Tag Archives: Professional Issues

Professional Issues

The role of value in adult self-esteem and life satisfaction

By Harvey Hyman December 19, 2017

While reflecting on my clinical experiences with adult clients during my postgraduate internship, I discerned a common thread. The thread was that the feeling of being valueless was at the root of my clients’ depression, anxiety, anger and substance abuse, as well as the violence and verbal abuse experienced within couples.

Although the immediate cause of the perception of being valueless varied (e.g., pervasive childhood neglect or specific episodes of childhood physical, sexual or emotional abuse), the consequences were the same in each case — chronic dysphoria of one kind or another. It is simply not possible to esteem oneself, to be vulnerable with others, to feel able to positively impact the lives of others through relationships or achievements, or to expect an enjoyable and meaningful future when one is convinced that she or he lacks value.

During the past few months, I have been learning about and practicing a technique involving mindful self-compassion designed to increase my sense of personal value, and I have been working with willing clients to teach them the same technique. I have written this article to voice my perspective on how self-perceived valuelessness is the major factor in transdiagnostic client suffering and to share a technique for building belief in your clients that they possess value as human beings.

 

The meaning of value and valuelessness in human life

In common parlance, the word “value” signifies having such positive qualities as worth, goodness, merit, effectiveness, usefulness, importance, attractiveness and desirability. People who perceive themselves as possessing value are much more likely to have self-esteem, self-efficacy and life satisfaction than are people who appraise themselves as lacking value. Believing oneself to be valuable is associated with resiliency and posttraumatic growth because external hardships and adversities do not destroy value but, rather, reveal it.

To lack value means that one is not lovable, desirable or worthy of mattering to and belonging with others. There are few, if any, sources of emotional pain greater than believing that you lack value. I believe that clients who are convinced that they lack value are the ones most likely to suffer from depression and to engage in self-destructive behaviors such as alcohol or drug abuse, the self-sabotage of relationships, cutting, burning, eating disorders and suicide attempts. When you are certain you lack value, it is equally certain you will hate yourself and will consider or perpetrate acts of self-harm. You may even want to end yourself to stop the pain of living with this certainty and being your own worst enemy instead of your own best friend.

I understand that genetic abnormalities that cause bad brain neurochemistry, especially during times of stress, can trigger self-hate, depression and self-destructive behavior. However, I am convinced that most of the time distorted thinking about the self (as being bad, incompetent or certain to fail at everything) and maladaptive coping behaviors arise from our clients’ belief that they are valueless.

Believing that you are valuable but constantly berating yourself for being a piece of crap or sitting in a squalid room injecting heroin into your veins with a used needle are totally inconsistent. Believing that you are valueless also rears its ugly head in interpersonal relationships. People who know they are valuable can shrug off the unfair accusations, attacking comments, insults and rejecting behaviors of others by recognizing that they come from ignorance, mistaken assumptions, implicit biases, defensiveness or fear. On the other hand, people who see themselves as valueless will perceive dire threat and react with fight, flight or freeze when exposed to these things because they confirm their inner sense of valuelessness.

 

The association between value and triggering

A very common bit of psychological jargon that I hear today is the word “trigger.” It is used in the sense that some statement, action or inaction of one person set off an intense, immediate and automatic emotional reaction in another person who felt unsafe. This person responds with crying, threats of violence, actual violence, emotional contraction, fleeing the scene and the like.

When one spouse says “Shut the hell up” to the other, strikes the other or gets in the car and drives off to parts unknown following a dispute, we can say that he or she was triggered, but what really happened? I think what happened is that the spouse who acted out had a thin, fragile scab over his or her self-perception of being valueless and something the other spouse said tore it off.

Whether we remind ourselves that we are valueless through our own inner critic (the usual way) or someone else reminds us by their statements or conduct, it hurts just as much. And when that pain sets in, our self-esteem plummets from whatever shaky height we had lifted it up to. We then temporarily lose our effectiveness as people because we turn away from the world to soothe ourselves with substances or punish ourselves with self-attacking words or deeds.

 

Intrinsic versus extrinsic value

According to sources as diverse as the Judeo-Christian Scriptures, the philosophers Immanuel Kant and Martin Buber, and the Declaration of Independence, human beings have intrinsic value. Theologists may see intrinsic value as coming from people being created by a perfect Creator, whereas philosophers might see intrinsic value as coming from our possession of rationality and our capacity to act ethically by choosing the good.

To believe in the intrinsic value of the individual is to believe that our value is not contingent upon externals such as one’s most recent successes, the current size of one’s bank account or the current level of one’s physical attractiveness. For Viktor Frankl, value becomes evident when a person establishes an authentic meaning for his or her life. For Abraham Maslow, it is when a person self-actualizes his or her potential.

Despite so many sacred and secular voices in favor of intrinsic value, virtually none of the people I have met buy it. Rather, they engage in constant self-evaluation in relation to internal standards of achievement and attractiveness, as well as external comparisons with family members, friends, co-workers, professional colleagues and even star athletes, movie actors and celebrities.

