state, “The therapist–client relationship is complex and multifaceted; different levels of communication occur simultaneously” (p. 8). At least two levels of communication are always happening in any relationship: content and process. Content level of communication: This is the plain, factual topic of the conversation, such as the facts, data, and views. It involves the what that the two persons are communicating about. Process level of communication: This is the tone, the atmosphere, the unstated feelings or perceptions, the indirect actions, indirect verbal or nonverbal expressions, and all other subtle aspects of the relationship. Process resistance is a way through which clients engage in a process level of communication to express something—something that the client cannot communicate directly. Since process resistance delivers a message that is unstated, it often causes confusion on the therapist’s part. If we persist, however, the confusion will lift, and we will often find that in process resistance, the unstated message the client is sending us can be decoded as this: “you have awakened some sensitive core issues in me; I am hesitant about whether or not to dive in further.” Deal with Process Resistance—Grab the Bull by the Horns Yalom (2009) states, “Eventually the interpersonal problems of the patient will manifest themselves in the here-and-now of the therapy relationship” (p. 48). As the interpersonal problems start to “go live” in the session, the therapist’s best way to deal with it is to take risks and point out what is going on in the interaction, like the bull rider grabbing the bull by the horns. Addressing what is happening at the process level in the session is a rather complex mental operation, requiring us to recognize three things: • • •

What the client said or did not say in the content level. What happened at the process level. The way the client’s underlying issues are played out in the here-and-now with you, the therapist.

Addressing what’s happening at the process level is the most effective way to deal with process resistance. Process Comments, Feedback, and Reality Testing Many clients are oblivious to how their behaviors affect other people. Their minds do not register the interpersonal reality. Without the ability to recognize this reality, clients create a lot of problems in their lives. It’s no wonder, Yalom (2009, p. 113) so states, A goal of therapy is to increase reality testing and to help individuals see themselves as others see them. It is through feedback that patients become a better witness to their own behavior and learn to appreciate the impact of their behaviors upon the feelings of others.

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When a client carries her distorted schemas into her daily life, her reality testing ability diminishes. The therapist’s feedback to the client helps her see the interpersonal interaction for what it really is, rather than what she assumes it to be, therefore, increasing the client’s reality testing. Through constructive feedback from the therapist, the client learns to differentiate what is real and what is assumed. She sees more clearly that her behaviors do have an impact on others’ feelings, and that she does play a part in her interpersonal affairs. Constructive Feedback: Unusual Yet Effective for Client Transformation Giving constructive feedback, or process comments, to your client has a unique power in therapy. As Kiesler and Van Denburg (1993) assert, “the most essential intervention in interpersonal communication therapy occurs when therapists provide meta-communicative feedback that labels the interpersonal impacts they thematically experience” (p. 5). You are implementing the most important tool that you have to influence client change when you give feedback on the dynamics between you and your client (Teyber & McClure, 2016). This way of talking with each other, however, may be unfamiliar to clients and therapists alike, as it is totally unusual, totally against social mores. As unusual as it is, when done with sensitivity and respect, this kind of honest feedback enables both therapists and clients to work through any impasses and bring progress to the therapeutic interaction. Using “Impact Disclosure” to Give Constructive Feedback As mentioned, constructive feedback is also referred to as process disclosure, process comment, or impact disclosure (Chen & Rybak, 2018). Why are the words “disclosure” and “impact” used? To give interpersonal feedback, we need to attend to the subtle energy shift and the unspoken data transmitted in the interpersonal process. And then, genuinely, truthfully, we need to disclose our feeling reactions to the impact that clients’ behaviors have on us. The key to success in your impact disclosure is being authentic—to disclose what you are experiencing at the present moment. Obviously, you have to be aware of what you are experiencing at the visceral level. If you learn to respect and trust your visceral self, you can learn to increase your confidence in putting your affective experiences into words. The more you are able to put what you are experiencing into words, the more you will be able to clearly convey how you are experiencing your client’s behaviors at the present moment and the more your client can hear the impact of their behaviors on you. Three Things Not to Do When Giving Constructive Feedback Three things that you don’t want to do when giving your client constructive feedback: •

•

Don’t try to ignore your emotional reactions or feel guilt about your feelings. When our client’s patterns create an impasse or process resistance, we will have emotional reactions. Our emotional reactions give us clues about how people in the client’s life might react in similar situations. Don’t get defensive. The client has learned and is well-practiced using process resistance to cope with their emotional challenges from their past. It is not about you.

Influencing Skills 177 •

Don’t try to use persuasion to talk your client out of his process resistance. Since process resistance serves as an indirect way of communication, its hidden message needs to be explored and decoded, rather than unaccepted and be persuaded away.

The Best Time to Give Constructive Feedback—Notice the Two Cues The timing of delivery often determines much of the success of this skill. When you notice the following two cues emerging in the therapy, you know that it’s time to give constructive feedback to your client (Kiesler & Van Denburg, 1993): 1. Your reaction to the client has a repetitive pattern. 2. The pattern of the transactions between you and the client parallels the pattern that the client has with his significant others outside of therapy. When both of these cues are present, you can rest assured that your reaction to your client is not counter-transference. It is a genuine reaction on your part to his behavior pattern. At this juncture, you can trust your inner reactions and disclose them to your client. Of course, sometimes, it might not be possible to process a here-and-now event in a session when these cues are present. If so, just file the event away in your mind. Come back to it when it reappears in a future session. Do remember this: Constructive feedback must be delivered in a way that both supports the client’s self-esteem and confronts the behavior pattern. The way you package your constructive feedback can make or break the session. Please see Figure 9.2 on how a client’s coping behavioral pattern has an impact on the counselor’s reactions.

Figure 9.2 The Possible Impact of a Client’s Coping Behavioral Patterns on a Counselor’s Reactions in Therapy

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Package Your Interpersonal Feedback with Care and Acceptance We need to learn to package our process comments or constructive feedback in ways that feel caring to our clients (Yalom, 2009). For example, if a client’s inability to go to deep issues suggests his distrust of others and you, the trust issue needs to be commented on but with a good dose of acceptance. In other words, in our feedback, we need to convey this: given the clients’ history, his behaviors, though resistant, do make sense. In the following example, consider how the feedback is packaged with care and acceptance: — “Felitsa, although I feel pushed away and saddened by your not wanting to work on this critical issue in therapy, I completely respect your hesitance. Indeed, you are absolutely right not to trust others and not to trust me because people in your life have used it against you in the past when you let yourself be open and vulnerable.” [Impact disclosure with a great deal of acceptance] Five Principles of Giving Constructive Feedback Keep in mind these five principles when giving constructive feedback in order to maximize the effect of your feedback-giving: Give only small doses of “action-able” feedback Try to deliver the feedback in a small dose each time. Too much feedback at one time may overload the client, creating confusion and defensiveness. Further, the suggestion implied in the feedback must be “action-able” and within client’s control. Describe your persistent reactions. Avoid judging the person When giving your feedback, describe the client’s behaviors and your reactions. Don’t judge. Let’s try to differentiate describing from judging: Judging: “I don’t like your behavior because you’re constantly interrupting what I have to say.” Describing: “Please correct me if I’m wrong, but I’ve observed your tendency to jump in before I finish what I have to say. I often find myself feeling pushed away, and at the same time feeling rushed to finish my sentences before they get cut short. Do you observe this behavior as well?” Try “working on the edge” Carl Rogers stressed the importance of “working on the edge” of our clients’ consciousness (in Sommers-Flanagan & Sommers-Flanagan, 2015).This means that we provide clients with feedback about their behavior when the client is almost ready to have an insight but has not yet been fully conscious of it. Working on the edge requires us to be extremely sensitive and respectful of the client’s tempo of inner working, to not get too ahead of or behind his readiness. Choose words showing how the closeness of the relationship is being impacted In giving feedback, Yalom (2009) suggested that we focus on how the client’s behavior impacts the closeness of the therapeutic relationship. Words of such nature may include

Influencing Skills 179 “disconnected,” “shut out,” or “distanced.” These words, paradoxically, demonstrate “your wish to be closer, more connected and more engaged, and it is difficult for clients to take umbrage in that” (Yalom, 2009, p. 69). Focus on the here-and-now Even though feedback focuses on recurring behavior patterns, it should be a response to a here-and-now behavior occurring in the session. Don’t go over behaviors that happened a while ago. When noticing a client’s pattern for the first time, make a mental note to yourself. Later, when it appears again in the here-and-now of the session and when the timing is ripe, give feedback in that moment. After you have given the feedback, ask the client for reactions to the feedback. Examples of How to Give Constructive Feedback The Case of Sue Client [with a recurring pattern of attending to others’ needs and feelings while minimizing her own needs and feelings] Counselor [feeling distanced from the client]: “Let’s stop a moment, Sue. I may be wrong but whenever you have a feeling arising, I see you minimize it immediately, and then you doubt if your feelings are real. When this happens, I feel distanced from you. Is this something that you’ve noticed?” Client: “Oh, I’m so sorry. I don’t mean to make you feel pushed away.” Counselor : “My intent isn’t to point out what you do wrong, Sue. But I thought I could help you understand the possible reason why your relationships have been dissatisfying for you by examining my firsthand experience with you. I do see that you play down your feelings a lot. It’s as if you’re telling me not to take your feelings seriously. When you do that, I feel pushed away. How do you react to this?” Client [shocked but intrigued to hear this. The message did ring true to her; no one had ever hit so close to home before—an awakening that was a turning point for the client] After the session, Sue decided that she would tell her boyfriend, Frank, about his use of humor and how she feels brushed away, increasingly feeling unheard and frustrated. In the following session, Sue could hardly wait to report that she had mustered her courage and opened up to Frank. Predictably, he used humor in response. But Sue didn’t shut down this time. She insisted that Frank hear her out. She was surprised to learn that he was just trying to rescue her from her own discomfort. She discovered that acknowledging and owning up to her uncomfortable feelings actually helps her feel more comfortable and safe. Other examples of interpersonal feedback: — “Mike, let’s stop for a moment. I’m feeling something similar to what I felt in our last session. I may be wrong, but I feel as if there’s an invisible wall between us that leaves me feeling disconnected from you. At the same time, I understand that your coping mechanism is to play it safe, to be the good guy, to be the one who doesn’t cause any trouble. I see you using this coping mechanism in our relationship, too. Everything feels very safe and very much on the surface. This is preventing me—and perhaps others in your life, too—from getting to know you and supporting you.”

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— “This may be a little off, Maya, and I’m actually not that comfortable telling you this, but I owe it to you and to our relationship to share this with you. The thing is—I’m feeling shut out right now because every time I invite you to ponder an interpretation I make, I get an instant comeback from you without much pondering or consideration. I don’t know if I’m too sensitive about this. Have any others told you something similar to what I just said?” — “Russ, while listening to you, I have a reaction. Please disregard what I say if it doesn’t fit. Anyway, we’ve been talking about problems in your relationships with people at work and in your personal life, and while we’re talking, I notice that I’m feeling increasingly disconnected with you because you tend to dismiss almost everything I say. I’m feeling the distance between us widen due to the constant rebuttals. Do you think my reaction might say something about your difficulty in relationships with others?” — “Liz, I may be wrong, but as we continue to explore various issues related to the rigidity of your exercise rituals and your anxiety, I notice that you often flee from questions regarding your family and become evasive about your feelings. During these times, I feel like I’m kept at arm’s length. I get a message telling me not to come too close to you. I wonder what your experience is.” — “Jesse, I have some reactions that I’d like to share with you. I may be wrong, but throughout our sessions, you’ve rebuffed almost every perspective that I tried to offer. I feel increasingly detached from you. You say that people in your program often keep you at a distance, which makes you feel discriminated against. I wonder whether they might feel the same way I do. I wonder whether they might feel pushed away by your rebuffing style of interaction just as the way I feel. And when they shy away from your style, it confirms your perception of your being discriminated against.” — “Anna, we’ve been working together for a few sessions now. Maybe I’m wrong, but I’m feeling increasingly concerned that you’re telling me what you think I would like to hear rather than what’s most important for you. When you do this, I feel disconnected to you. I wonder whether you do this in other relationships, too. I wonder whether you tend to put other people’s needs or demands first, sacrificing the expression of your true self, leaving you with your needs unmet and with feelings of resentment and frustration.” — “Chris, I have some reactions that I’d like to share with you. If I’m wrong, please feel free to disregard them. While we were talking, it seems to me that you keep asking me for help, and when it is offered, you keep saying, ‘Yes, but. . . .’ I feel pushed away when you do that. Do you think my reaction might say something about why people tend to keep distant from you?” — “Eddie, I’d like to stop here and give my reactions to what you’ve been saying. I may be way off, but when you talk about the death of your dad, I feel a wave of sadness, yet I’m concerned that you show no sadness at all, not even a tinge of feeling. I feel like I’m being kept at arm’s length from you. Do you sometimes come across to others as being non-feeling?” VI. TRIANGLES OF INSIGHT: AN INTERPRETATION SKILL The sixth influencing skill you can use to heighten client awareness is triangles of insight. Triangles of insight stand out as an interpretation skill in the school of psychodynamics and in other approaches to therapy as well.

Influencing Skills 181 Repetition Compulsion and Relational Schema Playing Out in the Session People begin developing certain relational patterns as early as when they form their attachment to their caretakers. These relational patterns—the way they feel, assume, and expect—repeat themselves in adult relationships, including the therapeutic relationship (Greenberg & Mitchell, 2013; Mitchell, 1988). To account for this tendency, psychodynamic therapists look to the phenomenon of repetition compulsion (Summers & Barber, 2013), whereas cognitive therapists, relational schema. Be it schema or repetition compulsion, clients’ patterns of expectations, thoughts, and feelings will sooner or later play out in the therapeutic relationship. Help Clients Work through Emotionally Charged Relational Patterns When this happens, it presents a valuable opportunity for therapists to help clients work through their patterns so they can experience a breakthrough in their emotional relearning. To help clients work through these emotionally charged relational patterns, Malan (2018) suggested that we use the triangle of insight. In this skill, the therapist connects events from three different times, each time forming a point on a triangle: • • •

The client’s here-and-now relationship with you, the therapist. The client’s relationships with past key persons. The client’s relationship with current key persons.

See Figure 9.3 for a visual presentation of the triangle of interaction pattern. As therapists, we can use the triangle of insight to deal with any emotionally charged interactions with the client (Levenson, 1995). This interpretation skill helps clients see, with more clarity, how they play a role in shaping their social environment and others’ responses to them.

Figure 9.3 The Triangle of Interaction Pattern: The Here-and-Now, the Past, and the Present

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Principles of Using the Triangle of Insight To judge whether a behavior truly has a repetitive quality, we need to allow the pattern to display itself a few times to ensure that it is not just in our imagination. Once you know for certain, practice this skill with the following principles: • • •

Use it only when the therapeutic relationship is well developed because it might dredge up emotionally charged material. Work up a description as detailed and as concrete as possible before you apply this skill, so your client can recognize the pattern clearly upon hearing it. When applying it, remind your clients that interpretation is not the discovery of truth, but simply a possibility.

Examples of How to Use the Triangle of Insight Following are a few examples of how to use the triangle of insight: — “Brian, please let me know if I am wrong. I have heard you say that everybody is on your back, wanting you to be more committed in their areas of interest; this includes your parents in the past, and now your girlfriend as well as your club members. Right now I sense that you see me as another one of those people on your back making demands on your time.” — “Irene, correct me if I’m wrong. It’s been many sessions since we’ve explored something more personal. It’s possible that you’re hesitant to open up to me because you opened yourself up in the past with other people, including your family and friends, but were discouraged because no one seemed to truly understand your pain, leaving you feeling alone and in even more pain. And now you’re afraid that if you open up to me here that I might do the same thing, leaving you to feel injured all over again.” — “Robin, I understand that one part of you really wants to trust me, yet another part of you doesn’t feel safe at all. You took risks to trust others in the past as well as in your current life but were taken advantage of, leaving you feeling hopeless and depressed. I understand how much it would hurt you if I were to betray your trust, and I don’t want you to go through that terrible experience again.” — “George, this is just my impression, please correct me if I’m wrong. In jail you have learned to never let your guard down, to protect yourself against being exploited. In your family, you guarded yourself so that you would not be abandoned. Even right now, in therapy, you are not sure whether you can trust me with your feelings or whether I’ll use them to exploit you.” VII. CHALLENGE AND PROPER CONFRONTATION In therapy, challenges are the fires that refine the block into the diamond. In its everyday use, the mere words “challenge” and “confrontation” may turn you away with the aggressive, battling images that they convey. In therapy, however, the skills of challenging actually encompass a wide range of skill sets, ranging from gentle challenges to stimulating confrontations. Properly used, this final influencing skill can heighten client awareness. This section presents what to challenge your client about and how to do it properly.

Influencing Skills 183 What Client Behaviors Merit Your Challenges? You might use challenge responses to heighten client awareness when you observe the following behaviors: • • • •

Incongruence Inconsistency Discrepancies Distortions

• • • •

Biases and prejudices Blind spots Evasiveness Self-defeating tendencies

You want to challenge these behaviors because these behaviors have been “previously unknown, disregarded or repressed” (Young, 2013, p. 171). When challenged, your clients will actually be given an opportunity to become aware of these behaviors and the consequences. This newly gained awareness is precious. You Can Challenge As Much As You Have Supported Many new counselors and therapists fear that their challenge responses might offend their clients. Truth be told, your challenge won’t offend your client if you strike a balance—between your challenge responses and your empathy responses. According to Egan (2013) “challenge without support is harsh and unjustified; support without challenge can end up being empty and counterproductive” (p. 160). As long as you follow the rule of the game, your challenge will be well received. The rule? “You can confront as much as you’ve supported” (Meier and Davis, 2011, p. 9). When you deliver your challenging response, remember to first give a great deal of empathy and support. With that in place, you can then be confident in delivering your challenge response. Challenge Responses as an “Act of Grace” Young (2013) emphasizes that we focus our challenge responses on the unknown, disregarded or repressed aspects of clients’ dysfunction. In contrast, Wright (2003) emphasizes that our challenges should be “acts of grace.” That is, we should challenge clients’: • •

Undeveloped potentials Under-developed resources

• •

Unused talents Misused strengths

In this, Wright completely reframes the concept of challenges. In this, challenges truly act as the fires that purity and shape the diamond inside clients. They bring out clients’ previously ignored possibilities. With this, our challenges to our clients come from a place of grace and love. When Not to Use a Challenge Response We should be mindful of the following contraindications when attempting to use a challenge response: Don’t use challenges with self-centered clients: Some people respond well to challenges, but “a narcissistic and self-centered client may resist being challenged” (Ivey, Ivey, & Zalaquett, 2014, p. 237). Observe before you proceed.

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Avoid challenges with Asian and American Indian clients: Some people, like those with European American and African American cultural backgrounds, react well to appropriate confrontations and challenges. Others, like Asian and American Indians, usually don’t react well to challenges. They might experience the challenging response as disrespectful and insensitive (Sue & Sue, 2016). Instead, choice theory and reality therapy tend to meet Asians’ and American Indians’ needs for pragmatism and, at the same time, show respect to their cultural values, according to my (Mei’s) clinical experiences. Hold back from challenges with clients under extreme distress: With clients under extreme distress, we should refrain from challenging them (Hepworth, Rooney, DewberryRooney, & Strom-Gottfried, 2013). For example, if your clients are in great emotional pain, going through grief, or struggling with extreme anxiety or depression, you will need to delay any challenge responses even if their in-session behaviors might be selfdefeating. Wait until they are “out of the woods.” Then you may proceed to help them become aware of their behavior patterns. By then, they will have more capacity to hear it. Principles of Using Challenge Responses If you decide the time is ripe to challenge your client, please take heed of the following principles for skill execution: Use tentative language to deliver your challenges: Try to deliver your challenge in a tentative, nonjudgmental, loving, and encouraging manner. The following tentative lead-ins will soften your challenge, making it easier for your client to stomach: — — — — — —

“I wonder if . . .” “Could it be . . .?” “Is it possible that . . .?” “Does this make sense to you . . .?” “How do you react to this perception . . .?” “On the one hand . . . On the other hand . . . How do you put these two things together?”

Challenge only when a trusting relationship has been established: Challenges should be used sparingly. Good timing is a key. Until the therapeutic relationship is fully established, it is neither wise nor helpful to challenge your client. In general, the stronger the trust within the therapeutic relationship, the more powerful your challenge response can be. At this stage of the relationship, your clients will believe that you care about them enough to challenge them. If we don’t care about our clients and their improvement, there is no point of using a challenge. Ask for permission to challenge: I find it effective if I ask for permission before I challenge my clients. It shows respect to the client and increases client receptivity. For example, I may say, — “Would you allow me to challenge you on one thing?” Often, clients nod in giving me permission and, at the same time, anticipate it with their eyes wide open. This is the receptive state in which we want the message to be taken. Follow your challenge response with large dose of empathy: The challenge should be based on your careful observation of clients’ behaviors. After challenging your client,

Influencing Skills 185 give him a high dose of empathy by showing your warmth and acceptance. This will re-establish the therapeutic relationship. In the following, we present five types of challenges frequently used in counseling and therapy: 1. 2. 3. 4. 5.

Challenging clients’ discrepancies Challenging clients’ distortions Challenging clients’ disowning of strengths Nudging clients to act Confronting clients with ignored information

1. Challenging Clients’ Discrepancies Of the five types of challenge/confrontation responses, challenging discrepancies is the most frequently used in therapy. Here, therapists point out the incongruence between clients’ verbal and nonverbal communication. Of course, we must wait until the timing is ripe. As Yalom (1983) points out, clients whose nonverbal cues are brought to light prematurely may feel as if they are being treated as objects. When delivering your challenge, remember to use respectful, nonintrusive, and sensitive language. Consider the following examples: — “Fran, even though you said you’ve worked through the event, your voice cracks when you talk about it. I get a sense that a lot of emotions remain unresolved. I wonder if we could talk more about this.” — “Howard, you said that you’re fine, but I notice a facial tic in your cheek when we talk about your being a token of affirmative action at your work. Could it be that there are still some feelings we ought to explore?” — “Rita, I notice that when you talk about painful events, you laugh. How do you put these two together?” — “Eli, would you allow me to challenge you on one thing? You said everything is great back home. And yet whenever you talk about your father, you begin to fidget nervously. I wonder, what do you make of this?” — “Rod, you said that your home life was uneventful when you were young. But I’ve noticed that whenever you speak about your relationship with your stepfather, you begin tapping your foot quickly. How do you put these two together?” — “Jean, each time we discuss your mother’s verbal abuse, you say it doesn’t matter, yet you hang your head down and clench your fists. How do you put these two together?” — “Hal, I apologize for being late due to the traffic. I may be wrong but I sense that you seem angry with me for being late, which I understand. But you say that you feel fine. How do you put these two together?” — “Would you allow me to challenge you on one thing, Annie? You are saying ‘yes’ with your words but ‘no’ in your body cues. Would it be OK if we talked about this?” — “Bill, although you say you’re interested in developing a better relationship with your wife, in your stories it also shows that you don’t take the time to listen to her feelings or to communicate basic understanding to her. How do you put these two together?” — “June, you say you want to improve your grades, but I don’t hear you putting much effort and time into reading, library research, and homework. How do you put these two together?”

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— “Debbie, you’ve talked about wanting to get more in touch with your feelings. Yet, I notice that every time you get close to a feeling, you run away. How do you put the two together?” Be Respectful toward Culturally Conditioned Discrepancy Facial expression, movement, and eye contact are all culturally conditioned. Before challenging a discrepancy, therapists should consider it within the cultural context. For instance, with Asian clients, restraint of feelings is a culturally sanctioned behavior. These clients may talk about painful experiences while having blank facial expressions. A Japanese client may feel extremely uncomfortable, yet smiles and laughs. Instead of using challenge response, you can use advanced empathy (see Chapter 4) to bring the discrepancies to client attention. Here is a scenario: You are working with a minority client who is smiling and laughing while talking about her inability to speak up in the staff meeting. Consider the following responses and their level of appropriateness: — Culturally insensitive counselor response: “While listening to your difficulty in speaking up, I notice that you’re smiling and laughing. I wonder whether you’re hiding your anxiety behind your smiles.” [Inappropriate challenge of incongruency] — Culturally sensitive counselor response: “While listening to your difficulty in speaking up, I notice that you’re smiling and laughing. I can understand the sense of inadequacy you feel in not being able to speak up in classes, and at the same time, I am touched by your effort to work around the taboo of not talking about your personal struggle with a stranger or with me.” [A combination of advanced empathy with a positive feedback] 2. Challenging Clients’ Distortions In this second form of challenge, the therapists point out to the clients their distorted or inaccurate perceptions. We often misinterpret others’ actions and motivations because of lack of information and because we view events through the narrow lens of our past experiences. Clients do the same. As we challenge their distortions, we provide our clients with a reality check. The same principles of challenges shall apply here. Consider the following examples: — “Lanny, you’re afraid of teachers because of your past experiences. Now you see your sociology teacher as distant, although in reality, she’s a warm and caring person. Is it possible that your past experiences somehow influence the way you’re interpreting the intention of her behavior?” — “Lillian, you said that your boyfriend is insensitive, egocentric, and cold. Yet, by the list of things that he’s doing for you, he seems to be a supportive, caring, and loving person. How do you react to this observation?” — “John, would you allow me to challenge you on one thing? You’ve talked about your trouble relating to male authority figures and about your desire to relate to them more realistically. Yet, I notice that you have put your supervisor on a pedestal and now you write him off just because he makes human mistakes. Could it be that your disappointment in him is being impacted by the way you related to authority figures in your past?” — “Lisa, you told me that your dad never pays attention to you. But he’s attended every one of your volleyball games this season. Is it possible that your earlier views about him have prevented you from seeing another side of him?”

Influencing Skills 187 3. Challenging Clients’ Disowning of Strengths This challenge confronts clients about how they disown or neglect their inner strengths and resources. This kind of challenge, believe it or not, is a hallmark of strength-based therapy. Do not think that strength-based therapy is all about affirmation and positive feedback. Confronting clients’ under-use of their own potential shows that you actually recognize their strengths, and it urges them to put them into full use. Client [describing herself as fragile and unable to tolerate her own emotionality]: “Somehow I feel I shouldn’t have revealed myself to you the way I did.” Counselor : “Actually, you seemed able to hold yourself together when the topics were intense.” Other examples of challenging clients’ denial of strengths: — “Ben, you worry that you can’t get your life together, but I see you as a resilient and resourceful person. Is there anyone you can remember who also saw these qualities in you?” — “Tammy, you say you can’t cope, but judging from what you’ve done, I believe you have the strength to make it this time.” — “Dan, you say you’re no good to anyone. But I see a kind, caring, helpful person in you. Have others seen you this way?” — “Carol, you say you’re concerned about not having the ability to complete a graduate program, yet you graduated with honors as an undergraduate, and I see you as a motivated, intelligent individual. How do you react to this?” 4. Nudging Clients to Act For clients who go on talking and talking about taking charge of their lives, yet never really take action, this fourth type of challenge will come in handy. This challenge skill gently nudges this kind of client • • • •

To To To To

take initiative in life, instead of complaining. act in accordance with their best interests. own up to the impact that they have on their environment. take responsibility, instead of assuming a victim stance.

Nudging clients to act in their own interests is another feature of strength-based therapy. It helps build clients’ sense of self-efficacy. Caution: avoid slipping into advice-giving or lecturing when urging clients to act. Consider the following examples: — “Ray, we’ve discussed your difficulty in going out to meet people because of your introversion. Now that you’ve gained a great deal of insight through our discussions, it seems to be the right time to go out there and test out your new knowledge. How do you respond to this challenge?” — “Sara, you say you want to prove your parents wrong. This is now a great opportunity to do so. How do you respond to this challenge?” [This is not reverse psychology, but a challenge response] — “Andy, you sound convinced of what you need to do. The only thing left is for you to actually try it out. How do you respond to this?”

