Tag Archives: therapeutic alliance

Building better counselors

By John Sommers-Flanagan and Kindle Lewis November 6, 2017

In the opening chapter of the sixth edition of Counseling and Psychotherapy: Theories and Interventions (published by the American Counseling Association), David Capuzzi, Mark Stauffer and Douglas Gross make the case that the helping relationship is central to all effective counseling. Not many counselors would argue with this idea. Nevertheless, many counseling practitioners still feel pressure to implement empirically supported or evidence-based mental health treatments. Consider this case:

Darrell is a 50-year-old Native American. He identifies as a male heterosexual. In his first counseling session, he talks about feeling “bad and sad” for the past six months and meets diagnostic criteria for a depressive disorder. Darrell’s counselor, Sharice, is trained in a manualized, empirically supported cognitive-behavioral model for treating depression. However, as a professional counselor, she values collaborative counseling relationships over manualized approaches. She especially emphasizes relational connections during initial sessions with clients who are culturally different from her.

The question is, how can Sharice be relationally oriented and still practice evidence-based counseling? The answer: She can use evidence-based relationship factors early and throughout the counseling process.

Evidence-based relationship factors

Back in 1957, Carl Rogers wrote that “a certain type of relationship between psychotherapist and client” was “necessary and sufficient” to produce positive change. In contrast, if you immerse yourself in contemporary research on counseling and psychotherapy, you might conclude that relationship factors in counseling are passé and that, instead, cutting-edge (and ethical) practitioners must use empirically supported treatments. But you would be wrong.

Most reasonable people recognize that both relationship factors and techniques contribute to positive outcomes. However, it is also true that relationship factors in and of themselves have strong empirical support. More than 60 years of scientific evidence supports Rogerian core conditions of congruence, unconditional positive regard and empathic understanding. In fact, counseling relationship factors are just as scientifically potent (and maybe more so) as so-called empirically supported treatments.

Newer terminology for acknowledging the research base for therapeutic relationships has been coming for about 15 years. In 2001, a task force from Division 29 (Society for the Advancement of Psychotherapy) of the American Psychological Association coined the phrase “empirically supported therapy relationships.” The task force’s purpose was to place therapeutic relationships on equal footing with empirically supported treatments. Despite those efforts, many (and perhaps most) psychologists value technical procedures (for example, cognitive behavior therapy) over relational factors. In contrast, because of counseling’s emphasis on therapeutic relationships, in some ways, empirically supported therapy relationships are much more relevant to professional counselors.

In this article, we use the broader phrasing of “evidence-based relationship factors” (EBRFs) to represent ways in which professional counselors can integrate research-based relationship knowledge into counseling practice. But what is an EBRF, and how can counseling practitioners implement them in ways that are more specific than simply saying, “I value the therapeutic relationship?”

EBRFs include the three Rogerian core conditions and other purposefully formed and implemented relational dimensions. Below, we provide concrete examples of 12 EBRFs that are empirically linked to positive counseling and psychotherapy outcomes. For each EBRF, we use the case of Sharice and Darrell to illustrate how Sharice can work relationally with Darrell and still engage in evidence-based practice.

Evidence-based attitudes and behaviors

Rogerian core conditions of congruence, unconditional positive regard and empathic understanding are foundational EBRFs. Although Rogers described them as attitudes, they also have behavioral dimensions. Additionally, counselors bring other relational factors into the room, such as role induction, cultural humility and scientific mindedness. Together, these EBRFs create a welcoming, safe and transparent environment that fosters therapeutic relationship development. Simultaneously, counselors are responsible for managing their countertransference throughout the relationship development process.

Congruence

Congruence implies counselor self-awareness and involves holding an attitude that values authenticity. Clients typically experience counselor congruence as the unfolding of a genuine relationship with their counselor. Genuineness involves counselors striving to be mindfully open and honest in their interactions with clients. This usually, but not always, involves self-disclosure, immediacy and offering feedback.

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Sharice displays congruence in several ways. First, she presents Darrell with an informed consent document that is written in her unique voice and that includes information on how she works with clients in counseling. She also greets Darrell with clear interest in learning more about who he is and what he wants. To focus on him, she might sit and emotionally center herself before going to meet him in the waiting room.

During the session, when Darrell talks about details of his professional work, Sharice openly expresses curiosity, “Oh, you know, I’m not sure what you mean by that. Could you tell me more so I can better understand what you’re experiencing in the workplace?” After Darrell shares details, she says, “Thank you. That helped me understand what you’re up against
at work.”

Role induction

Role induction is the process through which counselors educate clients about their role in counseling. Role induction is necessary because clients do not naturally know what they should talk about and because they may have inaccurate expectations about what counseling involves. When it goes well, role induction is interactive, and counselors simultaneously exhibit Rogerian core conditions (“I hope you’ll always feel free to ask me anything you want about counseling and how we’re working together”). Role induction begins with the written informed consent form.

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Sharice includes in her informed consent document what her clients can expect in counseling. She also explores these topics with Darrell in their first session.

Sharice: I’d like to share a bit with you about what we’ll be doing in this first session. To start, I want to hear about what’s been happening in your life that brings you to counseling now. As you talk, I’ll ask a few questions and try to get to know you and your situation better. We’ll talk about what’s happening now in your life and, if it’s relevant, we’ll talk some about your past. Then, toward the end of our session, I’ll share with you some ideas on how we can work together, and we’ll start to make a counseling plan together. Please ask me questions whenever you like.

Unconditional positive regard

Unconditional positive regard involves the warm acceptance of clients. Rogers himself noted that unconditional positive regard was an “unfortunate” term because no counselor can constantly experience unconditional positive regard for clients. However, to the extent that it can be accomplished, unconditional positive regard involves acceptance of the client’s self-reported experiences, attitudes, beliefs and emotions. Unconditional positive regard allows clients to feel the safety and trust needed to explore their self-doubts, insecurities and weaknesses.

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Throughout their time together, Sharice shows Darrell unconditional positive regard by listening to his experiences, attitudes, beliefs and emotions without showing judgment. She’s open to whatever he brings into the session and encourages him when they encounter subjects he finds difficult to explore. She not only listens nondirectively but also asks questions such as, “What’s your best explanation for why you’re feeling down now?” and “What are you thinking right now?” These questions show acceptance by supporting and exploring Darrell’s self-evaluation rather than focusing on Sharice’s judgments.

Empathic understanding

Empathy is one of the strongest predictors of positive counseling outcomes. However, there is one interesting caveat. It doesn’t matter if counselors view themselves as empathic; what matters is for clients to view their counselors as empathic.

Although measuring empathic responding is challenging, there is consensus that using reflections of feeling and engaging in limited self-disclosure are effective strategies. Also, there is evidence from neuroscience research that resonating with or feeling some of what clients are feeling is part of an empathic response.

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When responding to Darrell, Sharice uses her facial expressions, posture, voice tone and verbal reflections in an effort to comprehend Darrell’s unique thoughts, feelings and impulses. She expresses empathy as he talks about work stress.

Darrell: I feel pressure coming at me from everywhere. Deadlines that need to be met, clients to make happy, bills that need to be paid, and I need to maintain this image in the community, you know?

Sharice: That sounds stressful. You have people counting on you, and it feels overwhelming.

Following an initial reflection of feeling, Sharice uses what Rogers referred to as “walking within” to emotionally connect on a deeper level.

Darrell: It’s starting to get to me in ways stress hasn’t before. Like, I can’t sleep, it’s harder to focus, and I feel like I’m going to burn out soon.

Sharice: It’s like you’re saying, “I don’t know how much more of this I can take, and I don’t know what to do.” Do I have that right?

Later, Sharice uses a reflective self-disclosure (which combines congruence with empathic understanding) in an effort to deepen her empathic resonance.

Sharice: As I listen to you, Darrell, and as I try to put myself in your shoes, I feel physically anxious. It’s almost like this pressure and pace make me feel out of breath. Is that some of what it feels like for you?

Just like Carl Rogers would do, Sharice intermittently checks in with Darrell on the accuracy of her reflections (“Do I have that right?”). Additionally, if Darrell indicates that Sharice is not hearing him accurately, she uses paraphrasing to refine her reflection and sometimes apologizes while correcting herself.