Freud described this long ago as checking one’s self-evaluation in the mirror of one’s ego ideal and getting judged harshly by one’s superego for every discrepancy. Today we talk about the voice of the inner critic instead of the superego, but the process and consequences are the same. There is a constant need to reassure oneself of one’s value, and a failed attempt to do so is followed by self-attack, ego deflation and suffering. Kristin Neff, who has done pioneering research on self-compassion, has pointed out that self-attack is accompanied on a somatic level by release of cortisol and adrenalin, which make us feel sick.

 

Value and secure attachment

Why is it that a handful of people seem certain that they possess value while everyone else sees their value as questionable, fluctuating or even absent? The work of John Bowlby on attachment helps to shed light on this phenomenon.

Bowlby said that how infants and toddlers were treated by their parents, especially their mothers, had a huge impact on their sense of self. Infants and toddlers who received a consistent flow of love, caring, warmth, gentle touch, soothing vocalization and affirmation would develop what Bowlby called a “secure attachment” composed of feeling welcomed, loved, valued and wanted. The secure attachment was the germ of self-acceptance and self-confidence that fueled these children’s exploration of their environment and their ability to self-soothe when they experienced fear, physical pain or other adverse consequences.

In Bowlby’s framework, infants and toddlers who received love, warmth and caring in an unstable, episodic and inconsistent manner would develop an insecure or approach-avoid attachment style associated with a reduced sense of personal value and trust in others. The most damaged infants and toddlers were the victims of pervasive abuse or neglect who received the message that their caregivers hated them or did not care about them. These children developed an avoidant attachment style in which they reacted to others by distancing themselves emotionally and physically.

 

Therapeutic approaches to correcting self-perceived valuelessness

If secure attachment is the foundation of the self-perception that one has value, then the most effective therapy for clients who doubt their value or regard themselves as valueless should be some form of reparenting that has the effect of strengthening a weak attachment to others. Unfortunately, this type of therapy is demanding, prolonged and expensive, and is by no means guaranteed to work.

Cognitive behavior therapy is great at showing the falsity of automatic, negative thoughts about the self, but until the deep-seated conviction (the core belief) that one is valueless is gone, these thoughts will continue to arise. Trauma therapies work to desensitize, contextualize and reinterpret memories of adverse childhood experiences, but the conviction that one is valueless, resulting from pervasive abuse or neglect, is very tenacious. This conviction can represent the foundation of personality and self-identity and the form the ego took from parental shaping in childhood.

If it is not possible to remove and replace the psychological foundation of self-image, what can be done to solve this problem? My hunch is that behind the conveyance of a sense of value to the infant/toddler through parental holding, touching, warmth and affirmation is a programming of the brain (“I know I am loved”) and the heart (“I feel that I am loved”). Abuse, neglect or inconsistent parenting can confuse the brain of the infant/toddler (“I’m not sure I’m loved and lovable”) or program it to believe that “I am neither loved nor lovable.” These things can make the child’s heart feel the same message.

So, how can clients in therapy reprogram their brains to know and their hearts to feel that they have value? At this point in my investigation, I have only anecdotal evidence and nothing like the kind of systematically collected empirical evidence developed in the course of a randomized, controlled clinical trial based on an experimental design. Thus, my proposal is based on isolated experiences in the therapy office and is nothing like the sort of evidence-based protocol that an insurance company would want to see. On the other hand, positive clinical experiences can be the germ of subsequent studies to confirm or deny a hypothesis about those experiences.

The method I have been trying out on myself and some of my clients derives in part from what Kristin Neff and Christopher Germer call “mindful self-compassion.” The basic practice is to combine deep, slow, meditative breathing with eyes closed; an attitude of genuine compassion toward the self; the tender placement of hands upon one’s body (e.g., placing one open hand over your heart); and the inward repetition of chosen affirmations in a soothing voice.

I have tried out such affirmations as “I am worthy,” “I am valuable,” “I matter,” “I know my own goodness,” “I feel loved and included,” “I love and include,” “I am connected with all other beings and they with me,” “I trust that the universe supports me” and “the universe is unfolding in and through me, and I have an important role to play.” Individuals using this practice can create and try out different mantras until they have found some that resonate in a deep and profound way with them.

The meditative breathing serves to produce a trancelike, mildly euphoric state in which the parasympathetic nervous system is activated, the voice of the inner critic is switched off and there is a sense of warmth and expansive possibilities. The role of tender self-touch is to provide mammalian comfort and reassurance — to put oneself in a place of safety and trust.

The combination of meditative breathing with eyes closed and self-touch enables clients to become attuned to themselves in a way that could not happen in the therapy office with the distraction of glances, conversation, pauses and concern over the counselor’s opinion. When imbibed in this atmosphere of self-compassion and self-attunement, the self-affirming mantras take on the ring of truth, not New Age phoniness. Doing this exercise with sincerity is a form of self-reparenting that features the three elements that Dacher Keltner considers essential in loving mammalian connection: warmth, gentle touch and soothing vocalizations.

At this point, I have no evidence that this particular practice by itself can convert individuals who are convinced that they are valueless to people who know and feel they possess value. However, I am observing in myself and my clients that combining this practice with another therapy has a powerful, synergistic healing effect and that this practice has clinical promise.

 

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After 25 years of law practice, Harvey Hyman retired, studied Buddhism and world religions, and entered graduate school to obtain a master’s degree in mental health counseling. He graduated this past October and is now registering for a counseling internship in the Sacramento, California, area. He hopes to work in the field of trauma psychology. Contact him at harveyhyman56@gmail.com.