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5. Confronting Clients with Ignored Information The last type of challenge involves providing clients with information that they don’t seem to grasp fully or have tried to ignore. Proper confrontation with tough information serves as a reality check when clients’ expectations of life situations are unrealistic. Some examples are: — “Misty, people can get AIDS from heterosexual relationships. Indeed, eleven percent of teenagers who get AIDS get it from heterosexual relationships. How do you respond to this reality?” — “Vince, you said you don’t want to take the trip with your parents because you think the plane will crash, yet statistics show that less than two percent of flights crash in a given year. How do you react to this?” — “You seem to think that you’re immune to the need for protection during sex, Tina. This brochure may help you see that there’s no ‘grace period’ for age or number of unprotected encounters. Would you like to read it and discuss further?” — “Tom, you say you aren’t smart enough, but you actually got a higher score than the average on the SAT exam. How do you put these two together?” — “Luke, you said that you are over your grief of your mom’s death. Yet your eating habit started to get out of hand after your mom died. Studies show that food works well to suppress grief. How do you react to this information?” EXERCISES After each client statement, write a counselor response using the influential skill indicated next to the item number. 1. Interpreting the recurring theme Client: “I’ve got this new boss who’s driving me crazy. He’s a micro-manager. It’s really too bad because the job is my dream job. There’s always someone who has to spoil things for me. Like that teacher in high school who just picked and picked at me. Nothing was ever good enough. Nothing is ever right.” 2. Interpreting the coping pattern Client: “Friday night my date stood me up. There I am, standing around, waiting for the jerk that’s never going to show up. So my friend Stacy and I went out for a pizza and some ice cream. I’d really like to get even with that jerk. I’ll think of a way to get back at him. It may take me awhile, but I’ll get even, and it will be when he least expects it. He’ll never see it coming.” 3. Empathic responses combined with counselor self-disclosure to normalize client feelings Client: “Since my mom died, I don’t want to live anymore. She and I talked every day on the phone. She was my best friend, and I told her everything. I just got a call . . . she hadn’t even been sick . . . then she died, just like that. Some days I can’t even get out of bed.”

Influencing Skills 189 4. Use immediacy to address what is going on in the here-and-now Client: “I really don’t know whether this counseling is going to work at all. You have never gotten pregnant yourself. I suspect you don’t even understand how it feels to be a college dropout . . .” 5. Challenge the client’s distortion Client: “My mother-in-law hates me. She thinks I can’t provide for my kids. All she does is give them stuff. Fancy clothes, fancy games, a vacation to Disney World. She thinks I’m useless and a slut just because I’m between jobs. I’d give my kids those things if I could.” 6. Challenge the client’s distortion Client: “I want to be a doctor when I grow up. And an astronaut, too. I know that my grades aren’t that great, but I can get to be a doctor anyway. My dad is a doctor, and he will get me a job at a hospital.” 7. Positive feedback about client resilience Client: “I’m having a terrible time after coming back from Afghanistan. My legs are all messed up and they may have to be amputated. I worry about how I will take care of myself. I don’t know where I will find the strength to do it. I worry about my wife and children. I don’t want them to have to take care of me. I’m the one who should be taking care of them.” 8. Ask “the Question” Client: “I really see my behavior cycle now. When I’m mad at my boss, I take it out on my wife and son. They get the brunt of my anger. I even yell at the dog.” 9. Challenging client’s discrepancy. Client: “I’m so sad about my dad’s death. I really loved him.” (Client’s affect is flat, showing no emotion.)

10 Advanced Intervention Techniques

A therapist using advanced intervention techniques is sort of like an athlete in high gear. When it comes to helping your clients develop, utilize, and express their underdeveloped resources and mental skills, all other techniques pale in comparison with advanced intervention techniques. This chapter presents eight groups of advanced intervention techniques that have the power to help you turn your clients around. ENERGIZE CLIENTS WITH HIGHER LEVEL OF CHANGE ACTIONS Advanced intervention techniques find their best usage during the third stage of counseling: the problem resolution stage. The Problem Resolution Stage of Counseling The problem resolution stage of counseling steps up to the counseling process as the awareness raising stage trails off. At this new stage, both the therapist and the client aim to resolve the core issues at the root of their symptoms and emotion dysregulation (see Chapter 8.) Specifically, in the problem resolution stage, therapists strive to help their clients: • • • •

Reconstruct their schema. Learn effective interpersonal skills. Integrate disowned parts of their experiences through experiential techniques. Exercise their freedom of choice and implement their action plan in their lives outside therapy.

To accomplish these tasks, therapists turn to advanced intervention techniques. Intervention Techniques in High Gear Intervention techniques (as discussed in Chapter 8) are action-oriented techniques designed for facilitating change, and advanced intervention techniques put the change actions in even higher gear. They fuel your sessions with energy, power, and vitality. In particular, these advanced intervention techniques have the following characteristics: • •

The concepts at the heart of these advanced techniques are more abstract and complex. They instigate a higher or deeper level of change, not just symptom reductions or short-term change.

Advanced Intervention Techniques 191 • •

They may trigger emotionally charged materials and may reactivate clients’ deeprooted schemas. Before these techniques can be employed, a solid therapeutic relationship must have been in place, and the clients must have demonstrated readiness.

THIRD LEVEL CASE CONCEPTUALIZATION To pave the way for your use of advanced intervention techniques, this section presents the third level case conceptualization. It will help you gain a deeper understanding of the reasons why you want to use these advanced techniques. Schemas: Deep-Rooted Thought Patterns and Core Beliefs Many of clients’ emotion dysregulation and disturbances stem from deep-rooted patterns of thought and emotion, called schemas. It will take an advanced level of intervention to kick-start any change in the schemas. What is a schema? We as humans develop schemas to handle the large amount of information that we encounter every day (Bowlby, 2013). We develop schema about others, schema about the world, and schema about the self. Thus, schema embodies the deep-seated cognitive structure of our information processing. It bears some resemblance to the core belief, but is implicit in nature (Wright et al., 2017). By and large, schemas are adaptive. However, to handle difficult emotional information, some schemas employ distortions to help us survive. Distortion-filled schemas eventually become maladaptive, impinging on clients’ behavior choices (Wright et al., 2017). A major goal of the problem resolution stage of counseling is to help clients replace maladaptive schemas with adaptive ones. Please review Table 10.1 which gives a comparison between adaptive and maladaptive schemas. The Roots of Schemas Helping clients replace their maladaptive schemas with adaptive ones requires a complicated endeavor because schemas often operate under cover. This is because these implicit cognitive structures developed early in life without calling for conscious reflection. Implicit as they are, they have the power to prompt our current thoughts, feelings, and behaviors.

Table 10.1 Comparison of Adaptive and Maladaptive Schemas Adaptive Schemas

Maladaptive Schemas

“If I put my heart into something, I can master it.” “If I prepare in advance, I’ll learn better.” “I’m lovable as a person.”

“If I can’t do things perfectly, then I am to be ashamed.” “If I make a mistake, I’ll lose my control.” “To be a loveable person, I must always please others.” “I should never show my vulnerability.”

“I can learn from my mistake and be a wiser person.” “People, in general, have good intentions.” “People can’t be trusted.” “If I allow people to know me, they can better “If others really knew me, they wouldn’t like me understand me and support me.” or accept me.”

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Figure 10.1 Third Level Case Conceptualization: Schema from Its Roots to Its Perpetuating Effect

Please review Figure 10.1 for a visual reference of this process. It illustrates how our schemas, rooted in our tender young lives, become the perpetuating force for our current thoughts, feelings, and behaviors. To restructure something so implicit, we need to use our ability to understand its abstract nature and rely on advanced techniques to get from maladaptive to adaptive schemas. Examples of Early Maladaptive Schemas Entrenched maladaptive schemas can impair our emotion regulation and our functioning in relationships. J. E. Young (1999) established 18 early maladaptive schemas as the major causes of people’s suffering. In Table 10.2, we select and summarize just a few schemas that are most likely to be played out by clients. Behavior Change First, Then Schema Restructuring Will Follow Schemas, as stated in Chapter 1, have a self-perpetuating nature. These implicit cognitive structures resist change. Rather than target the schemas directly for restructuring, the counselor will have more success by using advanced techniques to help clients experiment with new behaviors. As clients’ behaviors change, a series of chain reactions will happen, leading to a restructuring of the schemas. Let’s look at the chain effect. As a rule, a reciprocal relationship exists between schemas, behaviors, and relational events (Meichenbaum, 1992); as one of these elements in the reciprocal relationship changes, the other two elements cannot help but change.

Advanced Intervention Techniques 193 Table 10.2 Frequently Played-Out Maladaptive Schemas Formed Early in Life Schemas

Beliefs

Possible Early Roots

Emotional deprivation

“My emotional needs will never be met by others.”

Emotion unavailability from the parents.

Abandonment

“One way or another, a close relationship will end, as always. I will soon lose them inevitably.”

Divorce or death of parents.

Mistrust

“Others will intentionally take advantage of or hurt me in some way.”

Childhood abuse or mistreatment.

Defectiveness

“I’m internally flawed, and if others find out about this truth, they will reject me.”

Parents being critical.

Self-sacrifice

“I must put others’ needs ahead of my own; otherwise I’m too selfish.”

The child growing up assuming parental responsibility.

Emotional inhibition

“I must keep a tight lid on my emotions and impulses; otherwise it will lead to total breakdown and utter embarrassment.”

Parental discouragement of the expression of feelings.

Unrelenting standards

“This is not good enough; I must always strive harder.”

Parental love was conditional, based on the child’s achievement.

Failure

“I’m stupid and inept. What’s the use of trying? I know I’ll fail.”

Being put down and treated as a failure in school or sports.

Source: Adapted from Cognitive therapy for personality disorders: A schema-focused approach, by J. E. Young, 1999. Sarasota, FL: Professional Resource Press.

But among the above three factors, the behaviors are the only item within clients’ control. Hence, the easiest way to initiate change in the system is to kindle a small change in the coping behavior. A therapist can help the client ignite a small change by using certain advanced techniques to direct the client into an experiential moment in the session. This small change will create a positive snowball effect in clients’ interpersonal lives. When social environments respond positively to the client’s new coping behaviors, the schemas will have a better chance to restructure themselves organically. You will feel it a privilege to see interpersonal neurobiology (discussed in Chapter 1) so organically in action. The following sections present eight advanced intervention techniques that have the power to help your client turn around at the neurobiological level. I. LIFE SKILL TRAINING The first set of advanced intervention technique is life skill training techniques. Among them, role-play and role-reversal stand out as powerful techniques for the experientially oriented as well as other approaches, not just in cognitive-behavioral therapy. This section introduces the proper use of role play and role reversal.

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Life Skill Training via a Hands-On Approach Until they build up a certain level of life skills or relational skills, clients will not reach a turnabout in their lives via cognitive restructuring. It takes relational skills to succeed in interpersonal functioning, and it takes success in relationships to reorganize clients’ cognitive structures. Given this cumulative relationship, relational skill training becomes the foundation of all therapies, including CBT. We cannot just coach client life skills by merely talking or by printed words. Clients can only learn relational skills through a circular feedback or a feedback-loop which provides both interpersonal and intrapsychic confirmation, helping them fine tune the skills (Andrews,1989). This feedback loop comes about only in a hands-on approach or an experiential approach. Two classic life skill training techniques that rely on this kind of hands-on approach are: • •

Role play Role reversal

1. Role Play Role play is a technique developed by the father of psychodrama, Jacob Levy Moreno. In this exercise, clients are given a metaphorical stage to play out their internal conflicts (Gendlin, 1998). The action—of getting in touch with internal conflicts and of playing them out—operates as an antidote to clients’ penchant for experiential avoidance (Hayes, Strosahl, & Wilson, 2011). Consider the following concepts regarding role play: It Renders Therapy Alive Instead of having clients talk about their feelings or their desires, the counselor directs clients to put into words whatever they need to express aloud. Playing out their inner forces, paradoxically, untangles their psyche. In this process, the client becomes an active agent in constructing his or her relational reality, rather than being a passive recipient. All the while, the therapy session becomes alive and energetic. You Can Tailor the Process to Meet Client Needs Once the role play is in motion, it may go in any direction. Certainly, we cannot muscle the role play to follow a predesigned path, nor can we charge it with our own agenda. But, we can tailor the process to meet the client’s needs and enhance their well-being. As we watch carefully what emerges in the moment, we can use the technique of directives to help clients tap into their inner voice. Clients Develop In-Depth Awareness During Action To really benefit clients, don’t just use role play to stage a behavioral rehearsal for a planned action. Role play has the power to help clients develop in-depth awareness during the action. Focus on the emerging awareness. Tap into it as a rich reservoir of a client’s resources. Remember: clients should not be urged to act on the new behaviors in their lives until they know what they are doing and feel adept in what they do (Nance, 1995). Prevent Clients’ Performance Anxiety Role play can be brief, taking about 5–10 minutes, instead of filling up the whole session. For some clients, role play provokes their performance anxiety—their worry

Advanced Intervention Techniques 195 about how they look or sound in playing the role. To prevent their performance anxiety, use the technique only when you have established a safe therapeutic relationship wherein the client has no worry about being evaluated or judged. Process Interpersonal and Intrapsychic Feedback After the role play, first, ask how the client feels during the action of role play. Explore any emerging awareness. Second, give clients feedback about how their skill of selfexpression comes across. Provide suggestions if there are needs for fine-tuning the skill. Here is an example of how to facilitate the role-playing and round it up with a feedback: Example 1 Client: “I probably will tell my father-in-law how much I appreciate his trustworthiness and steady guidance, which I never get from my father.” Counselor : “Janet, how about this? Let’s do something new. Try to say again what you just told me, but this time, say it directly to your father-in-law as if he were in this room. In other words, use ‘I-you’ sort of language to talk to him. Would you like to try?” Client [talking directly to the father-in-law as if he were in the room, tears flowing in her eyes]: “I have never got a chance to tell you how much I appreciate your trustworthiness and steady guidance. These are some things I wish I had got from my own father, but due to his own alcoholism, I could never trust him . . .” Counselor : “Janet, I can see how deeply you are getting into it. Your tears show a lot of grief, sadness, and relief, all at once. What kind of awareness is coming up for you?” [The therapists gives the client feedback and processes the client’s emerging awareness] Another example of role play: Example 2 Counselor : “Sana, it seems like there are so many things you would like to tell your mom. What would be the most important thing that you would want to say to your mom from your heart?” Client [replying what she would say but with no emotions]: “I would say that I think she did her best. She provided for me financially, but our relationship was emotionally bankrupt. She didn’t see that I needed my emotions to be taken seriously. There was a big part of me that felt neglected because of that.” Counselor : “Sana, let’s do it again on what you just said, but this time, we will imagine that your mom is sitting in that chair in front of us. Try to say to her what you’ve just said to me a moment ago and whatever else you have wanted to say but never got a chance. Say it as if she has the full capacity to hear you out. Would you like to try it out and see what happens?” 2. Role Reversal The role-reversal technique allows clients to see and feel something from the perspective of the other person. This is an excellent technique to facilitate perspective-taking (Chen, Froehle, & Morran, 1997). Consider the following concepts regarding role reversal.

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Train Clients to Take on Others’ Perspectives Many people in our society lack the life capacity to take the perspective of another person. They can only understand things from their own frame of reference. This results in a deficiency in information and a distorted assumption about others’ motivations and behaviors. Hence, they cannot see that other people are humans, too; they cannot see that others have human struggles and can react to the clients’ behaviors. The lack of perspective-taking skill, as mentioned in Chapter 1, inevitably leads to failure in mutual empathy—a major hindrance in interpersonal connection. By contrast, learning to look at events and others’ behaviors from the perspectives of the others can introduce a major cognitive shift—a cognitive restructuring that may help clients achieve a breakthrough in their interpersonal disconnection. Role reversal technique stands out as an effective method to help clients learn to take on the perspectives of others. Role-Reversal Requires Clients’ Imagination Skills Compared to role play, however, role reversal requires more skill on the client’s part. If clients have been engaged in a role-play exercise prior, then role reversal will be the next step for them. If the client has not tried role play previously, then role reversal might be too much of a stretch. Specifically, clients who are not used to taking on the perspectives of others may experience “stage fright.” If they lack imagination skills, they may actually come up empty-handed in their attempts to see things from the other’s perspective. Given this, don’t jump into role reversal unless you have sufficiently worked your client up to a comfortable level of role play. Make Sure a Trusting Therapeutic Relationship Has Been Established Role reversal should be implemented with much prior consideration. A solid therapeutic relationship must have been secured before we can engage the client in a role-reversal exercise. Without this, clients might be plagued with performance anxiety; worrying about how you might evaluate or judge their skill execution. Process Interpersonal and Intrapsychic Feedback After the role reversal, first, ask how your client feels during the action of role reversal. Explore any emerging awareness. Second, give clients feedback about how their ability to take on others’ perspective comes across to you. Provide suggestions if there are needs for fine-tuning the skill. The following is an example of the steps you can take to facilitate role reversal when the above conditions are met. Step 1: — “Janet, we’ve talked about the emotional absence of your father, Andy, for quite a while now. There’s a deep sense of loss in your heart because of your experience of being unable to feel close to him in your life. I was wondering whether we can do an exercise to see things from his side. Last time you did extremely well in the role-play exercise. This time we’ll stretch it a little bit. Would you be willing

Advanced Intervention Techniques 197 to play the part of your father? Would you be willing to put yourself in the role of your father and see things from his side?” Step 2: — “Great, if you’re ready, Janet, allow yourself to close your eyes first. Loosen up tight muscles of your body. Slow down your mind and concentrate on your breathing (Pause). Slowly feel your way into the role of your father. Imagine being your father. Imagine how he walks, how he talks, what his tone of voice sounds like. Wait until you can feel the energy. See what vibes come through. Focus on the energy. Stay there a little longer. When you’re ready, open your eyes. (Pause) Now you’re in the role of your father; you are Andy.” [Using a series of attention suggestion directives to guide the client into the reversed role] Step 3: — (Counselor speaking to the client in the role of her father) “Andy, your daughter Janet has struggled with a lot of loss in her life—one of which is that she has yet to feel close to you. Perhaps you can try this: say something to Janet about yourself that she might not have known about you. It will help her a lot in resolving her grief.” [Guiding the reversed role to talk] Step 4: (If the father, played by the client, gets nervous or starts to talk to you, coach “him” a bit and direct him to get in touch with the part of his life that his daughter has no knowledge of. Just direct. Avoid asking questions of him.) Step 5: (Counselor continues to coach the father to share his side of the stories until the client’s body shows a sense of energy relief ) Step 6: (closing) — “Thank you, Andy, for telling your side of the story! This has been very helpful. We’ll invite you to join the session in the future if we need your help again. Peace be with you!” [Thanking the reversed role] Step 7: (feedback and processing) — “Janet, you may revert back to yourself now. (Pause) I’m so touched by your willingness to try this new exercise. Let’s process a little bit about how it feels to see things from your father’s perspective, and what insights you’ve gained from this experience.” II. MINDFULNESS TRAINING FOR SCHEMA CHANGE The second set of advanced intervention technique is mindfulness training—a frequently used technique in Acceptance and Commitment Therapy (Hayes et al., 2011) and in many other therapeutic approaches.

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Practice Mindfulness When Maladaptive Schemas Are Triggered To help clients replace maladaptive schemas with adaptive ones, we can apply mindfulness practice with them in the session. Mindfulness practice stands out as an effective antidote for people’s tendency to go into “automatic pilot” modes of functioning in relationships and in life. Consider the following concepts about stress, maladaptive schemas, and mindfulness training: Stress Tends to Trigger Maladaptive Schemas Stress can pull a trigger on clients’ maladaptive schemas, skidding them into emotionally charged reflex responses—such as lashing out at others, blaming and accusing, or shutting down all at once—which inevitably hurt others’ feelings or push them farther away. Once their schemas are triggered, clients often cannot think objectively—as if they lapse into their short circuits. The schemas are literally acted out following their old life scripts. Use Mindfulness to Rewire Schemas, to Stay Calm When Triggered Mindfulness practice stops the client’s knee-jerk reaction in its tracks, replacing it with more mindful and conscious responses. Practiced over and over, mindfulness can slowly rewire clients’ schemas, helping them stay calm when triggered (Germer, Siegel, & Fulton, 2016). With this technique, we help our clients reach their own inner resources to come up with solutions to the problem without advice-giving. Watch One’s Own Thoughts and Feeling without Judgment What makes mindfulness so effective? In mindfulness, I (Mei) sort of watch my own thoughts and feelings, allowing them to go in and out, without judgment, attachment, or control. It exudes a quality of inner acceptance and self-nurturance; it’s nourishing to the tired body, the overworked mind, and the weary soul. We reach inside to connect to our own inherent resourcefulness. Mindfulness also yields a novel variety of self-awareness unlike that which is derived from self-examination and self-reflection. It is a kind of awareness, sweet and expansive, of our unbroken connection to our Divine Sources. This deep sense of acceptance and connection allows us to let go of the old schemas that we hold dear, making way for transformations of thinking, feeling, or behaving. Slow Down Is the Key of Mindfulness In mindfulness training, we need to teach our clients how to slow down to the tranquil speed of loving-kindness. As clients slow down, they are afforded an opportunity to connect to their inherent strengths and make wiser, more resonant behavioral choices. When we bring mindfulness to clients’ relational reactions, we give them back their freedom of choice. How to Coach Clients to Use Mindfulness As a New Response Repertoire The best time to teach clients mindfulness practice is when they are exposed to relational stress and tension. The following example illustrates how to teach a client to develop a new schema through the use of mindfulness practice.

Advanced Intervention Techniques 199 Step 1: — “Joe, I can see that you’re still all keyed up by the tense exchange you had with your boss. This might be a good time to try something new, called mindfulness practice. Would you be willing to try? Step 2: — “Okay—Great! It might be a bit unusual, but please uncross your legs for a moment so your energy can flow more freely. Now, if you’d please do this together with me: Take a deep breath down into your belly and feel it expand (Pause). Now slowly let it out and feel your belly sink in (Pause). Yes—just like that! Again— into the belly, and out very slowly (Pause). Let’s continue this breathing until you feel more grounded within your body.” [Using breathing retraining directives to guide the client into a relaxed state] Step 3: — “When you feel grounded, please close your eyes. At the same time, allow your breath to deepen a little (Pause). Now, as you breathe in, imagine that you’re breathing in fresh-loving air to your heart. As you breathe out, you’re breathing out angry-hurt-dark feelings and thoughts (Pause). As you breathe in, you’re breathing in trust and relaxation to your heart. And as you breathe out, you’re breathing out the feelings of self-righteousness and contempt for others into the air. Repeat this a few times.” (Allow sufficient time for the client to do this.) [Combining breathing retraining with imagery] Step 4: — “As you continue doing this cleansing breathing, you’re going farther to acknowledge that you have the power to make choices in daily living and that your choices impact the way other people respond to you, and vice versa (Pause). You realize that you have the power to create a favorable social environment when you slow down and use the healing breath to access the wiser you to generate kind, calm, and respectful choices.” [Planting the concepts of choice theory in the client’s mind] Step 5: — “Now repeat silently in your mind the following sentences: ‘I have the power to make choices in daily living. My choices do impact other people’s response to me. I have the power to create a favorable social environment when I slow down, and I have the choice to use the healing breath to come up with a kind, calm, and respectful responses.’” (Pause as long as it is needed.) [Self-affirmation training, see later section in Experiential Teaching] — “Stay in this place for a moment; let all the tranquility and peace at this moment soak in.” Step 6: — “From this calm and peaceful place, now go back to the scene where your boss was giving you corrective feedback. You can feel rage rise inside you. You can

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Advanced Intervention Techniques hear a voice inside your head screaming, wanting to lash out your anger, but you stop yourself in its track. You take a deep breath in and out and reconnect to your inner calm and peace. You come up with a different way to respond to your boss. You tell him what you need from him in a calm and respectful way (Pause). You feel proud of yourself for the new responses. You feel a surge of self-respect and confidence (Pause). Stay in this place for a moment (Pause). When you’re ready, open your eyes.” [New response retraining]

Step 7: — “Okay. Joe, you’ve tried something heroic today. Let’s process a bit how you experience this mindfulness practice.” [Feedback and processing] Consolidate New Responses After the mindfulness practice, we can consolidate the client’s newly ascertained response through a technique which I call behavior consolidation. I believe that real-life behavior change will not happen until after the new behavior has been tested, rehearsed and repeated for enough times during the session. This is why methodic practice and overlearning make a difference when learning a new skill. Methodic practice ensures that the new skills become second nature, available to clients even when under stress. It usually takes a while for new mindfulness to take root in clients’ relationships and to release clients from the tight grip of their old way of thinking and behaving. Mindfulness practice is a rather complex set of skills; it takes time and commitment to arrive at mastery. Consider the following illustration: Step 1: — “That’s wonderful, Joe. Would you like to elaborate a bit about what new realizations have come up in this mindfulness exercise?” Step 2: — “Wow! That sounds like something, Joe. I just know you can do it. You can make new choices. Now, to take it one step further, let’s check out what new ways of talking to your boss you’ve come up with during the mindfulness exercise. I’m going to role-play your boss, who’s giving you a hard time, with some kind of corrective feedback. This might trigger your anger and self-righteousness reflex. As it does, go back to the belly breathing and practice stopping the reflex in its track. Then talk to me, your boss, in the new way that you’ve come up with during the mindfulness practice. Okay? Let’s start!” [Therapist explains the exercise about the interactive role play] Step 3: (Client starts to role-play, in the session, the new response to the boss) Step 4: — “Fantastic, Joe. Your new ways of communicating are dramatically different from your old style. I’m very proud of your enormous achievement. If I were really

Advanced Intervention Techniques 201 your boss hearing this, I’d certainly receive it more readily and be more willing to consider your needs. I just have a little suggestion about some minor fine-tuning of the responses. Would you like to hear it?” [Encouraging the client’s action; asking permission for giving feedback] Step 5: (The counselor provides observations and helps the client fine-tune the responses.) [Processing and giving feedback] Loving-Kindness Meditation for “The Child-Self” Here is another mindfulness practice that has the effect of helping clients achieve a higher level of emotion regulation and behavior change, which I call the “lovingkindness meditation for the child-self.” In this practice, I combine mindfulness training with the concept of the child-self from transactional analysis theory (Berne, 2015; Summers & Tudor, 2000). Transactional analysis theory proposes that we are psychologically structured with three parts of self: the parent self, the adult self, and the child self. The parent-self behaves, feels, and thinks like a parental figure; the adult-self behaves, feels, and thinks in rational and realistic ways; and the child-self behaves like a young child (Berne, 2015; James & Jongeward, 1996). Our child-self embodies a precious part of our presence—not only as the source of emotion, creation, and spontaneity, but also as our source of vulnerability, needs, and desperation. Our child-self may still long for approval and love if we did not receive it in early life. In therapy, we can encourage the client’s child-self to have a voice, and then enlist the client’s adult-self to take action to reparent the child-self. The aim is to create an internal relationship wherein the child within feels affirmed, validated, or protected. In this mindfulness practice, we guide the client to send the loving and kind blessing and message to her child-self that needs reparenting. This mindfulness practice, again, uses clients’ own inherent resources to provide resolution to their problems. Here is how we can do this: Step 1: — “Susan, we’ve talked about using self-parenting to rewire your relational pattern for the past few sessions, and you’re making headway. I’d like to introduce another practice to see whether it might enhance your re-parenting. Would you like to try it?” [Introducing the activity] Step 2: — “Great! Let’s create a safe environment for your child-self to have direct contact with your adult-self. If you’re ready, close your eyes. Become aware of your breathing. As you exhale, let the muscles all over your body release their tension. Relax into the present moment.” [Using Body Awareness directives to prepare the client] Step 3: — “Now bring your attention to your heart center. Let your breath be soft and relaxed. Breathe into and out of your loving heart. Imagine your heart as a safe

