Monthly Archives: August 2014

What counselors need to know about schizophrenia

By Bethany Bray August 22, 2014

The adjective “schizophrenic” needs to be removed from counselors’ vocabulary, says Elizabeth Prosek, a counselor and assistant professor at the University of North Texas (UNT).

Schizophrenia has a great deal of stigma and negative connotations associated with it, and referring to clients in the first person can lessen these, she says.

“I encourage counselors to advocate for what clients with schizophrenia can do rather than [focusing on] the limitations of experiencing psychosis,” says Prosek, who has counseled clients with severe mental health disorders and served on a support team for individuals with schizophrenia living independently. “I once heard someone discuss the ‘aggressive nature’ of those diagnosed with schizophrenia. I could not help but wonder where that perception evolved. In my experience, clients did not demonstrate aggressive behavior or language.”

Counselors, as part of a multidisciplinary treatment team of helping professionals, can play a critical role in the lives of people diagnosed with schizophrenia, say Prosek and Kara Hurt, a puzzlelicensed professional counselor who works with clients with schizophrenia at an inpatient psychiatric hospital.

Prosek and Hurt, who is also a doctoral student at UNT, recently collaborated to write a practice brief on schizophrenia for the American Counseling Association’s Center for Counseling Practice, Policy and Research (see sidebar below).

In the brief, the duo describes schizophrenia as a lifelong illness characterized by negative symptoms, including “delusions, hallucinations (most commonly auditory), disorganized thinking or speech and disorganized or abnormal motor behavior.” The estimated prevalence rate for schizophrenia is 1 percent of the population in Western, developed countries.

For counselors, empathy should play a big part in therapy – from knowing the many side effects of schizophrenia medications to fully understanding what it is like to live with hallucinations and psychosis, say Prosek and Hurt. Special training and workshops can help counselors understand the nuances of the disorder, as can materials from mental health agencies (see “for more information” below).

Prosek once attended a seminar at which participants sat through the experience – virtually – of living with hallucinations, experiencing paranoia and hearing voices intertwined with the dialogue of another person.

Prosek and Hurt led a course this past year in which they showed videos of clients with schizophrenia explaining their own experiences.

“When the students in the class debriefed after the video, many confirmed that hearing firsthand from a client decreased their misperceptions about the disorder,” says Prosek. “Watching a video of a client with schizophrenia who was articulate and successful in a career reduced stigma of the disorder. Also, I noticed that when person-first language is used when discussing clients with schizophrenia [as opposed to using the term “schizophrenic”], negative connotations are immediately lessened.”

 

What do counselors need to know about schizophrenia?

Elizabeth Prosek: Living with psychosis can be scary and challenging. When working with those diagnosed with schizophrenia, demonstrating empathic concern is essential to build a therapeutic relationship. In my experience, clients appreciated my willingness to embrace their perspective of psychosis. I think all of the clients I worked with experienced their psychosis uniquely, and it was imperative that I understood their lived experience.

Kara Hurt: Schizophrenia affects the client’s support system, not just the client. In my experience, it is just as important to provide counseling and support to family members and loved ones of people diagnosed with schizophrenia as it is to provide support and counseling to clients with schizophrenia. All of us counselors can help provide services in some way that help clients diagnosed with schizophrenia and those that love them.

EP: Counselors may provide family members and friends with psychoeducation on the symptoms and treatment options for schizophrenia. Furthermore, counselors may assist family members and friends to build empathy for the experiences of those diagnosed with schizophrenia. There are support groups for family members through the National Alliance on Mental Illness (NAMI). Find a local NAMI support group through nami.org.

For those clients who do not have a familial support system, encouraging the development of a community support network may be essential for the social and emotional well-being of clients diagnosed with schizophrenia. Regardless of diagnosis, humans in general seek “belongingness” in their community, and those diagnosed with schizophrenia are no different.

 

What advice would you give about working with clients diagnosed with schizophrenia?

EP: Recognizing strengths can be a great first step to creating an appropriate treatment plan. Several of the clients I counseled had creative interests, such as art and music, and we developed interventions to promote participation in those activities.

Also, I recommend communication with all professionals working with the client. In my experience, collaborating with the client’s psychiatrist and case manager allowed for a holistic approach when addressing current therapeutic needs. Having a multidisciplinary team also allows for clients to more easily transition in and out of inpatient psychiatric hospitalization when necessary. With the appropriate releases of information, all professionals involved can be aware of how the client’s psychosis presented, any medication changes and any changes in treatment recommendations after an inpatient hospitalization stay.

It did not take long after beginning my work with clients diagnosed with schizophrenia for me to recognize the need for socialization. Several of my clients lived in isolation but longed for social relationships. In collaboration with case managers, I organized social outings for clients, which allowed for a more genuine community-living experience. There are several community resources for clients diagnosed with serious mental health disorders, such as supported-work programs. Having knowledge of such programs in the community will serve as great referral sources for clients diagnosed with schizophrenia.

 

With what other types of issues can clients diagnosed with schizophrenia present?

KH: One of the presenting issues that I had not expected when I started working with clients diagnosed with schizophrenia was substance abuse. One client in particular stands out in my mind because of the extent of his illicit drug use, which worsened his paranoia and other delusions. When working with clients with schizophrenia, you may need to reconsider your assumptions to appreciate that these clients have many of the same kinds of problems as other clients.

EP: I agree. Substance misuse was prevalent among the clients diagnosed with schizophrenia that I worked with as well. I also observed many secondary diagnoses, including anxiety and depression. I connect the anxiety and depressive symptoms back to the potential isolation clients experienced. Furthermore, it seems to me hearing voices and feeling out of touch from reality would lead to feelings of anxiety. Helping my clients accurately explain symptoms to their psychiatrists allowed for more precise medication prescriptions.

 

What are some common misperceptions about schizophrenia?

EP: One of the common misperceptions I hear frequently when describing a client with schizophrenia is the term “medication noncompliance.” I advocate for this phrase to be removed from counselor language. From my observations, when clients did not take medications regularly or as prescribed, it was not with intentional noncompliance, but rather there was confusion when medication regimens became complex or changed with frequency. Moreover, several antipsychotic medications have uncomfortable side effects. On a bad day, when a client is not feeling well, he or she might not feel inclined to perpetuate the experience by taking medications that may worsen physical symptoms. In counseling sessions, taking time to hear clients’ concerns or complaints about side effects may help clients feel validated in their experience.

 

What challenges do counselors face in this area?

EP: I think there may be a perception that clients with schizophrenia only need a case manager and psychiatrist. From my perspective, counselors can play a vital role in the treatment team. Never underestimate the power of a space in which a client’s experience is heard and valued.

KH: I think it is absolutely critical to have good supervision when working with a client diagnosed with schizophrenia. I have felt frustrated with my perceptions of clients’ lack of progress or insight, but with supportive supervision, I have been able to be more flexible with my therapeutic expectations and shift my perspective to be a better counselor for my clients. I cannot underestimate the value of good supervision. It can help you gain awareness of potential burnout and the need for regular self-care.