 

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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.

@TechCounselor: A better way to email, Part I

By Adria S. Dunbar and Beth A. Vincent December 11, 2017

Most of us have a love-hate relationship with email. Luckily, there are many software solutions to help counselors and counselor educators handle email more efficiently. Let’s begin by identifying the email issues you want to fix. If you choose more than one, don’t worry. We will take it one step at a time.

 

1) Which inbox issue are you trying to solve?

  1. a) I write emails during nonworking hours (e.g., 4 a.m., weekends, holidays).
  2. b) The number of emails I receive each day is out of control.
  3. c) I need to translate my emails into tasks on a to-do list.
  4. d) My email signature leads people nowhere.
  5. e) I write the same email over and over again.

 

We will spend the next few months addressing each of these types of email issues, one at a time. For those who chose “I write emails during nonworking hours,” we suggest an email add-on that might save you a lot of time and energy. It’s called Boomerang (boomerangapp.com/), and it just might make your life with email a little easier.

 

Counselors, meet Boomerang

We are all trying our best to set boundaries with work and work-related tasks. Maybe you like to spend your Saturday mornings catching up on work, but sending an email on a Sunday evening or Saturday morning alerts people to the fact that you are available and working. Or perhaps you are a night owl who writes emails at 3 a.m. The meta-communication of when we send our emails says something to the recipients.

Regardless of your counseling role, email is a reality of the working world. Now that the majority of people have a smartphone, our emails tend to follow us everywhere — even when we are not physically present at the office. Everyone manages his or her connectedness differently, but as counselors, it can be challenging to set boundaries when it comes to responding to emails from clients, students or co-workers. Unfortunately, it can be easier to just go ahead and respond immediately rather than risking the sometimes unavoidable reality of forgetting to follow up at a later time.

Boomerang is a helpful tool that allows you to schedule when your emails get sent. What this means is that you can write and respond to an email whenever you choose — maybe that is at night after your children have gone to bed, or on the weekend when you said you weren’t going to be checking your email. Regardless, you can schedule the email to be sent to your client’s inbox at 8 a.m. on a Tuesday morning during normal “business” hours. This can help us as counseling practitioners or counselor educators to model better communication boundaries to our clients and students (i.e., suggesting that we are not instantly accessible) by limiting communication times and creating a culture of self-care.

In addition to setting boundaries, Boomerang allows you to schedule emails ahead of time, whether that is hours, days, weeks or months in advance. For example, perhaps you are planning a workshop or group event that is a month away, but you already have a list of attendees who have RSVP’d. Using Boomerang, you can write your email reminder now and schedule that email to be sent to attendees a week before your event takes place. This takes the pressure off of you to remember to send a reminder email.

Boomerang does come with some limitations. The tool is accessible both for Gmail and Outlook users. However, currently, you can schedule only 10 emails per month using the free version. Once you hit your 10-email limit, you are unable to schedule additional emails until a new month begins (unless you pay a monthly fee for the service).

In our view, there are definitely benefits to the paid services. For $5 a month, you can schedule messages to return to the top of your inbox at a set date, while also including a note to yourself with next steps or reminders. You also receive mobile access to the application. For additional fees each month, other features are available, including unlimited emails with Boomerang, recurring messages (e.g., weekly, monthly, yearly), a setting that allows you to pause email notifications and a setting to prioritize a VIP list of senders.

Whether wishing to disconnect a bit more, wanting to be more organized with your recurring messages or just needing reminders of the emails you sent that no one replied to, Boomerang can be a tool to help counselors reduce some of the mental clutter that we all experience because of our very full inboxes.

 

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Adria S. Dunbar is an assistant professor in the Department of Educational Leadership, Policy and Human Development at North Carolina State University in Raleigh. She has more than 15 years of experience with both efficient and inefficient technology in school settings, private practice and counselor education. Contact her at adria.dunbar@ncsu.edu.

 

Beth A. Vincent is an assistant professor at Campbell University in Buies Creek, North Carolina, in counselor. She is a counselor educator, licensed school counselor and former career counselor who is driven to learn everything there is to know about innovative productivity software so that she can help counselors be their most present selves. Contact her at evincent@campbell.edu.

 

Our Instagram is @techncounselor (instagram.com/techcounselor/).

 

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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.

Raising awareness of suicide risk

By Jerrod Brown and Tony Salvatore December 6, 2017

Suicides have increased steadily in the United States during the past decade. Suicide research has also grown, but pertinent findings are sometimes slow to reach mental health professionals and providers. Many misconceptions and gaps in the knowledge base remain. The role that mental illness plays in suicide is an area of research that both the public and many clinicians must better understand. This article touches on 10 aspects of the relationship between suicide and mental illness that mental health professionals should be aware of and should be able to share with others.

1) Serious and persistent mental health disorders sometimes contribute to suicidal behavior, but they generally are not the cause of suicides on their own. A suicide risk factor is a personal or demographic attribute found to be prevalent among suicide victims; a cause is a condition that brings suicide about. When suicide and serious and persistent mental illness are inappropriately linked, it can result in enhancing associated stigmas and misdirecting the focus of suicide prevention. Mental illness is sufficient to contribute to suicide but not absolutely necessary. Myriad factors and reasons, separate and aside from mental illness, can account for suicidal behavior. Keep in mind that antidepressants and other psychotropic medications may effectively reduce suicide risk only for the psychiatric disorder for which they are prescribed.