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Advanced Intervention Techniques place, a sanctuary (Pause). Now bring the image of your child-self, the child Susan, into your heart. Imagine your loving heart as a safe home for your tender childself.” [Contacting the child-self]

Step 4: — “Now begin to send a loving-kindness message to this child-self. Using a confident and gentle voice, repeat the following message: ‘I will be here for you. You can feel safe with me next to you. I will listen to you whenever you need an ear. I will accept whatever you’re feeling without judgment. Together we will overcome any fear, loneliness, or distress. You can be who you truly are without trying to be someone else. I love you, and I treasure your presence. May you be peaceful! May you be filled with loving-kindness’ (Pause). Use whatever words that work for you. Repeat them silently to yourself several times.” (Allow a few silent moments for the client to complete this step.) [The adult self-nurturing, affirming and validating the child-self] Step 5: — “As the meditation comes to an end, sit for a few minutes longer. Take in the feelings of love and warmth in your heart center. Remind yourself that you can always nurture this child-self of yours whenever you feel a need coming up. (Pause) When you are ready, open your eyes.” [Slowly wrapping up] Step 6: — “Susan, it looks as if you are waking up from a dream in another world. Welcome back! Let’s use a moment to process what it was like for you to get into contact and nurture your child-self with loving kindness. What it was like for you to do this for yourself?” [Processing and feedback] Step 7: — “I am so happy with your new realization and feelings emerging from this meditation. You did so beautifully even though this is your first time. I am thinking, it will be very reassuring for your child-self if you would get in touch with her and nurture her regularly. So, would you do this during the week? Take 5 minutes each day to do this meditation in your own way, as long as you are telling your child in your own loving and validating words. Would you like to try it for a week?” [Take-home practice] Cultivate the Observer-Self I would be remiss if I did not conclude in this section of mindfulness training the concept of the observer-self (Deikman, 2002; Thesenga & Pierrakos, 2001; Whitfield, 2015). Outside of the parent-self, the adult-self, and the child-self within us, we also have an observer self. The observer-self represents our higher self who can step back and observe what is happening in our lives. The observer-self epitomizes a benign witness to our inner processes and outer events. It simply observes whatever comes across the screen of our awareness, without judgment. The observer-self accepts messages from all sources,

Advanced Intervention Techniques 203 including the unconscious, bringing new information about ourselves to our awareness. The observer-self remains another inherent resource lying dormant within the client, waiting for us, the therapists, to discover and mine. The growth of the observer-self is a sort of benchmark, indicating the client’s higher level of consciousness is expanding. Instead of responding to the floating fragments of their consciousness and falling victim to the reflex of their impulses, clients—through mindfulness training and mutual empathy training—start to shift to a new stance where they can notice what they are experiencing at the given moment and respond in new ways. Clients hone the skill to pause, think, and make conscious choices before responding. This brings about more favorable responses from others, which in turn leads to clients’ schema reformation. Cultivating this observer-self helps to carry a kind of process comments in the back of the client’s mind, similar to having a therapist next to her—a priceless mechanism for self-regulation. Emerging from this growth of the observer-self is a more empowered and empowering person who embodies increased mindfulness, accountability, serenity, and creativity in his or her various levels of being. III. GUIDED IMAGERY AND THERAPEUTIC SUGGESTIONS The third set of advanced intervention techniques is guided imagery and therapeutic suggestions. Counselors and therapists have used guided imagery to direct clients’ thoughts and imagination toward a relaxed, focused state wherein they can plant therapeutic suggestions. This indirectly changes the schemas (Battino, 2007; Hall, Hall, Stradling, & Young, 2006; Schoenberger, 2000). At the heart of the technique of guided imagery is this notion: our body responds to what we imagine as real. Therefore, if we guide clients to create a mental image wherein they live on the new level of well-being, then their behaviors and thought patterns will respond to realize the mental image. Thus, their schemas are reprogramed. The reprograming power of guided imagery comes from its ability to put us in a state of receptivity, allowing therapeutic suggestions to take root in the soil of the clients’ psyche without resistance. What are therapeutic suggestions? These are impressions that we introduce to clients’ mind while they are in a relaxed state in order to help them creatively resolve their problems. It is only when in a relaxed state that clients can receive therapeutic suggestions without engaging their hyper-critical thought process. The techniques of guided imagery, when coupled with therapeutic suggestions, help to promote schema change. In the following, we introduce two guided imagery techniques accompanied with therapeutic suggestions. 1. Guided Imagery for Reprograming Self-Schema The first guided imagery aims at rescripting clients’ schemas or beliefs about their self. The following procedures illustrate how I usually go about it, but you can create your own: Step 1: — “Peter, these memories and images about yourself being a hopeless and powerless victim seem to hold you hostage. So, let’s try something to release their control on you. It is an exercise called guided imagery where I will guide you through a series of images. Would you like to try it?” [Introducing the exercise]

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Step 2: — “Great! If you’re ready, close your eyes. Focus on your breathing for now and notice any tight spots in your body. As you inhale, breathe in calmness and peace. As you exhale, breathe out all the tension and worry (Pause). Allow yourself to deeply relax, to deeply accept all parts of your experience” (Pause for a few minutes). [Preparing the client to get into a receptive state] Step 3: — “Now, in your relaxed state, try to come up with vivid pictures in which you are strong, tall, assertive, ferocious, and resourceful. Try to feel how it feels in your body—this sense of strength and assertiveness. Stay with this feeling until you’re so familiar with it that you can snap back to that feeling at any moment.” (Pause for a few minutes) [Reimaging the client’s belief about his self] Step 4: — “You’re doing great, Peter. Now, in your imagination, let’s go back to that memory in the school yard. This time, try to come up with vivid pictures in which your bully is weak, small, and stupid.” [Reimaging the client’s belief about the oppressor] Step 5: — “You’re feeling strong and tall. And you’re seeing your bully coming closer and closer to you. The closer he comes, the more he shows just how small and weak he really is. Try to come up with vivid pictures where you see very clearly that you’re asserting yourself in a calm, respectful and confident way, standing tall, firm, and strong for yourself. See yourself triumph over the scene.” (Allow a few minutes for the client to engage in the imagery.) [Reprograming the encounter of the client’s new self with the diminished oppressor] Step 6: — “Register the way that this ‘new you’ feels in every part of your senses. (Pause for a moment.) When you’ve soaked up that feeling in your body, you may open your eyes.” [Strengthening the new sense of self through the somatic sensations] Step 7: — “Fantastic, Peter! Let’s process a bit how you experienced this exercise.” (The therapist and the client process a while about the experience.) [Processing] Step 8: — “I’m so proud of you, Peter, for your ability to see so clearly your strengths that have been hidden inside you. Now let’s test-drive a bit of this new you, the new Peter with the newly recognized qualities that you’ve experienced in this imagery. Okay, let’s say that someone is curious about your life during your middle school time and wants to interview you. What kind of story would you tell about yourself this time?” [Behavior consolidation, see the previous section]

Advanced Intervention Techniques 205 2. Attending Your Own Funeral Some people find this guided imagery as macabre, due to the images of funeral and death involved, but this guided imagery can actually help clients restructure their value systems. We often hear people ask others the following question to help them reevaluate the value system they live by, “If you only have one week to live, how would you live your life differently?” This guided imagery also engages and modifies client’s value systems, especially when clients are stuck in their own thinking or behavioral pattern due to a misguided value or belief. We can use this exercise to help them claim a new perspective, awakened to a new realization. This, again, utilizes clients’ inner resources to help them reach their goals. Here is how this exercise might go: Step 1: — “Russell, I have a feeling that we seem to be stuck in the same place where obsession is still a concern. I’d like to introduce you to an exercise where I will guide you into a relaxed state and then guide you to have a fresh perspective on what you really want your life to represent in this world. Would you be willing to try?” [Dealing with here-and-now issue. Introducing the exercise] Step 2: — “Great! Let’s see what fun we might have. Close your eyes when you’re ready (Pause). Focus on your breathing for a moment. Put aside all the stuff that you’re worried about. Just ride the waves of your breath. If your mind wanders, or if any emotions arise, just notice them. Just watch them come and go like passing clouds. Don’t try to analyze them, and don’t try to push them away either. Just notice them without any judgment. Always come back to focus on your breathing (Pause). Allow yourself to deeply relax, to deeply accept all parts of your experience” (Pause for a few minutes). [Preparing the client to get into a receptive state] Step 3: — “Now imagine that for some indescribable reason, you’ve died, but strangely enough, you’re able to attend your own funeral, albeit in spirit. This may stretch your imagination a bit, but be creative and let your imagination have a free rein, like having an out-of-body experience.” [Guiding the imagery about self in his own funeral] Step 4: — “Now, in the funeral, your family members, your friends, your students, and your colleagues are preparing to begin the eulogies about you. Imagine that you are with these people in your funeral but are unable to speak to them, unable to do anything anymore, except to be there in spirit” (Pause). [Guiding the imagery about others in his own funeral] Step 5: — “Now, try to visualize what you’d like your children to say about you as a father; what you’d like your wife to speak about you as her husband; what you’d like your students to say about you as their teacher; what you’d like your friends to speak

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Advanced Intervention Techniques about you as a friend (Pause for a few moments). In other words, concentrate on what you actually would like to be remembered as a husband, a father, a friend, a teacher, a colleague” (Pause for a few moments). [Guiding the imagery about what the client would like to be remembered by people in his life]

Step 6: — “Now the eulogies have started, and you’re listening attentively to what is being said about you. One by one, they’re recounting what they remember about you. Focus on the listening. Allow what they say about you to register in your mind (Pause for a few moments). Keep a mental note about what strikes you the most when you hear their actual eulogies.” (Allow for a few moments to pass.) [Guiding the attention to the impact of the eulogy messages on the client] Step 7: — “When you get a good sense of what strikes you, contemplate the impression for a moment. When you are ready, we will end this imagery exercise and you may open your eyes.” (Pause for a moment) [registering and slowly wrapping up] Step 8: — “Thank you, Russell, for going all the way through this exercise. I understand that it must be weird to attend your own funeral, but I’m curious, what stood out when you heard their actual eulogies? Any differences between what you want to be remembered for and what people actually commented about you?” [Processing] Continue to process with the client about what this exercise evokes. Explore with the client any new perspective as well as any change of values. In future dialog, you will nurture any change of values that the client gains. IV. EXPERIENTIAL TEACHING The fourth set of advanced intervention technique is experiential teaching. Experiential teaching uses directives (see Chapter 8) to coach clients on how to tap into their own inner resources and strengths to reach resolutions to their problems from within. In an active, energetic, and creative way, this technique helps your client with building skills, self-empowerment, and integration. 1. Self-Affirmation Training Many people grow up in an invalidating environment wherein their primary emotions are constantly ignored or criticized. These invalidating experiences become internalized and take shape as schema. As adults, they continue to feed themselves with invalidating self-talk even after they have struggled to change it (Koerner, 2012; Linehan & DexterMazza, 2008). Examples of invalidating self-talk follow: — “I shouldn’t have reacted so strongly when he did not call back. Now I look like a shitty person.” — “I should have gotten over it by now. What’s wrong with me?” — “Why these emotions right now? Why can’t I control myself?” — “Wow, she must think I am such a burden. I shouldn’t have asked for help moving.”

Advanced Intervention Techniques 207 — “I shouldn’t feel depressed when there are people who have so many more problems than I do. I ought to be grateful.” — “So, I am lonely. It’s really not a big deal. I don’t want to be a big baby.” Invalidating self-talk is just as devastating as invalidating comments from the social environment. With these clients, we can use an experiential teaching technique called self-affirmation training. In this technique, we use directives to coach our client to change the way they talk to themselves. We help them to put on a new record of self-talk that is more selfvalidating, self-soothing, and self-affirming. An example of self-affirmation training: Client: “I shouldn’t have reacted so strongly when he did not call back. Now I look like a shitty person.” Counselor : “Valentina, I can sense how upset you feel. You regret lashing out at him.” [Empathic response, as covered in Chapter 4] Client: “I should have gotten over it by now. What’s wrong with me?” Counselor : “Valentina, your feelings really matter. We have talked about how important it is to refrain from invalidating your own feelings. It is happening right now.” [Here and now technique, as covered in Chapter 9] Client: “I want to be able to control my emotions. I just wish I could talk myself out of them.” Counselor : “Valentina, let’s try not to disconnect from those emotions too quickly. How about this? Let’s focus on your feelings. Observe and describe what is happening inside.” [Basic intervention—attention suggestion as covered in Chapter 8] Client: (calming down) Counselor : “Would you like to learn how to be compassionate with yourself when these emotions are triggered? [Client nodding] Great, let’s try a self-affirmation exercise.” [Initiating the self-affirmation exercise] Counselor continues: “OK, whenever you feel overwhelmed with negative emotions, try to say the following statement to yourself, ‘OK, I feel panic about this. I feel a lot of emotions, and that is OK, that is totally normal. It may take a few days to move through this, but it will pass, I can take care of myself.’ Can you use your own words to reiterate this statement?” [Self-affirmation training] Client: (practicing the self-affirmation statement) Counselor : “You are doing great. Now, let me give you a scenario and see what you would say to validate yourself, OK? Here is the scenario . . .” Client: (role-playing the new skill of self-affirmation) Counselor : “Valentina, that is excellent. We are almost running out of time, but before we close, let’s process how you experienced this exercise.” [Processing] Other examples of how to model self-affirmation statements: — “Paige, try on this sentence, ‘Just because it feels awful right now, that doesn’t mean I will always feel awful.’ ” — “Hugo, please try on this statement, ‘I can get past this even though it is going to take some time and effort on my part. It will be worth it. I will take care of myself.’ ”

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2. Reowning and Reclaiming Training From a Gestalt therapy perspective, clients unknowingly perpetuate their problems via their habits of disowning and disallowing. After a lifelong practice of disowning and disallowing, they can lose their ability to integrate their feelings and needs into their whole. Hence, disowning and disallowing serve as the leading mechanisms that perpetuate a person’s suffering (Elliott & Greenberg, 2007; Greenberg, Rice, & Elliott, 1996). What is it that gets disowned? Some examples are: • • •

Negative emotions Vulnerability The child within

We can use directives to train clients to reclaim fragmented or disowned experiences. As the disowned become reclaimed, the person gains greater energy, richer feelings, and greater capacity for love, work, and play. This integration creates a more robust individual who has the wherewithal to experience life more in its fullness, for better or for worse. How do we carry out the reowning training? First, it is necessary to bring awareness to the client regarding how they have disowned some segments of their selves and the resulting fragmentation that gives rise to inner tension. Second, use directives to suggest ways of integrating the disowned part back to the whole. Through reclaiming and integration, schemas can be organically restructured. Due to space limitation, we will illustrate only the second part of the training: using directives to suggest ways of integrating the disowned part back to the self: — “Rita, next time when you feel lonely, instead of using food to stuff down the loneliness inside you, become a good friend with that lonely part of you. Listen to that part of you. Ask that part of yourself what it is trying to tell you.” — “Jack, give a voice to that little boy within yourself—the little Jack. With the little Jack’s voice, try to talk to your father and express your revulsion.” — “Adria, tell the little girl inside yourself, ‘It was not your fault. It wasn’t your fault that Daddy did what he did.’ Tell that part of yourself from a place of adult conviction and power.” — “Rorina, it seems that there’s still unfinished business between you and the person who caused you to believe that you’re powerless and helpless. It seems like it’s still affecting you today. I want to suggest that you do the following: From the position of the adult within you, try to write a letter to that person. Don’t send it out. Just try to write this letter from the part of you that is strong, resourceful, and firm.” V. PARADOX The fifth set of advanced intervention techniques is a paradox. The paradox also uses directives, but for a unique purpose. Symptom Prescription As a Treatment In the technique of paradox, you ask the client to do something that seems to contradict the common sense of what is expected to be done in the therapeutic setting. Similar to reverse psychology, as you prescribe a negative behavior for the client to carry out, you surreptitiously wish the clients to rebel (Weeks & L’Abate, 2013).

Advanced Intervention Techniques 209 Paradox often involves asking clients to intentionally produce symptoms. By trying to produce the symptoms, instead of fighting them, the client paradoxically gains more control over the symptoms. Thus, the paradox surprisingly brings out a triumph otherwise unavailable to the client. Examples of Paradox Technique The following examples illustrate how to use paradox to bring about client change: — “In the coming week, try to produce your anxiety twice a day.” — “It’s clear that you’re worried about the problem all the time. During the week, try to consolidate your worry time. So every day from 8:00 to 8:30 am, sit alone and do nothing but worry about this problem. During the day if you start to worry, take notes about what you’re worried about. At 8:00 am the next day, concentrate on worrying about this problem that you took notes on. Make sure that you have worried about the whole problem.” — “I’m concerned here that you’re changing too quickly. Try to slow down your progress.” — “Because you can’t decide whether you want to commit to your girlfriend or not, try to postpone making the decision as long as you can.” — “I have an idea. Let’s have a debate. I’ll argue that you don’t really have a problem and don’t need to change. And you’ll argue the other side, that is, you do have a problem and do need to change. So your job is to convince me that there really is a problem here. Okay?” VI. INTERVIEWING “THE INTERNALIZED OTHER”— A NARRATIVE THERAPY TECHNIQUE The sixth advanced intervention technique is “internalized other interviewing”—a narrative therapy technique developed by Dr. Karl Tomm, a professor in the Department of Psychiatry at the University of Calgary (Haydon-Laurelut & Wilson, 2011.) The Therapist Interviewing a Referred Person Absent from the Room In this technique, the therapist interviews a referred person—not present in the room—with whom the client has some significant association. The client might have talked about this specific person for a while, but no insight can be reached. Rather than continue to talk about the referred person, the therapist chooses to talk to that very person directly, albeit through the client’s internalized representation of the person. Thus, the technique is named “internalized other interviewing.” This technique collaborates with the client’s inner resources. Through this atypical interview, the client may deconstruct their problematic way of seeing things while coconstructing a new relational reality where healing and wellness can happen. This represents a refreshing way to conduct Narrative therapy, off the beaten track of the well-known narrative techniques such as externalizing the problem, the exceptions, the preferred outcomes, etc. (Parry & Doan, 1994; White & Epston, 1990). Similar to, Yet Different from Role Reversal Similar to the technique of role reversal, internalized other interviewing can deepen the client’s empathic understanding of another person’s experiences and perspective (Burnham,

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2000), resulting in mutual empathy from which the client, the relationships, and the actual others can all benefit. Yet, begging to differ from role reversal, this technique allows the therapist to interview “the other person” (played by the client). Through the dialog between the therapist and “the other person,” new opportunities start to open up in which the client can reconstruct the meanings of her relationship with the other person. The interviewing has nothing to do with gathering information from “the other person.” What the therapist aims for is a dialog with the other person through which the client’s observer-self may deconstruct the misunderstanding and reestablish new understanding and a new meaning of the relationship. Methods of Conducting the Interview Obviously, not many clients understand the concept of their internalized representation of an actual person in their lives; hence, the therapist has some work to do. We have to explain the concept to clients and prepare them for how it might feel to talk in a way as if they were this “other.” Clients who are concrete in their information processing style might have difficulty getting into this technique. Not everyone passes as a suitable candidate for this intervention. But if clients have tried the role reversal exercise previously, they will feel at ease with this new technique. To help the client become grounded in the identity of “the other”, the therapist might start with a brief round of guided imagery. Step 1: — “If you’re ready, Colleen, close your eyes first. Slow down your mind and just concentrate on your breathing (Pause). When you feel centered, slowly feel your way into the father that you know from your heart. Imagine being your father, being Tom. Imagine how he walks, how he talks, his tone of voice. Wait until you can feel it. See what energy or impulse comes through. Give me a signal when you can feel his energy.” [Inducing the role of the internalized other] Step 2: — “Okay, you may open your eyes. I am now going to talk to you as Tom (Pause). Tom, thank you for giving me the opportunity to interview you! Your daughter, Colleen, has talked extensively about you in the session. I thought it might be helpful for me, as her therapist, to have a conversation with you in person. Do you mind if we have a bit of conversation so we can get a clear view from your side?” [Asking for permission from the internalized other for the interview] Step 3: (Therapist proceeds to interview “the other”, blending empathic skills and probing questions to gain access to the person’s inner experiences and perspective. The duration of the interview varies, but it is usually no less than 15 minutes) — Please note: Just as in any typical therapeutic interview, we have to nurture each of the internalized other’s statements or disclosures by responding with empathic or reflective comments. When ending the interview, we may want to say goodbye to the internalized other and close with a brief processing with the client.

Advanced Intervention Techniques 211 Step 4 (after 15 minutes of interviewing the other): — “Tom, I really appreciate your willingness to share this personal information with me. It’s been very helpful to get your perspective. If, in the future, I need to have a follow-up with you, we may talk again. For now, I just want to say ‘goodbye’ and ‘thank you!’ ” [Ending the interview] Step 5: — “Okay, please close your eyes and come back to yourself, Colleen. When you are ready, please open your eyes. Colleen, first of all, thank you for allowing me to interview your internalized father. You did a very good job of staying with his identity. We still have a few minutes left for today; let’s process a bit of how you experienced this exercise and what you have taken away from it. Would you start by sharing what you are experiencing right now?” [Processing and pursuing the new perspective that the client gets through being in the role of the other] VII. PART DIALOGUE: WORKING WITH POLARIZED PARTS The seventh set of advanced intervention technique is part dialog. What does “part” mean? Splits—Polarized Parts—and Internal Tension Incomplete experiences in life can lead to splits, or polarized parts of self. Polarized parts represent forces within clients that compete with each other. For instance, a part of a client gets furious, while the other part condemns the anger. Splits often stem from introjections, such as “Real men don’t cry” and “Good girls don’t get angry”—beliefs that have been internalized wholeheartedly without being evaluated and contemplated (Kellogg, 2004). For instance, the part of a client that condemns anger may stem from childhood due to a parental rule against feelings. Polarized parts create a noticeable internal tension and struggle (Greenberg & Watson, 1998; Pascual-Leone & Greenberg, 2007). If they are not integrated into the client’s consciousness, splits cause unexplainable anxiety and incongruent behaviors. These inner conflicts then grow into rifts, damaging interpersonal relationships while eluding the client’s understanding. How to Use Parts Dialog to Facilitate Integration of Splits When noticing splits or polarized parts in clients, therapists can use Parts Dialog to facilitate integration. Here, the therapist put the polarized parts into direct dialog with each other. At the end, the client usually becomes more aware of the dichotomy in their inner experiences, and therefore more able to negotiate between the two parts, arriving at a certain level of integration. Consider an example from Daldrup et al., 1988, p. 124. Example Counselor : “Feel the struggle in yourself between the part of you that flushes with anger and the part of you that follows your father’s rules.” Client: “That’s exactly it—I feel pulled in both directions.”

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Counselor : “Okay . . . I’m going to ask you to change the experiment. Would you speak from each of those parts of yourself to the other part? (Setting up two chairs facing each other) Start in either place.” (Daldrup et al., 1988, p. 124) Following are examples from Greenberg et al. (1996): — “It sounds like you are experiencing a kind of argument between two different parts of you. The purpose of putting the two parts in different chairs is to bring this inner dialog out into the open.” (p. 131) — “Okay, I am going to suggest that we put two sides of your struggles in different chairs. Presumably, you have never bounced around in chairs before and there may be some self-consciousness about it, but let’s just set it up and see where we go, okay?” (p. 128) — “Will you change chairs and tell her how you react to her criticisms?” (p. 129) — “The next thing is to take a minute and ask yourself: ‘What is this feeling all about?’ ” (p. 129) We offer more examples of Parts Dialog: — “You’re talking about two parts of yourself—the responsible Joe and the wandering Joe. The responsible part of Joe wants to settle down and give your fiancée a sense of security, and the wandering part of Joe just wants to keep having affairs. How about this? Try to have the responsible part of Joe talk to the wandering part of Joe about this problem.” — “Rasa, I’m going to put another chair beside you. When you hear your inner voice of fear, talk from the chair where you’re sitting. When you hear your inner voice of self-assertion, speak from this chair.” — “Here are two puppets, Irene. Put a puppet on one of your hands to represent the good girl part of you and put the other puppet on your other hand to represent the bad girl part of you. Have them talk to each other about how you feel about your dad.” — “Saari, it seems like you have two parts of yourself that are tearing you apart. It’s like your mother standing on one side of your shoulder saying ‘Take it easy’ while your father is on the other shoulder saying, ‘This isn’t good enough; work harder!’ Here are two chairs. Sit in one and speak from the part of you that believes in your mother. Then move to the other chair and let the part of you that believes in your father’s statement speak.” — “Yoki, let’s take those sad feelings and mad feelings, put them in each of these chairs, and have them talk to each other. It may feel a little awkward, but let’s just try it and see what will come of it.” VIII. THE EMPTY CHAIR TECHNIQUE: MUTUAL EMPATHY TRAINING The Empty Chair technique—also called the Two-Chair Dialogue—triumphs as the most celebrated technique in Gestalt therapy (Daldrup et al., 1988; Greenberg et al., 1996; Leitner, 2007). At present, it also prevails in other therapeutic approaches and is the eighth set of advanced intervention technique that we will present.

Advanced Intervention Techniques 213 The Four Components of the Empty Chair Technique Boiled down, the Empty Chair dialog actually incorporates four previously presented techniques: • • • •

Role playing Role reversal Interviewing the internalized other Experiential teaching

Understanding these above-listed techniques is a prerequisite for any therapist who wishes to implement the Empty Chair dialog. Empty Chair Technique As a Monodrama The Empty Chair technique actually originates from psychodrama—a type of experiential therapy that uses deep action methods to explore and work through issues identified by clients (Dayton, 1994, 2005; Moreno, 1946, 2005). Unlike a typical psychodrama wherein manifold individuals participate in the healing action, the Empty Chair requires only one client, thus, it has another moniker—monodrama (Chen & Ryback, 2017). The Empty Chair technique engages the client in playing two persons by moving between two chairs, taking on two different perspectives. It is the technique of choice when a client needs to resolve certain unfinished business. When conducted properly, it has the kind of power to provide clients with the corrective emotional experiences (Alexander, 1980; Yalom & Leszcz, 2005) no other techniques can match. Like the role-reversal, the Empty Chair technique requires a client to use their imagination to step into another person’s inner world. Not every client will feel up to it, but if your client has done the role-reversal exercise presented in the previous section, the Empty Chair technique will be a breeze for her. Unfinished Business The notion of unfinished business consists of unresolved issues from our past, or something that continues to haunt us (Greenberg & Pascual-Leone, 2006). It may include unexpressed feelings associated with certain events or memories—loss, grief, resentment, anger, hurt, pain, or guilt—any feelings not fully experienced or processed. Whatever remains unfinished or incomplete tends to consume our psyche to the extent that the unconscious mind tries to resolve it by reliving it in the present (Greenberg & Foerster, 1996; Paivio & Greenberg, 1995). The reliving may take the forms of obsessive thoughts, compulsive behaviors, or self-defeating behaviors in a relationship. Hence, unfinished business, as Gestalt therapists believe, could dominate our lives; much energy could be spent battling it until we address these unexpressed feelings. To bring closure to unfinished business, most therapists rely on the Empty Chair technique. Develop Mutual Empathy with an Unavailable Person The Empty Chair allows the client to “bring” someone who is unavailable, geographically, physically, or emotionally, into the session. The chosen individual is actually the internalized other. With this “other” in the room, the client now can afford to address some unfinished business. In so doing, the Empty Chair represents the ultimate of using clients’ own existing resources and strengths to resolve their own issues.