EP: Supervision is helpful. I often felt frustrated with the mental health care system and how clients with schizophrenia became victims of gaps in continuity of care. I agree with Kara that there is a greater potential for burnout when working with clients in and out of crisis.

Another challenge for counselors might be understanding the differences in antipsychotic medications most commonly prescribed for clients with schizophrenia. Actually, Kara introduced me to an app (named Epocrates) that provides names, descriptions and side effects for medications. I remember when I first started working with this population, I had a hard time differentiating the medications the clients were prescribed. There are several research studies published outlining effectiveness and common side effects of antipsychotic medications which may be helpful to read.

Going back to one of Kara’s original statements about the importance of family supports, it may be challenging to help family understand the experience of schizophrenia. Counselors can serve as a good source of information to help educate and support family members. Consequently, family members can better support the client diagnosed with schizophrenia.

 

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For more information

 

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ACA Center for Counseling Practice, Policy and Research practice briefs

Prosek and Hurt’s information sheet on schizophrenia is one of 30 practice briefs available to American Counseling Association members through the Center for Counseling Practice, Policy and Research.

The briefs, which range from working with victims of domestic violence to animal-assisted therapy to posttraumatic stress disorder, are written by ACA members who are experts on that particular topic. New practice briefs are being added regularly.

The practice briefs are designed to be practical, evidence-based resources for ACA members, says Victoria Kress, executive editor of the ACA center’s practice briefs project and a professor at Youngstown State University in Ohio.

Counselors can use the practice briefs as a refresher on topics they may not encounter very often, such as schizophrenia, or as a jumping-off point for further research. Each brief contains links to in-depth sources and data on a topic, as well as therapy models and other tools.

Kress says each practice brief is written and edited to be practical and succinct, with focused bursts of information on topics that counselors in all works settings may encounter, from divorce and autism to perfectionism and suicide prevention.

The plan is to post 15 to 20 new briefs each year, Kress says, including on each of the new disorders added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Kress began soliciting practice briefs from ACA members, then editing and posting the briefs on the ACA website, close to two years ago. The idea grew out of ACA past president Bradley Erford’s focus on counselor use of evidence-based practices, Kress says.

“Counselors don’t always have access to, or the time to read, journal articles,” she says. “We wanted to provide an outlet for ACA members to sit down and get a quick overview. … It was really born out of this idea that counselors should be using evidence-based practices. We know that counselors are busy and have competing demands. … The ultimate idea is that it will improve their practice. It’s better for their clients and the profession.”

 

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

 

Prepping for the new SAT

By Lynne Shallcross August 21, 2014

Earlier this year, College Board President and CEO David Coleman faulted his own company’s test, the SAT, and its main competitor, the ACT, for being “disconnected from the work of our SAT-Smallhigh schools.” In an effort to address that disconnect, among other goals, the College Board announced it would be revamping the SAT, with a new version debuting in spring 2016.

Calling Coleman’s comment a “brave and honest assessment,” Jasmine Mcleod says she hopes the changes will address some of the SAT’s historical drawbacks. “What the College Board was doing was not working, and that was reflected in the fact that a lot of school systems at the secondary level, as well as the postsecondary level, were moving toward the ACT. So, they had to look at how they were going to meet the need, and I do believe the amendments made will benefit students,” says Mcleod, a scholar-in-residence at the American Counseling Association who also served on ACA’s former School Counseling Task Force.

High school students will be pleased to hear they can shred their flashcards with words such as abjure, inchoate and pulchritude because obscure vocabulary words will be absent from the new SAT. Gone also will be the previous penalty for guessing, meaning points will no longer be deducted for wrong answers. 

The revised SAT will revert back to the old 1,600-point scoring scale (a “perfect” score on the current exam is 2,400). In addition, the essay portion will be optional. The exam will continue to be offered on paper, but it will also be available online.

And in an effort to make prepping for the exam a bit more equitable, the College Board is partnering with Khan Academy to create free preparation materials that will be available online. Students from low-income backgrounds will also continue to be granted fee waivers, and on its website, the College Board says that it is “working with higher education institutions to ensure that every single income-eligible student who takes the SAT can apply to four colleges for free.”

Lynn Linde, a past president of ACA and the director of clinical experiences in the school counseling program at Loyola University Maryland, calls the elimination of the penalty for guessing at correct answers a “friendlier thing for test takers.” She also notes that Coleman, who joined the College Board as its president in 2012, was part of the group that created the Common Core standards. Not surprisingly, some of the changes to the SAT are aligned with the Common Core, which “makes absolute sense,” says Linde. The Common Core is a set of national educational standards for K-12 students in English and math that dictate (not without some controversy) what students need to know by the end of each grade level.

At Lincoln Northeast High School in Lincoln, Nebraska, all high school juniors take the ACT. Only 25 to 30 students each year — out of a class size of more than 300 — take the SAT. Part of the reason for Lincoln Northeast’s low SAT usage rate has to do with geography. Historically, the ACT has been dominant in the Midwest. The other part of the reason is that the high school is part of a pilot program in Nebraska to use the ACT as the state’s test for high school juniors, meaning all juniors take the exam for free. The SAT, on the other hand, is offered at only one public high school in Lincoln.

But the ACT has also gained ground nationally since the last SAT revision almost a decade ago. A recent analysis by The Washington Post found that when comparing the high school classes of 2013 and 2006, the number of students taking the SAT had dropped in 29 of the 50 states. Usage of the ACT fell in only three states during that time. The ACT also beat the SAT in total usage among students in the high school class of 2012, according to the newspaper.

Ruth E. Lohmeyer, the counseling center team leader at Lincoln Northeast High School, says that in her opinion, the ACT is a more straightforward exam — more “common sense” — than the SAT. In addition, she says, the ACT has offered a more accurate picture of college readiness for the students who take it.

However, Lohmeyer, who also facilitates the American School Counselor Association High School Professional Interest Network, has high hopes that the changes coming to the SAT will have a positive impact. She anticipates that at her school, these changes will lead to more students choosing to take both the ACT and the SAT.

In the past, Lohmeyer says, the perception among students was that the SAT was only for their peers who were the very best test takers, voracious readers or headed to Ivy League schools. She predicts a greater number of her students will now feel more confident and consider taking the SAT due to some of the revisions being made to the test.

Target of criticism

One of the primary criticisms of the SAT over the years has been the correlation between students’ scores and their socioeconomic status. Students from more affluent families and who attend schools in which there is an emphasis on college preparation and honors-level classes typically fare better on the SAT, says Linde, who served as the chair of the former ACA School Counseling Task Force.

“That’s not to say that every poor student doesn’t do as well on the SAT,” Linde says, “but there are years of evidence that students from inner-city schools, for example, don’t do as well on the SAT as students from their suburban counterparts.”