2) Many individuals who die by suicide do not have a diagnosed serious and persistent mental illness at the time of death. The Centers for Disease Control and Prevention’s National Violent Death Reporting System has found that just over 40 percent of those who die by suicide have a mental health diagnosis.

Despite methodological flaws, psychological autopsy studies that attempt to assign psychiatric diagnoses post-mortem through interviews of those who knew the deceased have routinely found that an overwhelming number of victims of suicide had a diagnosable, although perhaps not documented, mental illness. Nonetheless, this mode of research may sometimes exaggerate the role that mental illness plays in suicide. Mental health providers must understand that although mental health services are a critical component of suicide prevention, they should be only part of a comprehensive approach to deterring the onset or progression of suicide risk.

3) The rate of suicide and suicidal behavior has been found to be higher among people with a serious and persistent mental illness than in the general population, but the majority of those with a serious and persistent mental illness neither attempt nor complete suicide. Every mental health professional and provider organization must be sensitive to the potential for suicide risk and behavior in their clients regardless of their psychiatric histories. Retrospective studies of those who have died by suicide have found that not all of these individuals possessed discernible signs of any form of mental illness as identified by family members or friends. Therefore, outpatient providers must be careful not to minimize signs of possible suicide risk in the absence of mental illness.

4) Psychiatric hospitalization may stabilize and ensure the safety of people who are acutely suicidal. However, it does not in and of itself constitute long-term treatment or reduce the risk of suicidality in the future. Inpatient settings can reduce suicide risk through appropriate use of psychotropic medication when indicated. Psychoeducation about suicide and support groups should also be part of a treatment plan for a client who is suicidal. Community-based providers accepting referrals from inpatient facilities should review the attention given to a potential client’s suicidality while hospitalized and make sure that a predischarge suicide risk assessment was performed.

Suicide prevention must also be part of aftercare in the community. Outpatient providers should engage the client on this objective prior to discharge. Outpatient providers should be thoroughly familiar with the client’s discharge plan, and particularly those elements relating to ongoing suicide risk. If appropriate and with the client’s consent, the outpatient provider should consider a family conference to ensure that the client’s support system understands the individual’s ongoing suicide risk, the family’s role in managing it and what family members should do if the client shows signs of suicidality.

Most important, outpatient providers must maintain continuity of care and resume treatment as soon as possible. When short-term resumption of treatment cannot be accomplished, contact should be initiated by telephone or other means to support the client.

5) The first 30 days after discharge from inpatient psychiatric care is a period of high suicide risk irrespective of the reason for admission. Suicide risk has been found to be especially high in the first week after discharge. This must be acknowledged in outpatient discharge plans. Patients and families must be made aware of this risk, and providers must ensure that patients returning to the community engage quickly with outpatient services and adhere to medication regimens as applicable. Those leaving hospitals must be made aware of 24/7 hotline and crisis services that they can turn to if needed. The National Suicide Prevention Lifeline (at 800-273-8255) is one such resource.

6) Contracting for safety is a technique in which at-risk clients agree to notify their mental health providers or take other steps (e.g., calling a hotline or 911) rather than making an attempt on their life if they have thoughts of suicide. Many counselors, therapists and mental health practitioners continue to use this technique despite an absence of research supporting its efficacy. At best, safety contracts give mental health providers a questionable, if not groundless, sense of security regarding their clients’ potential risk.

Providers are better advised to use thorough suicide risk assessments and personal suicide safety plans with patients and clients. Providers and clients can collaboratively develop personal suicide prevention safety plans, and they have therapeutic value. These plans generally document factors such as warning signs, triggers, coping methods, supports, providers and sources of emergency help.

7) Many mental health providers do not have suicide prevention policies that mandate routine training or outline requirements for client and patient suicide risk assessment. In some instances, mental health providers lack guidance on what should be done in the event of the suicide of a client. This is a serious deficit given our exposure to potential client suicides. Agencies should have a formal suicide prevention policy stating the measures to be taken to prevent suicide and postvention actions to be initiated with staff affected by a client’s suicide. Providers should encourage licensed staff to include suicide prevention trainings among their required continuing education.

A client suicide is perhaps the most traumatic experience that a mental health provider can endure. Taking a risk management stance after a suicide is not sufficient and may be harmful to all concerned. Providers should supply grief support resources, such as Survivors of Suicide, to both staff members and to the deceased client’s family members.

8) Care of individuals who are suicidal has been delegated to the mental health system for evaluation and treatment. This has resulted in many at-risk individuals being assigned one or more diagnoses from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. These diagnoses often become the focus of subsequent care, which may overshadow the person’s ongoing suicide risk and the need to address his or her suicidality. The mental health field has access to some evidenced-based therapies that can assist in reducing suicide risk and deterring future suicidal behavior, but more research and education are needed.