Cultural humility

Cultural humility is an overarching multicultural orientation or perspective that includes three dimensions:

1) An other-orientation instead of a self-orientation

2) Respect for client values and ways of being

3) An attitude of equality, not superiority

Like the Rogerian core conditions, cultural humility is an attitude that counselors adopt before entering the counseling office, but there are also behavioral manifestations of cultural humility.

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In their first session, Sharice creates a space for Darrell to speak about what his culture means to him. She notes that even though they come from different cultures, understanding his culture is important to her.

Sharice: Thank you for filling out the intake form, Darrell. I know it can be daunting with all the personal information we ask for. I see that you are Native American. I’m a mix of German and Swiss and grew up outside of Denver. What this means to me is that I’ll be trying my best to understand your life experiences. If at any point you think I’m not getting your perspective, I hope you’ll tell me. Sound OK? (Darrell nods.) Thanks. Also, whenever you’d like, I’d be interested in hearing more about your culture and how it informs your way of being in the world.

Scientific mindedness

Scientific mindedness is a concept and skill originally described by Stanley Sue. It refers to the process of counselors forming and testing hypotheses about clients rather than coming to premature, and potentially faulty, conclusions.

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As Sharice gets to know Darrell and the issues that brought him to her office, she uses scientific mindedness to hypothesize how culture may (or may not) be a salient factor in his experience of stress in the workplace. When he talks about “immense pressures” that he puts on himself, she’s reminded of how some individuals from minority groups can feel added stress because they view themselves as representing their entire minority community. Sharice keeps this hypothesis in the back of her mind and, eventually, when the time seems right, uses a reflective listening response to test her hypothesis.

Sharice: When you talk about the pressure you put on yourself to perform, it sounds like you’re performing not only for yourself but also for others.

Darrell: Absolutely. I can’t help but worry because my family depends on me to generate income. (Somewhat to Sharice’s surprise, Darrell doesn’t identify his tribe or the reservation community as an additional source of pressure to perform, so she explores the issue more directly.)

Sharice: I’ve read and heard from some of my other Native American clients and students that it’s possible to feel added stress because they might view themselves as representing their tribe or other Native American people. Is that true for you?

Darrell: I always tell myself that that’s not an issue for me. But if I’m totally honest with myself and with you, I’d have to say that being an Indian man in an intense business environment makes for more stress. In some ways, I think it has less to do with representing my people and more to do with how I think my colleagues — and even my friends at work — somehow expect me to be less competent. I don’t know exactly what they think of me, but I feel I need to work twice as hard to earn and keep their respect. (After listening to Darrell’s disclosure, Sharice updates her hypothesis about how race and culture might be adding to his stress at work.)

Sharice: So, it’s not so much that you feel like a representative for your people. It’s more that you’re thinking and feeling that you should do double the work to prove yourself to your colleagues. I can imagine how feeling discounted compounds the everyday workplace stress you feel.

Managing countertransference

Countertransference is unavoidable. Countertransference includes the counselor’s emotional reactions to any or all clinically relevant client material (transference, client personality, content presented by the client, client appearance and so on). These reactions may be related to the counselor’s unresolved personal conflicts or the client’s interpersonal behaviors. Countertransference can be a hindrance or a potential benefit to the therapeutic process; it can distort your perceptions of your client, but it can also inform your relationship with the client.

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During their work, Sharice notices that she gets impatient with Darrell’s pace of speech and finds herself feeling annoyed with him. She brings this to her consultation group to understand why this is happening and how it is affecting her work with Darrell. Talking about it with her supportive group helps her deal with her emotional reactions more effectively and build understanding for why she is experiencing frustration and how to adjust so she can provide the best service possible to Darrell.

The evidence-based therapeutic alliance

The therapeutic alliance was a psychoanalytic construct until Edward Bordin described it in pantheoretical terms. Alliance factors include three dimensions:

1) The emotional bond

2) Mutual goals

3) Collaborative tasks in counseling

Additionally, progress monitoring and rupture and repair can be viewed as EBRFs related to the alliance.

The emotional bond

Although it can be difficult to measure an emotional bond, in the counseling context it is usually defined as clients showing a positive affective response toward their counselors. In many ways, the counselor-client emotional bond is a natural byproduct of the Rogerian core conditions and of the work that counselors and clients do together. However, counselors lead in this process by greeting clients with a positive affect and consistently showing interest in what clients talk about.

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When Darrell arrives at Sharice’s office, she is visibly happy to see him. In addition, she expresses her interest in working with him and her belief that he possesses the ability to overcome the issues with which he is struggling.

After a few sessions, Darrell begins to show trust in Sharice. He no longer looks anxious to be in her office, his speech is less guarded and he smiles more during their interactions. He mentions that although counseling is difficult at times, he appreciates having time every week with Sharice to talk about his life and sort out what is troubling him. He has become emotionally bonded to Sharice and looks forward to counseling sessions.

Mutual goals

In the first few sessions, counselors and clients explicitly discuss clients’ personal problems and corresponding counseling goals. Eventually, and sometimes even in the first session, clients and counselors agree on which goal or goals to focus on in counseling.

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Sharice (after discussing Darrell’s presenting problems and possible solutions): Darrell, we’ve identified several goals that we can work on together: stress management, managing the negative or critical thoughts you have about your work performance and getting better sleep. Which of these would you like to focus on first?

Collaboration on tasks linked to goals

After working with clients to decide on counseling goals, counselors introduce tasks or activities in session (or as homework) that are meaningfully related to the agreed-upon goals. These collaborative tasks often constitute the “technical” part of counseling.

When applying techniques, relationally oriented counselors:

  • Are careful to listen closely to what clients have already tried
  • Use reflective listening to gain a mutual understanding of what has worked worse or better
  • Jointly brainstorm new options with clients
  • Ask permission to try out technical procedures
  • Jointly monitor client reactions to new strategies

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Sharice: We’ve been talking about everything you’ve tried to help yourself sleep better. It sounds like you’ve been working on this for years. How about we rank which strategies have worked better for you and which have worked worse?

Darrell: Sure. (Sharice and Darrell work on Darrell’s rankings.)

Sharice: One of the things I’ve noticed that seems to work better for you is
when you’re able to distract yourself from your thoughts about work. Does that sound right?

Darrell: Absolutely. It’s so hard for me to get my brain to stop problem-solving.

Sharice: One thing I’d add to your list of possible strategies is mindfulness meditation. It can be a powerful technique to deal with racing thoughts. What’s your reaction to that idea?

Progress monitoring

After counseling goals are established and collaborative tasks identified, counselors and clients work together to evaluate counseling progress. There’s a robust body of research attesting to the positive effects of progress monitoring.

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Sharice consistently checks in with Darrell in two ways. First, she uses the Session Rating Scale after each session to gauge her therapy alliance with Darrell. Second, she directly asks Darrell about his reactions to the counseling strategies they are working on together.

As a part of her progress monitoring efforts, Sharice asks Darrell to keep a log of his mindfulness meditation activities, along with his sleep quality and quantity. Each week, they discuss what went well and what was challenging. She offers empathy and makes adjustments to his homework as needed.

Rupture and repair

Rupture is defined as tension or a breakdown in the counselor-client collaborative relationship. Repair involves counselors making statements and taking actions to restore the therapeutic relationship. Rupture can happen at any time during counseling. Usually it involves clients withdrawing or showing irritation.

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After a few weeks of logging his mindfulness meditation, Darrell appears agitated. When Sharice asks about the log, Darrell says, “This is a waste of time, and I don’t know why you thought it was going to help. I’m done with this stupid meditation.”

Sharice responds empathically and then explores with Darrell the source of his frustration. She discusses how embracing a passive attitude during meditation can be extremely difficult, especially because of the pressured and problem-solving orientation he has at work. She apologizes for pushing the idea of mindfulness meditation.

Darrell’s response is paradoxical. He spontaneously shares how important it is for him to find time to get out of his hard-driving mentality. Sharice then tweaks the mindfulness approach they have been using. The new emphasis moves away from formal logging and embraces small moments of progress.