Another major criticism revolves around whether SAT scores offer accurate insight into a student’s future success at college. “The research has shown that SAT scores are not a good predictor, that GPA is in fact the better predictor of student success,” Linde says. “That’s why there’s been such a movement … [It’s] not a groundswell, but you’re beginning to see more colleges that are not requiring either the SAT or the ACT or are making it optional for students.”

Loyola University Maryland, where Linde works, is one of those universities that has made SAT and ACT scores optional. Linde says the preliminary data since the change was made in 2010 at the universityindicate almost no difference in achievement between students who were admitted when the entrance exams were required and those who were admitted when the exams became optional.

Whether a high SAT score predicts success in college or instead reflects a student who could simply navigate the exam successfully is a fair question, Mcleod says. “You have students who are great students, who have very high GPAs, [who] take Advanced Placement courses, but they’re just not good test takers,” she says. 

On the other hand, some teenagers aren’t strong students but have families that can afford access to expensive preparation courses for them, Mcleod says. “It’s not so much that they’ve studied more or that they know more,” she says. “Rather, their test score is a result of them learning how to navigate the test.”

Mcleod, who has worked in Baltimore City and Baltimore County schools in Maryland, says the cost of the SAT exam itself and the cost of preparation courses that help enable students to excel on the exam have presented significant barriers to students from lower socioeconomic backgrounds. Mcleod says many school systems will pay for the cost of the SAT for these students, but she isn’t aware of any school that could afford to pay for exam prep courses for all of its students. “So [the College Board’s] partnership with Khan Academy is very exciting. We’ve yet to see the quality of the program … but the access to affordable test prep courses was a huge disparity.”

Transportation is another potential hurdle to students from less affluent communities. Students in the suburbs may not have to think twice about getting to an exam location because their parents can drive them or because they have their own cars, Mcleod says, but students in urban areas may need to plan a lengthy commute on public transportation to get to an SAT test site.

And as Mcleod points out, the stakes are high. College entrance exams such as the SAT represent access points for college-bound students. In many instances, scholarships and grants can be attached to how well students perform on the test. This means that how a student does on the SAT on a given Saturday morning can determine if he or she will go to a two-year college, a four-year college or perhaps none at all.

Still, Mcleod doesn’t believe criticism should be heaped onto the back of the College Board — especially in isolation. “I know the SAT has received its fair share of skepticism, but I’m not so sure that it can be held solely responsible for educational inequities,” she says. “There are disparities that occur way before the SAT is taken that influence a student’s readiness to perform on the SAT or any other standardized test for college access.”

Getting prepared

Although the redesigned SAT isn’t due out for another year and a half, Mcleod says the time for school counselors to start understanding the changes is now. High school counselors in particular need to familiarize themselves with the new design and the skills required to navigate and perform well on the test so they can pass that information along to students and their families, Mcleod says.

School counselors must also know how to interpret student performance outcomes and dig into the data of the results, Mcleod says. Valuable information is contained within the scores that students get back, she says, and counselors should be able to disaggregate those scores and explain them clearly to students and their families. “If used properly, these standardized tests can be used to show students and parents how to navigate toward a college or career goal,” Mcleod says. “But the first step is [school counselors] being familiar and comfortable with the data.”

School counselors also need to think through some of the choices that will be presented with the revised version of the SAT, Linde says, including the option of taking the exam online instead of on paper and whether students should choose to do the optional essay. “Counselors will have to understand all those ramifications,” she says.

For example, Linde anticipates that many universities may not require the essay and may not look at it even if one is submitted. So unless the college or university a student wants to attend requires the essay, there may be no clear advantage to doing that portion of the SAT, she says.

Where should high school counselors go to start educating themselves on changes to the SAT? Mcleod recommends visiting the College Board website (collegeboard.org/delivering-opportunity/sat/redesign) and signing up to receive announcements and updates. School counselors should familiarize themselves with the tools and information available there, she says. As the time to unveil the new exam gets closer, the College Board will be releasing more information, and counselors need to know where and how to receive it, she adds.

Mcleod also suggests that high school counselors visit Khan Academy’s website (khanacademy.org) to learn about the free SAT test preparation materials and how students can take advantage of them.

“There’s really a lot of professional development that is required to bring counselors up to speed every time there’s a change because they don’t want to give students and parents inaccurate information,” Linde says. “I think that’s always everybody’s fear when the sweeping changes come in: ‘Do I really understand what is going on now so I can give accurate information to my students and their families?’”

Lohmeyer hopes the College Board will make it easy for high school counselors to get clear and detailed information about the changes coming to the SAT. Both the College Board and ACT Inc. hold annual events in Omaha, Nebraska, she says, but they cost money to attend and necessitate taking a whole day away from school. “A lot of counselors say, ‘I can’t get out of the office for a whole day and pay,’” Lohmeyer says. However, she says, school counselors might be able to take part in a free webinar on changes to the SAT. Anything the College Board can put on its website that is student-friendly and counselor-friendly would be helpful, she says.

Time will tell

As 2016 inches closer, questions about the revised SAT are likely to linger in the minds of students, parents and school counselors alike. Will the changes coming to the SAT represent a net positive for test takers? Will the revised test do a better job of creating a level playing field for students of all socioeconomic backgrounds? Will the exam be a more accurate indicator of a student’s college readiness?

Linde believes it will be a few years before anyone truly knows the answers to such questions. “[We’ll need to be] pretty far down the road before people are going to have good answers,” she says.

Regardless of the results of the revised SAT, Mcleod reminds counselors that it is only one test and one piece of the puzzle that contributes to the total picture of each individual student. “My belief is that no one thing can predict student success. In education, naturally, we want to be able to identify that one tangible, magical quality that students have that will predict whether or not they’ll be successful in this pathway or that pathway so that we can perfect it. Well, it doesn’t work that way because students are individuals — they’re unique.”

As her comments suggest, Mcleod doesn’t believe in the existence of one determining factor when assessing a student’s capability. Therefore, she applauds colleges and universities that try to get a holistic picture of each individual student, with SAT scores representing only one element of that picture.

Although some universities, such as Linde’s, have chosen to make entrance exams such as the SAT optional, those schools are still in the minority. For a wide swath of students across the country, their postsecondary goals will still hinge on understanding how to navigate the revised SAT.

Knowing that school counselors will be called on to help students and parents prepare for the new version of the test leads Mcleod to a larger point about the role of school counselors in today’s high schools.

“I encourage schools and school systems to look at their counselor-to-student ratios,” she says. “When you have a counselor-to-student ratio of 1 to 1,000 students, it makes it very difficult for a counselor to give [a high] level of guidance and counseling to individual students. And when we have systems that are set up that way, the person that loses out the most is the student.”

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Lynne Shallcross is a former senior writer and associate editor for Counseling Today. She is currently pursuing her master’s degree in journalism at the University of California, Berkeley. Contact her at LShallcross@gmail.com.

Letters to the editor: ct@counseling.org

 

Group process from a diversity lens: Racists are just ignorant

By Lee Mun Wah August 20, 2014

The following vignette comes from an actual situation that occurred in one of my diversity workshops. In addition, I am including my thoughts/rationale and the interventions I used during the situation, questions for other group facilitators to consider, possible group/dyad exercises and a summary that helps to place the event in a larger societal context.