Those who survive a suicide attempt have an elevated short-term suicide risk and a continuing lifelong suicide risk. It is imperative for treating mental health professionals not only to provide therapeutic services but also to connect these clients with available community resources to reduce the likelihood of subsequent suicide attempts. Support groups made up of survivors of suicide attempts are optimal, but these groups are appearing only slowly in communities. In the absence of peer groups or provider-led support groups, consideration should be given to warm lines, chats and other online resources, or to videos and texts created by survivors of suicide attempts.

9) Effective treatment of serious and persistent mental health disorders may lessen suicide risk among impacted individuals. However, treatment for these disorders may not be the only answer. It is imperative for mental health professionals to also address other issues such as substance misuse, traumatic loss, shame, social disconnectedness, feelings of hopelessness or the belief that one is a burden to others when present. Suicide risk should be assessed whenever clients experience any adverse life events, regardless of clients’ adherence to therapy or counseling regimens. Assessing for risk of suicide may require ongoing attention throughout the entire treatment process.

10) The intense and persistent desire to die is experienced by some individuals with serious and persistent mental illness. However, by itself, desire to die is insufficient to bring about a potentially fatal suicide attempt. The person in question must also have overcome the inherent resistance to lethal self-harm. The mitigation of this resistance can occur through life experiences such as abuse, a history of violence, self-injury or traumatic grief, any of which individually can create a capability for significant self-harm up to and including suicide.

Conclusion

Certainly, some individuals with serious and persistent mental illness die as a result of suicide. Nonetheless, suicide is preventable. Mental health treatment providers are well-positioned to minimize the impact of suicidality after onset and to address any ongoing suicide risk. Several steps can be taken to accomplish this.

Every provider should have a suicide prevention policy that outlines measures to identify suicide risk in clients and appropriate responses to such risk. Such a policy should detail what must be done in the event of a client suicide. A suicide risk assessment should be considered as part of new client intake depending on prescreening responses. This involves both clinical judgment and an evidence-based risk assessment instrument.

All staff need to be able to recognize possible warning signs of suicide in clients. We recommend requiring all clinical staff to complete a continuing education course on suicide prevention on a regular basis. Providers might also consider participating on suicide prevention task forces at the city, county or state level. Participation may provide additional access to suicide prevention experts and other resources.

Finally, clinicians must adopt what might be called suicide prevention literacy. They must rely only on evidence-based reports about suicide from researchers in their disciplines and related fields. They must be able to assess these sources and use them to develop evidence-based treatments and programs. Suicide prevention literacy means employing these skills to make suicide prevention a practice reality. It goes beyond participating in suicide prevention walks and runs, conferences and trainings to create a provider mentality that is prevention-oriented. It means using what is available to try to mitigate suicide risk and amplifying suicide protective factors in clients and in the community — not just talking about it.

 

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Jerrod Brown is the treatment director for Pathways Counseling Center Inc., which provides programs and services for individuals impacted by mental illness and addictions. He is also the founder and CEO of the American Institute for the Advancement of Forensic Studies and the editor-in-chief of Forensic Scholars Today and The Journal of Special Populations. He holds graduate certificates in autism spectrum disorder, other health disabilities and traumatic brain injuries. Contact him at Jerrod01234Brown@live.com.

Tony Salvatore is the director of suicide prevention at Montgomery County Emergency Service, a nonprofit crisis intervention and psychiatric emergency response system in Norristown, Pennsylvania. He has a particular interest in post-psychiatric hospital suicide prevention and has served on a number of suicide prevention task forces at the state and county levels in Pennsylvania.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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.

 

Bringing counselor expertise to court

By Jean Peterson November 7, 2017

As a counselor educator, I could have done more to prepare counseling students for involvement with the court system. Pertinent discussions were usually limited to child custody, records, privileged communication, subpoenas and counselors’ vulnerability in the courtroom. I had experienced depositions and had written clinical summaries, but I had never appeared in court. My own preparation had included nothing about being an external expert witness.

Then I had an experience that underscored the importance of teaching and learning about court involvement. Although attorneys might not think of counselor educators and school and mental health counselors first when needing an expert witness, a counseling perspective might be crucial to an outcome. Apparently, mine was.

A bit of history

During the 1980s and early 1990s, a number of articles and monographs addressed court involvement for helping professionals. During that era, psychologists were growing in number, assessment was valued and psychological witnesses were increasingly used. In addition, media outlets were discussing “recovered memory,” and a high-profile case led to criteria for admissible expert testimony. However, conceptual literature noted that attorneys did not always appreciate the expertise and objectivity of therapists in the courtroom, and, because expertise was not standardized, lawyers and experts with stronger credentials could challenge witnesses.

Roles and behaviors related to court processes were also being clarified for counselors. I paid attention to Ted Remley Jr., a helpful legal voice in the field. I learned that both general and expert witness roles are possible, with the former providing facts and the latter providing opinions. An expert witness educates judge and jury by reviewing and interpreting facts and records, making inferences and then informing in neutral, understandable language. School and mental health counselors are more likely to be general, or fact, witnesses, although experience and special training might make them desirable as expert witnesses.

Journal articles about counselors’ involvement have been rare since then, but thanks to contributors such as Carolyn Stone, school counselors can access guidelines related to subpoenas, court orders and privileged communication, for example. However, media interest in bullying and the growing number of states with pertinent statutes suggest that courts will increasingly be involved in cases related to school safety. In such cases, a school counselor or counselor educator may be asked to serve as an expert witness, examining counselors’ and others’ roles or perhaps providing an opinion about the climate or culture of a school.