The relationally focused, scientifically based counselor

Beginning with Rogers and moving forward into the 21st century, counseling practitioners have embraced the therapeutic relationship as central to positive counseling outcomes. However, at times, allegiance to and emphasis on the counseling relationship has been viewed as anti-science. The good news is that, now, more than ever, we have growing empirical evidence to support the efficacy and effectiveness of a relational emphasis in counseling. In this article, we reviewed and illustrated specific ways in which you can emphasize the therapeutic relationship and be evidence-based. This is welcome progress for the counseling profession in general and counseling practitioners in particular.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

John Sommers-Flanagan is a professor in the Department of Counselor Education at the University of Montana. He has co-authored many books, including Tough Kids, Cool Counseling (published by the American Counseling Association) and Counseling and Psychotherapy Theories in Context and Practice (published by Wiley). Contact him at john.sf@mso.umt.edu or through his blog at johnsommersflanagan.com.

Kindle Lewis is a doctoral student in counselor education and supervision at the University of Montana. She is a national certified counselor, holds a license in school counseling and has 10 years of experience working with youth in education and counseling settings both locally and internationally. Her areas of focus are youth and school counseling, community building and holistic wellness. Contact her at kindle1.lewis@umconnect.umt.edu.

Letters to the editor: ct@counseling.org

 

 

 

 

 

 

 

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Beyond words

By Nevine Sultan September 28, 2017

Attempting to work from a purely cognitive or emotional perspective with clients who have experienced sexual trauma is like trying to build a sturdy house without laying down a solid foundation. Facilitating recovery from sexual trauma demands the inclusion of the site of the original wounding — the body.

A clinical vignette

“Jerry” arrives seven minutes late for his intake appointment. He appears disoriented and confused.

“Please,” I say, inviting him to take a seat. When our eyes meet, he turns his gaze to the floor and explains, “I think I stopped at a gas station on my way here.”

Jerry’s face is flushed and his nostrils are fluttering. Although his head seems to be the most active part of him, I am drawn to Jerry’s feet, legs and hands. The rigidity in the lower half of his body is intense. Jerry’s left foot is twisted outward in a painfully supinated position. His hands are imprisoned beneath his thighs, and his shoulders are hunched forward. The word concave comes to mind. I feel a sense of hollowness in my core as I realize that Jerry is holding his breath like a dam straining to hold water that might cause irreversible damage if released all at once.

We talk briefly. Jerry tells me about his anxiety, the panic attacks that have besieged him up to twice daily over the past few months, his ceaseless hypervigilance, the memories that haunt him, the persistent need to wash his hands and the nights dotted with brief slumber from which he is jarred awake by horrific nightmares. “I’m also having problems with my girlfriend,” Jerry says. “I know I can trust her. It’s just … I can’t shake that feeling.”

As Jerry speaks, his voice is jittery and his lips tremble. His breathing shifts from closed to ragged. “I was out taking a walk in my neighborhood one night. A guy drove up to the sidewalk and asked for directions to the community pool.” Jerry’s pitch lowers, his articulation becomes less sharp, and he drifts inside himself. I shift in my chair to gently facilitate his return to the here and now. He looks up before continuing.

“As soon as I started talking, he got out of the car, opened the door to the backseat, and then … I don’t know. It happened quickly.” He pauses. “I woke up in a hospital. My wrists were really bruised.” Jerry scans the room with his eyes, which are filling with tears. “I couldn’t save myself.” He weeps, pulling his hands out from beneath him and rolling them up into fists.

My stomach clenches, and I feel a sting in my eyes. I am all too familiar with this narrative. Many of my clients who have suffered sexual trauma describe similar experiences of numbing and freezing and an overwhelming sense of self-betrayal. I take a deep breath and redirect my attention to Jerry, who is still sobbing. I give him a few minutes. As he recovers from his outburst, he returns to holding his breath.

“Jerry?” I say gently. He looks up. “Thank you for trusting me with that. See if it’s OK to exhale. Slowly.”

Understanding dysregulation

Every word that Jerry says matters. I note his narrative. It is significant. I also note the paranarrative — the cauldron of sensations, emotions and racing thoughts bubbling beneath the surface of his quivering demeanor. This agitated vessel is holding a fusion of fear, isolation, shame, avoidance, mistrust, physical and emotional numbing, negative beliefs, impulsivity, diminished agency and an outright inability to tolerate the present.

While Jerry’s thoughts and emotions are overly active, his body is entirely ignored. Consequently, he is caught in the unconscious frenzy of persistent fear and some terribly unforgiving stories: The world is dangerous. I will never be safe. I can’t protect myself.

The harm Jerry has endured did not compromise his thinking or his emotions alone, however. Jerry has suffered a severe wounding to his body; hence, his collapsed posture, his irregular breathing and his restricted movement, coupled with his overall sense of being overwhelmed and his inability to maintain a state of calm.

As French phenomenological philosopher Maurice Merleau-Ponty pointed out in his seminal text, Phenomenology of Perception, our bodies are the agents by which we exist in the world. They are also the receptacles of memories that, often vanished from our conscious awareness, are still deeply etched within our being. When those memories are triggered, we experience suffering at a highly existential level that transcends consciousness. Facilitating the recovery of clients who have experienced sexual trauma must include opportunities for repairing connections with all dimensions of their being.

John Hughlings Jackson, known as the “father of English neurology,” outlined a human nervous system composed of three parts: social, sympathetic and parasympathetic, which has since inspired Stephen Porges’ polyvagal theory. Jackson’s model is hierarchical: The higher elements inhibit the lower elements. When a higher element on the hierarchy fails, a lower component takes over.

The highest element of the nervous system is the social one, responsible for relational contact and communication. Lower on the hierarchy is the sympathetic nervous system, which kicks in when we experience a disturbance in our inner or outer environment, thus activating our fight/flight/freeze/dissociate response. Should we not fight or flee, we plunge into freezing, immobility and dissociation. Unless the parasympathetic nervous system is reactivated, we remain frozen, incapable of responding to our environment.

Paradoxically, nonthreatening surprise situations are likely to elicit a sympathetic nervous system response, whereas threatening situations are likely to elicit a parasympathetic response, which is why many of us freeze or dissociate when confronted with a seemingly hostile situation. A healthy nervous system is one that self-regulates through a balance of sympathetic and parasympathetic functioning — that is, an arousal-activation event is followed by a period of rest and digest. An unhealthy nervous system, on the other hand, remains in either hyper- or hypoarousal, giving rise to startle, panic, hypervigilance, restlessness and emotional flooding, or to emptiness, exhaustion, disorientation, dissociation and emotional numbing, respectively. Clients who have not resolved traumatic events are often stuck in hyper- or hypoarousal.

In the aftermath of a traumatic event, survivors are likely to develop generally maladaptive coping symptoms that offer temporary relief from dysregulation. These coping symptoms include various process and substance addictions, obsessions and compulsions, and self-harm. Regardless, clients suffer the following interruptions:

  • Physical/perceptual (inaccurate kinesthetic reactions to perceived threat, anxiety, dissociation, collapse)
  • Contextual (difficulty perceiving and making sense of surroundings)
  • Emotional (fixation on fear, rage or sadness)
  • Cognitive-behavioral (intrusive, racing thoughts; memory loss; self-destructive patterned behavior)
  • Spiritual/existential (loss of sense of self)

Jerry tends to cycle between hyper- and hypoarousal, as evidenced by his frequent experiences of hypervigilance and panic attacks, and his often collapsed and frozen posture. When agitated, he attempts to manage his dysregulation in a number of maladaptive ways, including engaging in impulsive (e.g., breaking up and making up with his girlfriend repeatedly) and compulsive behaviors (e.g., continually washing his hands).

Although traditional cognitively and emotionally oriented psychotherapy approaches may help Jerry ease some of these coping behaviors, they do not include methods for addressing his dysregulation. Working with Jerry’s physical process allows me to help him identify when he is in hyper- or hypoarousal and bring himself back to what leading neuropsychiatrist and interpersonal neurobiologist Daniel Siegel refers to as one’s “window of tolerance,” or the zone in which our arousal state is balanced.