All the vignettes in this series are adapted from my diversity training manual, The Art of Mindful Facilitation, although the manual is not necessarily meant to be a faithful adaptation of the video clip that accompanies each vignette. In each article in this series, I am also including examples of the presenting workshop issues related to the vignette — in this month’s case, the issues of blame, hurt and anger.

This is an interactive process, so I ask that readers follow the steps below in their suggested order.

1) Watch the short video clip below:

2) Return to this article and read the vignette.

3) Answer the practice process questions following the vignette description.

4) Before reading further, write your own intervention.

5) After writing your intervention, read the remainder of the article, which includes my thoughts, the intervention I used and a summary.

For an introduction to this series, read “Group process from a diversity lens” in the April issue of Counseling Today.

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In this instance, I was working with the Army and I had just shown The Color of Fear, my diversity training film about the state of race relations in America as seen through the eyes of eight men of Asian, European, Latino and African descent.

John, a Mexican American sergeant, stood up and shared a story about the racism his daughters racismhad experienced in college. He then explained how he told his two daughters to deal with racism. “I just tell my girls, ‘No. 1: When you’re dealing with a racist, you’re dealing with an ignorant person. No. 2: You walk away. No. 3: You’re there to get your education, so get your education and then we will show them who is ignorant and who is not.’”

Everyone laughed, and John got a standing ovation. He quickly sat down.

Practice process questions for the facilitator

1) What came up for you when watching the video clip and reading this vignette?

2) What are the key words to focus in on?

3) What are some of John’s issues?

4) What is your reaction to the group? Why?

5) What is hard about this vignette?

6) Who would you work with first? Why?

7) What does John need?

8) What is familiar about John’s attitude and behavior?

9) How would you incorporate the group into your intervention?

10) What is John not saying?

My thoughts

John struck me as a very confident and proud Mexican American man. He had learned how to get applause from his white counterparts by simply telling them that nothing could hurt him or his daughters. His daughters were going to be successful, educationally and financially, no matter what was done to them. The enemy was “over there,” while John and his daughters were “over here.”

This type of appeasement and assimilation is so familiar to me. Yet each time that it happens, I am amazed at how white folks unconsciously perpetuate this type of exchange. The advantage of an exchange such as this is that it gets white folks off the hook from having to take any action or to reflect on their own participation and responsibility in promoting racism. Everyone leaves safely and cleanly. Don’t ask, don’t tell.

The real work here was to find a way to have John share what he was really feeling, while simultaneously opening the eyes of the white audience members to their collusion in John staying silent. I also wanted to get to John’s life as a Mexican American, both as a boy growing up and then serving in the armed forces. Both would shed some light on his emotional and professional development and assimilation. Perhaps I needed to find an opening that would connect the two of us. Upon reflection, we had more in common than I originally thought. 

My intervention

I touched John’s shoulder and told him that as a father myself, I wondered what it must be like for him to work so hard to make sure his daughters were going to have a better world than he had, only to find out that no matter how smart, how responsible or how nice they were, they still ended up being victims of racism.

John broke down and cried. He talked about how hard it was to discover that the racism he had faced as a child was still alive and now confronting his daughters.

I then asked John what it was like in the U.S. armed forces as a Mexican American man. He shook his head and said, “You have no idea what it has been like all these years. You just come to accept it and hope that it goes away, but it never does. You try to not let it get you down. But it hasn’t been easy.”

Group/dyad process questions

1) What came up for you while listening to John?

2) Why do you think John kept his silence?

3) What’s familiar to you about John’s experience?

4) How many of you are parents? How many of you have had to tell your children that no matter what they achieve or who they become professionally, they can become a victim of racism at any given moment?

5) At what age did you experience racism? What was it like for you?

6) What did you learn about today? How did it move you?

7) How many of you were told by your parents about the racism you might face? What was it like for you being told? How did it affect you?

Workshop issues 

Blame

The definition of blame is assigning responsibility for a fault or wrong. Those who are heavily into blaming often feel powerless and/or overwhelmed by some perceived wrong. As a consequence, something in their lives remains unfinished and continues to wound and stimulate them.

Inquire whether they are blaming an individual, a group or an institution. The perpetrator or institution may be unavailable for dialogue, which brings about feelings of depression and hopelessness for the person or persons who were wronged.

Those who are blaming are often unable to be direct with their own feelings. Hence, they are often left with unfinished feelings that foster resentment and anguish.

What kinds of “rewards” do they get from being victimized? On the other side, what is lost from their lives when they are unable to feel relaxed and safe?

Suggested interventions

1) Through the use of role-play, have the participant confront his or her perpetrator(s) by choosing audience members who most closely represent the perpetrator(s).

2) Have the participant share what he or she needs to heal.

3) Ask the participant what effect this experience has had on his or her life. What has the participant “lost”?

4) Ask what part of the perpetrator(s) is also a part of the participant.

5) Does the participant want a solution?

6) Explore the kinds of feelings the participant is withholding.

7) What is the participant’s individual, group or family history regarding this issue?

Hurt

The definition of hurt is to feel pain or distress. Being hurtful is to cause distress to someone’s feelings.

Hurt is usually a painful experience that is unfinished. It takes energy to suppress one’s pain and to move on. However, that pain usually goes somewhere and can be triggered at any time by some familiar stimulus.

One of the manifestations of having been hurt is the fear of conflict. Another is the fear of being hurt and/or of hurting others.

Most participants deal with the present tense of a person’s hurt rather than exploring the root of the individual’s pain.

Suggested interventions

Participants who have been hurt often need to retell their stories and, in the process, be believed, understood and empathetically embraced.

Participants need to go back to the “scene of the crime,” expressing what happened and how it affected them, both then and now.

When hurt is unacknowledged and invalidated, it becomes anger. Allow the hurt to have a safe place to be expressed.

If participants have a set script to describe their hurt, ask them what is familiar about this and what the “rewards” are for playing out this scenario once more.

Use audience responses — repeating what audience members have heard and using the participant’s name — to help the participant feel seen and heard.

If participants are unable or unwilling to talk about their hurt, have the audience notice what happens when one feels unheard and unseen. The trauma can cause people to withdraw or to blame themselves to keep from being hurt again.

To help someone return to the scene of the crime, try to reconstruct the period of time and surroundings as closely as possible. A good storyteller uses key words that the participant used. This creates an “emotional ambience” that will translate into a trusting connection with the participant.

Often, it is easier for participants to share what they don’t need before identifying what they truly need to heal.

Anger

Anger is one of those emotions that people fear. The dictionary defines anger as a strong feeling of displeasure or hostility. Buddhists believe that to have no enemies is to take no prisoners, thereby de-escalating the crisis. Anger can be a catalyst for change and/or a means of destruction.