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By directly addressing the issues with the other within the safe confines of the therapist’s office, the client moves from a sense of powerlessness and vulnerability to a sense of power and control, and subsequently to a sense of resolution and closure. Moving back and forth between the two chairs, the client metaphorically takes two perspectives: his and that of the other. It is the perspective-taking that brings about the precious empathy (Chen, Froehle, & Morran, 1997). The Empty Chair technique cultivates the client’s empathy for the other, and vice versa. Thus, it engenders mutual empathy in both. A healing and rewarding experience for the client ensues—a moving phenomenon for the therapist to witness. Bring Closure and Healing to Unfinished Business Some clients say that one session of Empty Chair merits eight sessions of regular therapy. That statement does not surprise us. In Empty Chair, the client truly becomes the engine of change, the chief player in the therapeutic platform. They allow their emotions to be expressed fully; they are able to see the dynamics from the other person’s perspective and vice versa. What’s even more impressive is the fact that the “other” can be guided to offer empathic responses to the client and to deepen his self-disclosure. As a result, the client not only feels heard and understood by the other but also starts to understand something she does not expect. This helps to close the wounds and heal the pain. When I conduct the empty chair, I usually like to retreat to the background, becoming a gentle coach who offers calm directives. The client shines as the true hero in this platform because the healing that happens comes from the client, not the therapist. A Case in Point Rita (a pseudonym), a 37-year-old woman, comes to therapy for an array of problems. She had started drinking at 19 and progressed to daily heavy drinking into her 30s. When she was 35, she met Ben, quit drinking, and married him. Her marriage became an unhappy one. Having been angry ever since she was a child, Rita would easily become infuriated with her husband. Rita was an only child in a household where the mother was a raging alcoholic who ironically sobered up about the time Rita started drinking. Rita’s father, a softspoken artist, suffered from leukemia and frequented hospitals. He died of leukemia in his 40s when Rita was a teenager. Rita reported feeling closer to her father while disconnected from her mother. She wished that it was her mother who had cancer instead of her father. Still, she resented her father for not being able to stand up to her mother, but her anger toward him led to a tremendous sense of guilt, which in turn led to her shutting down her feelings. Rita reported that her husband, Ben, is also a child of an alcoholic, and just like Rita’s father, he is also passive. The Empty Chair technique might prove useful to help resolve Rita’s multifarious issues, albeit one at a time. However, to guide the client through the technique, we must be intimately acquainted with the principles and the execution of this technique (Daldrup et al., 1988). The following illustrates the principles and the execution when conducting the empty chair for the case of Rita.

Advanced Intervention Techniques 215 Provide the Rationale for Use of the Technique Unfamiliar with the technique, the client may benefit from some explanation about its rationale and structure. Most clients have probably not experienced something like the empty chair dialog. We can help them become more receptive by a bit of introduction. Example Client: “I just can’t help but get really angry when Ben acts exactly how my father used to be, passive to the point of making me sick.” Counselor : “Rita, it sounds like your husband’s placid attitude triggers some unresolved feelings that you still hold for your father who, as you reported, was never able to stand up for himself, or stand up for you, to your alcoholic mother.” Client: “Yeah, I always feel that I have some sort of reactivity with Ben, and any triviality can set me off. It sounds ridiculous, but I just can’t stop it.” Counselor : “Perhaps the reactivity is connected to some unfinished business, as you said because they’re so similar. Here’s an idea, Rita, we can try an exercise called the Empty Chair dialog. Through the dialog, you may be able to work out some of the unresolved issues with your father, even though he can’t be physically here. Would you like to try that?” Client: “Of course . . . if it is ever possible.” Counselor : “I am very hopeful that when we are open, many things are possible.’ Set Up the Two Chairs and Seating Arrangement This is a necessary step to orient the client into the two-chair dialog. Example Counselor : “Okay, if you’re ready, we’ll put the two chairs here facing each other; one will be for you, the other for your father, Jim. When you’re in your chair, you can say everything you have wanted to say to him but never got a chance. You will have the opportunity to be heard without interruption. Then you’ll change to sit in your father’s chair and take on the persona of your father, responding to what’s just been said. So the dialog will go back and forth a few times until both of you feel completely heard. How does this sound to you?” Client: “Interesting, and a bit strange, but I am open to it.” Counselor : “I’ll certainly guide you through this exercise, you can rest assured.” Counselor : “We’ll start with you sitting on your chair, and your father will be on the chair in front of you.” Get the Enactment Going In the enactment, the client is induced to enact or play out her interaction with the other person on the other chair. — “Okay . . . now that you’re seated, please close your eyes for a moment. Try to go back to one particularly upsetting event wherein you felt angry, disappointed, frustrated, or unprotected by your father. When you can feel these feelings, open your eyes. (pause until the client opens the eyes) Okay, from your heart, tell your father about what happened and how it had an impact on you.”

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Do Not Ask Questions! Just Make Process Suggestions! When conducting the two-chair dialog, do not ask questions. Rather, just make process suggestions. Use directives (see Chapter 8) to guide your client. Why not to ask any questions? For two reasons: first, your questions will take your client away from her experience with the internalized other, turning the attention to you. Second, questions tend to shift the client from emotional experiencing toward an intellectual stance. You don’t want either of those. You want your client to stay focused on her dialog with the person in the other chair. Whatever the question you wish to ask, modify it to become a process suggestion using directives. Consider the following process suggestion for Rita: — “Rita, try to tell him all that you feel, including your sense of guilt. He has the capacity to hear it all. There is no need to suppress any of your feelings.” Don’t say: “Rita, what are you feeling right now? Are there any feelings that you wish you could relay to him?” Direct Clients to Change Global Complaints to Specific Resentment Global complaints do not lead to problem resolution because they lack focus. When clients present their issues with global language, guide them to describe the problems in specific behavioral terms. Consider the following examples: — “Rita, instead of saying, ‘You were never there to stand up for me,’ try this: ‘Dad, I’m angry when you become so passive that you allow Mom to do whatever she wishes.’ ” — “Rita, rather than saying, ‘It made me mad to not have anyone around,’ say: ‘Dad, I felt abandoned when you disappeared into the background as Mom took out her anger on me.’ ” — “Rita, rather than saying, ‘You were a bad parent,’ say: ‘Dad, I’m disappointed that you could not be my protector as my parent.’ ” Use Attention Suggestion to Direct the Dialog Our ability to focus on bodily sensations helps us connect to our emotions. Because the empty chair is all about resolving unfinished business, developing this skill can bring previously unconscious emotions to the surface, enabling resolution of the past. Many factors exist as barriers preventing clients from accomplishing the above, such as a client’s affect falling flat or the client could get trapped in the vortex of storytelling. To break through this barrier, we can use attention suggestion or experiential focusing technique (Chapter 8) to coach the client to release the suppressed parts of the self. — “Rita, try to notice how your voice trails off as you speak about feeling unprotected. Tell your father the feeling that is behind this trailing-off of your voice.” Make Process Comments on Clients’ Deflected or Constricted Emotions When trying to work on unresolved issues, the client’s maladaptive behavior patterns may emerge as she interacts with the internalized other. For example, when facing difficult emotions, the client may change the subject or turn away from the empty chair dialog and talk to the therapist. In another example, a client may hold emotions

Advanced Intervention Techniques 217 in her body by holding her breath. Both the deflection of emotions and the holding of breath represent a form of avoidance. When this happens, you can make a process comment on the avoidance behavior observed and then suggest how he or she can get back on track. — “Rita, I notice that you’re moving into your head and are intellectualizing about why you are the way you are today. Try to express your feelings instead of explaining them.” — “Rita, I can sense that you’re controlling your anger. Your breathing is tight, and your hands are clenched. Allow your muscles to relax so your anger and sadness can be freed.” Foster Congruency between Verbal and Nonverbal Expressions We can also bring the client to higher awareness by pointing out the incongruence between verbal and nonverbal behaviors. — “Rita, I hear your angry words but what I see in you is a polite smile. Try to say the words again without smiling them away.” — “Rita, I hear the words of anger, but I don’t see the emotion.” Support Full Affect Experience Often clients feel guilty about expressing their negative emotions. When negative emotions arise, clients tend to push them back. This prevents the empty chair exercise from reaching its maximum effect. If this is the case, give permission for the free expression of clients’ feelings. — “Okay, Rita! Stay with that anger! Allow yourself to go as far as you can with that resentment.” Bursting into tears—a client’s most common reaction when they allow their full affect to come out—is cathartic and often leads a client to feel better. Don’t be afraid of a client’s tears. Allow emotions to come in waves. As they flow, so will they ebb soon. When crying happens, we can say: — “You are doing good work. It is okay to cry. You are safe here. Stay with these sad feelings as long as you need to.” Change to the Other Chair after Emotions Have Waned Using the principles illustrated above, we guide the client’s emotions and their expression to build up to a healthy point. When the emotions are fully experienced, it is time to change to the other chair. The timing is critical. Many new therapists rush through the empty chair dialog, directing the client to move back and forth with a break. Rushing renders it impossible for the client to benefit from this technique. So, allow your client the time to experience her emotions. Only after they have waned will you direct her to change the seat. — “All right, Rita, now that you’ve released your anger, you may come to this side and sit on this chair and be your father (Pause). Please close your eyes and get in touch with Jim’s manner of thinking and behaving (Pause). You may open your eyes now (Pause). Hi, Jim, thank you for coming here to be with us.”

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Evoke Empathic Responses in the Other Person When the client reverses the role, sits on the other person’s chair, and speaks from that person’s voice, she naturally gains the other person’s perspective. You can increase the chance of mutual understanding for the two parties by evoking empathic responses in the other person. — “Jim, we’ve invited you here today to help your daughter process some painful memories. You’ve just heard Rita tell you how frightened she felt when your wife got drunk and became belligerent. You’ve also heard that Rita felt like you weren’t there to protect her. Please respond to Rita right now with the best capacity you have to hear her out.” Feed the Person Some Sentences to Try-On Sometimes, the internalized other in the chair struggles and is unable to put his inner experiences into words. For this circumstance, you can guide him with a suggestion or a “try-on.” — “Jim, I sense some strong emotion in you that you seem to have no language for. Try this on but with your own words: ‘I feel inadequate in containing your mother’s drinking problem, and I’m ashamed of my inability to protect you from her rage.’ ” Bring on Heart-Felt Responses to Each Other After the internalized other tries to express these difficult emotions, let him sit with it for a while. Then change chairs. Have the client respond to the earnest emotions expressed by the internalized other. — “Okay, you may return to your chair. OK, Rita, your father has just said something very important. Now try to respond to him from your heart.” Help the Client Tell the Truth of the Internal Conflict Sometimes your client may get stuck, unable to get to the truth of her internal tension. At this juncture, you may interpret her behavior so that she can explore the problems at a deeper level. — “Rita, from what you just said back to your father, it seems that one part of you wants to get close to your father, yet another part of you can’t forgive him. These two parts are in an intense power struggle. Try to tell your father the truth about the two sides of you.” Stay with the Ebb and Flow of Emotions until All Are Released Crying typically happens in the Empty Chair dialog when old wounds are reopened, when stuffed feelings are released. Crying, itself a cathartic process, induces much relief from the tension of the unfinished business. To facilitate the cathartic process, encourage clients to let their emotion reach its climax and then release it. Let this process continue. You will know the process has reached the climax when you see your client’s body relax. No more waves of emotion need to be expressed at this time. A sense of quietness and peace permeates the room.

Advanced Intervention Techniques 219 Example Client (sobbing): “I forgive you, Dad. And I miss you so much.” (Stronger rush of tears) Counselor : “It’s okay to let out the tears that have been building up.” Client: “Dad, I love you very much and I never got enough of your time. I feel as if I’ll never get over the loss of you.” (Bouts of tears and sobbing flow even more.) Counselor : “That’s right, Rita, just let all that sadness come out. Let your tears flow freely like the rainwater falls and nourishes the hopeful seedling.” Client: (The sadness reaches its climax, and then her body starts to relax.) Counselor : “That’s it, Rita. Now notice how your body feels peaceful and relaxed after the weight of your emotions has been lifted. Just stay relaxed and be aware of the quietness you feel inside yourself.” Client: (Remains relaxed and serene while resting; then another wave of sadness overtakes her and another wave of tears floods her eyes.) Counselor : “That’s okay. It’s just another wave of sadness coming out from below. Let it out like what you did before. Trust yourself and let it happen. Let yourself ride the wave and relax into those tears.” Client: (Tears build to a climax and dissipate as before.) Close the Empty Chair Dialog After clients have reached some sort of emotional climax and the old wounds have been cleansed, close the dialog through a symbolic ceremony of closure. Clients can revisit the issue anytime they choose, but they will resume in a different place with greater wisdom and strength. Example Counselor : “Rita, if you have a sense that you’ve finished some old business with Dad, I suggest you do a short ceremony to say good-bye to him. Express to your Dad whatever new feelings or gratitude you’re experiencing after his conversation with you.” Client: “Dad, I’m ready to say good-bye to you for today. I realize that although you had a hard life and were unable to be there for me, you’ve left me with that loving part of yourself that even death can’t take away from me. I’m grateful for the time we spent together in the past and today. You will always be a part of me, and I will take care of myself as you would want me to.” Counselor : “If you need to, allow yourself to stay with this gratitude and love for as long as necessary.” Processing As with any intervention technique, when the work of the empty chair reaches the end, therapists must process with the client about what she has experienced and what she will take away. Client: (Appears surprised and relieved by the outcome of this empty chair dialog.) Counselor : (Helps the client process the new understanding and its accompanying feelings gained through the exercise.)

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HEALING AND MEANING—RECONSTRUCTION What will happen when we apply these advanced intervention techniques presented above? Several processes will happen. With time, you will see that clients organically start to do the following, as postulated in the beginning of the chapter: • • • •

Reconstruct their schema. Build up effective interpersonal skills. Integrate disowned parts into their self. Exercise their freedom of choice and action in their lives outside therapy.

Your session shall be teeming with energy and aliveness. A higher or deeper level of change starts to happen, beyond symptom reduction. This section explains this higher level of change. Co-Construct a New Narrative of Life We, humans, give meanings to our life events through the way we tell about our self, others, and the world (White & Epston, 1990). To know whether our therapeutic interventions have made the preferred influences on the clients, all we have to do is to observe and inquire into how our clients change the way they tell the stories of their life. If the therapy has been successful, inevitably our clients will construct a new narrative of their life despite the chaos and challenge created by their personal adversity— loss, trauma, invalidation, oppression, worries, internal subjugation, etc. Though the life events did not change, their “internalized reality” has changed. It is as if the windshield of a car has been cleaned—the image is the same, but the client is now able to see clearer. It is also as if a “silver lining” has been added to the clouds— the event remains the same, but the meanings of the whole event have changed (Holland, Currier, & Neimeyer, 2006). To be specific, what makes up the client’s internalized reality includes: • • •

Their assumptions about others and the world ( Janoff-Bulman, 1989). Their assumption about themselves, or so-called self-narrative (Neimeyer, Baldwin, & Gillies, 2006). Their all-encompassing cognitive schema (Wright et al., 2017).

These three types of assumptions establish the way clients construct meaning in their lives. When adversity hits and tethers, clients experience a sense of chaos and meaninglessness; their assumptions about their self, others, and the world become distorted. But with the help of therapy, clients slowly recreate meaning in their life. They start to reexamine things from a lens that heals and integrates. Reconnect to Those Internal Representations of Important Others Experiential techniques such as the Empty Chair, the Internalized Others interviewing, and even Role Reversal help clients challenge their established assumptions regarding their internal representations of those important in their lives ( Janoff-Bulman, 1992)— their internalized others. As their cherished beliefs about these important others change, clients are able to weave together new nuances of meaning and form a new connection to their important others—characterized by purpose, meaning, order and predictability (Neimeyer, 2001).

Advanced Intervention Techniques 221 Reorganize the New Self-Narrative As the therapy goes on, and as the process of integration and meaning-making continue, clients eventually will be able to reconstruct their sense of self, resulting in a fresh selfnarrative. With it comes a new set of assumptions and beliefs that guide actions, thoughts, feelings and ways to relate to others (Calhoun & Tedeschi, 2006). The new self-narrative stands for a new self-identity; a new way of making sense of the adversity; a new way of integrating the new meanings of the adversity into the client’s personal, practical, existential, or spiritual self. In turn, the client reaches a higher level of internal coherence. EXERCISES After each client statement, write a counselor response using the skill indicated: 1. Parts dialog Client: “I am really split about how I feel. The little girl in me wants to just run away and hide, while the grown up person knows she has to talk to the doctor about how my mother is being abused in the nursing home.” 2. Parts dialog Client: “Part of me is like a ‘party girl’ who wants to just have a good time drinking and drugging with my old friends. The other part of me is the ‘get on with your life girl’ who thinks that it’s time to settle down and do something with my life. Really, how long can I keep this up? Sooner or later, I’m going to have to grow up and get a job or do something like go to school. The ‘girls’ fight and usually ‘party girl’ wins because she always wins.” 3. Empty-Chair technique initiation Client: “Today it has been 10 years since my mother walked out on my dad and me. I still think about her all the time. There are so many things that I would love to tell her about my life but it is too late.” 4. Paradox Client: “Our house is a mess beyond belief. My partner and I are real hoarders. To get through the living room, we have to clear a path. The landlord is complaining that our house smells. We care but we don’t know where to start.” 5. Mindfulness training Client: “I am so anxious today that I don’t know where to start. My mind is jumping all over the place.” 6. Empty Chair Dialog The client came to counseling wanting to explore her lack of motivation. The relationship between the client and her family came up very early in the session. As she gloated about her family, she mentioned that her father was always very critical of her and that

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there had been things she had always been unable to talk to him about. She also mentioned that her father had never shown her any signs of encouragement or understanding. The client expressed a feeling of inadequacy and mentioned several times that she felt “stuck” in her current situation. As the client talked about her family, she became tearful and was visibly saddened by the thought of her father and the fact that he will never have the ability to accept or validate her.

11 Termination Skills

Like everything in life, the therapeutic process has a beginning and will have an end. No matter how good the relationship between the therapist and the client has been, parting will ensue. Loss is an integral and existential part of being alive, and the same applies to being in a therapeutic relationship. Yet with the loss, a new life, full of potential, also begins. THE STAGE OF TERMINATION Second in difficulty of entering therapy, the difficulty in termination lies in wrapping up the therapeutic relationship. Loss and Separation in the Termination Stage Termination shatters clients’ fantasy of an ideal relationship wherein their needs of dependency, stability, and continuity will be met. At the stage of termination, fantasy meets reality and thus activates the agony of loss for many. Some are able to reconcile the loss of their dream; others struggle to comprehend and deal with this loss. The agony of loss is even more palpable for those whose treatment focus has been on issues surrounding loss and separation; the ending of any relationship triggers the feelings of grief associated with prior losses. They may have trouble saying goodbye and may simply not show up to the last meeting. It hurts to face loss and grief. Period. The Tasks of the Termination Stage The termination stage may occur at various points in time, depending on the type of therapy. In long-term therapy, the termination stage stretches over a longer period. Only when the core problems have been resolved does the therapy come to an end. When it comes to the time, the issue of separation commands thorough discussion and often receives full attention. In brief therapy, on the contrary, thoughts of termination are typically at the back of our mind from the beginning—possibly because we feel the weight of being accountable for the outcome of therapy. Thus, in brief therapy, separation issues are worked through from the beginning, and the termination stage can be short. Be it long-term or brief therapy, the task of the termination stage largely remains the same: • • •

Help the client evaluate his progress and transfer what he learns to real life. Assist the client to anticipate future challenges and to envision strategies for coping. Help the client bring closure to therapy.

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On Premature Termination Once in a while, clients may terminate prematurely before their problems get to a resolution. They drop out of therapy with or without notification, for untold reasons— financial difficulty, lack of time, feeling stuck, discomfort, searching for a quick-fix, etc. Lacking a smooth or clear termination, a question is left in the mind of the therapist—whether to follow up with a phone call or a letter inviting the client for a closure session. In the premature termination, the ball is in the clients’ court. We must respect their decision. This respect may mean taking certain actions or taking no action at all, depending on the client and the circumstances. If you think the client is unstable, you may need to follow-up with the client or with members of the client’s support network. To prevent unnotified termination, we need to educate our clients to be direct with us regarding their experiences throughout the counseling process. Armed with the proper knowledge, we can adjust our approach to meet their needs. We may also need to inform clients that productive therapy inevitably gets uncomfortable at some point. Breakthroughs can be painful, but if the client can persist, without dropping out prematurely, their efforts are likely to be rewarded with healing and liberation. PRINCIPLES OF TERMINATING A THERAPEUTIC RELATIONSHIP With so much at stake in ending therapy, therapists must keep in mind certain principles of how to appropriately terminate the relationship. Never Terminate Suddenly Unless it is Unavoidable To meet the standard of care, therapists must continue serving the client until the relationship has been properly terminated. As therapists, we must “avoid sudden endings” (Younggren & Gottlieb, 2008, p. 502), unless it involves unfortunate circumstances, such as a sudden illness or death. For examples, at different times, one of my (Mei’s) previous supervisors died unexpectedly in a car accident; while another, on a surgery table. All of their clients had to face the sudden ending of a therapeutic relationship which had been cared for and nourished for so long. You can imagine the shock and grief these clients have to work through with other therapists who step in to continue the care. Discuss the Termination Process with Clients Prior to Termination Under normal circumstances, we must discuss the termination process with the client prior to termination and document the decision-making and discussions involved. If this process is not done, they may feel abandoned and angry when the therapist suggests termination. With a clear message about the upcoming termination, clients will be more prepared to deal with their sense of loss and separation anxiety. If any unfinished businesses hang like loose threads, clients will have a chance to process it fully. The therapeutic relationship, therefore, will have closure in a positive and hopeful way, and termination is done in the best interest of the client.

Termination Skills 225 Under optimal conditions, counselors should prepare clients for termination early on in therapy. Once an agreement of termination is reached, its date should be set and only be changed with an additional agreement with the client. Reassure an Intermittent Termination or Slowly Wean Them Off Clients should be reassured that termination does not have to be absolute, that they may come back to visit if circumstances arise unexpectedly in their life, compelling them to return to therapy. In this case, you are providing the reassurance of an intermittent termination. This reassurance helps clients feel free to move on and also feel safe to return to therapy, should the need arise. Some clients may cling to certain residual issues in an effort to maintain the therapeutic relationship, reluctant to move ahead in life on their own accord. In these cases, therapists may suggest less frequent sessions during the termination phase. This gives the client an opportunity to gradually separate themselves from the therapeutic relationship, while starting to build up their lives outside therapy. Help Clients See Termination As a “Graduation” from Therapy To prepare clients, therapists should remind them that the end of the therapeutic process is actually the beginning of a new life, full of potential. We should frame the termination as a “graduation” from therapy. We should review the skills that clients have learned in this process, encouraging them to continue to fine-tune these tools and apply them in their lives. In so doing, we are supporting them as they advance toward individuation. Accepting the boundaries and the limitations inherent in the therapeutic process, clients can actually cultivate a new perspective and a new reconciliation with life. Embrace Separation As a Pathway toward Individuation Individuation is a key concept in Jungian depth psychology. In his classic text, The Integration of the Personality, Carl Jung (1939) stressed that to develop the elements of our personality into a coherent whole, we must struggle to become individuated. In the struggle to become individuated, all of us must embrace the reward and pain of growing up and maturing. We embrace the reward, as we have become our own person, our “true self ”; embrace the pain, as we endure a series of even longer separations from what we have cherished. As such, the separation in therapy is a rite of passage. If we do well in facilitating clients’ separation from us, we are helping them move from one stage of their lives to another—a more fruitful one. HOW TO CONDUCT A PRODUCTIVE TERMINATION This section details the skills required to conduct a productive termination. Please note: • •

•

The skills detailed below may carry over a few sessions. Due to space limitation, we can only provide a few illustrations of the therapistclient dialogue. Please remember: each clients’ responses to your probing questions should be nurtured with validating responses. You don’t want to turn termination into a question-answer-question-answer session. After the termination, complete a discharge summary (see Appendix D) and place it in the client’s chart.

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Process Feelings of Separation Prior to Termination Invite clients to express their reactions; their fears, concerns, sense of loss, and grief, about separation from the therapeutic relationship. Therapist: “As agreed upon, when you are ready to move on with your life, we will terminate therapy. It seems like you are ready. It means our time together will end soon. How do you feel about ending therapy?” [Focusing] Client: (expressing her mixed feelings) Therapist: “You feel relieved, sad, and anxious all at the same time. That completely makes sense. A part of you really feels ready to spread your wings, so to speak, yet another part of you feels nervous about how to venture out on your own.” [Validate the client’s experiences via reflective responses] Client: (expressing more) Use the Scaling Question to Assess Client Progress Your effort in assessing clients’ progress reminds them that they have come a long way since they started therapy. This brings hope, a sense of celebration, and a feeling of self-confidence—a message that they have the ability to move forward on their own. One of the techniques helpful in assessing progress is the simple scaling question that we covered in Chapter 8. Counselor : “Bogart, I just want to get a sense of where you are in terms of your progress. On a scale of 10, where ‘0’ represents an extreme sense of hopelessness, powerlessness, and the worst sense of yourself, while ‘10’ represents an optimal sense of confidence, feeling good about yourself, and trust in life. Where were you when you first came in? And where are you now?” Client: (reporting) Counselor : “So you have moved from a scale of 2 to a scale of 8 during the course of counseling. I am inspired to hear your progress.” Track the Client’s Narrative Change: Pursue the Change Talk Clients start to create their new narrative at virtually any point in the process of therapy (Mendes et al., 2010). For example, in the beginning stage of therapy, the new narrative tends to tip toward a deeper personal reflection and awareness; at the later stage, toward a reinterpretation of who they are, and toward an integration of their fragmented self. At the termination stage, the therapist needs to consolidate the client’s new selfnarrative. This is done by tracking her narrative change (Holland, Currier, & Neimeyer, 2006; Mendes et al., 2010) or by pursuing the change talk (Glynn & Moyers, 2010). This is based on the premise that the more we track and pursue the details of the client’s change, be it her behaviors or perceptions, the more she will change toward the preferred direction. Therefore, steer your communication with your client to change talk. Ask specific questions to bring out the details of how the client has changed her way of viewing herself, of viewing others in their relationships, and of viewing the world. Consider the following possibilities: — “How do you perceive yourself now? In other words, how does the way you tell others about your own life differ from the way you did in the past?”

Termination Skills 227 — “How have your assumptions, feelings, and reactions to others in your life changed? In what way have they changed?” — “How have your assumptions, feelings, and reactions about life, and the world in general, changed? And in what way have they changed?” An example of how to pursue the change talk: Therapist: “In what way have you changed over these past sessions, Bogart? How has the way you see yourself changed?” [Inquire about client’s narrative change] Client: “I don’t feel as broken as before. I have gone through so many losses and tragedies in recent years. These losses had cracked me, but they did not break my spirit. I keep going. I keep plowing ahead.” Therapist: “So life’s difficulties cracked you, but they cannot break you. You have triumphed. You are a person who becomes more resilient when life gets tougher. [Reflect client’s change talk] As you said this, your eyes became brighter; I can see the spark in them.” [Immediacy] Client (nodding and smiling) Therapist: “In what other way has the way you see yourself or others changed Bogart?” [Track client’s narrative change] Client: “In the past, I had to keep myself busy all the time to avoid feeling my emotions. Now, I am learning to give myself quiet time, to be with myself. I tell myself, it is OK to feel sad at times. I miss my father’s presence, and I know that although his body no longer exists in this world, his spirit and his voice remain with me.” Therapist: “Wow! You are allowing your emotions to be part of you, you welcome them and put them back to who you are. As a result, you become whole. At the same time, you accept the physical loss of your father, yet you realize that he continues to exist inside you. Death cannot take him away from you. I feel tears in my eyes as I hear you say this.” Client: (nodding and smiling) Therapist: “How about your feelings toward your mother? How has your resentment towards her changed?” Client: “I have come to accept the way she is. Her demands and dependence on me are her way of grieving. She and my father had a very close relationship. Yes, they were so close together. And to lose her spouse and best friend is probably more devastating than me losing my father, now that I think about it.” Therapist: “You are seeing your mother from a new angle, which helps you understand the difficult behaviors she sometimes exhibits. You know, Bogart, as I heard you talk about the relationship between your mom and dad, I am thinking, they have passed on a precious legacy to you—a legacy of how to be in a successful marriage. Many people do not have that kind of role model.” Client: (eyes light up, smiling again). Help Clients Extend Their New Self-Narrative to the Future The goal of therapy is that the client will be able to reconstruct a new storyline about themselves, extending it into the future, to form a coherent new self-narrative—a new identity wherein the self stands tall as a powerful and resourceful agent. In this process of reconstruction, the therapist acts as a witness to the formation of this new selfnarrative (Carr, 1998; Mendes et al., 2010).