Honoring the somatic narrative

The somatic approach to healing trauma was inspired by a phase-oriented model for treating trauma and dissociation that was established in the early 20th century by French psychotherapist Pierre Janet. The somatic approach requires an understanding of how nervous system dysregulation is activated as a consequence of trauma and which parts of the body and brain are involved. The counselor uses this information to help clients create a sense of safety, to facilitate clients’ use of internal resources to regulate arousal and enhance self-efficacy, and to help clients address traumatic memories and explore novel ways of being in the world. Interventions include focus on nonverbal experience, kinesthetic awareness and reshaping body movement.

In the aftermath of his traumatic assault, Jerry’s ability to organize his experience was compromised, resulting in dysregulation of arousal, challenges tracking his surroundings and increased cognitive and emotional processing. This sent his thoughts and feelings into overdrive, making it difficult to control his impulsivity. With his inability to self-regulate, Jerry is virtually incapable of remaining connected with his present moment, and specific trauma-related (and sometimes neutral) stimuli can trigger an immediate impulsive response.

According to Pat Ogden, the pioneer behind the popular attachment-based somatic approach to healing trauma known as sensorimotor psychotherapy, a primary task faced by counselors working from a somatic approach is to help clients create a balance among the various processes used to organize experience. This is done using a bottom-up model that views human experience as an initially sensory process that informs emotion, which then informs thought and behavior. Focusing on the here and now is especially important when using a body-centered approach because it allows the counselor to address how a past event is manifesting in the present.

Finally (or perhaps first and foremost), when working with the somatic dimension, high levels of therapist presence and attunement are needed to support a therapeutic alliance with appropriate boundaries that is built on safety and trust.

Creating shared space

Essential to facilitating Jerry’s connection with his physical process is my personal embodiment — that is, my ability to be in contact with and present in my own body. By anchoring myself in my body and my present-moment experience, I am better able to create an empathic space for our encounter.

I use my sensory experiences to inform the therapeutic process and guide me toward a well-rounded understanding of how Jerry exists in the world based on how he exists in the therapy room. Understanding the experience of my body when I am in contact with Jerry helps me reach out within our intersubjective space with the deepest respect for his pace while acknowledging that I am affected by his experience. From this place of compassion and empathy, sharing and being, and phenomenological engagement, an integrative somatic process begins in which I serve as a bridge between Jerry and the rest of the world.

“When you are ready,” I say to him in gentle invitation.

Organizing the client’s experience in the here and now

I listen to Jerry’s verbal narrative. I also attune to the story his body is telling and how my own body is receiving that. What body postures does Jerry fall into as he recounts specific parts of his story? What gestures accompany certain words, phrases or recollections in the here and now?

Such physical manifestations are indicative of how Jerry’s body has encoded certain events implicitly. Jerry is physically manifesting content from his implicit (unconscious), somatic memory of the traumatic event that may or may not be congruent with his declarative (conscious) memory. Keeping in mind the fallibility of declarative memory, working from a somatic approach supports access to Jerry’s implicit memory, which offers us additional insight into his experience.

Attending to Jerry’s somatic narrative, I notice that his fists hold the highest energy. My own fists are wound so tightly that I can feel my nails digging into my palms. I also notice that I am holding my breath in anticipation. I release my breath, unfold my fingers and share some observations with Jerry in the form of brief contact statements designed to enhance his awareness.

I also pose exploratory questions. “I’m noticing that as you talk about feeling incapacitated in the moment you were grabbed, your hands are balled into fists. Would it be all right to bring your attention to your hands for a moment?” Helping Jerry consciously connect with the most reactive part of his body invites his capacity to self-witness and be self-aware. This activates the prefrontal cortex that, according to body-centered trauma expert Bessel van der Kolk, is responsible for emotion regulation, cognitive and social behavior, and decision-making.

As Jerry accesses his past experience in the here and now from a nonreactive place, he is better able to observe it, recognize that it happened in the past, notice how it is manifesting in the present and identify new ways of understanding it. Next, we work to identify the emotions that arise with the declarative and implicit memories of the experience and any thoughts that accompany the physical and emotional manifestations.

“What are you sensing in your fists right now?” I ask. “Examples of sensation are tingling, tightness, cold, heat.”

“They’re stuck,” Jerry says. “I can’t do anything with them.”

I ask Jerry to name the feelings that accompany that sense of stuckness. “Examples of feelings are anger, sadness, guilt, fear. ‘I feel …’ Can you fill in the blank?”

Jerry stares at the ground. “I feel … angry.” He begins to weep inconsolably. “I’m so, so angry.” He drops to the floor and curls into a fetal position. I give him a few minutes to be where he needs to be, to experience being balled up and angry.

“I’m so mad at myself. I didn’t save myself. Who does that?” I recognize that I didn’t have to invite Jerry to reflect on any thoughts accompanying the emotion and the sensation; the thoughts are emerging on their own.

Minutes later, Jerry is still holding his fists, but his tears are subsiding. I grab a box of tissues and sit on the ground near him, close enough to offer the nonphysical support he may need. I pull out a tissue and drape it gently over his left fist. He flinches and opens his eyes, looking straight ahead.

I wonder if it might be helpful to invite some awareness around how he is organizing this experience. “What are you holding inside your fists, Jerry? And what is that doing for you?” Jerry continues to look out into the ether. “Your fists,” I prod gently. “If your fists had a voice and could speak, what would they say? ‘I …’ Can you fill in the blank?”

Jerry is silent for a few seconds. “I … I am …”

“Yes, Jerry. Keep going,” I encourage him.

“I am … very angry,” he offers meekly.

“Is that what the anger inside of your fists sounds like?” I nudge gently. Jerry shifts slightly in his fetal position and then stops. “What does your body need to do right now?” I ask. “Expand? Contract? Walk away? Move closer? Is it OK to explore that need?”

“I think I need to move,” Jerry says. Without further invitation, he sits up. His upper body is still collapsed, and he seems undecided. I invite him to attend, once again, to what his body needs. Jerry inhales a little more deeply, expands moderately with his intake of breath, tightens his fists further and bellows, “I AM SO ANGRY!”

“Say that again,” I urge. “Give your fists the voice they need.”

“I AM SO ANGRY!” he screams, over and over. Twenty times. Thirty times. “I WILL NEVER LET ANYONE DO THIS TO ME AGAIN!” Jerry says even louder, holding his fists chest high and shaking them like he has someone by the collar.

Once Jerry has experienced a full release of energy, his tight fists unfold, although with some reservation. “Would it be OK to let go of the rest of that?” I invite.

Jerry’s eyes close, and I realize he may be unwilling to let go. I offer a compromise. “You don’t have to let go of your anger forever,” I say. “Maybe you can leave it in a safe place so that you can have it back whenever you want it.”

Jerry seems open to this idea. After some deliberation, he looks at a print hanging on the wall behind me and says, “I think I’ll leave it behind that picture.”

Jerry and I have just worked through a process of using an implicit memory (balled-up fists) connected with his traumatic incident to initiate a recalibration of his nervous system. This process involved:

a) Creating a shared space facilitated by my presence

b) Helping Jerry identify different facets of memory (implicit and declarative)

c) Using contact statements to help Jerry recognize the orienting patterns he is using to organize his experience (“I’m noticing …”)

d) Inviting Jerry to name his sensory, emotional and cognitive experience (“What are you experiencing …?”)

e) Allowing Jerry’s body to tell its narrative (“If your fists had a voice and could speak …”)

f) Exploring modification of Jerry’s orienting patterns (“What does your body need right now?”) and experimenting with new ways of being

g) Restoring empowering actions (“Give your fists the voice they need.”)

The next step involves making sense of our process. The hope is that Jerry will use his new understanding of his experience to make new choices informed by the here and now.

Creating meaning and energizing change

“What was that like for you?” I ask.

“I don’t know,” Jerry says. “I feel like a heavy load has been lifted.” I nod. “From these,” he continues, raising his hands.

I acknowledge and affirm Jerry’s reflection. “Those fists were holding on pretty tight. What did it mean to hold tight?”

