CFN9885 - SECTION 2: COMPONENTS OF EFFECTIVE COUSELING
Counseling typically follows a series of overlapping stages. Initially, clients help clinicians understand their current difficulties, that is, help clinicians to understand why they are seeking counseling. Based upon this initial contact, clients commit to counseling as a way to address their problems.
This stage is followed by conversations and activities that lead to a deeper understanding of the clients’ needs and desires. This is followed by clients and clinicians agreeing on goals for change and an action plan to accomplish these goals. This is followed by periodic assessment or re-evaluation of the counseling goals and the effectiveness of the strategies used to achieve these goals.
If new information emerges that changes either the understanding of the problems or the goals of counseling, the process is adapted to meet the need of the new circumstances.
The basic stages of counseling are: 1) Developing the client/clinician relationship; 2) Clarifying and assessing the presenting problem or situation; 3) Identifying and setting counseling or treatment goals; 4) Designing and implementing interventions; and 5) Planning, termination, and follow-up.
Developing the Client/Clinician Relationship
Fundamentals of the Counseling Relationship
Effective counseling has both process goals and outcome goals. Outcome goals are the intended results of counseling. Process goals are what the clinician and the client are going to try to do to realize their outcome goals. (Welfel & Patterson, 2005) The research consistently shows that the single most important factor in a successful counseling outcome is the presence of an open, trusting, and empathic clinician/client relationship. (Lambert & Barley, 2002) If counseling is to be successful, a strong counseling relationship must be formed early in the counseling process, preferably in the first few sessions.
There are two concepts that are fundamental to the development of the counseling relationship: collaboration and attachment. In terms of collaboration, clinician and client must invest in the work jointly. In terms of attachment, it is essential that clinician and client form a bond with each other to effectively work together. (Gelso & Fretz, 2001)
The therapeutic relationship consists of three basic parts: 1) agreement between the clinician and client on the goals of counseling, 2) agreement about how the goals may best be obtained, and 3) the emotional bond that forms between the clinician and the client.
Agreement on the goals, how the goal will be achieved, and the emotional bond all contribute to strengthening the alliance between the clinician and the client. In turn, the strength of the alliance between the clinician and the client facilitates agreement on the goals and how best to achieve them. Both the clinician and the client must be genuine, that is, they must be willing to be open, honest, and authentic with each other.
Only when clients experience a sense of hope for change and a belief that the clinician truly understands and supports them are they ready to engage in the difficult tasks of self-exploration and behavioral change.
Carl Rogers was among the first therapists to talk about the necessary conditions for a therapeutic relationship. The conditions he identified are accurate empathy, clinician genuineness, and an unconditional positive regard for the client. (Rogers, 1957)
Empathy has two levels. First, clinicians must demonstrate they understand what the client is saying, that is, the content of their narrative. Second, clinicians must understand the meaning clients attach to their narratives. The meaning may be not only what clients are saying, but also what clients are implying or stating incompletely. (Egan, 1998; Welsh & Gonzales, 1999)
Genuineness is a feeling of being comfortable with one’s self, that is, there is congruence in the clinician’s words, actions, and feelings. Finally, unconditional positive regard means the clinician sees the inherent worth or value in the client no matter the client’s current circumstances. These qualities are conveyed to clients through the clinician’s attitude and verbal and nonverbal behaviors.
Other writers have proposed additional core characteristics including respect (clinicians have high regard for a client’s worth as a person); immediacy (clinicians are sensitive to the immediate feelings and experiences of the client); self-awareness (clinicians understand and accept their own feelings, attitudes, values, and inadequacies and the impact these have on others); trustworthiness (clinicians uphold the moral, ethical, and legal standards of the profession); and cultural awareness (awareness of their own and their client’s cultural assumptions, values, beliefs, and experiences and how these factors impact counseling) . (Nugent & Jones, 2005; Sue & Sue, 2003)
To summarize, effective clinicians should strive to have the following characteristics:
- Empathy: Clinicians should not only attend to, listen, and reflect to communicate an accurate perception of what the client is saying, but additionally, the clinician should be aware of how they can influence the client through self-disclosure, directives, or interpretation.