A surprising request

Eventually, I was contacted from a distance by the attorney for Wendy (pseudonym), a bright 22-year-old, in a civil case against a school district. Alleged negligence in the wake of extreme harassment had contributed to two extended traumatic experiences for Wendy.

My purpose here, in describing my experience as an expert witness, is to provoke thought about counselor court involvement, roles and behaviors, institutional cultures, ethical behavior, systemic contributors to harassment, and potential developmental impact of harassment and retaliation after reporting. Details about the process and time involved might lessen counselors’ concerns if asked to be involved.

Traumatic experiences

I was told that, during ninth grade, Wendy was assaulted physically and harassed with graphic sexual language by a school bus driver almost daily for several months. Allegedly, he had groped her when she entered and exited the bus, jerked her clothing to expose her underwear and asked about her sexual behavior. Wendy observed another student’s similar experiences.

Wendy realized that her younger sister, beginning to mature physically, soon would be vulnerable. She talked with her sister, who talked with the elementary school counselor, who contacted Wendy’s mother, who in turn contacted the school principal, superintendent and sheriff.

The second traumatic experience occurred after Wendy’s parents filed a complaint. Allegedly, the bus driver began drug- and sex-related rumors about Wendy, which were then perpetuated by students who considered the driver an ally. Their unrestricted behavior on sports-team buses (e.g., beer, pornography) matched the driver’s voyeuristic interest in their social lives. He talked with them about Wendy’s parents’ complaint, and, according to an interview during the investigation, encouraged one student to lie on his behalf. At school, Wendy, who formerly had enjoyed social ease, was harassed and marginalized. At the end of her junior year, she transferred to another school.

During the criminal case, which took place after Wendy’s transfer, the bus driver was acquitted. According to Wendy’s new attorney, who contacted me, adolescent witnesses for the prosecution had not presented themselves well in court, even in how they were dressed. Wendy would tell me later that she herself was “not prepped.” This new attorney was now preparing a civil case, focusing on the school system.

Credentials

I was initially surprised to be contacted. Then I considered my professional background. I was knowledgeable about school culture. When the attorney met with me, I told him I had been a teacher, counselor or group specialist in schools for 25 years and a counselor educator for 15, supervising school- or agency-based field experiences. I had worked closely with school administrators in several schools.

In addition, principals-in-training at the university were required to enroll in my Introduction to School Counseling course, and they interacted with the school counseling students formally and informally about their respective professional roles. As a counselor educator, I had led a national study of bullying and was acquainted with trauma literature through a 15-year qualitative study of a survivor of trauma. Beyond that were coursework and clinical experiences in family therapy. I had licenses in school and mental health counseling. Thinking about these experiences gave me confidence. Still, I had anxiety: I would be a first-time expert witness.

An educational experience

What I was asked to do fit my expertise. Training and experience in school counseling were important for my first formal opinion, whereas experience in counselor education was important for my second. The attorney initially traveled to meet with me for two hours. He described what he had learned about the bus harassment and the responses of school personnel after Wendy’s parents filed the formal complaint.

We soon communicated again by phone. I explained relevant concepts, including the developmental lens I routinely used as a counselor, examining developmental tasks (e.g., identity, direction, relationships and autonomy), “stuckness” and task accomplishment. I described findings in my study of trauma and noted literature related to posttraumatic stress disorder (PTSD). We discussed the bullying study and my study with John Littrell of a school counselor who transformed a school culture from bloody fights to harmony. In the latter, the school culture was deemed to be malleable, and a strong counselor-principal partnership was essential to the positive change. I assumed that principal and counselor roles and relationship, school culture and climate, bullying and PTSD all would be important to this case.

At that point, I formally agreed to be involved and was asked to keep track of hours. I said I would ascertain whether bullying legislation existed in that state when the alleged harassment occurred, and the attorney agreed to locate student handbooks of the school from that time. I subsequently met with a faculty member in educational administration at the university and consulted by email with a superintendent who was a former middle school principal, asking how he would respond to an anonymous scenario resembling Wendy’s. His details were helpful as the attorney and I considered what administrators did and did not do in Wendy’s case. I also received university permission to engage in the court process. This permission included a formal admonition that I be clear, both in oral and written testimony, that I did not represent the university or its perspective.

The attorney later sent me a thick loose-leaf binder containing documents and resources for me to study, including:

  • The student handbooks and the school district’s anti-harassment policies
  • Depositions from the superintendent and a teacher for the earlier trial and Wendy’s affidavit
  • Wendy’s mother’s formal complaint
  • Summaries of student statements in the sheriff’s investigation report
  • Polygraph results for Wendy and the bus driver
  • A letter regarding the bus driver’s disciplinary record and his responses to two sets of interrogatories
  • Wendy’s school attendance, academic performance and psychological evaluation records

I studied these materials in preparation for my upcoming meeting with Wendy. The attorney’s assistant arranged for my in-person interview with Wendy and clarified my focus:

1) Wendy’s experiences during the harassment

2) How experiences with the bus driver, students and staff affected her mentally, emotionally and psychologically

3) How she was treated by school counselors

4) Whether permanent damage had occurred

I then developed an interview protocol. The interview lasted 3 1/2 hours.