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Aligned with this goal, you can ask questions that require the client to envision the way her life will look as she continues her new self-narrative. Consider the following examples: — “What will your life be like when you continue to view yourself, others, and the world, from this new way of seeing?” — “How will you help yourself to continue to reinvent the new you after termination?” — “If you were a consultant for someone who experienced a difficulty similar to yours, what wisdom would you share with him or her?” — “I’d like to co-create a certificate for you as an indication that you have overcome the effect of depression. What would you write on the certificate about yourself?” An example of how to extend a client's new self-narrative to the future: Therapist: “Paco, how do you envision carrying this new way of seeing yourself toward your future?” [Inquire about client’s future narrative] Client: “I should build myself up . . .” Therapist: “Sorry, I was not clear enough. Please allow me to clarify. I am interested in hearing what you envision yourself ‘will’ do, not what you ‘should do’ or ‘need to’ do. Do you get a sense of the difference?” [Redirect] Client: “Oh, I get it now. When I was young, I got a lot of ‘shoulds’ from my father and seldom got validation from him. This had a big impact on my self-confidence. Now I have realized that I can validate myself, I can build myself up. So going forward, I will try to focus on my achievements, rather than what I have failed to do.” Therapist: “I am so glad to hear that you will give yourself validation rather than wait for someone to give it to you. You have made so much progress in these past 7 sessions in being your own supporter.” [Focusing on change talk] Client: (nodding and smiling) Therapist: “A while ago, you said that you finally got the courage to tell your wife about things that you had simmered for a long time inside yourself. You were surprised that your wife actually responded positively to the communication; that she did not focus on what you failed to achieve. It seems like you were happy to discover that your assumptions towards your wife’s reactions do not always line up with her reality. Would you please talk more about this?” [Bring on another change talk] Client: (smiling and talking more about his new experiences with his wife’s reactions. He realized that his assumptions were more influenced by his past, rather than founded in reality; he just assumed the worst which sent him hiding; he now wants to take more risks to be true to himself with his wife.) Therapist: “How will you continue into the future with this new way of communication with your wife?” [Steering toward future narrative change] Client: “I will not worry about how she thinks of me. I will check her out and say what is on my mind.” Therapist: “So you are saying that you will check the accuracy of your assumption with her, rather than let your assumptions fester inside of you, blocking you from having an authentic communication with your wife. Is that what you mean?” Client: (energized and talking more his new found freedom when he checks the accuracy of his assumption) Due to space limitation, no further therapist–client dialogue will be provided.

Termination Skills 229 Give and Receive Feedback Giving your client feedback helps him gain an objective view of what he has accomplished in therapy and of how you experience him as a person. In everyday conversation, people rarely give one another honest feedback. They may give compliments or make superficial observations, but seldom do people give and receive meaningful, constructive observations about how one comes across to the other. When reviewing the progress made in therapy, the feedback you give to your client— saying from the depth of your heart—is a precious gift: — “This is what I’ve seen in you . . .” — “These are things I hope you will think about doing for yourself . . .” You can also request feedback from your client about how she experiences you. This is not only for the purpose of helping you, but it gives the client a feeling of respect knowing that their opinions are greatly prized. What’s more, in their effort to give you feedback, clients must summarize their experience, and they must trust their feelings. This is another constructive way to bring closure to the counseling experience: — “I’d like to hear from you some feedback about my working style. What has been most helpful for you? What has been least helpful for you? What would you like me to do differently?” Make Referrals If Necessary At times, clients may still need to work on issues that are best served in other settings or with other therapists. For example, a great deal of interpersonal learning happens most effectively in group counseling. We can refer clients to a specialist, a more experienced therapist, or to a special type of group, such as a process group. At the core of making a referral is taking action for the best interest of the client; it is not a reflection of our lack of skill. When referring clients to other therapists, make sure that a written agreement for the release of information is obtained from the client and placed in their file, so that we can communicate with the other therapist if and when the need arises (Welfel & O’Donnell, 2011). As therapists, we ought to be aware of referral agencies in our local area, ensuring that clients have enough information about their options. Compiling a list of referral agencies is a part of our clinical tasks; our knowledge of referral agencies will grow as we continue to learn and interact with professionals in our community. Create a Ritual of Saying Goodbye: Share Appreciation and Regret The last step in bringing closure to the counseling relationship is saying goodbye. The most meaningful way to say goodbye is to mutually express appreciation as well as regret: appreciation for sharing an intimate journey together; regret for not being able to continue the relationship. Many people feel awkward in expressing appreciation and regret since they are uncomfortable in saying goodbye. But when done from the heart, this ritual brings humanity and dignity to both parties. It is not only the clients who have difficulty in separating, but sometimes therapists experience the same difficulty. Some counselors even wish to maintain a certain kind

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of contact so as to find out how the clients are doing. This is not a wise practice, though, because it shows dependency on the counselor’s part. Keeping contact with clients may inadvertently cause them to come back for unnecessary sessions, needed more by the therapist than by the clients. You may want to say something along the lines of the following to share your appreciation and regret with your clients: — “I want you to know that I deeply appreciate you sharing yourself with me. I’ve enjoyed seeing you over the past few months, and I’ll miss our interaction.” — “Thank you for trusting me and allowing me to get to know you as a person. I’ve come to deeply admire your courage and integrity in your struggle and the growth you’ve made. I’ll miss talking with you.” It is wise to invite the client to share their appreciation and regret. If a client is unable to express his or her feelings at the time of termination, then allow her a period of silence. Unspoken words often convey more meaning than verbalization; silence often speaks for a communal experience of spirituality. If the client cries, wait patiently until her tears subside. Tears do not indicate that additional sessions are needed, but just that the client is touched by the emotions of termination. EXERCISES After each client statement, write a counselor response using the skill stated. 1. Deal with premature termination Client: “I feel like we’re making progress, but I’m really too busy to come to counseling anymore. This will be my last session.” 2. Assess client’s overall progress Client: “I think that I’m feeling more hopeful now. In fact most of the time, I think that I’m doing well and I think that I’m moving ahead. I am happy with my life at home and the progress that I am making at school.” 3. Mutual feedback-giving Client: “I appreciate what you’re saying about me—that you’ve seen progress in me. When you say that you’d like me to give you feedback, what do you mean by that?” 4. Deal with feelings of separation Client: “I know that I’m ready to stop counseling because I’m doing so well, but I’m really going to miss not seeing you every week. It has meant a lot to me that you’re here and that I had your support. I am not quite sure that I can make it on my own.” 5. Manage referral Client: “I need a counselor who knows about trauma. I know this is not your area of specialization, and my insurance company will only pay for a counselor who is certified in trauma therapy. Could you give me a referral?”

Termination Skills 231 6. Help the client carry the learning further Client: “Where do you see me going in the future? What do I still have to learn?” 7. Say goodbye by sharing appreciation Client: “I want to thank you for everything that you’ve done for me.” 8. Suggest intermediate sessions Client: “I think that I am ready to end counseling, but I’m not sure.” 9. Assure client that she can always come back if needed Client: “I know that we have set this as our last session, but what if something really bad happens and I need to talk to you again?” 10. Suggest to the client that the end of counseling is the beginning of a new life Client: “I’ve been coming to see you every Thursday morning at 10:00 for a year. What will I do now with that time since I won’t be coming here?”

12 Counseling Persons with Special Needs

Though not rehabilitation counselors, therapists should be prepared to work with clients with disabilities—a population which is growing. Per the 2010 U.S. Census Bureau, approximately 30 percent of families in the United States have at least one person with a disability, and about one in five people live with a disability (U.S. Census Bureau, 2010). By and large, clients with special needs see counselors who have the necessary training, skills, and experience to help these clients. At times, however, counselors with such expertise might not be available for various reasons. The clients with special needs may live in a rural area where few counselors with such expertise exist. Such clients may go to a school where the school counselor is the only person available to serve the mental health needs of large numbers of students. Regardless, therapists may at times be called upon to serve clients with special needs. Therefore, counselors and therapists should have a fundamental understanding of the following: • • •

The language of disability. Basic ethical principles related to helping persons with disabilities. The core set of underlying principles of treating persons with disabilities.

This chapter presents ways to increase a therapist’s cultural competence in working with clients with special needs. CLIENTS WITH DISABILITIES Types of Disability A disability, defined as functional limitations as a result of certain impairment, may restrict a person’s ability to engage in certain activities and interact with society or the world. Disability comes in a variety of forms: • • •

Sensory disabilities involving vision, movement, or hearing. Cognitive disabilities, involving thinking, learning, remembering, or communication. Mental health disabilities.

While most disabilities are visible, some are not. Indeed, a person may have a disability unnoticeable to the naked eye.

Counseling Persons with Special Needs 233 The Challenges of Living with a Disability Living with a disability can challenge the person beyond the disability itself. Many individuals coping with a disability develop their lifestyle, routines, and special coping strategies to accommodate the disability. But other additional challenges are caused by the effects of the disability on affect regulations, social interaction, and relationships. Above all, the challenge is a result of the prejudice, discrimination, and injustice that persons with disabilities face every day (Fine & Asch, 1988; Sue & Sue, 2016). These challenges may lead to anger, depression, or relationship difficulties. How Mental Health Therapists Can Help When such emotional, mental, or interpersonal concerns arise, a therapist can offer help in the following ways: • • • •

Normalizing the emotions a person is experiencing. Addressing any coping difficulties. Empowering and building up their strengths. Resolving interpersonal complications.

You, as a therapist, after securing client agreement, may invite the person’s partner, family members, or close friends to join her in a session. In the joint session, you can help the person’s loved ones understand how to best support the person with special needs in the adaptation process. You can discuss and resolve the interpersonal difficulties or any issues that arise as effects of living with a disability. DEVELOPING CULTURAL COMPETENCE IN WORKING WITH CLIENTS WITH DISABILITIES Lacking familiarity with the methods of working with clients with disabilities, many counselors and therapists are skeptical about the degree of benefit that clients with disabilities can receive from counseling sessions. This lack of confidence in themselves and the clients stems from the lack of cultural competence in working with clients with special needs. Clients with special needs are persons first with special needs second. You just need to tweak how you use the general counseling skills and techniques so that they are accessible to your clients with special needs. Clients with special needs can improve their coping, relationships, and communication through counseling. They should not receive any less amount of mental health services. To help you develop your cultural competence, this section addresses principles of how to work with clients of special needs. Avoid Diagnostic Overshadowing Many counselors and therapists regard any emotional or mental disturbance as part of the picture of a disability, even if it cannot be accounted for by disability. Thus, signs of mental health difficulties get lumped under the disability diagnosis. This bias is called diagnostic overshadowing ( Jones, Howard, & Thornicroft, 2008; Mason & Scior, 2004). As a result of diagnostic overshadowing, many persons with disabilities who also have mental health difficulty don’t get the mental health services they need. A client

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with a hearing disability might be actually struggling with general anxiety or depression but never diagnosed beyond the developmental disability. As therapists who have a chance to work with clients of special needs, we should treat their mental health needs exactly as we would with any other client; we should not allow disability to overshadow what we see, and we should always be on the lookout for some psychological struggle or maladaptive behaviors that cannot be explained by their disability. In other words, we should be the advocate, looking for ways to meet their mental health needs, deeming disability as another issue that our client brings to the session— another issue that helps us better understand our clients in their context. Go Beyond Empathy! Challenge the Clients! Another mistake that counselors often make when working with clients with special needs is that they listen and respond with empathy, but fail to go beyond that. They fail to apply more advanced skills and techniques; they do not challenge their clients’ cognitive distortion; they do not point out their maladaptive behavioral patterns; they don’t give clients homework; they don’t suggest a role play, a role reversal, a part dialog, or an empty chair technique. Due to their lack of knowledge regarding disability, the uninformed therapist experiences anxiety when facing these clients. Unfortunately, their anxiety leads to emotional distance in the interpersonal interaction with these clients (Daughtry, Gibson, & Abels, 2009). Bottom line: clients with special needs have been unfortunately treated as inherently fragile. The uninformed counselor fears they might somehow overwhelm their clients if they apply more advanced skills and techniques to work on more substantial issues. We, the therapists, should not be blind-sided by disability. We should see the person behind the disability. Granted, some clients with special needs may experience difficulty with adaptation and flexibility, but it does not mean that they won’t benefit from your skills and techniques. Adjustment in the way you deliver your intervention techniques is all that is needed. Your clients will appreciate the way you take their struggles seriously. Seek Consultations and Open Ourselves to Learning Some clients with disabilities may prefer a therapist who is living with a disability (American Psychological Association, 2013). If that is the case, make a proper referral if possible. If a referral is unavailable, we must seek consultation with therapists who have disabilities (Whyte et al., 2013). We must research, read books, and comb articles. We must progress the cultural competence in working with clients with special needs as an ethical mandate. As we open ourselves to learn, we will learn to make subtle adjustments such as: how to address the client, how to place ourselves at eye level with the client in a wheelchair, and how to communicate with a client with a hearing impairment in an appropriate fashion. We may not know everything, but we can ask our clients with special needs to teach us. The following sections present some suggestions for therapists to consider when working with clients with special needs.

Counseling Persons with Special Needs 235 THE PROPER LANGUAGE TO USE The first rule of thumb in working with clients with special needs is heeding the proper language to use with them. Language is inherently powerful. It has the capacity for healing or for hurting. When addressing clients with special needs, we should regard the person first rather than the disability (Artman & Daniels, 2010). We should use personfirst language, such as “persons with disabilities” or “individuals with visual impairments” to describe the client, avoiding terms like “the disabled” or “the blind” (Daughtry, Abels, & Gibson, 2009). This section illustrates how to put the principles in action—how to use a language that shows respect to persons with disabilities. Avoid Labels that Diminish the Person Terms such as “autistic” and “blind” are labels which can be harmful when they are used to diminish the person. On the other hand, labels can sometimes be helpful, for example, when a person with schizophrenia needs to have a proper diagnosis in order to receive Social Security and Medicaid. The label or diagnosis becomes a problem if it causes the person to suffer from lowered self-esteem or a sense of helplessness. The worst is a label that contains judgment. Do not say: “He’s retarded.” Do say: “He has an intellectual disability.” Do say: “He has a cognitive disability.” Put the Person First By putting the person first and the disability or illness second, we are recognizing that the person is not the disability. The disability should not be an adjective used to describe the person. Consider the following examples: Do not say: “the blind person” Do say: “the person who is blind” Do not say: “the autistic person” Do say: “the person with autism” Do not say: “the cancer patient” or “the melanoma in Room 4100” Do say: “the person with cancer” How to Address Persons with a Mental Health Diagnosis When talking about a person with a mental health diagnosis, take the following principles into your consideration: Do not say: “He’s crazy” or “She’s a psycho” or “He’s gone over the edge.” Do say: “She has schizophrenia” or “He has bipolar disorder.” Do say: “He has a mental health diagnosis.” Do not say: “He is ADHD.” Do say: “He has ADHD.” Do not say: “He has gone to the asylum.” Do say: “He has gone to the hospital.” Do say: “She has gone to the hospital for treatment for anxiety.”

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When talking about the mother or the father of a person with a mental health diagnosis, consider the following: Do not say: “It is the mother’s fault.” Do say: “She is the mother of a child who has a mental health diagnosis.” Avoid Making Generalizations about Persons with Disabilities Avoid making generalizations about persons with disabilities or risk losing the trust of the client. Do Do Do Do Do Do

not not not not not not

say: say: say: say: say: say:

“All people with intellectual disabilities are happy and friendly.” “All people with schizophrenia are dangerous.” “All people with AIDS are depressed.” “Kids with learning disabilities have a hard time making friends.” “All kids with Down Syndrome are really cute.” “He would not have symptoms of mental illness if he just took his meds.”

Avoid Blaming the Victim People, including counselors and therapists, tend to assign a cause to the disability as their way of dealing with the fear of disability. For example, when we face a person with a mental illness, we may assume that the patient’s family, the person’s drug habit, or the person’s lifestyle cause the disability. In the same vein, whenever a person develops mental illness, people look for a cause for the problem. Searching for a cause can be helpful unless that search turns to trying to find someone to blame. Frequently, society blames the parents. When parents are blamed for their children’s mental problems, it causes the whole family to suffer. The fact is, most parents are victims, too. But they have already blamed themselves for the illness of their children despite evidence to the contrary. When the blaming from society is added to the picture, it can lead to a self-castigation, making mental illness even more of an alienating and isolating condition. A case in point is Albert Einstein—a father who looked for a reason his second son developed schizophrenia (Isaacson, 2014). Although Einstein concluded that it was a genetic problem over which he had no control, his feelings of guilt rendered him unable to communicate with his son for the last 20 years of his life. Einstein rationalized that this communication would be upsetting to his son when in reality he simply could not face him. Einstein supported his son financially but could not deal with him interpersonally (Isaacson, 2014). Let Our Language Convey Respect for Our Clients It is imperative that we are constantly vigilant that our language conveys the highest possible respect for clients. We should always use respectful language when discussing clients. Unfortunately, counselors and therapists commonly breach this ethical principle. For example, I (Nan) was at the grocery store when I overheard a counselor talking on his cell phone with a colleague about a client. He said, “That guy is just crazy and should be locked up.” Everyone in the long checkout line heard this comment. This incident, unfortunately, is not an isolated event. We all must be constantly watchful about behaving respectfully and ethically. In addition, the ethical responsibility

Counseling Persons with Special Needs 237 to maintain confidentiality prohibits counselors from discussing a client except in a consultation context. COUNSELING CHILDREN AND YOUTH WITH LEARNING DISABILITIES Learning disability (LD), according to Individuals Disabilities Education Improvement Act of 2004 (IDEA), is “a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which disorder may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations” (Sec. 602.30A). Indeed, the diagnosis is idiosyncratic, and persons with LD are affected in different ways. The Social and Emotional Challenges Endured by Children with Learning Disability To meet the needs of students with learning disabilities, the school will develop an individualized educational plan (IEP) for each student. These plans include a variety of interventions for teachers and other school personnel to use. IDEA specifies that counseling services may be included in IEPs when it will support the education and learning of children (Lambie & Milsom, 2010). The method of diagnosing learning disabilities is shifting. In the past, the diagnosis was based on a deficiency model reflecting a gap between test scores and lower school performance. More recently, a model based on response to evidence-based instruction and interventions is used for diagnostic purposes (Rathvon, 2008). Regardless of how the diagnosis of learning disability was made, children with a diagnosis of LD often have to endure social and emotional challenges. They can become easy targets for bullying; they may suffer from social isolation; they may feel different and actually treated differently by their parents, teachers, and other adults (Lambie & Milsom, 2010). Counseling Children with LD Throughout the Four Stages of Therapy Resonating with the ideas of Lambie and Milsom (2010)—that counseling services can be included in IEPs—we illustrate in the following example, how a counselor can, throughout the four-stages of counseling, help children dealing with difficulties caused by the label of LD. Stage 1: Problem Exploration In the first session, the counselor listens as the child explains his or her problems and how the diagnosis of learning disabilities and its related problems are affecting her life. The counselor should listen and respond with the reflection of meaning, values, and feeling. Consider the following examples: Client: “Everyone looks at me like they think I’m weird or something. Now I have to go into that room for special treatment and everyone thinks I’m dumb.” Counselor : “You feel like you’re different and that things have changed for you since you got sent to the LD classroom.”

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Client: “Ever since I got the special tutor at school, no one will sit next to me at lunch. I’m at my own table, all alone every day. The only kids that I could sit with are the weird ones.” Counselor : “So you feel lonely, especially at lunchtime when you used to eat with your friends.” Client: “My parents always nagged me, but now it never stops, ‘Do your homework. Is your homework done? You can’t go out until your homework is done. What did the teacher say?’ My parents have gone psycho on me. They watch me all the time, and it’s like being in jail.” Counselor : “So you feel under a microscope at home.” Stage 2: Awareness Raising In the second stage of counseling, the counselor raises awareness of the client’s problems. The client accepts and owns up to patterns, recognizes her strengths, and works through resistance. Counselor : “In the meeting, we had last week, you told me about your problem with school, your parents, and the kids at school. Could we give your problem a name?” (the counselor names the problem to put it outside of the client, as suggested by Lambie and Milsom (2010)) Client: “I would call it Special Ed. Maybe ‘Ed’ for short. That’s my problem. Ever since Ed came along, my life sucks. Everything is different since I got Ed.” Counselor : “What were you good at before Ed came along?” Client: “I was good at choir, playing the piano, talking on the phone, ice skating . . .” Counselor : “What else are you good at? Anything at school?” Client: “Well, I’m good at recess and fixing my hair, and drawing pictures. I get A’s in art, music, and gym.” Counselor : “So you have a lot of things that you were good at before Ed. Are you still good at these things even though Ed is around?” Client: “Yeah, none of that has changed.” Counselor : “So, you’re still the same ever since your problem got a name.” Client: “I guess that’s right, but my friends still seem different.” Stage 3: Problem Resolution In the third stage of counseling, problem resolution, the counselor helps the client to see alternative ways of behaving and helps the client implement an action of choice. Counselor : “The last two times we met, you told me about your problem and named it Ed. Then we talked about how you’re still the same as you were before “Ed” came. You’re still good at the same things you were before, such as choir, playing the piano, drawing, fixing your hair, ice skating, and recess. Let’s talk about how you can make one change to make your life a little better. We can do one step at a time. Are you willing to try?” Client: “Okay, but I don’t think that anything is going to help.” Counselor : “Let’s start with your parents. Can you think of a time before “Ed” when your parents were nagging you?” Client: “Sure, lots of times. They’re famous for nagging me.” Counselor : “Tell me about one time.”

Counseling Persons with Special Needs 239 Client: “When we got Harry, the dog, they were always nagging me about taking Harry out for a walk when I got home from school. Mostly I did it, but sometimes I forgot. Then I started doing it every day.” Counselor : “What made you start to do it every day?” Client: “Well, one day I got home late to walk Harry and he lifted his leg and wet my backpack. Everything got soggy and smelled bad. I had to copy my homework over because it was all yellow and smelly. After that, I remembered to come home.” Counselor : “So it’s easier to come home and walk the dog than to clean up the mess.” Client: “Yeah, Harry showed me.” Counselor : “So your parents want you to do your homework after you walk Harry. What would happen if you did it then?” Client: “Well, I would have it done and my parents would shut up.” Counselor : “So it would make things easier for you to do it then. Would you be willing to try it once and see what happens?” Client: “Well, okay, I’ll try it today, but just once.” Counselor : “That would be great! Just try it once and see what happens.” Stage 4: Termination In the termination session(s), the client evaluates her progress. The counselor helps the client to anticipate future events in the process of ending therapy. Counselor : “Well, last week we talked about how you were going to try one thing to make your life better even with Ed around. How did it go?” Client: “I walked Harry, and then I did my homework.” Counselor : “That’s great! You took charge. Then what happened?” Client: “My parents came home, and they saw my homework finished. They didn’t yell. In fact, they took me out for a hamburger for dinner.” Counselor : “How did you feel about that?” Client: “Parents really get happy over stuff like that. I liked getting the hamburger, and Harry got the leftovers.” Counselor : “You’ve really found out how to take charge of the situation of your homework, your dog, and even with Ed.” Client: “I don’t know if I can do that every day, but I can try because I sure like not getting in trouble every day.” Counselor : “I bet you can figure out ways to get your friends back, too. You are your own person and the same girl you always were.” Counseling College Students with Learning Disabilities Students with learning disabilities frequently come to college with expectations that won’t be met. If they have received services throughout their elementary and high school experience, as mandated under IDEA of 2004, they may expect the same level of accommodations at college. In college, however, students are expected to take more responsibility for their own education. The accessibility office at the college may be understaffed and overtaxed with students. To this, Beecher, Rabe, and Wilder (2004) advise, “At the postsecondary level, however, this student must visit the disability resource center, establish proof of disability, be aware of appropriate accommodations, and approach each teacher to find someone in the class who would be willing to take notes for him or her” (p. 84).

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Consider the following six examples of how to counsel college students with learning disabilities: Example 1: First Client Counselor : “I’m wondering why you missed your last two counseling appointments with me.” (Counselor confronts the issue of missed appointments head on.) Client: “I’m sorry that I couldn’t come. Sometimes I am up late at night with my Crohn’s disease, and it’s hard for me to get up in the morning.” Counselor : “Would it be easier for you if we schedule our appointments in the afternoon after your last class?” Client: “Yes, that would help a lot.” Example 2: Second Client Counselor : “You seem really down today. Is that because you got a D on your English paper?” Client: “Yeah, I’ll never be able to get through college if I can’t even write a decent paper.” Counselor : “One bad paper doesn’t mean that you can’t get through college. Lots of students do poorly on a paper. Then, if they go for tutoring at the English lab, they do better the next time.” (Here the counselor helps to decrease all or nothing thinking, offers resources, and increases client self-efficacy.) Example 3: Third Client Client: “I got sick again in class and had to run out during a lecture. The teacher looked really mad. But I couldn’t help it.” Counselor : “So you can’t tell when you’re going to get sick. It just happens.” (Counselor addresses the issues of lack of predictability of the illness.) Client: “It’s just awful. I think that I am going to be okay and then the cramps start and I have to get out of there fast.” Counselor : “Could you talk to the teacher before the next class and tell him about your illness so that he will understand when you leave suddenly?” (Counselor helps the client prepare for lack of predictability.) Example 4: Fourth Client Client: “I’m always saying dumb things to girls. When I want to ask a girl out, I say stupid stuff because I am afraid that she won’t want to go out with a guy who is blind.” Counselor : “Lots of guys get embarrassed when they talk to girls. Most guys get nervous like you do. Do you think that what you’re feeling is not just because you’re blind but may be due to the fact that you are a guy?” (Counselor normalizes the feelings of the client.) Example 5: Fifth Client Client: “I can’t keep up with this workload. Because I have a learning disability, it takes me longer to do the reading. I’m afraid that I’m going to flunk out.” Counselor : “Since you need to take your time when you read, it would probably be a good idea for you to take only one course each term where there’s a lot of reading. The book lists are published a month ahead of time. You could look at the list, go to the bookstore and decide what you can handle ahead of time.” (Here the counselor helps the client set realistic goals, make independent decisions, and plan ahead.)