- Positive regard: Clinicians should pay attention to, and reinforce, the positive aspects of the client’s thoughts and behaviors.
- Respect: Clinicians should feel and state positive opinions of their clients and openly and honestly acknowledge, appreciate, and tolerate differences.
- Warmth: Clinicians should show genuine appreciation and concern for their clients through their nonverbal and verbal expressions.
- Concreteness: Clinicians should speak in a language that their clients can understand and develop interventions that have measurable outcomes.
- Immediacy: Clinicians should initially focus on the immediate needs of the client and only after these needs have been addressed, focus on other needs and problems.
- Objectivity: Clinicians should be able to be subjectively involved with their clients, but also have the ability to stand back and see things objectively.
- Responsibility: Clinicians should be able to recognize their own responsibilities and the responsibilities of their clients to make changes in clients’ lives.
- Countertransference awareness: Clinicians should be aware of any countertransference issues they may have with clients and avoid identifying and becoming too involved in their clients’ lives.
- Confrontation skills: When necessary, clinicians should discuss differences, incongruities, and discrepancies in their client’s verbal and nonverbal behaviors and suggest alternative ways of feeling and behaving.
- Genuineness and Congruence: Clinicians should be authentic in the way they lives their lives and the ways in which they communicate with their clients and model appropriate thoughts and behavior.
- Sense of Humor: Clinicians should have the ability to laugh at themselves and find humor in many of life’s situations.
- Self-awareness: Clinicians should develop an understanding of their own values, feelings, and assumptions in order to grow, be open to change, and model appropriate thoughts and behavior for their clients.
- Good Psychological Health: Clinicians should be in good psychological health, living their lives in the same way they want their clients to live their lives.
- Competence and Knowledge: Clinicians should be well trained, knowledgeable, and have training and experience in their areas of practice.
- Gender, Race, and Cultural Awareness: Clinicians should be knowledgeable about, and respectful of, gender, race, cultural, and other differences in their clients.
- Clinician Powers: Clinicians should be aware of the potential power they have to influence their clients both positively and negatively.
- Ethical Orientation: Clinicians should be ethical and professional in the ways in which they live their own lives and the ways in which they counsel. (Corey, 2001a; Ivey & Ivey, 1999; Okun, 2002)
Clinicians can have a great deal of knowledge about how to do counseling, but if they lack the human qualities of caring and compassion, honesty and authenticity, and insight and sensitivity, they will not be very effective with clients. In a very real sense, therapy at its core is a deeply personal encounter that should be guided by mutual respect and trust.
Clinicians should respect their clients when they listen to them and learn about them as individuals, accept and trust them, be concerned about them, and view them as capable of being in charge of their own lives.
Clients can also make significant contributions to the working alliance. Probably the most essential feature is a capacity to trust, because without trust there can be no healthy relationship. Client who are defensive or resistant, who lack at least some ability to look at themselves and their world, will probably not do well in the counseling relationship.
Clients who do not appear to have any desire to change will probably not do well in counseling, though there are things that clinicians can do to try to help clients develop a motivation for change. In conclusion, the therapeutic working alliance combines client characteristics with clinician characteristics for the purpose of facilitating change.
In an analysis of what clinicians intend in their interactions with their clients, researchers found 19 intentions: 1) structure the counseling sessions, 2) get information, 3) give information, 4) give support, 5) help focus the discussion, 6) clarify what has been said, 7) give clients hope, 8) allow clients a chance to talk through feelings, 9) identify illogical thinking or attitudes, 10) give feedback about clients’ inappropriate or maladaptive behaviors, 11) help clients get more control over thoughts and behaviors, 12) encourage acceptance and expression of feelings, 13) help clients gain insight, 14) help clients change, 15) reinforce change, 16) help clients overcome obstacles to change or progress, 17) challenge clients, 18) work on problems in the client/clinician relationship, and 19) examine clinician needs. (Hill & O’Grady, 1985)
Clinicians try to use various skills to enhance the therapeutic process. Listening, attending, and social influencing skills are very important because these are some of the primary ways in which clients get the feeling that what they are saying and doing is important. (Ivey, Ivey, & Simek-Morgan, 1997)
The clinician uses listening skills to gain information and encourage clients to talk about themselves and to help clients express how they perceive themselves and their problems.