As I asked about Wendy’s experiences, including during the criminal case, I included questions about development. I also assessed her morale, alert to possible depression, suicidal ideation and PTSD. As directed, I asked about contact with school counselors, whether and how much administrators were aware of her distress, the responses of teachers and peers, and attendance and classroom achievement. Subsequently, I submitted a report to the attorney. Over the next three months, we conferred four times by phone as I prepared to write an affidavit.

The affidavit

Writing the actual affidavit required about seven hours. I needed to peruse the binder materials and notes from my interview with Wendy, communicate once with her by phone to verify details and develop a carefully written, facts-based document. In it, I first presented my credentials and professional employment record as well as a list of the documents I had examined. I explained that I had conducted an interview of a specific length, and I asserted that the information I had gathered from Wendy was the kind counselors rely on during assessment of concerns. Then I presented two formal “opinions.”

First opinion

The first opinion was that the district failed to exercise reasonable care to protect Wendy from a backlash of ridicule and retaliation by faculty and students that was foreseeable under the circumstances. Both action and inaction were part of this neglect. I then discussed pertinent aspects of school administration, school counseling and school culture. I first described some differences in the roles and training of principals and counselors. Pertinent to this case, a head principal sets the tone and establishes the professional culture and climate, including expectations of ethical behavior from counselors and institutional tendencies to ignore or address conflict and other systemic concerns.

I explained that a school counselor can be an oasis for troubled individuals while also staying alert to general student morale. Trained to be nonjudgmental, objective, proactive, collaborative and not a disciplinarian, the counselor is skilled in listening and responding and helping students cope with stressors and live effectively. The American Counseling Association’s 2014 code of ethics, which makes respecting the dignity and promoting the welfare of clients the counselor’s primary responsibility, guides decision-making and behavior. The American School Counselor Association’s ethical standards state clearly that school counselors’ primary obligation is to the student and that they are to inform officials about conditions that are potentially disruptive or damaging to school mission or personnel. All of these aspects were pertinent to the case against the school.

Inaction: Administrators’ inaction suggested a school culture not geared to ensuring a safe environment for learning. School became a hostile and dangerous place for Wendy. Her parents were her only adult advocates.

1) Administrators did not take Wendy’s situation seriously, even though they were aware of the sheriff’s interviews at school and an earlier complaint about the bus driver. According to a deposition, a key administrator did not read students’ statements.

2) Administrators did not suggest that Wendy see a school counselor, who could have focused on her emotional health, and did not partner with school counselors to ensure her protection after the retaliation began.

3) Administrators ignored the bullying. According to Wendy, “About 15 [students] routinely harassed me.”

4) Administrators did not direct teachers to be alert for situations needing intervention, an action that might have given teachers permission to support Wendy. She sensed distance from formerly approachable teachers. Only two teachers, over the course of two years, offered a supportive comment (e.g., “Sorry to hear about everything”).

5) The harassment was visible to teachers. On one occasion, a clique of high-profile students interrupted a class, asked for Wendy and bullied her in the hall with threats of rape.

6) An administrator did not honor Wendy’s request to see a counselor after she was accosted by the girl whom Wendy had witnessed being assaulted. The girl would not acknowledge being assaulted and denied that Wendy had been assaulted. Only Wendy was sent home.

7) Administrators and teachers never asked why Wendy was often absent in the afternoons (“because I couldn’t take it anymore”), even when they had seen her earlier in the day. One of Wendy’s parents usually came to the office while she signed out, in full view of a principal.

8) The bus driver continued to drive his school route for several weeks after the complaint.

The inaction of the counselor Wendy consulted was also pertinent. Wendy’s well-being was at issue, and an alleged sexual abuser/harasser was under investigation prior to the first trial.

1) The counselor did not intervene with the bullies/harassers (e.g., talking with them individually) and was not active on behalf of a student in crisis, especially in a complex situation that involved threats and a distressed target.

2) When Wendy wanted to talk with the counselor after being accosted (“I’d done the right thing and gone to him”), he did not advocate for her when the principal sent her home.

3) Unlike her sister’s counselor, who appropriately called Wendy’s mother, Wendy’s counselor listened during their several meetings after the retaliation began (“I was often red-faced and crying”), but did not validate feelings or speak of reporting the situation to administrators. The collaborative aspect of addressing serious problems was missing.

4) The counselor did not contact child protective services or discuss that possibility with administrators. The situation involved a school employee with responsibilities for minors (“full power,” according to the student handbook), alleged sexual harassment of a student and implied danger for other students.

Actions: The superintendent was not receptive to Wendy’s parents’ complaint and was not respectful when they initially met with him. Administrator actions suggested a toxic school culture that gave permission to school personnel to treat Wendy and the situation inappropriately.

1) After Wendy’s mother complained about the incident in which harassers/bullies asked that Wendy come into the hallway, the teacher who had deferred to them said to Wendy, “I can no longer trust you.” The implicit school-culture message was that students should not tell parents about distressing incidents.

2) Wendy’s mother learned that one junior high teacher had commented to a neighbor that “[the bus driver] always liked the young girls. … I thought it was consensual.” This indicated that at least one teacher was aware of the bus driver’s behavior and normalized it.