“I think … I felt in control.”

“Can you say more about that?”

“Yeah. Like I wasn’t going to lose it, I guess.”

I feel that Jerry and I are in a safe enough place for my next question. “What would happen if you allowed yourself to completely lose it?” Jerry clenches. “OK to exhale?” I invite.

Jerry releases his breath slowly. “I don’t know.”

“Jerry?” I invite him to make brief eye contact with me. “I’m not sure I buy that.” I smile gently. “What would happen?”

Jerry thinks but maintains eye contact. “I mean, I just lost it, right?”

I offer a perspective: “Seems like you trusted yourself with that too.”

“I did,” he says solemnly.

“What is it like for you to trust yourself?” I ask. “‘I …’ Can you fill in the blank?”

“I feel pretty big right now.”

“Hmm. What does big look like?” I invite. “Can you show me?” Jerry lifts his body and expands his chest. Although he does this slowly and with seeming caution, I am aware that he has given himself permission to explore a place beyond his wound. I open the door for a final inquiry that will help Jerry take what he has learned about resourcing himself outside of the therapy room: “What might you do with that bigness, Jerry?”

Working through roadblocks

Accessing and working with certain memories in the here and now is not always a straightforward process. In Jerry’s case, he sometimes exhibits an aversion to being in the present. For example, although Jerry shows relative ease connecting with his anger, in a later session he experiences great difficulty accepting his shame.

Jerry’s resistance manifests, initially, as indirect eye contact and fixation on the ground. Once we begin exploring this and Jerry identifies the emotions and thoughts connected with it, he manifests an outburst of physical agitation that is marked by twitching in his chair until he falls to the ground.

I invite Jerry to remain seated on the floor and connect with the ground (using a process we call grounding), which helps him feel connected to and supported by something outside of himself. Next I ask him to explore his center of gravity by way of a process called centering, which brings his attention back to his physical experience. Finally, I suggest containment, a self-holding exercise designed to facilitate self-regulation and awareness of one’s boundaries and overall physical presence.

Because of their focus on the physical, these exercises shift clients’ attention from the self-destructive emotional and cognitive narrative to their internal resources. With this, the counselor is tasked with pacing the session so that the client is not overwhelmed. Introducing these safety-enhancing exercises is often helpful as sexual trauma clients experience the need to recalibrate from the potentially overpowering experience of confronting their trauma.

Establishing a time frame for the therapeutic process

Clinicians working from a somatic approach are highly aware of the challenges of creating time parameters for their therapeutic work. On the other hand, it is not uncommon for clients to ask, “How long will I be in therapy?” My response is that it depends on a number of factors, including:

1) Whether the traumatic event was a single, first-time incident or is recurring

2) The client’s developmental history (i.e., milestones, attachment patterns)

3) The client’s current coping strategies

4) Systemic factors (i.e., family, community and broader social support)

5) Client openness to working with the body

6) Therapist consistency and the quality of the therapeutic alliance

That said, somatic therapy tends to be time intensive, unlike, say, brief solution-focused or cognitive-behavioral work. Jerry attended weekly 80-minute therapy sessions for approximately 10 months, followed by biweekly 50-minute sessions for three months. He is currently coming in for monthly 50-minute check-ins.

Although Jerry has not forgotten his traumatic incident, he has learned how not to be hijacked by memories, how to self-regulate when confronted with somatic, emotional or cognitive triggers and how to tap into internal resources (including his body) to address present-moment needs.

Closing reflections

Embracing a somatic approach in working with Jerry’s sexual trauma engages his verbal and nonverbal narratives, opening a door to reshaping his way of being in the world and catalyzing new intentions and experiences. It also helps us focus on what is versus what was or what might be.

Working in the present enhances Jerry’s awareness of who and how he is in the world, what he does and how he does it, and how remaining stuck in the past or allowing himself to be hijacked by the future are choices he can modify as he works to reconnect with his window of tolerance. Being aware brings present-moment possibilities and options center stage. The emphasis is no longer on irreversible past or anticipated future experiences but on what is happening in the here and now.

Thus, clients take responsibility for their needs, feelings, thoughts and actions. Taking responsibility and ownership of situations and experiences is, in itself, a holistic, anchoring and awareness-enhancing behavior. With it comes an increased ability for clients to push the boundaries that are stifling their self-expression, identify immediate needs and engage in self-mobilization, creative experimentation, somatic expression and self-regulation, all of which are at the heart of an existence that has made peace with its past and is grounded in the present. As clients’ awareness is ignited on a holistic level, they are empowered to decide whether their patterned behaviors still serve a purpose and how those behaviors can be modified to meet present needs.

How we inhabit our bodies reflects our way of being in the world. Through our bodies, we sense and experience, receive and perceive. Exploring the physical body and its manifestations of past sexual trauma helps clients integrate the physical, emotional and cognitive dimensions of their experience. Sensory-kinesthetic exploration brings history to life in the present and anchors it here, where it is more accessible.

Conscious engagement with the body’s innate knowledge permits clients to access their own strengths in the process of healing. How empowering and transforming for our clients who have suffered from sexual trauma to recognize that their well-being exists within their own bodies — the very site of their original wounding.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Nevine Sultan is an assistant professor of clinical mental health counseling at the University of St. Thomas in Houston and a licensed private practitioner specializing in trauma, dissociative disorders and grief. She embraces an embodied phenomenological approach to counseling and psychotherapy, research and teaching. Contact her at nevine.sultan@gmail.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Helping students change with dignity

By John J. Murphy August 26, 2016

“We may need to solve problems not by removing the cause but by designing the way forward.”

— Edward de Bono

 

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In the book All I Really Need to Know I Learned in Kindergarten, author Robert Fulghum said he had learned life’s most important lessons as a young child in kindergarten. In that same spirit, this article could be titled, “Most of What I Know About Counseling Students, I Learned From Students.”

As much as I appreciate my formal training, the best lessons of all — the ones that really got my attention and took hold — have come from the young people I’ve been privileged to serve. MurphyThese lessons can be condensed into two practical principles of school-based counseling: 1) Involve students and 2) build solutions from strengths and resources.

As further testimony to the expertise of my youthful teachers, these two strategies are strongly supported by mountains of empirical research in counseling and psychotherapy. More specifically, research indicates that counseling outcomes depend largely on the quality of the client-counselor alliance, the client’s hope for a better future and the extent to which the client’s opinions, values, strengths, social supports, life experiences and other “client factors” are incorporated into counseling.

This article translates these findings and principles into the following steps and techniques of solution-focused counseling, a practical and culturally sensitive approach to helping young people change with dignity.

Step 1: Establish collaborative relationships

The client’s perception of a strong client-counselor alliance is the most reliable predictor of successful outcomes, and client involvement is the key to a strong alliance. The more involved students are in their own counseling, the better the outcomes. The following techniques help to strengthen alliances and improve outcomes in solution-focused counseling.

Adopt the ambassador perspective. Approach every session as a cross-cultural exchange and every student as a unique “culture of one,” with the humility, respect and curiosity that a foreign ambassador would show when entering an unfamiliar country or culture. Good ambassadors look, listen and learn from people before making any assumptions
or suggestions.

Compliment students. Anything we can do to boost students’ hope will improve outcomes, which is why compliments are an important part of solution-focused counseling. Compliments help to reframe students’ views of themselves and their circumstances, and they are often folded into questions in solution-focused counseling. For example, asking a student who complains of being stressed out and depressed, “How have you managed to juggle so many things for so long?” invites a more hopeful and empowering self-perception. Students can be complimented for attending counseling sessions (“It takes courage to meet like this”), cooperating in the conversation (“I appreciate your help and patience in answering my questions”) and trying to improve their lives (“With all you’ve been through, where do you find the strength to keep on trying instead of giving up?”).

Fit counseling to students versus students to counseling. Just as a tailor adjusts a suit to fit the owner, we need to customize counseling to each student rather than requiring students to conform to our favorite ideas and methods. This means incorporating students’ key words and phrases into the conversation, exploring their theories and opinions, and determining what they want from us and our services.