The clinician uses attending skills to understand and clarify clients’ feelings and to convey they understand the client. Most of us can recall instances when we have been with people whose verbal and nonverbal behavior indicated disinterest or perhaps anxiety about communicating. These same attentive and inattentive behaviors can have a profound impact on the counseling relationship.
Good attending skills communicate the clinician’s undivided attention to the client’s concerns. Attending behavior encourages the client to freely talk and therefore reduces the need for the clinician to talk. Attending is both an attitude and a skill that requires paying attention to and practicing. Some of the basic listening and attending skills are:
- Open questions: what, when, how
- Closed questions: usually begin with “do,” “is,” or “are,” and the question can usually be answered in a few words
- Encouraging: repeating back to clients what they have said to encourage them to elaborate
- Paraphrasing: repeating back what the client is saying to show understanding and encourage elaboration by the client
- Reflection of feeling: attention to the emotional content of what the person is saying, doing, and feeling
- Summarization: to clarify what has been discussed so far
Social influencing skills help clients to explore more deeply their concerns and encourage them to make changes in their attitudes and behaviors. Some of the most important social influencing skills are:
- Interpretation/reframing: provide client with a new way to view or understand the situation
- Challenge/directive: support clients but pointing out discrepancies or mixed messages in their thoughts or behavior and suggesting alternative ways of thinking and behaving
- Self-disclosure: clinicians share selective personal experiences with the client when appropriate
- Feedback: provides clients with information on how others might perceive their thoughts or behavior
- Influencing summary: clarifies what has been discussed so client will be encouraged to think or act in different ways between sessions
An effective counseling relationship or alliance occurs when acceptance, understanding, and trust develops between a clinician and a client and it is maintained throughout the counseling process. The clinician and the client work to establishment a strong emotional bond where they agree about the goals for counseling and they agree about how the goals will be accomplished.
Most clients arrive at the first session feeling ambivalent, uncertain, or anxious about talking with a clinician. During the crucial first few sessions, clinicians should try to lay the foundation for their work with clients. Laying this foundation can be difficult because in the first sessions clinicians are trying to create an atmosphere of understanding, acceptance, and warmth, while at the same time, communicating to the client the parameters and requirements of the counseling process and trying to gather enough information to make an initial assessment of the problem.
There are a variety of ways to begin the first session, but usually a simple statement such as: “Tell me what brings you here for counseling today?” works well. If the clinician has already spoken with the person when the client was setting upon the appointment, the clinician might say: “Last week when you called you said you had recently separated from your husband.”
Besides setting an atmosphere of acceptance, warmth, and understanding, clinicians need to explain to clients what they can expect from being in counseling with them including what their, or their agency’s, policies are on such things as payment or reimbursement, canceling sessions, confidentiality, rights of privacy, and other legal and ethical considerations.
I will never forget my very first clients as a marriage and family trainee. They were a married couple in their mid-30s. She was an aspiring actress working primarily as an accountant. He was starting a new career as a screenwriter. As stated by them, the presenting problem was “they fought too much.”
I arrived an hour before their scheduled appointment to get the room ready and review the materials and notes I had prepared before the first session. While I had taken all of the classes, read all of the required books (and then some), the minute they walked into the office it quickly became apparent to me that I knew very little about how to progress through a single therapy session let alone a course of therapy.
It has been said that all successful therapy is based on a meaningful relationship between the therapist and the client. When my first clients walked into the room, the mental checklist of “things” I had learned that I needed to accomplish during the first session quickly seemed irrelevant. I quickly saw my primary task becoming how to establish a meaningful therapeutic relationship with them. Thoughts such as being attentive, empathic, genuine, and open, not theories or techniques, now dominated my thoughts.