Counseling Persons with Special Needs 241 Example 6: Sixth Client Client: “Is someone going to be appointed to take notes for me in class?” Counselor : “You’re going to have to ask in each class for someone to take notes for you. In this way, college is not like high school. In college, you’re an adult and can take more responsibility for your learning than you did in high school.” (The counselor teaches the student how to advocate for herself. The counselor also points out that increased responsibility is being placed on the client in college.) COUNSELING CHILDREN WITH AUTISM Autism is a diagnosis distinct from LD. Additionally, there is a strong exclusionary clause in the autism definition that eliminates kids with behavioral disorders or emotional disorders. Autism is difficult to define, although it is manifested in problems with communication, repetitive behaviors, sensory processing issues, and problems with selfregulation (Siri & Lyons, 2014). A lot of controversies exist about where kids with autism get services under IDEA. Autism has often been defined too narrowly, as it does not include Asperger’s syndrome. Now autism is thought of as existing on a continuum of severity (Paxton & Estay, 2007). It is now recognized as a separate and discrete category that entitles children with these symptoms to services (See wrightslaw.com and autismnnow.org). Usually, school counselors are not asked to counsel children with autism. Typically counselors act as referral agents for other services as defined by their district. For the counselor who does deal with this population, many alternative therapies are now recommended (Siri & Lyons, 2014). This section focuses on three therapies for children with autism documented by Siri and Lyons (2014): • • •

Animal-assisted therapies Equine therapy Dance and movement therapies

Animal-Assisted Therapies Animal-assisted therapies (Fine, 2014) can be highly useful when treating persons with autism. Many people relate to animals more quickly than humans because of the accepting, noncritical nature of many animals. Dogs are the most commonly used animals with children, and cats, birds, and horses have also been found to be of great help to children with autism. The Delta Society, a group of professions including doctors, veterinarians, counselors, and other interested people, has spent decades studying the human–animal bond. A counselor who is interested in how to initiate animal therapy should read the organization’s guidelines (Delta Society, 2006). The Delta Society has found that animals can provide social lubrication, modeling or interactions, and companionship. For persons with autism, the world can be a lonely place; however, when an animal (trained or sometimes untrained) enters their lives, loneliness is soothed. Some autistic children are hypersensitive to the smell of animals. Often, washing the animals prior to visiting with children is a good idea. Animals, such as cats, that spurn bathing may be wiped down with scent-free dryer sheets. Animals can be useful as adjuncts to therapy in counselors’ offices, schools for children with special needs, hospitals, and other therapeutic settings. Programs are now

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starting to have dogs sit with children as they read aloud. The dogs sit upright for 10–15 minutes as the children, often those with reading or speech problems, read to the dogs. Children who are afraid to read to humans often feel more comfortable with the uncritical dogs that listen patiently and appreciatively. In general, animals get people outside of themselves, allowing them to interact with other sentient beings. Social skills learned with animals can be transferred to humans. If you are a lover of animals and already appreciate the healing they can bring, look into how animal-assisted therapy might enhance your counseling. Counselors can learn a lot about their clients by watching how they interact with animals. Equine Therapy Equine therapy is called hippotherapy after the Greek word for “horse.” This type of therapy should not be confused with riding lessons, as they are quite different. The principles of equine therapy revolve around the natural inclination of the horse to seek peace and safety. Research studies (Ewing et al., 2007; McCormick & McCormick, 1997) have shown the therapeutic impact that equine therapy can have on at-risk youth in programs where the horses act as co-facilitators with the counselors. The emotionally challenged children are required to concentrate on their mind and their body to learn to connect with the horse. Children must face their fears and be present without other distractions. Once children have learned to interact with an animal, human interactions become easier. Dance and Movement Therapies Because autism is a disability that significantly affects verbal and nonverbal communication, the counselor must look for alternative ways for children with autism to express themselves. Movement is one such alternative. The main pillars of dance/movement therapy (DMT) are that personality is conveyed through movement. If a person changes her movement, this will eventually lead to changes in personality, and the more movements an individual knows, the more options she has for coping with the environment (LeFeber, 2014). DMT began in the 1940s and has evolved into a field with certification granted by the American Dance Therapy Association (www.adta.org). Since people with autism have problems with verbal communication, dance, and movement may provide a viable form of communication. Improving muscle coordination can improve communication skills. With this in mind, therapy is individually designed for each participant in order to help improve specific muscular coordination needs. As children with autism move and breathe together, they begin to feel a social connection with each other. Social connection is important to all children, but especially to those who are isolated by deficiencies in verbal language. The Film Autism: The Musical (www.hbo.com/documentaries/autism-the-musical/ index.html) portrays the joys and tribulations of putting on a musical production with children who have autism singing and dancing. In the end, the director, who has a child with autism herself, sees her effort rewarded in the joy and pride of the children and their parents. Each of the therapies suggested above requires special training. If a counselor does not wish to seek this training, it is helpful to know about types of services so appropriate referrals can be made.

Counseling Persons with Special Needs 243 COUNSELING PERSONS WITH PHYSICAL DISABILITIES Most counselors, regardless of whether they are in the rehabilitation field, will serve some clients who have physical disabilities, immediately apparent or not. When counseling a person with a physical disability, the same principles apply as with any other client, and establishing rapport is the first, foremost, and ongoing priority. The Challenge of Establishing Rapport with Persons with a Physical Disability Establishing rapport with a person with a physical disability may be more difficult than with able-bodied clients. It is perhaps because the former have usually been through hospital and government systems that are very cumbersome. Oftentimes, getting urgently needed services requires strong advocacy and persistence, which a person with limited energy and resources may not be able to muster. Being caught in systems may lead people to become angry and distrustful of the helping professions. After spending days caught in phone trees, with obstacles such as being transferred or being promised services that are never delivered, clients with disabilities and their families may not be able to readily establish trust with a counselor. Although this is not always the case, mental health professionals should be aware of this possibility. Tips for Counseling after the Initial Interactions After initial interactions, the counselor follows the basic strategies for counseling— exploring the presenting and underlying problems, finding patterns of behavior and reacting, determining methods of eliminating these unproductive behaviors, and helping the client break vicious cycles of behavior. As Marmé and Skord (1993) state, “Specific counseling issues include the client’s anger, awareness of deficits, judgment, and problem solving, and overestimation of skills” (p. 19). If the client is blind, counselors must keep their posture as though the person is sighted, because their speech must be directed toward these clients. If you look away, the person will be aware of this and will interpret your posture as that of disinterest or rejection. People who are blind are typically highly sensitive to sound and will immediately know when they are not being treated as one would treat a person with sight. Counselors should also keep the same nonverbal behavior they would use with any other client, such as smiling, nodding, and other common behaviors. Remember that people who are blind are not deaf, so counselors should not raise their voices when talking to them. Educate Ourselves about the Client’s Physical Disabilities Clients’ physical disabilities are only one part of their lives. They may come to see you with a presenting problem that is not related to the disability at all, such as getting married or problems associated with aging. Thus, counselors must see persons with disabilities just as they would see other clients—multifaceted people with multiple things going on in their lives. Many clients are dismayed when their therapists ask questions about their physical disabilities. A counselor who asks about the general symptoms of an illness such as multiple sclerosis is wasting the client’s time and money. Instead, counselors should do research on their own time. It is not the client’s duty to educate the counselor. There are several good resources on the Internet such as webmed.com, the University of Wisconsin Medical School website, or the website of the Mayo Clinic.

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Watch Out for Comorbidity To complicate matters, persons with disabilities frequently have more than one disability or related problem. For example, addiction may be a problem for a person with an acquired brain injury if pain medications have been prescribed long-term or alcohol and drugs may be used as a coping mechanism. Also, other problems may coexist with or predate the injury. In the case of veterans, a person may have acquired a physical disability from an injury during combat as well as posttraumatic stress disorder. It can be complicated for the therapist to figure out all the stressors in a person’s life. It is also difficult to determine which problems existed prior to a disability, such as concerns arising from earlier exposure to family issues, and which problems developed later in life. A List of Suggestions We may make mistakes when working with persons with disabilities, such as making insensitive remarks or failing to understand the client’s world. If you make a mistake, admit it and apologize to the client. Such honesty and respect are necessary to establish and maintain rapport. Most people with disabilities are grieving or have grieved at one time or another. Being sensitive to these issues is of paramount importance. It is often more important who the counselor is than what the counselor says (Yalom, 2009). Please review Table 12.1 for a list of suggestions advised by (Marmé, 2010). Keeping these suggestions in mind when talking with a person with a disability shall help establish and maintain rapport, which is a foundation for the deeper emotional work together. OTHER CONSIDERATIONS WHEN WORKING WITH CLIENTS WITH SPECIAL NEEDS Due to space limitation, we will conclude this chapter with just two more suggestions. Include the Family and Caregivers in Therapy Another matter often ignored when counseling persons with disabilities is: the whole family is affected. A person with a disability does not exist in isolation. Clients’ stressors also impact family members, and, in turn, the family’s stressor can bring pressure to bear on the client with a disability. Many persons with disabilities wish to spare their parents stress and thus hide their true feelings and problems. Sometimes persons with disabilities find it more difficult to watch a family member in pain than to deal with pain themselves. Therefore, we shall include the caregivers in therapy as much as we can. As Sue and Sue (2016) state, we should include family members and other social supports in our assessment, goal formation, and treatment. In addition, the outside caregivers who serve the person with a disability may need therapeutic support as well. As we all know, the task of taking care of persons with disability can often be draining and taxing for the caregivers. For example, Michael Schwass—a star high school hockey player who ran into a wall during a game, leaving him quadriplegic—describes how keeping caregivers from quitting is crucial (Schwass & Trausch, 2005). “I know they want my appreciation, and at times I get weary and sick of feeding it to them” (p. 226). He continues, “This one condition [helping the helpers] in my life, apart from the paralysis itself, is a constant source of anxiety” (p. 250).

Counseling Persons with Special Needs 245 Provide Both Compassion and Challenges in the Therapeutic Relationship Counselors must not only be good listeners, but they must actually hear what clients are saying. Only when we have heard the people who sit with us, can we begin to understand the complex people who allow us into their worlds. Michael Schwass—the hockey player introduced above—asserted that the constant relationship with his counselor, Trausch, is critical in his recovery. With the counselor, Michael was finally able to establish a rapport after having tried numerous other counselors and social workers. He says, “I needed understanding, and to have someone get inside my head, discover what was true at my core, and not to let me off the hot seat about what I needed to face and deal with” (Schwass & Trausch, 2005, p. 115). These words—about getting inside the client’s head, not letting him off the hot seat—may represent what most clients wish to say but do not know how to say it. These words highlight the need for counselors to be compassionate with the clients and at the same time hold them accountable for what they need to face and deal with. EXERCISES 1. Counselor (gathering information) Client: “I don’t have any friends ‘cause everyone thinks I’m weird because I get pulled out of the regular class to go to the class for nerds.” 2. Counselor (responding with a feeling statement) Client: “They call me ADHD and I have to go to the other room for two hours a day.” 3. Counselor (inquiring about client’s strengths) Client: “Before Special Ed came along, stuff was OK. Now it sucks.” 4. Counselor (asking a question for a client to explore options) Client: “I can’t keep up with all the work in college. I carry a full load of courses, work 20 hours a week, and have two kids who are three and five.” 5. Counselor (introducing canine “Read to Me” program at the library) Client: “They make me read out loud and I get all nervous and scared.” 6. Counselor (making referral to equine therapy program) Clients: “Our son has attention-deficit disorder. We have tried everything and he still can’t focus.” 7. Counselor (acknowledging feedback and apologizing) Client: “When you talk to me, you yell. I’m blind but I can hear fine.”

Don’t talk as if the person with a disability were not there, such as, “What time does he get up in the morning?” Don’t approach the person tentatively. Don’t tell a PWD that they are inspirational for living with a disability. Don’t use the following words: deformed, hunchback, midget, dwarf, normal. Don’t talk louder than usual. Don’t speak slower or louder to a person in a wheelchair. Don’t say “cripple”. Don’t say “wheelchair bound.” Don’t say “confined to a wheelchair.” Don’t assume that a deaf person uses sign language, reads lips, speaks aloud or does not speak aloud. Don’t assume that a person with a cochlear implant can hear you from any vantage point.” Don’t assume that a person regards being deaf as a disability. Don’t use term “traumatic head injury”

Person with a Disability (PWD)

Person in a Wheelchair

Physical Disability

Deafness

Visual Impairment/Blind

Don’t . . .

Disability/Injury

Table 12.1 Suggestions for Language Use with a Client Who Has a Disability It Is Okay to . . .

Say “Let’s walk over there.” “He is in a wheelchair.” “He uses a wheelchair as an alternative to walking.”

Say “What did you see on your vacation?”

Use term “acquired brain injury” Say “He’s physically disabled.” “He has a (M. Marme personal communication, spinal injury.” “She has cerebral palsy.” January 12, 2010)

Look at the person rather than at the interpreter. Maintain eye contact (Peters, 2007).

Look directly at the person, and talk exactly as you would with a person with sight. Arrange your chair to make room for a wheelchair. Say, “person who needs mobility assistance.” Say, “person who uses a wheelchair.”

Do acknowledge the disability Openly discuss the disability. early on. Be open-minded in accommodating people with suitable appointment schedules. Say “physical disability.” Say “curvature of the spine.” Say “person who is small in stature.” Say “nondisabled or ablebodied.”

Do . . .

13 Counseling Persons with Diverse and Multicultural Backgrounds

As we learn to apply the skills and techniques with our clients, we need to keep in mind that emotional dysregulation and distress are not only caused by inner experience, but life events and external social environment can be powerful stressors in shaping clients’ marginalized life, leading to their sense of powerlessness. Such external social factors may include but not be limited to race, gender, sexual orientation, religion, ethnicity, or socioeconomic status. This chapter strives to inform counselors and therapists about these external social factors in order to allow a deeper sensitivity and foster a nurturing environment. DIVERSITY VERSUS MULTICULTURALISM Many people falsely assume diversity is one and the same as multiculturalism, but this is far from the truth. As Robinson (1997) indicates, diversity and multiculturalism beg to differ from each other. This section attempts to clarify the misassumptions, and address the challenges faced by diversity and multiculturalism. Diversity Diversity describes differences among clients. The dimensions of the difference may include gender, age, religion, race, ethnicity, country of origin, sexual orientation, etc. A given difference that manifests itself most pronouncedly is in communication style. For example, many cultural minorities tend not to attach much importance to verbalizations in the same way as Caucasians (Sue & Sue, 2016). Continuing, Sue and Sue (2016) highlight that African Americans tend to communicate in a style that is strident, animated, intense, and confrontational, perhaps in an effort to act as advocates for the position they take. In contrast, White middle-class people tend to communicate in a style that is more detached, impartial, veering away from being provocative, perhaps in an effort to act as a spokesperson. The mere difference in communication styles can cause misunderstanding and distrust among diverse groups when they come to face each other. Multiculturalism While diversity deals with differences, multiculturalism deals with power and privilege (Lenski, 2013; Lott, 2002) To put it simply, Lott (2002) explains: power is “access to resources” and privilege is “unearned advantage” (p. 101). Though dissimilar to each other, power and privilege tend to work in unison to impact people’s lives. For example, those who have unearned privilege may misuse

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their access to resources to exploit those who do not have either privilege or power, consciously or subconsciously. People with power and privilege are often unaware that they have enjoyed what others never get a chance to have. To counter this unawareness, multiculturalism arises as a movement (Patterson, 1996) to advance from ignorance to awareness and an effort to “willingly sharing power with those who have less power” and to use “unearned privilege to empower others” (Robinson, 1997, p. 6). Biases and Prejudices: Racism and Microaggressions Much of the emotional distress that clients of diverse and multicultural backgrounds experience stem from environmental stressors—biases and prejudices that they have to deal with daily—events that render them powerless. For example, many LGBTQA individuals face bias, prejudice, and maltreatment. Among these environmental stressors, racism stands out as the most challenging. In our modern society, racism remains rampant and has become quite insidious. It is becoming trickier to identify, as Casas (2005) points out, “racism is not restricted to overt behaviors but also includes everyday opinions, attitudes, and ideologies” (p. 502). The most studied covert racism is racial microaggressions—cunning comments that convey denigrating messages to people of color (Sue et al., 2007; Sue, Capodilupo, & Holder, 2008; Yosso et al., 2009). Compared to covert racism, racial microaggressions are often more subtle—so subtle that the perpetrator might think he is well-intentioned or might not even know it. Yet, the psychological injury remains the same (Sue, 2010). BUILDING YOUR COMPETENCE IN WORKING WITH DIVERSE AND MULTICULTURAL CLIENTS Considering the biases, prejudices, racisms, and microaggressions that many of our clients have to endure daily in our society, counselors need to ensure that we develop the competence to help clients with these backgrounds. A therapist competent in helping mainstream clients may not be competent in serving those from the multicultural and diverse background (Sue & Sue, 2016). This section presents a few principles—affordable within the space limitation—to consider in building your competency in this area. Understand the Person and His Issues Within the Social and Cultural Context When counseling clients who are non-native English speakers, we, the therapists, first need to be prepared to recognize the barriers these clients face in communicating with fluent English and in self-disclosure. Due to communication difficulty and fear of exposure, these clients may not be forthcoming in sharing their personal information (Segal & Mayadas, 2005; Singer & Tummala-Narra, 2013). Second, we need to educate ourselves that these clients might express their symptoms differently; they might attribute the causes of, and ways of coping with, mental health problems differently. Some immigrants will only accept self-help, others may prefer alternate sources of help more aligned with their cultural origin—herbalists, acupuncturists, priests or imams. Third, some clients may come from a culture where there is a stigma attached to mental health problems. Others may come from a culture that views seeking help from

Diverse and Multicultural Backgrounds 249 therapists as an act that exposes a family weakness or a family malady, therefore bringing shame to the family. In counseling clients from a diverse background, we must, as suggested in Chapter 1, consider the interaction of the person and the environment. Individuals must be understood and respected within their social identities—gender, race, ethnicity, age, sexual orientation, social class, disability/ability, and immigration status—when we address their mental health needs. Armed with the acknowledgment of social and cultural factors, we will enhance our credibility as therapists and foster greater hope in clients for our ability to assist them in solving their problems. Be Aware! Our Clients Could Be Underdiagnosed or Overdiagnosed The tendency toward diagnostic overshadowing ( Jones, Howard, & Thornicroft, 2008; Mason & Scior, 2004) does not only happen when we counsel clients of special needs. It can happen when we are counseling clients of diverse and multicultural backgrounds. It is too easy to reduce any emotional or mental disturbance to cultural differences (Cozolino, 2004). Diagnostic overshadowing could lead to clients from diverse and multicultural backgrounds being underdiagnosed and undertreated. Conversely, your client could be overdiagnosed. It is too easy to blow the cultural differences out of proportion and mistake it as a mental illness (Cozolino, 2004). For example, black men’s distrust with white counselors and their ways of communication— presented previously as strident, animated, intense, and confrontational—may be overdiagnosed with paranoid schizophrenia. We need to allow clients who are culturally different from us to teach us about their social identity and their culture before we draw any conclusions about their psychological conditions. Be Flexible in Our Counseling Style When counseling American Indians, Asian Americans, Black Americans and Hispanic Americans, we need to build rapport with them in a different way. They will trust more readily if you demonstrate the ability to counsel with a more active, directive and pragmatic style (Sue & Sue, 2016). According to our clinical experiences, clients from these backgrounds tend to see counseling as a special training that enriches and empowers them. To trust you, they need to get a sense that you have the knowledge and wisdom it takes to do the job. Once they trust you, they will open up at a profound level. Thus, seeing all different types of clients within a day, we need to have the flexibility to tailor our counseling style to meet the needs of the clients according to what will benefit them the most. As we become able to shift our helping style to meet the cultural dimensions of our clients, we will see them more clearly. We will see that people are not just controlled by their intrapsychic forces, but by the social, cultural, spiritual and political forces as well (Sue & Sue, 2016). Be Sensitive in Our Use of Language It may take a while before a client will disclose his sexual orientation to a therapist. We may not know what kind of diversity issue we are dealing with. So we need to

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be sensitive with our use of language. For example, we need to try to minimize heterosexist bias in our language in therapy (Simoni & Walters, 2001). We also need to familiarize ourselves with the social injustice—prejudice, discrimination, and oppression—that LGBTQA clients endure (Dermer, Smith, & Barto, 2010). An easy way to begin building your competence is to consult the Association of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (Association of Lesbian, Gay, Bisexual, & Transgender Issues in Counseling, 2008). In the same vein, we need to aim for minimizing bias in our therapeutic language. A casual comment to a client of color about their skin color may come across as racial microaggressions that drive clients away from the helping process (Sue, 2010). Be Self-Reflective, But Don’t Be Worried about Saying the Right Thing As counselors and therapists interacting with clients of diverse and multicultural backgrounds, we are often afraid of saying the wrong thing and offending a client. This can restrain us from addressing important issues with the client. But what matters does not involve saying the right thing, what matters is listening. As we endeavor to really hear the client, we will shift the focus from our self to the client. Listening to the client and constantly being sensitive to the unique needs and experiences of each person is the heart of effective multicultural counseling. The ability to listen deeply begins with a therapist’s ability to be self-reflective. In Chapter 3, we have discussed how important it is that counselors and therapists engage in reflective practice. Here we want to suggest revelatory questions for us in our selfreflective practice with diverse and multicultural clients: — “Why am I having these feelings—positive or negative—toward this person?” — “Where did this idea that I have come from? Is it possible that it is a bias or a prejudice?” — “Do I know something about my client’s social and cultural context?” Personal self-examination can be a painful process, but it is certainly necessary because clients have the innate ability to detect counselors who do not get it, or do not accept them. SEVEN GUIDELINES FOR MULTICULTURAL COUNSELING The following are seven basic guidelines for multicultural counseling formulated by Nan: 1. Don’t Assume That You Know How Your Clients Identify Themselves: Always Ask In the first impression, we often cannot know how individual clients identify themselves. For example, a Latina client who was born and raised in the United States can vary greatly from a Latina who was born in another country. This Latina client may also be working through gender, spiritual, academic, career, and other issues. We shall strive to find out which dimensions of her life are currently most problematic. An African American person growing up in poverty in Chicago will differ from a person born to two movie-star parents in Los Angeles. We must not assume but always ask to find out how clients view themselves and their problems.

Diverse and Multicultural Backgrounds 251 A good example of how to talk to people about racial identity was demonstrated by Oprah Winfrey on her television show. She was interviewing a person who represented a Native American group but did not identify herself as being Native American. Oprah said something like this: “You will have to forgive me, and I don’t want to offend you, but I don’t know how to address you. Should I call you a Native American, an American Indian, an aboriginal person? Please help me know what name you are most comfortable with.” The guest was quiet for some time, obviously thinking. Then she responded that she was offended by all of these terms. None of them really describes who she is. There is something about what Oprah said above that we, therapists, can learn. Indeed, we should follow the steps that she took when addressing sensitive topics with a client: • • • • •

Admit your lack of knowledge. Ask the client for help in understanding. When asking your questions, maintain an attitude of respect and a desire to learn. Remain open to the answer the client gives you. Understand that answers to the same questions will differ among your clients.

2. Acknowledge Differences between Counselors and Clients We all need to learn how to talk comfortably about race with our clients; it opens the clients up to such sensitive topics. As Sanchez, Del Prado and Davis (2010) assert, “The discussion of race early on in treatment is believed to increase the likelihood that clients will discuss racial issues that might adversely affect the therapeutic work” (p. 273). Counselors who can address racial differences tend to appear more competent than those who cannot. Paniagua (2016) has found that addressing racial issues helps to decrease client dropout rates. As we learn to address racial and cultural issues, we shall learn how to properly time these discussions. Please ponder how you can help the client feel understood in each of the following situations: • • • • •

You are an African American counselor and your client is Caucasian. You are a White woman and your client is a Middle Eastern man. You are a male, and your female client was recently raped. You are an Asian male who is 25 years old and your client is a 60-year-old Asian. You are a Latina counselor who does not speak Spanish, and you are called to work with a family where little English is spoken.

We suggest that you address the differences between the two of you early on and especially when you sense that the difference is interfering with the therapy or when the client brings up the difference. Consider the following examples of how to do just that. Asian Counselor and African American Client Client: “I don’t think you understand what I’m talking about. How could you know what it’s like to grow up in Atlanta in the 60s?” Counselor response option 1: “Sounds like you’re thinking that the difference in our races is getting in the way of my understanding your experience.”

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Counselor response option 2: “I don’t know what you went through, but I’d like to understand. Would you be willing to tell me about it?” The following are examples in which the client brings up the difference: A Caucasian school counselor and a Latino adolescent client Counselor : “Hi, Luis, I am the freshman counselor here at Kennedy High School. Thanks for coming in today so that we could talk for a few minutes.” Client: “Great—another white person I have to listen to.” Counselor : “Okay, let’s talk about that. I am white. How do you feel about talking to me? I know that some students would rather not talk to a counselor who isn’t of the same race as they are.” Caucasian male counselor and African American female client Client: “I had a bad experience last night in the parking garage.” Counselor : “What happened?” Client: “I thought I could talk to you about it, but I can’t.” Counselor : “The referral form says you were raped. Is it hard to talk about it because I’m a man?” Asian female counselor, age 25, and Asian female client, age 65 Counselor : “Welcome to counseling, Ms. Chen. I’m Julia and I’ve been assigned as your counselor.” Client: “Hello.” Counselor : “On your intake form, you said that you feel anxious. Could you tell me about that?” Client: “You remind me of my daughter. She’s in graduate school to become a teacher. Are you in school with her?” Counselor : “Mrs. Chen, I’m wondering how you feel about having a counselor who is the same age as your daughter. Do you think I’m too young to understand what’s going on with you?” 3. No Need for Matching Therapists’ and Clients’ Race, Ethnicity, or Culture In their own design, clients often seek out therapists with certain characteristics. Perhaps a male client may only seek out a male therapist with whom he feels comfortable discussing a specific issue. A senior citizen may wish to talk only to a senior counselor. A Spanish-speaking person may feel comfortable speaking only to a counselor who is fluent in Spanish. A person who is a recovering addict may feel at ease only with one who has overcome an addiction. Is it always necessary to match therapists’ and clients’ race, ethnicity or culture in order for the therapy to succeed? Not necessary. It it true that when the therapist and the client share a similar ethnic background, as presented in Chapter 2 (The Common Factors), it helps to eliminate the number of premature terminations. Yet, the ethnic similarity itself does not have much of an impact on the outcome of therapy. Even though African American clients tend to disclose more to African American counselors than to White counselors, at the end of the day, ethnicity similarity alone does not dictate therapeutic success (Shin et al., 2005; Glass, Smith, & Miller, 1996).

Diverse and Multicultural Backgrounds 253 Indeed, even when the client is matched with a therapist racially similar to her, their diverse experience might not produce a helpful therapeutic alliance. For example, a Latino counselor born in the United States to parents also born in the United States might not understand the experience of a Latino who is an undocumented person born in Mexico. If rapport cannot be established, a referral should be made. In other cases, the counselors may identify too closely with the client and not be able to separate their issues from those of the client, or the counselors may develop strong emotional ties to clients with similar experiences and, in so doing, lose their objectivity (Schwarzbaum & Thomas, 2008). Above all, what matters most is that the client and the counselor speak the same language. If not, a translator will need to be hired. In family counseling, therapists should not accept the arrangement that the children do the translating. As translators, children may put their parents in a lower status, diminishing the self-respect of the non-English-speaking parent, giving the child undeserved power. Further the child might not translate accurately, whether accidentally or maliciously, which puts the therapy off course. 4. Use Racially and Culturally Appropriate Intervention Strategies Although each client is unique, researchers (Paniagua, 2016; Schwarzbaum & Thomas, 2008; Sue & Sue, 2016) have provided certain general suggestions about how to conduct interventions with clients from different races. Though these suggestions may error in the side of oversimplifications, I (Nan) will summarize them in the following for your consideration: African American Clients •

• • • • •

Don’t blame clients’ parents for the current problems. Clients are more inclined to see their problems as stemming from society rather than their families (Paniagua, 2016) Use techniques that empower the client, such as problem-solving and social skills training (Paniagua, 2016) Use a quicker responding style Give advice, direction, and teaching, as these are more likely to be effective than nondirective therapies Use counselor self-disclosure to help clients self-disclose (Paniagua, 2016) Address racial differences between client and counselor in the first session. African American clients usually prefer same-race counselors, but common experience and cultural competency may be more important factors (Sue & Sue, 2016)

Hispanic Clients • • • • •

Be formal during the first session, then gradually become less formal (Paniagua, 2016) Recognize the concepts of machismo and marianismo in the family. These terms mean that the husband is dominant and the wife is submissive (Paniagua, 2016) In family therapy, begin by talking with the father alone, since he is the head of the family (Paniagua, 2016) Recognize that client self-disclosure may not be compatible with the culture Speak softly and slowly if the language is an issue (Sue & Sue, 2016)

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Asian Clients • • • • • • • •

Dress professionally, and avoid being too personal (Paniagua, 2016) Establish your credibility with the client by discussing your experience and education (Paniagua, 2016) Be patient with clients, and do not force them to talk about personal things until they are ready (Paniagua, 2016; Sue & Sue, 2016) Recognize that Asians often present with somatic complaints because physical problems are more acceptable than psychological ones (Sue & Sue, 2016) Stress the positive assets of the client Focus therapy on goal setting as a mutual project Seek help for recent immigrants who have basic needs such as food, housing, and medical care (Cornish, Schreier, Nadkarni, Metzger, & Rodolfa, 2013) Provide advocacy for these clients, especially when language is a barrier to communication (Sue & Sue, 2016)

American Indian Clients • • • • • •

Remember that time is a relative concept. Clients may be late or expect to spend long amounts of time with the counselor Keep in mind that listening to the client is more important than talking (Paniagua, 2016) Recognize that self-disclosure may not be compatible with these clients (Sue & Sue, 2016) Speak softly and slowly Use silence Once rapport has been established, slowly move into asking more questions and begin goal setting

5. Be Open to Learn: Seek Referrals When Appropriate Sometimes clients may present information that seems impossible or even strange. In this case, we must, above all, respect the client and listen to the story being told. We need to suspend our own personal belief systems when dealing with values and beliefs different from our own. We shall never reject clients’ cultural beliefs and value systems. Consider the following example of how to show respect to differences. Native American Client — “The trees talk to me. They learn things through their roots and from the whispering of the wind. I listen, and they tell me things.” Poor response: White counselor (thinking that this client might be delusional or schizophrenic) “How long have you been hearing the trees talk to you?” Better response: White counselor (thinking that the client is reflecting views of the culture) Remains silent and listens with nonverbal acceptance. Back then when I (Nan) was a counselor intern, the following interaction occurred between a counselor and a client’s mother. The counselor demonstrates how to suspend our own personal belief systems and how to respect the client’s beliefs. White school counselor: “Thank you for coming in today, Mrs. Lopez. As you have heard from Maria’s teacher, Maria is having trouble paying attention in school.”