The Chinese believe that a crisis represents both danger and opportunity. I seldom hear of anger as an intimate part of relationships or an important opportunity for growth. And yet, it is an inevitable part of all healthy relationships, as is the process of reaching reconciliation. I view anger as an opportunity and as a window into many truths.

One of the prerequisites for helping group participants deal with anger is learning how it is dealt with in your own life. That exploration and understanding will be invaluable to your helping others. You will only go as far as you have learned. Understanding our own histories with anger provides us with an opportunity to grow and heal.

Often, when anger is expressed, it is because some hurt has not been acknowledged. Unacknowledged, that hurt becomes anger. Getting to the hurt is the goal of working with someone who is angry. The rite of passage into the hurt is to first listen and acknowledge the anger.

Someone once said that to tame a wild bull is to give it a wider field. We often expend too much energy and time trying to manage and prevent folks from expressing their anger. But anger always goes someplace. Whether it is into the body or through being irritable, violent, abusive, uncooperative or disinterested, it always recreates itself somewhere else — sometimes to the point of causing physical harm to one’s health.

Anger is a scary emotion to many people. Acknowledge this aspect with your audience members because they often have stories that will justify their struggles and resistance. Hearing and empathizing with those stories collectively helps to dispel the myth that they are alone and isolated.

Use the anger in the room as a catalyst to stimulate more discussion. It will lead to other emotions and stories. Transformation often requires a crisis.

Suggested interventions

1) Have participants fully express their anger verbally and emotionally so that their words and bodies match their anger. Then ask the audience what it observed.

2) If possible, have participants identify whom they are angry with or about (without using names or identifiable descriptions).

3) Have participants share what hurt them about the incident.

4) Ask participants what they need and what they don’t need. Invite the group members to be a part of the solution by asking what they noticed.

Group summary

As the facilitator, I presented the following summary to the entire group:

“As you can see from today, one of the hardest things to endure as a person of color is having to live with the reality that you cannot protect your children from racism.

“And for those of you who have never had to tell your children — how lucky you are. I hated telling my son when he was 6 what he would be facing because he was Guatemalan. I had to tell him because he had already experienced racism at the age of 3.

“I want you to hear what it has taken for John to get to this room, what he has had to endure. The question is, do you want to know? Do you want to do something about it?”

Martin Luther King Jr. was right. Real peace is not the absence of conflict. It has always been the presence of justice.

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Lee Mun Wah is a Chinese American documentary filmmaker, author, educator, community therapist and diversity trainer. For more information, including a link to his services and trainings, visit the StirFry Seminars & Consulting website at stirfryseminars.com.

Letters to the editorct@counseling.org

The Hope Chest: Unpacking the hurt

By Kim Johancen-Walt August 19, 2014

When I first met Ally, 17, she surveyed the seating arrangement in my office and chose the chair closest to my door. Obviously guarded, she sat with both arms and legs crossed looking at me with green eyes slightly camouflaged by blond wispy bangs. Ally’s mother had been trying to get box_unpackingher to come to therapy in recent months because of Ally’s deepening depression. Her mother believed Ally’s depression was due to an abortion Ally had had several months prior to our first meeting. The mother had only insisted on therapy after reading a journal entry in which Ally had made it clear she was thinking about suicide.

As I began to ask Ally some questions during our initial visit, she stated that she did not need therapy and expressed anger at her mother for forcing her to come to my office. Although Ally knew I was aware of the journal entry and the abortion, I honored her resistance by staying in shallow waters, asking only about things such as hobbies, school and friends. I purposefully avoided the topic of loss. At first she answered questions but became increasingly quiet and then stopped talking all together. Counselors working with teens dread these moments, wondering how we will get through the hour when our young clients refuse to talk to us despite our best efforts to connect, create safety and begin the therapeutic process.

By the time many kids get to my office, they have come to believe that most of the adults in their lives cannot help them. They feel misunderstood, sometimes blamed, and tend to find their own emotion overshadowed by the emotion of others. They are also desperate for relief. I strive to educate these kids about the connections between unresolved grief, loss and suicidal behavior, about how therapy can help them manage pain differently and how to cultivate hope and resiliency along the way.

Sitting in silence, I explained to Ally that I actually did not need to know much about her to know that she was in incredible pain due to her suicidal thoughts. I told her that I knew I was looking at the tip of a very large iceberg. It is important to communicate to kids our knowledge of what may fuel suicide, that we take it seriously but are comfortable talking about it, and that we do not judge them for their thoughts and actions. I told Ally I knew she was doing the best she could to take care of herself as she dealt with unbearable pain.

Not believing that they can (or should) seek support and care from others, many kids come to believe that they must be fully self-reliant. Otherwise, they think they will risk more injury to themselves or become even more burdensome to those around them. Add to this the developmental (and oftentimes skewed) belief about the need to seek independence, and many teens retreat completely into themselves. Affected deeply by the things that happen in their lives, these teens believe they are mainly (if not solely) responsible for their losses, their pain and their inability to cope. Rather than asking for help, many of these teens become increasingly desperate as they find themselves drowning, with little or no ability to swim to the surface.

 

The overflow

When working with suicidal teens, I have found it useful to tell them about the invisible box that we each carry. It is a place where we store the painful events or losses in our lives, packaging them tightly to avoid the feelings associated with those events. Although this process of stuffing may work for a while, over time our boxes can begin to fill up, leaving us little room or tolerance for added stressors. I remember vividly the reaction of one of my 16-year-old male clients who, after I explained the box metaphor, stated, “If that is true, then I have a field of boxes buried in the ground.”

Once full, we find ourselves frantically trying to keep the lid on the box tightly sealed. But regardless of how hard we try, it is at this point of distress that painful content may begin to leak over the sides. When there is no room left in the box, many teens find themselves spilling over into what I term the “Overflow.” Desperate, they may turn to self-injury, substance abuse or suicidal behavior. After using this metaphor to explain the connections between my clients’ feelings and behaviors, most begin to understand the importance of making room so they can stay out of the Overflow. They become primed for therapy and ready to cautiously explore methods of healing and more effective ways of coping.

Although the unpacking is necessary, it is also a tender process. After a few sessions spent building both trust and safety, Ally started discussing the details of the abrupt and painful breakup with her boyfriend that occurred soon after her pregnancy. She cried quietly as she talked about his cruelty, along with how her mother had also abandoned her, “forcing” her to have an abortion and telling her she was irresponsible and an embarrassment to the family.

Ally believed she was fully to blame for the pregnancy, for having disappointed her parents through her reckless behavior and for her boyfriend leaving. Furthermore, she believed that her inability to cope and “just get over it” were signs of a flawed character. She believed she was weak and selfish for having aborted her baby. She continued talking about what happened, looking into the deep well of grief over having lost a child.

Throughout her process, I seized every opportunity to listen, understand and treat her with love and compassion. We discussed how her coping was outstripped trying to deal with complicated grief and that her suicidal feelings were the result of what had happened. In other words, I told her that her depression and increasing suicidal thoughts made sense.