Incorporating students’ language into counseling conversations validates their perceptions and reinforces the client-driven emphasis of solution-focused counseling. For example, if Maria says, “My teacher gets on my back all the time about my behavior,” we could ask, “What have you found helpful in getting your teacher off your back?”

Another way to fit counseling to students is to explore their opinions about the problem and potential solutions. This can be done through asking questions such as, “What needs to happen to improve things at school?” and “If you were counseling people in a similar situation, what would you advise them to do?” A student’s ideas about the problem and its possible solution can be cobbled into interventions that are more likely to be accepted and implemented by the student than interventions that come from other sources.

Obtaining feedback from students is another way to ensure the provision of student-driven rather than counselor-driven services. The Outcome Rating Scale and Session Rating Scale — two four-item client feedback scales that take one minute to administer and score — provide ongoing snapshots of students’ perceptions of counseling progress and alliance. Collecting feedback from clients during every meeting, and adjusting services based on this feedback, has been shown to dramatically improve counseling outcomes regardless of one’s theoretical orientation.

Step 2: Develop practical goals

In addition to providing students with a sense of hope, purpose and direction for the future, goals help them persist in the face of setbacks and obstacles. Effective goals share several characteristics that can be summarized in the 5-S guideline: significant, specific, small, start based and self-manageable.

Significant: The most important feature of a counseling goal is its personal relevance to the client. Good goals are goals that matter to students, and we can develop these goals by asking questions such as “What are your best hopes for counseling?” and “What is the most important thing you want to change about school right now?”

Specific: Goals also need to be specific and concrete so that students, counselors and anyone else involved can tell when they are reached. The following sample questions help counselors partner with students to develop specific goals: “If we videotaped you being less anxious at school, what would we see you doing?”; “What will be happening next week to let us know that we’re on the right track?”

Small: Practical goals are small enough to be attained, yet challenging enough to inspire action. Questions that help in this regard include the following: “What will be the first small sign that things are moving in the right direction?”; “You rated school as a 2 on a 10-point scale. What would a 2.5 or 3 look like at school?”

Start based: When asked what they want from counseling, most students tell you what they don’t want: “I want to get in less trouble at school” or “I want to be less depressed.” When students state goals in negative terms, we can ask the following “instead of” questions to encourage goals that express the start or presence of something desirable rather than the end or absence of something undesirable: “What will you be doing in class instead of getting in trouble?”; “What would you rather be doing instead of being depressed?” In addition to being more noticeable and measurable than negatively worded goals, start-based goals are more motivating because they focus students’ attention on moving toward what they want (solutions)
rather than away from what they don’t want (problems).

Self-manageable: Students may initially focus on how other people should change instead of considering what they could do differently (“My teachers need to back off and chill a little”). This perspective, accurate as it may be, usually impedes solutions by holding others responsible for changing while placing oneself in a passive and powerless role. When this occurs, counselors can acknowledge students’ perceptions while inviting them to consider what they might do to improve

the school situation: “What have you found helpful in getting your teachers to back off and chill?”

Step 3: Build on what is ‘right’

Instead of emphasizing what is wrong, missing and not working (problems, deficits, limitations), solution-focused counseling invites students and others to notice and build on what is “right” with students and their lives (successes, strengths, resources).

Build on exceptions. Struggling students typically are aware of their failures and problems at school, which is one reason why building on exceptions is so effective in grabbing and keeping their attention. Exceptions refer to the “good times” at school — times when the problem could have happened but did not. These nonproblem occasions are minisolutions that are already happening, just not as often as people would like.

Building on exceptions is a core technique of solution-focused counseling that involves three steps: 1) eliciting exceptions (“When is the problem absent or less noticeable?”), 2) exploring the conditions under which exceptions occur (“How did you make that happen? What was different about your approach?”) and 3) expanding their presence and frequency at school (“What will it take to make that happen more often at school? Are you willing to try that approach in another class?”). This strategy is based on the practical idea that it is more efficient to increase what students are already doing than it is to teach them brand-new behaviors from scratch.

Many students are surprised to learn that they are doing “something” right, and they become more hopeful when they realize that they already have what it takes to turn things around at school. On a more personal level, building on exceptions encourages struggling students to change the question from “How can I be more like other students?” to “How can I be more like myself during my better moments?”

Build on other student resources. In solution-focused counseling, all students are viewed as resourceful and capable of changing. It is our job as counselors to help them identify and apply the “natural resources” in their lives toward school solutions. Natural resources include heroes and influential people (family, friends, actors, athletes); resilience and coping (students’ abilities to cope with life’s adversities); values (students’ deeply held beliefs); special interests (cooking, sports, movies); and community support systems (places of worship, neighborhood groups, clubs). These resources, individually or in combination, can be woven into respectful Branding-Images_Studentsinterventions that improve school behavior while respecting students’ cultural heritage and life experiences.

Let’s look at a quick example involving Ben, a 10-year-old student who loved baseball. After a few minutes of general baseball talk, we explored similarities between the challenges of school and the challenges of baseball. For instance, we talked about how long the baseball season is and how important it is to not let a few bad games ruin the entire season. Ben agreed to try a baseball experiment at school that involved “stepping up to the plate every day” and doing his best, knowing that he would sometimes “strike out” and have bad days. Ben improved his classroom behavior over the next two weeks, and his teacher commented on his impressive turnaround.

This example captures the general nature of building on student resources — identify an available, naturally occurring resource in the student’s life and link the resource to a school solution. Because every student offers a unique set of resources, resource-based interventions are constructed one student at a time with no preconceived notions about what they should look like. You are not likely to find them in treatment manuals or lists because a) they cannot be selected or developed before meeting the student, b) they evolve from the student-counselor relationship and are often formulated on the spot in collaboration with the student and c) they are based completely on material supplied by the student — which is precisely why they work so well. I describe these techniques and many others in greater detail while offering more than 50 real-world illustrations in the new third edition of my book Solution-Focused Counseling in Schools (2015), published by the American Counseling Association.

Solution-focused counseling rests on two main values. First, students should be given every opportunity to be actively involved in their own care because they are the very people for whom school-based counseling services are designed. In addition to honoring core principles of multiculturalism and social justice, giving clients a voice in shaping and evaluating counseling services results in better outcomes. Second, all students are doing “something” to help themselves — if only to keep the problem from getting worse — and these assets and resources can be applied toward school solutions. Without denying the reality and pain of school problems, we can improve outcomes by identifying students’ strengths and resources and incorporating them into the counseling process.

I hope this article was successful in showing that solution-focused counseling in schools is far more than a set of techniques. It is instead a new and different way to approach young people, problems and solutions.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

John J. Murphy, a professor in the Department of Psychology and Counseling at the University of Central Arkansas, is the author of several well-regarded books, including the third edition of Solution-Focused Counseling in Schools, published by the American Counseling Association. Contact him at jmurphy@uca.edu and learn more about his work at drjohnmurphy.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling ‘unlikeable’ clients

By Laurie Meyers August 25, 2016

It’s not a politically correct statement, but, sometimes, clients are tough to like. Yes, counselors are supposed to remain professional at all times and practice unconditional positive regard. But they are also human, and fending off creeping feelings of “dislike” can be a challenge, especially when clients espouse racist, misogynistic or homophobic beliefs; have abrasive personalities; or simply remind counselors of someone in their own lives whom they find difficult to be around. So the question becomes, how do counselors handle that reality?

Tamara Suttle is a licensed professional counselor (LPC) in Castle Rock, Colorado, with more than 30 years of experience in mental health. She also runs a business in which she provides supervision, consultation, private practice coaching and counseling for other therapists. In her Branding-Images_Difficultopinion, most counselor education programs and the counseling profession itself don’t do enough to prepare future clinicians for those instances when they will experience negative feelings toward a client. In truth, she says, it’s a bit of a taboo topic.

“If your professors don’t talk about these things and our clinical supervisors don’t talk about these things and our colleagues and our friends and our bosses and our professional associations don’t talk about these things, then we learn pretty quickly that we aren’t supposed to talk about these things or even experience these things,” says Suttle, a member of the American Counseling Association.