3) In class, a teacher compared “the bus driver thing to the McDonald’s hot-coffee case.”

Second opinion

The second opinion was that Wendy suffered long-lasting psychological injury — PTSD, depression and developmental stuckness — as a result of the school district’s failure to protect her.

Scholars have theorized that bullying inherently involves a power differential. The bully or someone with more power than the bully is responsible for stopping bullying, not the person with relatively little power. Wendy said the bus driver had “total control.” She said, “I tried to sit in back. If called to the front … I tried to laugh it off, told myself that I was just being oversensitive.”

Wendy’s behaviors make sense in that context. In addition, many adolescents do not report harassment because much is at stake, and they are not likely to know how to handle that level of embarrassment, especially in front of peers. The lack of a supportive and protective response from school administrators during the bullying had an impact on Wendy’s well-being and development.

Emotional development: Stuck in sadness, anger. With her experiences invalidated, Wendy said, “I analyzed myself to death.” Reflecting feelings of hopelessness, she said, “I feel like it’s never going to end. Why can’t I be done with this?” She was “nervous about the future,” asking, “Will I ever be able to move on?”

I concluded that her symptoms of depression did not reflect a neurological predisposition: “Other than this, nothing in my life could be called ‘unhappy’ — boyfriend, family.” All of her sad language was related to the situation with the bus driver and the consequent bullying. She felt deep anger about the situation being “pushed aside” even by people who were supportive in public. When asked to elaborate on her statement about “the system,” she referred to the school failing her and the bus driver being acquitted. She then said, “I can understand why people … seek violence instead of authority.” 

PTSD: Stuck in reactivity. Wendy described symptoms associated with PTSD in my study of trauma: hypervigilance; extreme, confusing emotions; and high reactivity to contextual reminders. She was “afraid I’ll run into the principal at a public event.” She was “terrified” when she saw the bus driver in the lobby at her worksite: “I wanted to hide in the back.” When seeing a school bus, “my hands become sweaty.”

Social development: Stuck in not trusting. Workplace relationships and friendships had been affected. In the past, she had “friends all over the place.” Now it was “hard to let people get close.”

Physical/sexual development: Uncomfortable, self-conscious. Wendy’s responses to my questions about physical and sexual development fit the literature about sexual abuse: “My body image was fine. … I wore anything, happy with myself.” Now there was doubt: “Maybe I let too much show.” She said she currently wore T-shirts and jeans with “nothing showing.” She worried, “Will they see me as provocative?” The bus driver’s comments had led to reactivity to even playful sexual comments, which affected her relationship with her boyfriend: “I’m still uncomfortable with sexuality.”

Career development: Stuck. This former honor student said her vision of her future was “absent.” When I asked where she might be now without this experience, she said, “I’d be a teacher.” About higher education, she said, flatly, “I thought about college, but I don’t know what I could do forever [as a job] to make me happy.”

Outcome and implications

After the attorney studied the affidavit, we had two conversations. Eventually, he reported that the school district had refused to settle out of court and that the defense would probably want a deposition from me. However, three months later, he sent news that the case had been resolved. The terms would remain confidential, but he added, “I do believe this case will do some good down the road for similarly situated students.” He said I could reference the case in the future, and he approved the manuscript for this article. He indicated that he had learned from me.

Wendy’s parents’ persistence and the attorney’s investment and instincts about school-system culpability were advantageous. During several years of struggle, Wendy and her parents demonstrated courage, first at school and then during two court cases. This case is a reminder to counselors and counselor educators of the potential impact of receptivity and nonreceptivity of school personnel to frustrated parents and distressed students. It also underscores the potential impact of adult and peer aggression on development.

I encouraged the attorney, when a trial was expected, to incorporate the concept of school culture, not just climate, into his argument. Cultures have norms, protocols, actual and de facto leaders, and implicit and explicit rules. Behaviors at many levels here reflected well-established constraints, permissions and toxicity. Wendy’s experiences in her new school were in stark contrast to those in the school she had left.

Counselor educators can raise awareness in their teaching that institutional cultures differ, reflect leadership and affect students’ and clients’ well-being. A school counselor’s actions and inaction can affect school culture just as any other school leader’s behavior can. Counselors elsewhere can similarly contribute to and be affected by institutional culture.

More situations such as Wendy’s are likely to generate court cases. State laws now define bullying and require school districts to address bullying behavior, giving children and their parents leverage for complaints. However, counseling professionals’ knowledge and experience, especially related to development, ethical behavior and systems, can be applied beyond bullying cases. Their expertise is potentially valuable across a wide range of cases with similar overtones.

I am now an expert witness for the second time, for another case involving bullying. Regardless of whether it goes to trial, I am reminded that counselors and counselor educators can indeed be expert witnesses. I believe that discussing such court involvement during counselor preparation can help counseling professionals be confident in that role if asked, and I hope that first-person accounts such as this one might help counselors embrace the process.

 

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Jean Peterson, professor emerita at Purdue University, focused most of her clinical work and research on the social and emotional development of gifted youth, with special interest in those not fitting common stereotypes. She received 10 national awards related to research and 12 at Purdue for teaching, research or service. Among her several books is Talk With Teens About What Matters to Them. Contact her at jeanp@purdue.edu.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Related reading, from the Counseling Today archives:

 

 

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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.

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.

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