Many of my clients have dealt with multiple losses and are unaware that each new wound can awaken others that are tucked away in dark corners. Overwhelmed with grief, most of these clients do not realize that the only way to make room is to unpack their losses one by one. And, sometimes, one explosion can be followed by several other mini blasts. For example, if our clients are not met with love, support or compassion after the initial bomb goes off, then their injuries can deepen, their framework distorted by multiple losses. They come to expect loss, perhaps blaming themselves and losing hope. Ally not only lost her child, but she also felt abandoned by some of the most important people in her life. She couldn’t stop the bleeding despite her best efforts to avoid stepping on additional land mines.

 

Handle contents with care

When I discuss the box metaphor with teens, I assure them that they are in charge of what content they choose to remove. Not wanting these young clients to feel further overwhelmed, it gift1is critical to move forward at a gentle pace and to focus on the importance of making room rather than what is actually emptied. After explaining the therapeutic process in this way, many kids naturally begin looking at what is taking up the most space in their containers, knowing that the bigger objects are what contribute to their inability to handle added stressors.

We do not want our clients to empty everything at once, and each container must be handled with care. I want kids to know they are in control of their therapy, but I also want them to be aware that the unpacking is necessary if they are going to make room, build tolerance and effectively stay out of the Overflow. Throughout therapy, we assess safety and coping constantly, knowing that without careful attention to the process, speed and wounds touched, we may inadvertently push our young clients closer to the edge rather than away from it. We find ourselves dipping in and out of raw material.

Through our conversations, Ally slowly began building confidence in her ability to handle painful feelings. Gradually, we were ready to invite her mother into session to discuss what had happened. Both women cried together as Ally’s mother discussed feeling deep remorse for how she had handled the situation and for not considering Ally’s feelings surrounding the abortion. Through her own accountability, Ally’s mother opened the door to begin repairing the cherished relationship between mother and daughter. And in addition to cultivating compassion for herself, Ally was able to begin finding compassion for her mother. She came to realize that her mother had also done the best she could at the time and acted in what she believed to be the best interests of her daughter.

Through therapy, we help our young clients to uncover new pathways that were previously out of their view. We celebrate their victories and watch them gain confidence not only in their ability to cope but also in their ability to heal. And as we end therapy, we remain aware that they may have more work to do. Whether they collect new losses over time or whether older losses begin to reemerge, we know that future excavation may be needed — although that process may not happen with us.

We have done our job if we have given our young clients a new framework to work through the inevitable human experience of grief and loss, if we have taught them the importance of seeking help from caring others and if we have helped them learn how to effectively stay out of the Overflow. Through our work, these teens leave therapy with a new definition of healthy independence rather than one that finds them overwhelmed and in dependence. Through our connections with caring others, we are reminded that even in times when things are not OK, we will be OK.

 

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Kim Johancen-Walt writes “The Hope Chest” column exclusively for CT Online. She is a licensed professional counselor with almost 20 years of experience. Her clinical experience includes working as a therapist for La Plata County Human Services, where she helped develop a treatment model for adolescents in Durango, Colorado. She has presented her clinical work at mental health conferences nationally, including at the annual conference for the International Society for the Study of Self-Injury. Additional clinical experience includes a position as assistant training director and senior counselor in the Counseling Department at Fort Lewis College. She currently operates a full-time private practice in Durango. Contact her at johancenwaltks@gmail.com.

 

Read her previous column, “The Hope Chest: The GIFT of therapy,” here:  ct.counseling.org/2014/06/the-hope-chest-the-gift-of-therapy

Connecting with clients

By Laurie Meyers August 18, 2014

Modern counseling models and techniques are as varied and diverse as the counselors and clients who use them. Most counselors have a particular theory, method or school of thought that they embrace, whether it is cognitive behavior therapy, solution-focused therapy, strength-based, holistic health, person-centered, Adlerian or other. Yet all of these approaches and techniques Therapeutic-alliance_brandinghave at least one thing in common — their potential effectiveness is likely to be squelched unless the counselor is successful in building a strong therapeutic alliance with the client.

The crucial nature of the therapeutic alliance is not a new idea. In 1957, Carl Rogers wrote an article in the Journal of Consulting Psychology outlining the factors he considered necessary for achieving constructive personality change through therapy. Four of the six items directly addressed the client-therapist relationship. Rogers asserted that the therapist must:

  • Be genuinely engaged in the therapeutic relationship
  • Have unconditional positive regard for the client
  • Feel empathy for the client 
  • Clearly communicate these attitudes 

In the decades since Rogers’ article was published, many other studies have explored the therapeutic alliance. In 2001, a comprehensive research summary published in the journal Psychotherapy found that a strong therapeutic alliance was more closely correlated with positive client outcomes than any specific treatment interventions.

So, what constitutes a therapeutic alliance?

“Most scholars who write about the therapeutic alliance describe it as a relational factor in counseling that includes three dimensions: goal consensus between counselor and client, collaboration on counseling-related tasks and emotional bonding,” explains American Counseling Association member John Sommers-Flanagan. “The best ways to form and strengthen the alliance are specific counselor behaviors that contribute to those three ‘alliance’ dimensions. Focusing on these dimensions helps grow the therapeutic relationship.”

“For example, goal consensus or agreement involves listening closely to the client’s distress and hopes and then being able to articulate that distress and hope back to your client,” says Sommers-Flanagan, an author and associate professor in the Department of Counselor Education at the University of Montana. “This can happen from any theoretical orientation. For a cognitive behavioral therapist, it could include collaboratively generating a problem list. For a more existentially oriented counselor, it could involve asking the client ‘What do you want?’ and then gently exploring the many nuanced dimensions of how your client answers that question.”

“Collaboration on counseling-related tasks can involve nearly any task that is clearly described and that clients understand as related to their problems or goals,” he continues. “This could involve everything from taking a social history to implementing a progressive muscle relaxation procedure.”

“Emotional bonding between counselor and client is different for every unique counselor and client,” Sommers-Flanagan says. “It might involve compassionate or empathic listening or humor, or just sitting together while the client experiences strong emotions, or giving positive and supportive feedback to clients.”

The power of relationship

Although it may be next to impossible to find a counselor who doesn’t agree that bonding with clients is important, becoming overly reliant on technique and method still poses a common temptation for many professionals.

“Counselors are in love with their techniques and interventions,” ACA member Jeffrey Kottler says ruefully. “We hungrily buy books and attend workshops hoping for the next latest and greatest breakthrough.”

Kottler appreciates what research into evidence-based practices and promising theories can contribute to the counseling profession’s body of knowledge. At the same time, he contends that specific techniques aren’t nearly as important to the therapeutic process as some practitioners might think.

“I can recall few instances, either from research studies or my own practice, in which clients reported that it was some singular technique or intervention that was most helpful to them,” says Kottler, a prolific author, researcher and professor of counseling at California State University, Fullerton. “Instead, they so often say that they felt heard and understood and valued by their counselor. They talk a lot about the power of the relationship.”