But in reality, all counselors experience discomfort with and dislike of a client at some point in their careers, says Keith Myers, an LPC and ACA member in the Atlanta metro area. “If someone tells you that it does not [happen], they’re not being honest with themselves,” he says. “We are counselors who also happen to be human beings.”

Digging deeper

The key is being able to set aside and even learn from those negative feelings when they pop up, Suttle says. To do that, counselors need to discern what is truly at the root of those feelings.

Lauren Ostrowski, an LPC at a group private practice who also works at a community mental health agency in Pottstown, Pennsylvania, agrees. “To me, what is far more common [than fully disliking a client] is working with clients who do things or have traits that I don’t like,” says Ostrowski, a member of ACA. “Even if I feel like I have a client I don’t like at all, I make it a point to figure out what it is they are doing or saying that I don’t like. Then I figure out whether the problem is really me — [making] a value judgment perhaps — or whether they are doing something in session that also affects their everyday life that they are motivated to change.”

Suttle acknowledges that after reflecting on her negative feelings toward a client, she sometimes discovers that the problem actually resides with her. She is reacting with dislike because the client triggers personal issues she has struggled with herself, such as having been raised to be a people pleaser.

“I’m sure many therapists can relate to having a certain type of client that they simply prefer not to work with,” Suttle says. “For me, that has historically been a client who is so focused on people pleasing and [is so] passive or passive-aggressive that she is often unable or unwilling to own her truth and … tell the truth.”

“After years of struggling with this type of client and [having] lots of opportunities to reflect on my struggles, I now recognize my discomfort as being much more about me and my own people-pleasing tendencies than those of my clients,” she continues. “It’s one of those issues that I must continually be cognizant of and work on in order to work with clients.”

Likewise, Myers says that his feelings of dislike or discomfort with a client are often about him. “Most times … it’s [dislike] about an interpersonal issue or a client reminding me of someone I know or knew,” he says. “I think, for me, it comes down to countertransference and how a client may stir up my own unconscious — or, at times, conscious — parts of me.”

Myers and Suttle both stress the importance of counselors practicing self-reflection to identify personal issues that can creep into counseling.

When Suttle works with other counselors who are struggling to like one of their clients, she looks for what she calls “signature issues” in the counselors’ backgrounds. She does this by helping them to construct genograms. The purpose is to identify how a counselor’s family members interacted in relationships going back several generations, such as Suttle’s long line of people pleasers.

Together, Suttle and the counselor search for behavior patterns related to family relationships. For instance, passivity might be a pattern in the counselor’s family. Suttle also asks about how conflict was handled in the counselor’s home growing up. As an example, a counselor whose father punched walls when he was angry might not be comfortable with conflict. This could engender a negative reaction to clients who push back, are stubborn or struggle to control their anger, Suttle notes.

Identifying the personal issues and biases that contribute to a counselor’s dislike of a client is an important step, but that alone will not solve the problem, say Myers and Suttle. Both stress the importance of counselors receiving supervision and even engaging in individual therapy when their personal issues trigger feelings of dislike toward a client.

“Supervision and consultation play a huge role in processing the material and my own internal responses that occur within my counseling relationship with clients,” Myers says. “Having someone who comes alongside me in my process of helping others and is willing to see me through a different lens … who is often challenging me and exploring my conscious and my unconscious feelings. … [That] is so important to me keeping those ‘dislikes’ [about a client] in check.”

“Another thing I do is participate in individual therapy,” Myers says. “Sometimes if a client is rubbing me the wrong way or I feel irritated or agitated with a client, my therapist provides me with a safe space to be able to process those things.”

In addition, Ostrowski urges counselors to seek more informal supervision when struggling with negative feelings toward a client. “This doesn’t have to be the official [type of] supervision with a contract and consultation agreement, etc.,” she says. “While I think that kind of supervision is important, here I’m talking more about a trusted co-worker or another clinician where you can just have a discussion about exactly what you are reacting to, how you reacted in session and what you are going to do moving forward.”

Suttle has a consulting group that she meets with regularly, and she urges other practitioners to participate in similar groups to help them deal with problematic feelings toward clients.

Setting aside personal beliefs

In accordance with the ACA Code of Ethics, counselors know that they must not force their own beliefs on clients, but what happens when a client espouses beliefs that are hateful, personally hurtful or just uncomfortable to the counselor?

“Sometimes working with clients who have different values can be challenging,” Ostrowski says. “In that case, I really try to learn more about the client’s worldview and, in some cases, ask about how looking at a situation in a certain way may affect them or their family. Often, they are already aware of these things and will say that they understand that it causes certain trouble with extended family dynamics or may be part of why they don’t have a relationship with someone important to them. There can be some very fruitful discussions about how important their beliefs are to them compared to what it is that they want in life and whether there is some sort of balance that they see.”

When Myers, a past co-chair of the ACA Ethics Committee, is working with a client who has strong prejudices or biases against certain groups and is making judgmental or harsh comments in session, he tries to tie it back into the therapeutic process.

“I normally use this time to explore these comments so that I can gain further insight into the client’s background, values, beliefs [and] family-of-origin issues,” he explains. “This is usually an opportunity to hold the tension while exploring deeper with the client. And if we believe it’s important to be fully accepting and nonjudgmental with all clients, then it’s important for us to accept those who are different from us and who hold very different values and opinions, even when they are being judgmental.”

Although Ostrowski often manages to make therapeutic use of a client’s biases or prejudices, she acknowledges that it isn’t always easy, recounting the story of one of her recent cases as an example. “A few days after the tragic shootings in the Orlando nightclub [at Pulse in Florida on June 12], I had a client discussing his beliefs on the whole idea with me. Let’s just say that [the client’s beliefs and Ostrowski’s beliefs] were about as far opposite as one can get, and on top of that, he had a lot of the facts incorrect. I did mention that I had heard different facts on the news, but he disagreed,” she says. “I stopped trying to point out things that were different from what I had heard, and I allowed him to discuss how all of this had affected him, restating what he was saying and asking for more information.”

Ostrowski says the situation served as a good reminder for her to closely monitor her reactions when faced with a client’s prejudicial statements and biases. “I will say that for the rest of the session after the topic was brought up, I was checking every statement or question I used before I said it to see whether it was to benefit me or my client,” she notes.

It is important for counselors to know themselves well so they can better guard against their personal beliefs and biases slipping into the counseling session, Ostrowski says. However, that doesn’t mean that counselors have to give up their personal beliefs.

“We can keep our worldview [as counselors] and simultaneously learn more about the world as our clients see it,” she explains. “For that matter, it’s not even about hiding our beliefs, but more about disclosing only those that would further the conversation we are having with our clients about what they believe and leading them in the direction of their therapeutic goals.”

Regardless, hearing a client spout hateful or misinformed comments in session can still take a toll on counselors, Myers and Ostrowski say, and that is one reason why they think counselor self-care is crucial in these situations. Myers take breaks to walk in nature after client sessions that may have been upsetting because the activity helps him clear his head. Ostrowski, meanwhile, has found that staying grounded helps her and can be particularly useful while in session.

“[Staying grounded] may decrease the feeling of being emotionally flooded or overwhelmed,” she explains. “[It] can be as simple as taking the time to notice your feet on the floor or your hips in the chair. The possibilities are endless. Each and every one of us can find some way that we can move or notice the location of our body in the room or the chair in a way that is not distracting to a client. It takes only a matter of seconds and can change the trajectory of the session because of having an increased ability to stay present with the client in that moment.”

‘Liking’ versus ‘accepting’

Other clients can be difficult to like not so much because of their beliefs but because they possess abrasive personalities.

Christine Moll, an LPC who practices in the Buffalo, New York, area, points out that no one ever said that counselors have to like every client they come in contact with. She cites the writings of Carl Rogers — one of the founders of the client-centered approach — to support her statement.

“He called for empathy,” Moll explains. “Nowhere did he say like, but [rather] embracing the person with concern or care, wanting the best for that person.”