Diverse and Multicultural Backgrounds 255 Client’s mother (Haitian, recently moved to the United States): “Maria is possessed by the devil since we moved here.” School counselor: “I understand that you are from Haiti and people there are sometimes possessed by the devil. What is done to help when this happens?” Mother: “We call in the priest, who prays and makes the devil go away.” School counselor: “Ms. Lopez, I’m sorry but I’m not familiar with this, but I’m going to consult with my colleagues who will advise us on how to proceed. Next week when we meet again, I’ll have their suggestions for you. In the meantime, could you and I discuss some things that we can do to help Maria this week?” The DSM-V lists several cultural-bound syndromes—such as Amok (Malaysia), Brain fag (West Africa), Mal de ojo (evil eye, Mediterranean cultures), Susto (Latinos), and Zar (Africa). These are not considered DSM diagnoses and they are treated by shamans. Many things in the world cannot be explained by reasons. It is better to be helpful than right. Being helpful means acknowledging the culture-bound belief systems of our clients, and making proper referrals to therapists who are from similar cultures and who hold similar belief systems. 6. Be Creative in Choosing Your Techniques As the population becomes increasingly diverse, traditional methods of doing talk therapy will become increasingly obsolete. Sometimes traditional talk therapy simply does not work. Paniagua (2016) estimated that half of the clients from culturally diverse groups do not return for a second session. This means that the needs or expectations of the clients are not being met and they did not feel that the first session was helpful. Sue and Sue (2016) emphasize that we need to tailor our tone of voice, the speed of speaking and responding, and content of remarks, to that which the clients are receptive. For example, using confrontational techniques may not be conducive due to its being in direct opposition to a client’s cultural values. Rather than confining ourselves to a strictly Western method of talk therapy, we need to develop new techniques tailored to individual clients. New ways of counseling may have to be developed to meet the needs of an increasingly diverse client population. Consider the following example where a White female counselor uses an art therapy technique to help an African American female client open up: Client: “I really don’t want to talk to you. I’ve got nothing to say to you.” Counselor : “It seems that you don’t have anything to say to me today, but I’m wondering if I could ask you about the dress you’re wearing. It’s really beautiful, and I’ve never seen one like that before. I can see that you like bright colors.” Client: “Yes, I bought this dress in Paris when I went there last year. I really love these colors and the pattern.” Counselor : “I’m wondering if that dress might reflect an interest in art.” Client: “Yes, I love art. I never had lessons but I enjoy putting fabric together.” Counselor : “Although you’re not anxious to talk today, I’m wondering if, for our next meeting, you’d be willing to make a cloth collage that describes your current situation.” [The counselor uses an art therapy technique to engage a client and helps her open up] Client: “Sure, I can do that but it won’t be very good.” Counselor : “It doesn’t have to go up in an art gallery. I just want you to have a way to express yourself comfortably.”

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To establish rapport, a feeling of safety is a prerequisite. Clients often feel safest doing what they do best. Granted, what clients do best, what they are interested in doing, are often not obvious as in the above example. Even so, the therapist could ask the following types of questions to get some clues: — — — — —

“What do you like to do in your spare time?” “If you walk into a bookstore, what section do you go to first?” “What do you like to read (or write, or watch on TV)?” “What do people say that you are good at?” “Do any of these words apply to you; artist, musician, writer, athlete, . . .”

When their interests and skills are brought forth in the session, clients will: • • • • •

Feel respected by the therapist. Feel comfortable and safe doing something that is familiar to them. Feel empowered to express their own voice. Feel a rapport with the therapist. Be more likely to return for counseling sessions.

Allowing ourselves to be creative in tailoring our techniques to meet the needs of diverse clients will bring us rewards and gratification. Perhaps a client, who would not have come back for a second session, decides to do so. Possibly a client gains a greater sense of self-confidence because of our honoring their abilities and interests. 7. Understand the Universal Themes and also Recognize the Unique Differences The way we conceptualize our client may fall somewhere on a continuum between cultural universality and cultural relativism (Sue & Sue, 2016). Cultural universality holds the following beliefs: • • •

Counseling is basically the same for everyone. Normalcy and pathology are consistent across all races and cultures (Sue & Sue, 2016). Universal themes—such as love, abandonment, birth, death, courage, creativity, good and evil—exist in every culture but are played out in different ways.

Cultural relativism, on the other end of the spectrum, argues that it is the unique and different lifestyles, cultural values, and worldviews that affect the expression and determination of each person’s behaviors, normal or deviant (Sue & Sue, 2016). Neither cultural universality nor cultural relativism holds the absolute truth about our clients. A golden middle in the middle of the spectrum is a realistic position. While we all know that all humans, across culture and diversity, share similar essential needs, we also have to accept the facts that differences among culture do shape people’s perceptions and behaviors. The following illustrates how to respectfully appreciate the differences: African American client: “I don’t think you’re ever going to be able to understand me. How could you possibly know what it’s like to be African American?” Poor counselor response: “I think you’re overestimating the differences between us. I really don’t see you as being an African American. We’re all the same.” Better counselor response: “You’re right. I’ll never understand what your experience as an African American is like, but I want to try to understand. Could you help me do that?”

Diverse and Multicultural Backgrounds 257 INCREASING OUR CULTURAL SENSITIVITY Collins and Arthur (2010) point to awareness as the key to successful therapy with diverse and multicultural clients. They assert, “Awareness of one’s own personal culture and awareness of client culture is consistently identified as foundational to multicultural counseling competence” (p. 218). In the same vein, Sue et al., (1998) point to the essential role of awareness in developing our competency in counseling diverse and multicultural clients: 1. Awareness of one’s attitudes and beliefs about issues of diversity. 2. Knowledge about one’s worldview and the worldview of others, especially of our clients. 3. Specific techniques for working with clients from differing groups. This section brings a closure to the concepts and techniques of counseling multicultural and diverse clients by highlighting the actions we can take to increase our cultural sensitivity. Advocate for Social Justice Racism and poverty—according to Jimmy Breslin, the Pulitzer Prize-winning commentator—are the two greatest problems in the United States. Most of us will believe that Breslin is correct, but few can put our money where our mouths are. For example, in most states, public schools with high minority populations often lack the funding of wealthy majority-White districts. This brings up the idea that the roles of counselors and therapists in a multicultural society must extend to include advocacy (Sue & Sue, 2016). Advocating social justice must be a priority for the multicultural counselor. Before we can step into this action, we must examine our own biases. White counselors often feel guilty about being part of an oppressive group that has “white privilege.” These counselors might think their clients of color are angry with them just because they are white. This may be true in some cases. But some clients are angry at their circumstances and at being mandated to attend counseling. They see counselors as soldiers who have never been to wars. Taking a stance of being an advocate for social justice, we should try to understand what the clients are really angry about—stepping into their war zone to feel the wars they have to fight. Simply trying to maintain a relationship with clients without really advocating for them is hypocrisy (Schwarzbaum & Thomas, 2008). Step Outside Our Comfort Zone: Experience the World of Our Clients Increasing our cultural sensitivity should be a lifelong process and an enjoyable one. Culture expresses itself in various ways, including food, music, literature, ceremonies, dress, visual arts, theater, lectures, and social interactions. Exploring these different venues can be a life-changing experience. Going to ethnic restaurants and reading books by authors from various races and cultural backgrounds can be eye opening. Cultural art museums, movies, concerts, parades, lectures, television programs can help us understand people different from us. Travel, according to Mark Twain, is lethal to prejudice, bigotry, and narrowmindedness. Visiting other countries can be the best multicultural education of all. One counselor who is Nan’s acquaintance learns Spanish and goes to Mexico City once a

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year. Once there, he often sits on a park bench in the central plaza and talks to people there. When he comes back, his Spanish is ever more fluent and his understanding of the culture is ever deeper. As counselors, we strive to step outside our comfort zone and experience the world of your clients, so we can gain a glimpse, or a deeper understanding, of how cultures and diversity play out in their personal worlds. Seek Out Additional Multicultural Training As counselors, we can never fully understand the world of another person. To become a competent multicultural therapist in an ever-evolving world, we must maintain continued professional development to hone our multicultural sensitivity and competency. We need to join professional organizations and attend their conferences whenever possible. Multicultural topics are usually offered at professional conferences. One novice counselor under Nan’s training described a powerful experience in attending a national conference: “I went to a conference sponsored by a large charitable foundation for the purpose of increasing cultural sensitivity among educators and counselors. The three-day agenda consisted largely of listening to life stories told by persons of various races and cultures. After the second day, as one of the few Caucasian people in attendance, I started to feel isolated and overwhelmed by all the stories of oppression suffered by persons of color. I felt guilty and helpless. “Then, on the second evening, although totally exhausted, I attended a play. It was written and performed by an African American woman with a Ph.D. in the performing arts. The playwright acted as the main character whose great-greatgrandmother was sold as a slave. During the course of the play, she stood up on the small stage with the lighting dimmed. I looked closely and was alarmed to see that she was naked and was in agony as she portrayed a woman being sold, as if she were an animal, to the slave buyers. People in the audience were then to yell, ‘Bid ‘um up.’ “I wanted to run up on stage to cover her up. I thought that no woman should humiliate herself in such a way. I was insulted by being expected to recite the line given to the audience. Then I thought about my great-great-grandmother who had a difficult life. Many of her children died, and she worked all the time as a farmer’s wife but she NEVER had to stand up on a slave block, naked, and be sold. At that moment, I had a life-changing insight. I knew that as a White woman, I would never understand what it is to be a Black woman. I could read a thousand books and listen to life stories until I died, still, I would never understand. Experiencing that play forever changes my life and my sensitivity to people of the oppressed backgrounds.” Join a Network of Counselors and Therapists Try to join a network of counselors and therapists within your affordable schedule. Most communities have a group of mental health professionals who offer free networking. They present workshops, discussion groups, professional development, and skill development focusing on working with a diverse clientele. Discounted admission exists. Community groups also help counselors to feel part of a larger group and avoid isolation. Local universities are good resources for contact information for these groups.

Diverse and Multicultural Backgrounds 259 EXERCISES 1. To admit your lack of knowledge and ask the client how you shall identify her Client: “When people look at me, they usually assume that I am an African American.” 2. To acknowledge the differences in age between you and the client Client (65 years old): “I’m not sure if you are old enough to remember the Vietnam War. I’m a Veteran of that war.” 3. To explore whether or not a referral to a bi-lingual counselor is needed Client: “Can you speak French? I am more comfortable speaking French than English.” 4. To respect the value of marianismo while reflecting client’s conflict Client (Latina): “My mother did everything that my dad told her to. I was born in this country and all my friends are more independent than I am. It is hard to know how much I should go along with the old ways to please my mother.” 5. To acknowledge the feeling of the client (a mother) while being accepting of her beliefs Client: “I could feel a bad energy coming from him and I didn’t want my daughter near him. He could spread his evil energy onto her.” 6. To use a creative technique consistent with the client’s statement Client: “Music is my inspiration. When I sing the old songs, peace fills my heart.” 7. To respectfully establish rapport by asking for some information about Indonesian food that the client has talked about Client: “My mom cooks the old way all the time. Do you know what Indonesian food tastes like?”

14 The Journey Forward—Into the Practical World

Now that you have trekked through the jungle and learned the craft of our trade; the challenge of learning the new skills and techniques has primed your brain to grow rapidly. Seeing the sun shining brightly above, you take a breath of relief, and ask, “Now what?” This chapter aims to answer this question; it welcomes you to the journey forward, into the world of clinical practice. WELCOME TO THE WORLD OF THE IMPOSTER PHENOMENON The first thing you see as you make your way forward in the world of clinical practice is a road sign: “Welcome to the imposter phenomenon.” On Board with the Feeling of Being an Imposter It is common knowledge that it takes about 5000 hours of direct client contact for a therapist to start feeling comfortable in her own skin. Before hitting that number, you will deal with feelings of inadequacy and self-doubt in the first few years of your field experience—a feeling known as the “imposter phenomenon” (Clance, 1985; Clance & O’Toole, 1987). You feel as if you have others fooled into believing that you are something which you are actually not; you fear that your lack of ability will, sooner or later, be discovered (Clance & O’Toole, 1987; Kumar & Jagacinski, 2006; McElwee & Yurak, 2010; Sakulku & Alexander, 2011). This perception fills you with an unsettling sense of distress and anxiety. Your Impostor Cycle To cope with the anxiety of feeling like an imposter, you may go to either extreme: over-preparation or initial procrastination followed by frenzied preparation (Thompson, Foreman, & Martin, 2000). Even after you have completed your tasks, your initial sense of relief and accomplishment may not last, and soon enough you find yourself in the realm of anxiety. Thus, the imposter cycle continues. Even when you receive positive feedback about your accomplishments, you continue to doubt your ability. Your perceived identity stands in stark contrast to the positive feedback your receive (Sakulku & Alexander, 2011). Such is the difficulty in establishing your identity as a practicing therapist or counselor. You feel as though you may be walking on quicksand, not knowing when you will sink.

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You Are at the Right Place Where You Need to Be Please rest assured that you are not the only one who feels like an imposter; this feeling pervades every practitioner when they first start. The truth is, there are a vast knowledge base and skill set in the field of therapy and counseling, and it would be impossible to know it all. Mastering the knowledge and skills is a slow process and you cannot rush it. Based on my conversations with many practitioners, it takes about five years of practice to start feeling in command of the skills and interventions. When you are in your first year, don’t compare yourself with seasoned practitioners. Don’t try to match their speed. Embrace the process and know that you are exactly where you should be. Embrace a Realistic Expectation—A Lifelong Learning Put your feelings of being an imposter to good use—allow it to motivate you toward lifelong learning. As a therapist or counselor, you will constantly be evolving in your learning. As you evolve, your growth will surround three themes (Moss, Gibson, & Dollarhide, 2014): • • •

Adjusting your expectations to become more realistic. Gaining confidence and freedom to be yourself. Separating from your self-doubt and integrating what you might have disowned.

Every minute of working with a client will contribute to your growth on these three themes. Your clinical supervisors from your practicum, internship, or externship placements will help you develop a well-honed awareness. In addition, during your evolution, you will find it necessary to commit yourself to these three tasks (Moss, Gibson, & Dollarhide, 2014): • • •

Moving from idealism toward realism. Finding ways to turn burnout into rejuvenation. Shifting from a tendency to compartmentalize, toward a desire to embrace congruency.

You will mature and thus free yourself from the shackles of the imposter phenomenon. One day, you will find that you are ready to supervise or to provide consultation to other therapists and counselors. You will find that being part of this profession, as Yalom (2009) pronounces, has been such a mind-blowing privilege. But for now, you are right where you ought to be: welcome to the world of the imposter phenomenon. WELCOME TO THE WORLD OF DOCUMENTATION AND RECORD KEEPING The second thing you see, on your journey forward, is a road sign, “Welcome to documentation and record keeping.” On Board to Meet Standard of Care To meet the standard of care by the code of ethics, in every mental health treatment facility across the country, counselors and therapists are required to create and maintain documentation (Drogin, Connell, Foote, & Sturm, 2010; King, 2010; Luepker, 2012).

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Documentation is a track record for your clinical assessments, interventions, and results or follow-ups. Through a good practice of documentation, you abide by standards of care. In the practice of proper risk management, documentation also becomes an imperative. As a risk management motto goes: if you didn’t document it, you didn’t do it or it didn’t happen. Should any legal, ethical, supervisory situations occur, good documentation can be called into evidence to show that proper care and correct procedures had been implemented. From our conversations with many counselors and therapists, it is obvious that documentation is the most time-consuming and less enjoyable part of their work. Unfortunately, it is an essential part of client care. Good documentation will also be a benefit to you. First, it reminds you of the trajectory of the client’s history and progress. In fact, when you work with numerous clients, you won’t remember every detail about each one; you have to rely on your case notes. Second, should you need a temporary or permanent leave from your position, good documentation makes it possible for someone to fill in for you and to take good care of your clients. Case Notes—The Heart of Documentation Documentation encompasses a broad and multifaceted process. With the upsurge of electronic records, the impact of electronic communication, and the need to adhere to the guidelines of the Health Insurance Portability and Accountability Act (HIPPA) (Feigenbaum, 2007; Mitchell, 2007), the topic of documentation becomes so overarching that it requires an entire book to cover it all. Due to space limitation, we will focus on the matter of case notes—the heart of documentation. Therapists write case notes to record the client’s conditions before, during and after treatment. Different clinical settings have different standards for case notes. In general, three types of case notes must be kept in the client’s chart: • • •

Intake notes Progress notes Termination summary

Intake Summary The therapist completes the intake summary right after the intake interview. The intake summary provides a detailed clinical picture of the client’s reason for entering therapy, their current symptoms, and coping methods. The intake notes usually contain the following information: • • • • • •

Demographic information Presenting problems History of the problems Mental status Family background The client’s goal

Please see Appendix B for an example of what an intake summary looks like.

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Progress Notes Counselors and therapists must write session notes or progress notes after each session, although the specificity varies widely. Progress notes record the work you have done each session with your client. The information in the notes should be sufficient, yet brief with carefully chosen language. Sufficient to an extent that by glancing at your progress notes before a session, you should be reminded of the client’s current condition of therapy. If you work in a multidisciplinary treatment setting, the progress notes provide sufficient info so that different clinicians are able to stay aptly informed. Brief and with careful language to the extent that it only states the facts, excluding your own speculations or judgment. First, the progress notes can be subpoenaed in a legal proceeding. Second, your client might read their progress notes as these notes technically belong to the client. The client not only has the right to have their information be kept confidential, but also the right to know what is written in their progress notes. With this in mind, case notes should remain brief, with careful language, and avoid unnecessary and potentially troublesome personal details. That being said, all emergency issues related to threats needs to be included. Session cancelations, lateness, and payment status should also be included in the notes. Four Major Formats of Progress Notes There exist various formats of progress notes. Due to space limitation, this text will cover just four major formats: 1. SOAP Case Notes Subjective Objective Assessment Plan (SOAP) notes document clear and concise information about the client’s care. This format allows a clear and thorough way to document client concerns and what has transpired in the session (Cameron & TurtleSong, 2002). Here is what SOAP notes entail: S = O = A

=

P

=

Subjective: the clients’ subjective report of problems. Objective: the counselor’s objective observations of the client’s affect, nonverbal behaviors, appearance, or mental status in the session. Assessment: the counselor’s assessment of the client’s core issues, themes, or behavioral patterns; clients’ strengths and resources; clients’ progress. Plan: the counselor’s plan on how to achieve the client’s goals, how to improve the working alliance, or how to increase client awareness of behavior patterns, discrepancy, and forgotten strengths/resources, as well as how to maximize the client’s sense of competence and self-efficacy.

Please see Appendix C for two examples of SOAP notes. 2. PAIP Notes and 3. GIRP Notes Two other formats of case notes commonly used by practitioners are Problem Assessment Intervention Plan (PAIP) and Goal Intervention Response Plan (GIRP) notes (Bedrossian, 2016). PAIP format covers the following: P

=

Problem: the problem that the client brings to the session and is currently the focus of treatment

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= =

P

=

Assessment: similar to the assessment in SOAP notes Intervention: the therapist’s treatment and intervention provided throughout session Plan: the steps that the therapist/client will take before the next session and the issues that are planned to be addressed in future sessions

While GIRP format covers the following: G I R P

= = = =

Goal: specific goal in which you are currently working Intervention: similar to that of PAIP Response: the client’s response to each intervention listed above Plan: similar to that of PAIP

Due to space limitation, we are unable to provide examples of PAIP notes, nor GIRP notes. 4. Narrative Case Notes Narrative case notes provide an overview of what has transpired in the session, from the counselor’s point of view. It generally follows the chronology of the session, although themes or topics may be treated discretely. Due to space limitation, we cannot provide examples for narrative notes, either. Termination Summary Regardless of the length of the treatment or the nature of the termination, at the end of each client’s treatment, the therapist must compose a termination summary (Renk & Dinger, 2002) and put it in the client’s chart. The termination summary provides an overview of the demographics, issues identified, goals established, interventions made, the nature of termination of the therapy, and any referrals/follow ups. Please see Appendix D for an example of termination summary. BURNOUT AND THERAPISTS’ SELF-CARE As you travel further along, you will see the third road sign which reads “Burnout and Self-Care.” Our Professional Hazard—Burnout Burnout is the single most common consequence of practicing therapy (Kottler, 2017). Yalom (2009) also echoes this by lamenting, “psychotherapy is a demanding vocation, and the successful therapist must be able to tolerate the isolation, anxiety, and frustration that are inevitable in the work” (page 251). Entering into the inner world of the client, day in and day out, we bear witness to their suffering. Putting our own needs on the back burner, we relentlessly delve into their unspeakable feelings, assumptions, thoughts, and behavior patterns. There comes a point at which we become weighed down; we start to suffer the common phenomenon of our work—Compassion fatigue, also known as burnout. Several factors, inherent in this profession, can lead to burnout. First, when we feel that we give more than we receive, burnout begins to creep in. Second, unable to vent our frustrations or to celebrate our small successes with others (due to the confinement of confidentiality), we become socially isolated. Third, burdened by the slowness of

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clients’ actual progress (due to our tendency to compare it with our ideal vision of what therapy should be), the weight of compassionate fatigue starts to take its toll. New therapists—those who feel compelled to work overtime, to get emotionally invested in client’s progress or lack of it, to ruminate about clients’ problems even in their own personal time—are on the fast track to burnout. The following are personal reflections from two new therapists regarding this very phenomenon: “I have realized that burnout is very easily reached in this line of work. I am two months into my internship (not long at all), and I find myself tired, worried, and stressed out about everything that I want to accomplish, not only academically, but also with my clients.” “I had a really rough day on Monday. I was feeling very down; my internship was stressful, and then I had a difficult session with a difficult client. I went home Monday night, and the day was still with me. I felt very down, and couldn’t shake that feeling off. I woke up on Tuesday, still feeling down. Then I started to worry. How can I do this job if I can’t shake it? I was also nervous because I was due to see three clients in a row, take an hour break, and then co-lead two groups spanning three hours. If I myself continue to feel down, how can I help others?” Practical Suggestions for Therapist Self-Care To have a healthy longevity in the therapeutic profession, we must cultivate our spirit, mind, and body. A caretaker by nature and often the reason they are drawn to this profession, most therapists shine at caring and nurturing others. Their gifts, however, can become their curse as they tend to leave out self-care, playing a part in their tendency toward burnout. To reverse this tendency of burnout, regular self-care is of the utmost importance. In a career like this, top priority must be given to taking care of our own heart and mind so that we can do the same in return. Based on the literature (Cherniss, 2016; Linley & Joseph, 2007; Skovholt & TrotterMathison, 2014), we summarize some practical ways that you might want to consider utilizing for regular self-care: • • • •

•

• •

Establish clear boundaries on self, clients, and therapy. Honor your limits. Charge a fair wage without guilt. Work within reasonable hours. Take a vacation; get out of town once in a while. Wear several hats if possible—you can reduce therapy hours, allowing room for you to engage in teaching, supervising, writing, consultation, etc. Spreading your talents across several areas—but still centering on your core “official” discipline— will refresh your spirit, help you weather through any potential crisis, and actualize your full potential. Create and maintain a personal life outside therapy that includes at least three of the following that nurtures you emotionally and spiritually: creativity, leisure, hobbies, friendships, loved ones, exercise, etc. Read nonprofessional literature. Read for fun. Get to know other professionals. It will reduce your isolation, and increase your opportunities for collaboration in creative projects.

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Following are reflections from two new therapists on their self-care: “The most important aspects of my realization is that I have become adamant about self-care; I have learned to say ‘no’ when I have too much on my plate. I have learned to get my nails done every couple of weeks. I have become more open to taking time off and vacationing. Lastly, I have learned to cherish the time I have with my family, which I used to take for granted.” “After having two very tough days in my internship, I have learned to take better care of myself. Practicing some yoga and meditation, eating a good lunch, and then heading to my internship. I review last week’s session notes and write up some reminders for each of the day’s clients, just to make sure I am prepared for each session. As I work with each client, I feel more and more energized. By the time I have finished my three back-to-back sessions, I feel even better. Helping others, indeed, lifts my own spirits.” Take Care of Your Inner World The private, personal world of the therapist is our most important tool (Cozolino, 2004; Yalom, 2009). As the managed care pushes more and more for brief therapy and psychopharmacology, it might be tempting for us to stay “above the neck”, sealing off our inner world (Cozolino, 2004), in an effort to stay afloat. We don’t need to be a pawn in the hands of the powerful. Therapy is about providing a relationship in which your client can discover himself. The length of therapy does not need to be long, but it does require that you share how you feel when your client does or says something. As you bring this self-awareness to the session with your client, you increase your rate of success. To bring mindfulness and an expansion of self-awareness into the session, we must dedicate ourselves to ongoing self-discovery of our own inner world. We can expand our self-awareness through meditation, wisdom philosophy, spending time in nature, playing with children, playing with pets, or attending therapy ourselves. Following a reflection from a new therapist on how she invests in taking care of her inner world: “After meeting my client, I found myself torn between my own perceptions/ stereotypes and what I was beginning to hear from her. I found memories and feelings from my own past come up. Triggers were coming up for me along the way. Immediately, I sought help from my therapist. I know my potential for countertransference needs to be explored so I can continually show up in my sessions with my clients, free from any debris that may have lingered. I know that I have to begin to let go of my preconceived notions and witness her as a clean slate. With this self-knowledge, I have increased my own personal therapy sessions during my internship. I am happy to say that this personal investment in the care of my inner world allows for my time with my client to become a journey to a place I have never visited.” APPRECIATE OUR PRIVILEGE Further on your journey forward will be another road sign that reads, “Appreciate Your Privilege.”