“[Obviously] in many cases, clients need a lot more than feeling understood or enjoying the benefits of being in a respectful, facilitative alliance,” he adds. “Yet without the foundation of a constructive relationship, anything else that we do isn’t going to work very well or last very long.”

After all, one key to effectively addressing a client’s issues is to first understand those issues within the context of the client.

“It’s critical for the counselor to learn the client’s worldview in order to enhance cooperation in the counseling process,” says ACA member Jeffrey Guterman. When counselors diagnose the problem and launch into a prescribed method of treatment without first discussing the client’s concerns and goals, they are likely to be met with resistance, explains Guterman, a licensed mental health counselor (LMHC) in Fort Lauderdale, Florida, and the author of Mastering the Art of Solution-Focused Counseling, published by ACA.

It is also difficult to accomplish true change unless the counselor is listening to what the client wants, not what other people think the client needs, says Guterman.

He recalls one client in particular. “I had a case of a 71-year-old man with alcohol abuse who was persistently resisting efforts by several mental health professionals, relatives and friends to get him to go to Alcoholics Anonymous (AA). He had a long history of alcoholism, but all along he insisted he didn’t believe in a higher power. Other professionals said to him, ‘It doesn’t have to be religious; it could be spiritual.’”

Rather than dismissing the man’s objections to AA, Guterman took the time to listen and attempt to understand where he was coming from. The client had previously tried treatment programs that followed the AA model, Guterman says, but he always ended up drinking again. “When he was referred to me, I assessed that he was an atheist and that this was the defining worldview in his life,” Guterman notes. “That was the main barrier to his entering into treatment.”

Guterman referred the client to a program that took a secular approach to treatment rather than asking those in recovery to focus on a higher power. The man felt validated and listened to by Guterman and willingly accepted the referral into treatment.

Guterman says it is not uncommon for people wrestling with alcohol or drug abuse to reject the idea of addiction and thus be unwilling to consider abstinence. Some clients come to treatment seeking only to control their drinking, he says, and under the AA model, these individuals would be considered in denial. Although it might be best for people who struggle with alcohol abuse not to drink at all, Guterman says, if a client isn’t ready to consider that option, he believes it is better for a counselor to address what goal the client is ready to work on, such as controlling alcohol intake. Otherwise, the client may drop out of treatment altogether, which means he or she isn’t getting any help at all. But if a counselor meets the client where he or she is, there is always the possibility of change, Guterman says.

Giving clients room

“It’s a difficult lesson to learn — to allow space for the client to take the session where he or she wants it to go and at the pace he or she feels comfortable with,” says ACA member Olga Gonithellis, an LMHC in New York City. “This requires therapists to challenge their automatic tendency to want to direct the session and [instead] approach certain topics only when the client has opened the door.”

Allowing the client space while simultaneously trying to establish communication, and ultimately an alliance, sometimes requires a bit of creativity and a lot of patience on the part of the counselor, Gonithellis notes.

“An adolescent girl came to see me after her psychiatric hospitalization for suicidal ideation,” she recalls. “For the first three to four sessions, she refused to talk about the incident, made minimal eye contact and played with her cell phone during the session while repeatedly stating that she didn’t need therapy.” 

Initially, Gonithellis alternated between giving the girl space to be silent and validating her emotions, but the client remained distant.

“The next time she came in, I had brought some magazines, glue and scissors,” Gonithellis says. “I told her, ‘I know you don’t want to talk, and I’m OK with that. But instead of just sitting here in silence for the next 45 minutes, maybe we can go through these magazines together and cut out pictures that we like and create a collage. Is this OK with you?’ and she nodded yes. Her affect and energy level changed drastically as she became more present and animated. We spent the session being verbally silent, yet speaking through our selection of images.”

In the next session, the girl made more eye contact and seemed more comfortable. In subsequent sessions, she continued to grow more relaxed and less guarded. “It seems like presenting her with another way of connecting was meaningful and symbolic of being willing to meet her halfway,” Gonithellis says.

For Clayton Martin, meeting clients halfway was a little more complicated, requiring him to stare down hostility and, in some cases, even household implements. Martin, an ACA member, started his career by providing in-home counseling as part of a Medicaid-funded community health program in Fort Lauderdale. His clients were troubled youths who were in counseling only at the insistence of a parent or other authority figure. And these adolescents definitely did not want Martin in their homes. 

“I’ve had young people come at me with a fireplace poker the minute I set foot in the house,” he recounts. “I’ve had children display extreme resistance. I’ve been the eighth counselor to come into the home … where the seven counselors that preceded me just wagged a finger at this kid or were completely out of touch with [the client’s] worldview and just tried to enforce discipline.”

Rather than being intimidated, Martin sought to understand what was behind each client’s bravado and anger. “The first step when you walk into the home and this kid is demonstrating extreme resistance, cussing you out, coming after you or just ignoring you is to just roll with it,” he says. “Accept it, don’t show any fear and don’t show any anger.”

Martin tried to look at the situation from the adolescents’ point of view. “They may have been set up to distrust authority figures or helpers. Instead of letting myself get thrown off by a violent reaction, [I would] accept what they were doing as a natural and understandable personal safeguard,” he says.

When it comes to adolescents, Martin says, counselors cannot fake a sense of acceptance or a willingness to understand their stories. Adolescents know when they are being lied to, he says. “Insincerity is blood in the water to the youth client. They know when someone is being genuine, and they know when someone is not being genuine,” Martin notes.

Retreating into the role of the authority figure or trotting out scripted “advice” is a sure way to lose (or never gain) the trust of these clients, Martin says. “But if you can just stand there and let them blow themselves out like a hurricane, showing no fear, showing acceptance of how they feel, eventually [most of them] will come around,” he says. “They’ll see that you’re not there to wag a finger at them, that you are not going to treat them with kid gloves or from a certain distance because you are frightened of them, and they’ll open up.”

Validation, acceptance and empowerment

Another critical part of getting young clients to open up is making them feel heard and understood, Martin says. “The next part of this process for me is to validate their story. [I’ll say something] like, ‘Hey, it’s obvious that you don’t like me being here. I can’t say I blame you. If some strange guy were to walk into my house who my mom had made show up because I’m not acting right, I wouldn’t want him there either. I’m just wondering whether you can tell me a little bit about some of the counselors you might have seen in the past or the things that led up to your mom thinking I needed to be here.’”  

Validation and acceptance are necessary parts of any therapeutic intervention, regardless of the client population, notes Gonithellis. “Allow room for feedback [and] keep checking in every so often,” she urges. “By making space for clients to give feedback about the counseling process, the therapist shows acceptance of the client’s sincere feelings, good or bad. Simply asking a question such as ‘How are we doing?’ or ‘Are these sessions helpful?’ gives clients the chance to express themselves, while conveying the message that their reactions, positive or negative, will be heard and respected.”

Lauren Ostrowski, a licensed professional counselor and ACA member in Pottstown, Pennsylvania, concurs. “Meet the client where they are,” she says. “This is true even if this means spending five minutes on topics that are important to the client that may not be directly related to the reasons they are coming into counseling.”