Moll, an ACA member who is also a past president of the Association for Adult Development and Aging, says she has definitely encountered clients whom she didn’t like, but she always tries to put her personal feelings in perspective. “I have worked with clients that I have found difficult, arrogant, elitist or biased,” she says. “But I am not in their lives. I don’t need to share a fence with them. I think to myself that if I [have to put my reactions] aside, it’s just for 50 minutes, and I tell myself, ‘It’s not about you.’”

Regardless of how a counselor feels about a client, the goal should always be to help that client find and attain a good quality of life, says Moll, who is also a counselor educator at Canisius College. “I try to use what I’ve not liked about a person and figure out how to reframe it,” she notes.

For instance, clients might come to counseling complaining that no one likes them and they don’t know why. Moll explains, “I might point out a [client’s] passion for life that other people might see as a chip on the shoulder and say, ‘I see your energy and your passion for life, and if you feel threatened and put up against a wall, you are going to fight back. That’s great. That’s a gift. But can you see how that can lead people to see you negatively?’”

Ostrowski suggests exploring whether a client’s difficult personality is connected to the reason that person is seeking counseling. “For example,” she says, “if clients come across very gruff and unpleasant, it could be that they have emotions that they don’t understand or they struggle to have effective conversations, thereby leading them to react in ways that are perceived as unpleasant because of self-protection strategies.”

Moll also tries to identify positive aspects in even the most unpleasant client. “I was raised with the idea that everyone’s got something [good] about them,” she says. “If I find a glimmer or find a good quality, I praise it.”

Myers comes back to the importance of always putting the client first in the counseling relationship. “I will say, yes, it is harder to work with a client that I don’t like, at least at first. But then I remind myself that I must accept each client where they are in their lives and that I don’t have to like them necessarily to fully accept them, support them and offer them respect.”

 

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To contact the counselors interviewed for this article, email:

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

 

Radical alignment: A psychospiritual approach to conflicting values

By Carol ZA McGinnis

Standard A.4.b. of the 2014 ACA Code of Ethics notes that “counselors are aware of — and avoid imposing — their own values, attitudes, beliefs and behaviors” in an ethical practice. Counselor educators and students often need a practical approach for accomplishing this goal when it comes to conflicting religious or spiritual perspectives in the counselor-client relationship. Through a process of radical alignment, this ethical mandate can be accomplished.

Despite recent legislative trends, most notably in Tennessee, the prohibition of referral due to counselor-client value conflict may present a problem for practitioners who need additional help in adopting a genuine empathetic orientation.

One way to approach this potential dilemma is to adopt a psychospiritual approach that is oriented toward the identification of “common ground” or universal themes that are likely to exist in any counselor-client relationship. This kind of self-awareness and exploration is found in pastoral counseling programs that have a vested interest in integrating a religious or spiritual view in counselor training versus secular versions that tend to view this aspect of the client simply as a component of client diversity. The problem with the latter view is that it discounts intellectual and emotional aspects of religious or spiritual beliefs that inform the counselor photo-1462663608395-404cb6246eaffrom a holistic level. When we are not able to bring our full capacity into the session — if we merely bracket, ignore or set aside this part of our humanity — it would seem implausible to fully attend to a client’s needs.

No empirical research has been conducted on the term “radical alignment.” The idea is supported, however, by the collective works of Kenneth Pargament, Henri Nouwen and Pierre Teilhard de Chardin, each of whom contributed to a wider understanding of how religious and spiritual views intersect with human interaction. They determined that religious and spiritual beliefs are an invaluable part of daily living oriented toward meaning, spiritual growth and our identity as a member of a larger community.

Recognition of universal themes that connect all people regardless of faith tradition, spiritual orientation or creed can provide the counselor with valuable insight into the inner workings of the client without compromising the counselor’s core beliefs.

 

Authenticity and trust

The idea of radical alignment begins with the premise that the humanistic principles of authenticity and trust must reside at the core of the counseling relationship. We find these same fundamental principles in the ACA Code of Ethics as veracity and fidelity, which seem difficult, if not impossible, to promote when personal values have been completely removed from the interaction.

Although counselors are health professionals much like physicians and nurses, we rely on the establishment of rapport in the counseling relationship, which is more akin to religious confession than a physical checkup. In this complex aspect of the counseling relationship, only the affirmation of commonly held beliefs and values can provide a tangible path to an ethical practice.

The crux of the problem then becomes more about the “how” of finding solid ground when a counselor’s and client’s beliefs and values clash. How does the counselor begin to determine these elements to connect, or align, with the client? The answer is to return to the fundamentals of what it takes to provide a comprehensive counselor education: the development of appropriate awareness, knowledge and skills (http://www.cacrep.org/wp-content/uploads/2012/10/2016-CACREP-Standards.pdf).

 

Awareness, knowledge and skills

To accomplish this, counselors-in-training need practice in exploration and self-awareness activities that will help them to identify and validate their own beliefs and values. These activities will increase their knowledge of religious or spiritual language and behaviors that may alienate clients who hold very different views, while also helping them develop skills for determining universal themes through which radical alignment can occur.

Awareness in this capacity might involve exploration of previous beliefs and values that have stayed consistent or changed over the counselor-in-training’s lifetime. Core values may be highlighted through activities such as journaling, digital storytelling and discussion board exchanges in an online environment. Through these activities, counselors-in-training can learn how to communicate specific meanings, values and beliefs that they have attributed to specific life events and that might guide their day-to-day decisions.

Face-to-face exploration might involve dyad or group activities that include the creative expression of core beliefs. This could involve sharing symbols, rituals, sacred texts or even types of food that help to bring about deeper awareness of how beliefs and values are affirmed and communicated.

Gaining knowledge of what others believe, with attention given to ritual, family tradition and sacred texts, can help counselor-in-training learn about language and actions that clients could interpret as hostile or distancing. When structured responsibly, respectful exposure to various religious and spiritual views can help affirm the belief systems of counselors-in-training and provide a deeper understanding of how these values may fit within the larger context of other worldviews.

This process should not be part of a master plan to bend or subordinate individual beliefs. Rather, it should highlight similarities and differences that can be important in counseling. For example, the concept of prayer may seem universal to one student until further exploration highlights how this term can mean very different things to different clients, or even potentially have no connection to clients who hold Eastern religious/spiritual views.

To determine universal themes, the counselor-in-training must learn to identify client beliefs and values that may be related to the client’s presenting problem without feeling threatened. Although it is still possible for unexpected countertransference to occur, previous exploration and awareness of counselor beliefs will mitigate this response and allow the counselor to focus on determining underlying universal themes. Even if these themes are not completely consistent with the client’s views, recognition of these elements can help the counselor to align with the client in a radical way.

Let’s say, for example, that the counselor-in-training is a Pentecostal Christian with devout beliefs that relate to the sanctity of marriage. The client, meanwhile, professes no particular faith and engages in casual sex with many partners. Further exploration of the client’s values may result in the prioritization of truth as a core belief. This value would be understood as a universal theme that cuts through religious and spiritual orientation and can provide the counselor with a platform to align with the client. The counselor-in-training may not be able to genuinely empathize with the ramifications of the client’s sexual promiscuity, but her desire for truth in all relationships would be a place where radical alignment could occur.

So too might a Muslim counselor-in-training who possesses a strong religious belief to honor his father and mother connect with a client who regularly lies to his parents through a shared universal theme of a desire for justice. This focus would permit the counselor-in-training to be genuine in his empathy for the client who feels bullied and ignored by those people who are closest to him in his life. Through radical alignment, the counselor-in-training could build trust with this client. That sense of trust would be needed by this client to help him move away from self-destructive behaviors and toward healthier goals that have been identified in an authentic counseling relationship.

In short, this process occurs through three steps:

1) Collect and identify client beliefs and values associated with the presenting problem.

2) Determine a core belief that can be understood as a universal theme that is shared by the counselor-in-training.

3) Engage in radical alignment with the client to promote fidelity and trust in the counseling relationship.

 

 

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Carol ZA McGinnis, a licensed clinical professional counselor and national certified counselor, is a pastoral counselor and counselor educator who specializes in anger processing. Her passion involves teaching with attention paid to religion and spirituality as positive factors in both counseling and counselor development. Contact her at cmcginnis@messiah.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

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