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Despite all of the challenges, stresses, burdensome paperwork, and the potential threat of burnout, being a therapist can be incredibly rewarding and meaningful. The rewards are primarily intrinsic in nature: the honor and the privilege to be invited by our clients to enter into their intimate and personal world and to walk with them through and out of the woods. This last reflection gives you a glimpse of how a new therapist reaches a place where she really appreciates the privilege given to our profession: Immersed in my internship and my first experience as a therapist, I have found myself becoming more existentialist than ever—I have found myself contemplating what a magical experience it is to face my first clients. The breakthroughs and ‘aha’ moments excite me, but even they pale in comparison with the atonement of an empathic rupture. Nothing can compare to the experience of being wrong and knowing that I have to admit it, knowing that being honest and humble is the only way that I and my client will grow. I have experienced tears, laughter, and everything in between in ways that I hadn’t before—things that create connection and healing at the same time. These are the moments when I feel what a privilege it is that I am in this field. The ‘magic’ hasn’t ended with my clients, though. I have also experienced a special connection with other therapists, with other interns, with my supervisors and with everyone with whom I have come into personal contact. It is like my eyes are opened to a new kind of energy dynamic. Surprisingly, I have discovered how much I love running therapy groups. I have the opportunity to run a group—a difficult one in itself. I test my group leadership muscles by running it as an interpersonal process group. It works! My experience of running the group deepens my desire to pursue this as one of my future career options. Despite having felt a full range of emotions, despite having found myself overwhelmed at times, I have grown tremendously as a practicing therapist, I have learned to lean on others when things get tough, and most of all, I have learned what a privilege it is that I am a therapist.

Appendix A An Example of a Service Disclosure Brochure

Welcome to the North Shore Counseling Center. We appreciate your trust and the opportunity to be of help to you. This brochure is designed to inform you about our counseling services. As you read it, please feel free to make marks on any matters that are not clear to you or write down any questions that you may have, so we can discuss them during our first meeting. This brochure is yours to keep. WHAT TO EXPECT IN COUNSELING In counseling, you the client, set the agenda. Initially, you will speak with one of our counselors about your reasons for seeking assistance. Then, you and your counselor will make a joint decision on which approach is most appropriate to meet your needs. Any personal concerns may be explored in counseling. It is important to realize that nothing is “off limits” to discuss. We are here to work with our clients who have experienced a wide variety of difficulties and struggles. Mostly, you will meet individually with your counselor on a weekly basis, each session lasting between 45—50 minutes. As you talk with your counselor, you may begin to see your feelings and needs more clearly; you may develop different goals or motivations for yourself. In working with you, we, the counselors, strive to help you understand yourself, develop greater self-confidence, define your preferred direction, or develop a greater awareness of the needs of yourself as well as of other people. Within the counseling relationship, we help you work toward overcoming anxiety or depression, understanding addiction related problems, or improving your interpersonal relationships. Often, clients who come in to deal with one particular concern decide to continue counseling to work on issues other than, or in addition to, the concerns that initially brought them to counseling. You may experience this kind of perspective change during the counseling process as well. CONFIDENTIALITY Counseling requires an open and trusting relationship in which you can feel safe and secure to talk about whatever issues concern you. In order to safeguard this, the information you share in counseling is treated with the strictest confidence. Therapists, however, are ethically obligated to breach confidentiality in cases where clients report child abuse or potential harm to themselves or others. We may keep intake notes and progress notes about our work together. These notes will be retained in a secure, locked drawer and will be kept confidential, as mandated by our ethics codes. The staff counselors and therapists within the center may occasionally

Appendix A 269 consult with each other. In such cases, only information pertinent to consultation or supervision will be shared. If you have any questions about the confidentiality of counseling information, please feel free to discuss them with us. CLIENTS’ RESPONSIBILITY We can help you only if you are willing to receive help, attend regularly scheduled sessions, and try new ways of thinking, perceiving, behaving, and interacting with others outside of the counseling setting. You are responsible for keeping your appointments. Regular attendance is important for successful counseling results. If you cannot keep an appointment, please notify the Counseling Center at least 24 hours in advance. THE COUNSELING STAFF Our counseling staff consists of professional counselors with a variety of backgrounds, skills, and interests. We are trained in counseling, counseling psychology, or clinical psychology and hold doctoral or master’s degrees in these fields of study. If you are interested in knowing about your counselor’s training and background, please feel free to discuss this with your counselor. EQUAL OPPORTUNITY You have the right to counseling services without prejudice as to person, character, belief, or practice. Informed Consent Form I have read the Services Disclosure Brochure of the North Shore Counseling Center. I understand my rights and responsibilities in the counseling relationship and agree to abide by them. I understand that all information I share in counseling will be kept confidential except in cases of child abuse or potential harm to my own self or others. I hereby agree to participate in counseling provided by the North Shore Counseling Center.

Client signature ________________________ Date ______________

Appendix B Intake Notes

(Client with a pseudo name and protected identity) • Demographic Information & Presenting Problem Reina is an Asian American woman, married, with one son. She and her husband have been actively involved in IVF treatment for a second child. As she is about to turn 44, she promised herself that she would not continue IVF treatment after turning 44. The idea that she may not have another child saddens her. She states that she is currently dealing with a great deal of stressful events, including renovating their home while living in it and having it on the market, a part-time job, caring for her son, and her husband’s frequent business traveling. • History of The Presenting Problem Reina has always wanted two children. She married at 37 and struggled to get pregnant with her first child. Finally, her son was conceived after 6 months of attempting numerous fertility procedures, including two rounds of IVF treatments. She has since had four failed IVF attempts. She is very hopeful that she will conceive with this current one. When she successfully conceived her first child, life was not as stressful as now. With the current stress, Reina feels a lot of anxiety since life does not always happen according to her plan. And according to her, she is a “planner.” • Family Background There is no mental illness, drug addiction, alcoholism, or trauma to note. Reina has always been very close to her mother. Her father has always lived in Korea and is remarried and started a new family. Reina’s mother was her father’s “mistress” as so referenced by Reina. She and her mom only got to see him when he was in town which did not sufficiently form a relationship. This part of the family background did not come out until I inquired about the missing part of the picture—her father. It is obvious that this is an area in her life that has remained unexplored. She does not seem to want to talk about it, and frames it as “no big deal”. • Observations of Nonverbal Cues Reina smiles a lot and seems tense. She frames most of her statements in exceedingly positive light even when she is discussing something painful, such as not having a relationship with her father. Her face changed dramatically when she discussed her father: she spoke almost entirely through a frown.

Appendix B 271 •

Client’s Short-Term & Long-Term Behavioral Goals

Short-term goal: Reina wants to feel less anxious around the idea of getting pregnant. She wants to get to a place where she can come to terms with not getting pregnant, if that’s how it turns out. Long-term goal: This has not been completely fleshed out, but the implication is that Reina would like to alleviate anxiety that she experiences surrounding her needs for planning and control.

Appendix C SOAP Progress Notes

(Client identity is protected) SAMPLE 1 Subjective: Reina began the session presenting a new issue she has been grappling with. Her son has always been attracted to dolls, wearing dresses, and more femininerelated interests. In the last few weeks, he has asked to be called a girl. She and her husband decided to take away his dolls and are refusing to call him a girl. A couple of weeks ago, Reina was ok with the way her son was identifying and believed that God “doesn’t judge, so why should I judge?” She has since been convinced by her husband, who is also from Korea and is a devoted Christian, that “God doesn’t make mistakes and God would not put a girl in a boy’s body.” When asked what it would mean to her if her child was trans, she cried, saying “I wouldn’t mind, but I would hate to watch him be bullied.” She also cried when she discussed how it would take a long time to come to terms with her son’s future. She did not “story tell” as much as usual, but instead focused on the internal struggle she was experiencing around this issue. Objective: Reina continuously asked questions. She sat cross-legged, with one hand trapped between her legs for almost the entire session, as if she was trying to stifle a part of herself. Her other hand moved a lot, expressing frantic feelings she has about this subject. When she discussed the potential pain her son would experience from being trans, she would get very still, and fight to hold back tears. At one point, in regard to her son being trans, she said “I have no control!” and then immediately stopped herself and said “No, I do have control. At this point, no dolls.” Assessment: The theme of anxiety and the behavioral pattern of control have surfaced again. She feels ambivalent about her son’s gender identity, and struggles to find ways to control the situation. In her mind, if she can “steer him in the right direction”, then he will not suffer, her husband will be happy, life will be all right. This is related to the theme of worrying about how the outside world perceives her/her family, and of worrying about judgment, originating from her father issue. Reina shows her strengths as she wants to embrace the way her son is by being open-minded and flexible. She was coping well with her son’s gender identity issue. However, when her husband interfered and “put his foot down” about the girl toys, etc., she started to struggle about which direction to take. More information about their relationship would be helpful in determining their roles.

Appendix C 273 Plan: We will continue to focus on the anxiety issue and the pattern of control. She had a very emotional response when asked about what her son’s behaviors meant to her. She appeared tormented by the thought of her son being bullied. Near the end of the previous session, Reina mentioned that she dropped out of school and left home as a teen. Did Reina feel bullied, rejected, isolated, or humiliated during her teen years, leading to her dropping out of school? This needs to be explored. SAMPLE 2 Subjective: Tom reported instances of injustice around him and the fights that ensured. He said he is becoming more aware of the emotional impact his actions are having on his wife. Although he reported that there is no problem between him and his wife, he proceeded to discuss the issues his wife is having with it, for the entire session. Objective: Tom showed little change in his vocal or physical nonverbal cues. He remained controlled, rational, passive, and inanimate. However, when the counselor role-played his wife begging him to relocate, he paused, his voice lowered and quavered, he sighed, his volume lowered, and his tone softened. Yet, when his choices were explored, his voice again became flat. The exception was when he was confronted with inconsistencies, he stammered, stuttered, and his pitch raised. He also avoided direct eye contact, looking at the wall rather than the counselor. Assessment: Tom’s conflict with his wife seems to be rooted in his early life, which was filled with familial chaos and conflict. He coped with this chaos and conflict by denying his emotions, keeping them at a distance. His strength is that he has a strong sense of morality and justice, and has high ideals for a better environment. However, to reach his ideal, he both literally and mentally struggles and fights. This perpetuates chaos and conflict, yet paradoxically fosters his sense of power, strength, and esteem. Through his actions and the heroic role, he gains a sense of leadership, importance, and worth. His actions place him and his wife in emotional and physical jeopardy. He is at risk of losing a healthy life and his wife. He claims to be growing tired of the responsibility that he has assumed and says that he cares about his wife’s stress about his fighting but does not know how to change. Plan: Although this session focused mainly on his conflict with his wife, other areas of conflict that should be discussed include: (1) conflict with neighbors; (2) conflict with in-laws; and (3) conflict with his mother. In the next session, Tom said he would like to focus on his conflict with his mother. Tom has cut off communication with her to avoid direct confrontation, which perpetuates the hurt he feels. Exploration of his feelings about his mother may help Tom resolve other areas of conflict in his life.

Appendix D Discharge Summary

(Client identity is protected) Reina, a 44-year-old Asian American, received counseling for eight sessions. Her chief concern was anxiety brought on by a sense of lack of control. Her goal was to reduce her anxiety around life issues that she cannot control; particularly her attempts to get pregnant. Our sessions have focused on the following: determining the source of her anxiety; healing old wounds associated with her father; establishing limits/boundaries; refocusing her energy on what she can control. Some interventions used include action-oriented homework, motivational interviewing, here-and-now feedback giving, Empty Chair mutual dialogue with her younger self, who has been burdened with a sense of shame. Near the end of treatment, Reina states that her anxiety has reduced greatly; she feels less need to be in tight control. Anytime the anxiety creeps in, she is able to use self-affirmation to talk herself out of it. Also, she states that our sessions have helped her realize the importance of having an objective person to discuss her issues with. She realizes that she does not feel comfortable talking to her friends about these issues; whereas therapy has helped her tremendously. She believes that the mere act of recognizing her issues with control and their sources, has already greatly reduced her anxiety and her need for tight control. Due to my transitioning to another phase of my life, our therapy has to be terminated. Reina plans to continue with another therapist whom she already has lined up. Case closed.

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Index

Page numbers in italic refer to Figures, those in bold refer to Tables.

Acceptance, of three basic human needs 18 acceptance and commitment therapy (ACT) 3, 133, 134, 144, 197 active behavioral changes 26, 147–148, 187 adaptive schemas 191, 191, 192 adolescent clients 166 advanced empathy 43, 62–63, 63 reflecting deeply seated feelings 63 reflecting the implicit meanings 65 advanced intervention techniques 134, 190–191, 220 Empty Chair technique 212–219 experiential teaching 206–208, 220 guided imagery 203–206 internalized other interviewing 209–211 life skill training techniques 193–197 mindfulness training 197–203 paradox 208–209 part dialog 211–212 therapeutic suggestions 203 advice givers 30 affect regulation 124–127 affirmation 41, 58, 59, 60 African American clients 247, 249, 250, 252, 253 Agreement is not empathy 41 American Indian clients 184, 254 animal-assisted therapies 241–242 Asian clients 65, 103, 184, 186, 249, 254 Assertiveness Training 133 assessment 45, 75–79, 82–84, 86–87, 88–95 assumptions 7, 48, 49 attachment theory 3 attending behaviors 43–44 attention suggestion 112, 128–130 attentive listening 42–43 autism 241–242 automatic thoughts 135–136 avoidance see experiential avoidance awareness 23, 27, 48, 110, 144–145, 150, 158, 198, 257

BARS see behaviorally anchored rating scale basic empathy 46, 47 affirmation 41, 58, 59, 60 paraphrasing 46–48 perception checking 54–55, 57–58 reflecting needs 46, 50, 56–57 reflecting the feeling content 46, 49–55, 53 reflecting the thought content 46, 48–49, 50 summarizing 60–62 behavioral activation 146 behavioral assessment 76 behaviorally anchored rating scale (BARS) 68–70, 69 behavioral patterns 154, 155, 156, 161–164, 165, 177 blurred boundaries 167 body awareness techniques 130–132 body language 49–50 Body-oriented directives 127–134 Attention Suggestion 128–130 Body Awareness Exercise 130 Breathing Retraining 131–132 Experiential Acceptance Retraining 132–134 breathing retraining 131–132 brief therapy see solution-focused therapy burnout 23, 103, 264–265 canned comments 30, 60 case conceptualization 33, 34, 36, 45, 46, 115, 151, 153–156, 156, 192 case study: Charles 161 Jackie 161 Rita 214, 216, 217, 218, 219 Sue 179 case notes 96–97, 262–264 CBT see cognitive behavioral therapy challenges 182–188 change 3, 5, 11, 12, 16–17, 25–26, 105

288

Index

children 7, 41 with autism 241–242 with disabilities 236 with learning disabilities 237–239 child-self, in Transactional Analysis 201 choice theory 9, 10, 157 clarifying statements 83–84 client-centered reflections 52, 110, 111 client factor, contributing to success in therapy 15–17 clients 15–17, 41, 108–109, 117, 166 client with disabilities 232, 233–237, 244–245 client nonverbal cues 64–65, 102, 118, 119, 185 client silence 101–102 clinical assessment 45, 75–79, 82–84, 86–87, 88–95 closing summarization 61 cognitive behavioral therapy (CBT) 3, 6–7, 9 cognitive defusion 134–135 cognitive distortions 6, 7, 134 cognitive fusion 134 cognitive restructuring 48, 134–137, 145–146 college students 239–241 common themes 153–154, 158–159, 164 common therapeutic factors 14, 15, 16, 18–19 client factor 15–17 therapist factor 19–21 treatment factor 21–22 communication barriers 113–116, 248 communication levels 174 communication styles 29–31, 247 see also response styles compassion 12, 54 compassion fatigue see burnout competence, in therapist factor 21 connection 2, 3, 22 constructionist therapy 10–11 constructive feedback 173, 174–177, 178–180 contemplation, in stages of change 26 content-focused therapy 117 control see experiential avoidance coping behaviors 154–155, 155, 156, 160–165, 165, 177, 193 corrective emotional experiences 5, 157 counseling skills 1, 12, 22–23, 25, 28, 34, 37, 123, 124 countertransference 109 critical inner voice, in performance anxiety 33 cross-examiners, ineffective response style 30 cross-session tracking 61–62 cultural beliefs 166, 248–249, 254–255 cultural relativism 256 cultural sensitivity 257–258 cultural universality 256 cultural values 166, 184, 248–249, 255, 256 curiosity, in constructionist therapy 11

dance/movement therapy (DMT) 242 dead-ends, in talk therapy 8 depression 3, 131, 135 diagnostic overshadowing 233–234, 249 directives techniques, four basic 127 attention suggestion 128–130 body awareness techniques 130 breathing retraining 131–132 experiential acceptance retraining 133–134 direct sense, in experiential approach 8 disabilities, clients with 232–237, 244–245 autism 241–242 learning disabilities 237–241 physical disabilities 243–244 disallowing, client habit of 208 discharge summary 225, 274 disconnection 2, 3 discounters, ineffective response style 29 discounting reassurance 29, 115 discrepancies 165, 185–186 disowning, client habit of 132, 208 distortions 7, 42, 186, 191 diverse background clients 248–250, 251–256, 257, 258 diversity 247 DMT see dance/movement therapy documentation 261–264 dynamically oriented therapy 5–6 effective response styles 25, 31, 32 emotional brain 11, 12 emotional well-being 20 emotion regulation 11, 124–127, 134 emotions 8, 11, 12, 49–50, 51, 124–127 empathic responses 2–3, 28, 31, 32, 38–39, 42–45, 54–55, 67–68, 70–74, 116–117 advanced empathy 43, 62–63, 63 basic empathy 46, 47 behaviorally anchored rating scale 68–70, 69 empathic skills 17, 46, 150, 151 see also basic empathy empathizers, the effective response style 31 empathy 40–41, 42–44, 45, 46, 54–55, 62–63, 63, 116–117, 151 see also basic empathy; empathic responses Empty Chair technique 212–219 equine therapy 242 ethics 18 ethnic similarity 20, 252–253 evaluative listening 67 evidence-based therapy 14–15 evocative questions, in motivational interviewing 141 exceptions 11, 98–99 expectation 18–19, 20, 120 experiential acceptance 42, 132–133 experiential acceptance retraining 133–134 experiential avoidance 9, 41–42, 112, 132–133

Index experiential focusing see attention suggestion experiential teaching 206–208, 220 Self-Affirmation Training 206–207 Reowning and Reclaiming Training 208 experiential therapy 8–9 experts, ineffective response styles 29–30 expressive arts techniques 142–143 external stressors 10 extreme questions, in motivational interviewing 142 eye contact 43–44, 65 face-to-face interviewing 76, 77–78 facial expressions 34, 50, 64, 118–119 facial mirroring 118–119 feedback 69, 173–177, 178–180, 229 feeling content, reflecting 46, 49–55, 53 feelings 49–50, 51, 53, 62, 69, 73–74, 83, 111, 112, 118 feeling words 53, 55–56 felt-bodily experiences 8, 12 focusing 82–83, 84, 97 formative influences 78 gender, in therapist factor 20 generic counseling skills 123, 124 Gestalt therapy 8, 208 GIRP (Goal Intervention Response Plan) Notes 263, 264 guided imagery 203–206 Hebb’s Law 12, 154 here-and-now 5, 7, 121, 169, 170–173, 179 hidden feelings, reflecting 63, 63–65 Hispanic clients 249, 253 Hope, in common therapeutic factors 18–19 “how-do-you-do-that” question 140 “I Don’t Know”, dealing with 106–107 IEP see individualized educational plan ignored information, confronting clients with 188 immediacy 167, 169, 170–173 implicit meanings, reflecting 65–67 imposter phenomenon 260–261 inadequate-regulation 124–125 indirect assessment 76–77 individualized educational plan (IEP) 237 individuation 225 ineffective response styles 29–31, 32 influencing skills 38, 45, 150, 151, 152, 157–159 challenges 182–188 counsellor self-disclosure 165–169, 167, 172–173 identifying themes & resilience 158–160, 164

289

identifying coping behaviours and pattern 160–165 feedback-giving 173–177, 178–180 immediacy 170–173 triangles of insight 179–182, 181 information gathering 77–78 informed consent 88 inner experiences 50, 51–52 inner voice 33, 48, 49, 194 in-session tracking 61 intake interviews 78–79, 86–87, 88–95, 270–271 intake summary 88, 96, 262, 270–271 intellectualization 48, 112, 115–116 interconnectedness 2, 156 interdependence 2 intermittent termination 225 internal coping resources 10 internalized other interviewing 209–211 interpersonal deficiency 4, 8 interpersonal effectiveness 4 interpersonal neurobiology 11, 12, 193 interpersonal psychotherapy 3–4 interpersonal reality 4, 11, 156–157, 175–176 interpersonal relationships 3, 4 intervention techniques 14–15, 19, 38, 123–124, 127–134, 190, 253–254 see also advanced intervention techniques intuition 23 invalidating self-talk 206–207 I-Thou Immediacy 7, 169, 170 Japanese clients 65, 186 language 116, 249–250 special needs clients 235–237, 246 therapeutic 25, 32, 44, 250 leading questions 82, 106 learning disabilities (LD) 237–241 life experiences, in therapist factor 20 life skill training techniques 193–197 listening 39, 42–43, 49, 158, 250 long-lasting relationships, in relationship differentiation 2 looking-back questions, in motivational interviewing 142 “loving-kindness meditation for the child self” 201–202 maintenance, in stages of change 26 maladaptive behavioral patterns 154, 155, 161 maladaptive schemas 5, 7, 42, 191, 191, 192, 193, 198 mindfulness-based therapy 7 mindfulness practice 3, 144, 198–203 mindfulness training 197–203 minority clients 103, 166, 186, 248–249 miracle question 139 mirroring 118–119

290

Index

misunderstandings 120–121 motivational interviewing 25, 141–142, 165, 266 multicultural background clients 248–249, 250–255, 257, 258 multiculturalism 247–248 ‘Musts’, restructuring the 137 mutual empathy 2–3, 16 narrative case notes 264 narrative therapy 10, 11, 99, 139–140, 156, 160, 209–211 Native Americans 251, 254–255 needs, reflecting 46, 50, 56–57 negative complaints 107–108 neurally integrated therapist, becoming a 13 neuroplasticity 12, 13, 157 nonstandardized assessment 75–77 nonverbal communication 43–44, 64–65, 119 nonverbal cues 34, 43, 64–65, 67, 119 normative reflections 52–53, 54 not-knowing position 84, 106 observer-self 202–203 one-down position 106 one-uppers, ineffective response style 29 open-ended questions 80–81 opening summarization 60–61 other-focused reflections 52, 110 outcome goals 99–100 over-regulation 124, 125 PAIP (Problem Assessment Intervention Plan) Notes 263–264 paradox 208–209 paraphrasing 46–48 part dialog 211–212 past records review 76–77 pattern-interpretation 162–164 peer counseling 34–36 perception checking 54–55, 57–58 performance anxiety 33–34, 37, 40, 119, 194–195 personal disclosure 167–168 personal therapy, of therapist 6, 20, 23–24 physical disabilities 243–244 polarized parts 211 positive feedback 173–174 precontemplation 25 premature terminations 20, 224 preparation, in stages of change 26 primary emotions 63, 63–64 private experiences 45, 46, 50, 51–52 probing questions 30, 77–79, 111 problem exploration, in stages of counseling 27 problem resolution, in stages of counseling 28, 190 problem solvers, ineffective response style 31

problem solving, premature 27, 39 process resistance see resistance professional disclosure 87–88, 268–269 progress notes 68, 96–97, 263–264, 272–273 psychodynamic therapy 5–6 psychological needs, universal 56 qualitative assessment 76, 77–78, 82–84 questions 97, 106, 226 leading 82, 106 open-ended 80–81 probing 30, 77–79, 111 Socratic 135, 137–139, 141–142 solution-focused 139–140 racial identity 250–251 racial microaggressions 248, 250 racism 248, 257 rambling 111–112 RCT see Relational–Cultural Therapy reactive emotions 49–50, 63 reassurance 29, 115 referrals 117, 229, 234, 254 referred person 209–210 reflective journaling 36–37 reflective practice 36–37, 250 relational–cultural mindfulness 3 Relational–Cultural Therapy (RCT) 2–3 relational schemas 7, 181 relationship differentiation 2 relationships, long-lasting 2 repetition compulsion 5–6, 181 resilience 9, 16, 19, 159–160 resistance 103–109, 174–175 response styles 25, 29–32 responsibilities 9, 10 role play 7, 193, 194–195 role reversal 7, 166, 193, 195–197, 220 scaling questions 140, 226 schemas 7, 181, 191–193, 192, 203–206 adaptive 191, 191, 192 maladaptive 5, 7, 42, 191, 191, 192, 193, 198 second sessions 96–100 self 4, 23, 36–37 self-affirmation training 206–207 self-awareness 198, 221, 226–228 self-care 119–121, 265–266 self-disclosure 20–21, 35–36, 165–169 of therapist 165, 166–169, 167, 172–173 self-efficacy 9, 150 self-expression 7, 142–143 self-involving disclosure 167, 169 self-narrative 226–228 self-observation 110 service disclosure brochure 268–269 shame 2, 42 ‘Shoulds’, restructuring the 137

Index silence 100–103 SOAP (Subjective Objective Assessment Plan) notes/progress notes 96–97, 263, 272–273 social constructionist theory 11, 156–157 social interaction theory 104 social justice 257 Socratic questioning 135, 137–139, 141–142 SOLER (Square, Open, Leaning forward, Eye contact, Relaxed) 43–44 solution-focused questioning 139–140 solution-focused therapy 10, 11, 99, 139, 146–147, 161, 223 speaking styles 32–33 see also response styles special needs clients 232, 233–237, 244–245 autism 241–242 learning disabilities 237–241 physical disabilities 243–244 splits 211 “stages of change” model 25–26 “stages of counseling” model 25, 26–28 standardized assessment 75 strategic questions 82 strength-based therapy 9, 10, 160, 187 stress 10, 103, 198 subjective experiences 45, 46 successive approximation 65 suffering 2–3, 9–10 Sullivan, H. S. 3, 4 summarizing 60–62, 97 surprise task 139–140 sympathy 54 take-home exercises 100, 144–148 talk therapy 8, 255 Taoist philosophy 38–39 technical expertise 19 techniques 22–23, 25, 37 termination 28, 223–230 termination summary 264, 274 testing, in standardized assessment 75 theme analysis 151–153 therapeutic factors 14 client factor 15–17 therapist factor 19–21 treatment factor 21–22 therapeutic language 25, 32, 44, 249–250 therapeutic outcome 14, 15, 16, 99–100 client factor 15–17 therapist factor 19–21 treatment factor 21–22 therapeutic process 1, 4, 16–17, 121

291

therapeutic relationship 4, 5–6, 17–18, 22, 40, 67–68 termination, during 223–230 trust 17, 21, 39, 42, 105, 184 therapeutic success 14, 15, 16, 17–18 client factor 15–17 therapist factor 19–21 treatment factor 21–22 therapeutic suggestions, in guided imagery 203 therapist factor 19–21 therapists 21, 42, 267 imposter phenomenon 260–261 nonverbal cues 43–44, 67, 119 personal therapy 6, 20, 23–24 self 4, 23–24, 36–37 self-disclosure 165, 166–169, 167, 172–173 silence 101–102 therapy 1, 3, 12, 14–15, 22, 266 therapists personal therapy 6, 20, 23–24 therapy sessions 1, 39–40, 96–100, 113, 119–121 thought content, reflecting 46, 48–49, 50 tracking 43, 60, 61–62, 98, 111 transtheoretical model of behavior change 25, 105 treatment factor 21–22 treatment plans 75, 123, 124 Triad Model of Peer Counseling 34–36, 35 triangles of insight 179–182, 181 trust 17, 21, 39, 42, 82, 105, 184, 249 Two-Chair Dialogue see Empty Chair technique unfinished business 213, 214 universal psychological needs 56 unlikable clients 117 vague responses 114–115 validation 7, 18, 41, 58, 59–60 verbal communication, in channels of communications 43 verbal mirroring 118 vicious circles 11, 147, 155, 156, 156, 157, 161, 162 well-being, therapists’ emotional 20 Yang principle 39 Yin principle 39 young clients 108–109