In the stories they told me it was clear that they came to therapy for help because they felt a degree of hopelessness and powerlessness over their situation. I saw my job as primarily giving them some hope for their situation by trying to give them some new ideas and help them establish confidence and competence in themselves and their marriage.
During the first few sessions I wanted to communicate to them: 1) that I cared about them and their problems, 2) that I had some training and experience in working with clients with their type of problems (though I did not emphasize this part very much), and, 3) I was confident that I could help them (though I did not feel very confident at that time).
I am not sure I helped them very much in the three months that I worked with them. I did run into them about a year later. They were still together and they thanked me for helping them to get through a difficult time in their marriage.
I have found that it is important for me to determine if I have the training or expertise to work with a particular client. I have also found that I need to determine if I can work successfully with a client given any restrictions that may have been placed on the therapeutic process such as limits on the number of sessions, types of diagnosis and treatment which will be reimburse, if the client has limited resources to pay for therapy, and/or if any restrictions are being placed by the agency or company where the counseling is taking place.
If I or the client decides that it would be better if the client worked with someone else, then the client should be referred to another clinician or agency. (Nugent, 2000)
I have found that it is important for me to constantly examine the issues I bring to my counseling and the ways these issues may be negatively impacting my clients. Carl Rogers said to have empathy for the client is “to sense the client’s private world as if it were your own, but without ever losing the ‘as if’ quality” and “to sense the client’s anger, fear, or confusion without getting bound up in it.” (Rogers, 1957: 11)
I have found that my personal life experiences can be both assets and liabilities in doing therapy. They can be assets in that they can help me identify and understand people’s experiences that are similar to my own, but they can be liabilities in that I can find myself thinking that people should see things and do things they way I do.
This lesson was brought home to me by one of my supervisors. He was the father of a son who earlier had substance abuse problems. It was because of this experience that he started doing counseling with adolescent substance abuser. However, I often felt that his experiences with his own son colored the way he worked with all of his adolescent clients and prevented him from being open to other ways of addressing the problems.
Later in my clinical training, I was doing therapy with a couple whose marriage paralleled to a large extent one of my best friend’s marriage. This experience helped me to understand their situation, but it blinded me to how to deal effectively with their situation. In essence, I think I unconsciously communicated to them that their marital situation was rather hopeless. The result was that they stopped seeing me and went to another therapist.
I have found that it is often with the clients that I intuitively understand the least that I can be the most effective because I am forced to listen and rely more on what they are telling me, rather than coming to conclusions based upon my own experiences. I am learning to try to keep my “voice of experience” at a relatively low level.
It is important to remember that the purpose of clients communicating with me is to help them to articulate their experiences, to offer a safe place for them to release pent-up feelings, and to help to clarify the true nature of the problems that need resolution.
It is important for clients to come to understand that while communicating with me is important, counseling is more than mere conversations. Rather, the primary purpose of communicating with me is self-examination and attention to the presenting problems.
Clients should get the impression that I care enough about them that I will work very hard to understand what they are saying, doing, and feeling. The client needs to feel that nothing bad will happen when they communicate with me and that something helpful is likely to occur. When clients feel comfortable disclosing this type of information to me, it shows the client that counseling is a positive experience that has the potential to help solve their problems.
To some extent, we as clinicians are modeling for our clients how they might live their lives, but at the same time not trying to impose our lifestyle or values on our clients. Our job should be to help clients to clarify their thoughts, feelings, and actions consistent with their own values and goals. What we, as clinicians, should try to model for our clients is our belief in the journey.
For example, based upon my personal experiences, I believe people can look at their lives and make meaningful changes because I believe I have done this in my own life. However, at the same time - because of my own experiences - I can get impatient with some of my clients whom I feel are unwilling or unable to attempt to make meaningful changes in their lives, or inclined to consistently blame other people or circumstances for their situation.
As an experienced clinician, I need to constantly remind myself that people can make meaningful changes in their lives in a variety of ways and I should not impose my experiences on my clients. The challenge for me is to know when to be supportive and when to challenge or push my clients. This is part of learning the art of doing counseling.