Allowing clients to stray from an ordained course to touch on these tangential — yet personally important — matters can help clients feel that the counselor sees them as more than just a set of symptoms or a diagnosis, Ostrowski says. In addition, these tangents often reveal important information about the client and empower them in session, which can further cement the therapeutic alliance, she says.

Enthusiasm for the work can be a boon to the counselor-client relationship as well. “I love working with the troubled youth clientele,” Martin says. “I love working with the kids who are going to come at you with a fireplace poker and cuss you out magnificently on the first session because … if you have good chemistry with these guys and the appropriate background and a fire for working with that clientele, you can do some amazing things with them.”

Hitting roadblocks

But sometimes, despite attempts to offer respect, validation and space, client and counselor still don’t click. Is it time to throw in the towel when both the client and counselor are frustrated?

Not necessarily, says Guterman, who reiterates the importance of first learning the client’s point of view. In such situations, he recommends that counselors again ask themselves if they have made their best effort at thoroughly understanding the client’s worldview.

If that’s not the problem, Guterman suggests evaluating the pace of the counseling sessions’ progress. “Are you pacing with the client? All clients are different, and some clients prefer to go slow,” he says. “You [the counselor] may be solution focused, but if you go too fast, the client who is very problem focused may think that the problem is being stolen away from them.”

Even counselors who have absorbed a client’s worldview may forget that it is the client who ultimately is in charge. The client will define the goals that he or she would like to achieve.

“Let the client determine what is most important,” Ostrowski advises. “Sometimes what seems small to a counselor may be the most crucial element of what is happening in a client’s life right now.”

It may also be helpful, both for strengthening the therapeutic alliance and for therapeutic progress, to shift the perspective periodically, Ostrowski says. Although the client is most likely coming in for counseling because he or she is unhappy or wants to change something, most clients can think of something in their lives that is going well, she says. “Allow for some positive discussion,” Ostrowski suggests. “Thinking of something that is going well … can provide a springboard for discussing strengths that can help with parts of their life that they would like to change.”

Another approach that can benefit the therapeutic alliance is subtly reminding clients that counselors are human too, with lives and interests that extend outside the office, Ostrowski says. For example, briefly talking about a movie that a client has seen recently can be a nonthreatening way to build or strengthen rapport, she notes. Some counselors might balk at engaging in these brief personal interludes, but Ostrowski believes they are helpful in connecting with clients. “Is there really any harm in spending less than a minute to discuss how loud the Fourth of July fireworks were this year?” she asks.

In cases in which a lack of therapeutic alliance exists, it is always tempting to look at the client as the source of the problem, but counselors should also look in the mirror, Guterman says. “We always tell our clients the only one you can change is yourself. This applies to us counselors too,” he asserts. “If we’re not connecting with our clients, what can we do differently?”

Extreme resistance

Guterman acknowledges, however, that it is particularly difficult to connect with clients who have been mandated to counseling. These clients, typically ordered into therapy by the courts because they have a history of being abusive parents or spouses, or because they have problems with anger or substance abuse, simply do not want to be there.

Similar to the approach Martin took with his angry adolescent clients, Guterman finds it best in such cases to get straight to the point. “Usually, the best thing is to join with the client and say, ‘Yeah, I can understand that you don’t want to be here. I wouldn’t either. But since you are here, what do you want to work on?’ … Enhancing cooperation rather than creating resistance is important,” Guterman emphasizes.

Another part of enhancing client cooperation, and thus strengthening the therapeutic alliance, is for counselors to demonstrate knowledge of and respect for diversity and multiculturalism. Possessing an understanding and appreciation of the client’s culture can play an important role in the approach a counselor takes.

For instance, abusive parents who get sent to court-mandated counseling might think there is nothing wrong with hitting their children. This could be because the parents come from a background or culture in which hitting is an acceptable form of punishment or discipline. Regardless of the parents’ reasoning, a counselor is not likely to be able to change that mindset.

“If you say hitting is never necessary, you’re going to get shut down,” Guterman says. “So you ask, ‘What is your goal?’ And often they will say, ‘To get these people off my back.’’

Guterman then summarizes the reality of the situation: If they hit their children again, their children will be taken away from them. This creates an impetus for the parents to let Guterman teach them other ways of disciplining their children.

In certain cases, however, counselors might find that they cannot make the unwilling client willing, despite applying all their skills.

“I’ve been in situations where I’ve exhausted my tool kit,” Martin acknowledges. “The next thing I will do is go to the parent and say, ‘They’re [the child is] not ready for counseling. Maybe they’re ready for a different sort of intervention — a wilderness program or something like that — but they’re not ready for counseling now.’”

Martin then would give the parents his card and invite them to call him if the situation changed. “I make sure that the client is there when I say to them directly, ‘If you change your mind and get to a place where you feel like we can do some work together, please give me a call,’” Martin says.

On occasion, the parents still didn’t want Martin to stop the counseling sessions with their child, so Martin kept going back and doing whatever he could.

“I had a kid who fought with me and ignored me for a year,” he recounts. “We had two conversations that led to some sort of therapeutic benefit, and at a point when he was really acting up and fighting a lot in school, I took this kid on a tour of an alternative school [for troubled children], and that turned out to be therapeutic. He decided he did not want to stay on track to go to the alternative school and made some adjustments to his behavior. Ultimately, that’s what got him out of therapy, because that’s what got him to stop getting into trouble.”

“So,” Martin says, “even if what we would consider counseling wasn’t effective, I was able to do something that produced a positive result for the guy.”

Constantly hitting walls while trying to connect with clients was tough, admits Martin, who eventually left his position as an in-home counselor and is now working with youth at a substance abuse center. But he doesn’t think his efforts were in vain.

“In some way, shape or form, I feel like I’ve connected with everybody, even the folks who have terminated on me or have found therapy to be unsuccessful on the whole,” he says.

Martin credits one of his first mentors with helping him understand that. “I came to her with a difficult case and asked, ‘What do you do with the person who won’t work, with the person who resists everything?’” Martin remembers. “And she said, ‘You accept what they’re doing and accept where they are on their personal journey, and you plant a seed and hope that it opens up later.’”

A spirit of excitement

Martin believes there is something — however small — that he can connect to on some level with every client, and that’s what motivates him to keep coming back.

“With everyone I counsel, no matter how much they despise me or how much they resist, I try to bring a spirit of excitement to the relationship,” he says. “[A spirit] that I can’t wait to come and have another session with them because there’s something about them that I find intriguing, something I want to learn and there’s something that I’m really excited to continue discussing with them.”

“I just try to convey that element of acceptance, of excitement,” Martin says. “So no matter what behavior they are manifesting, there is something really worthwhile [about them]. … Like that kid I fought with for a year. He was strong. That kid held on to a poker face for a year and didn’t flinch. And that made him interesting to me. I wanted to know how else that toughness manifested itself. 

“And sometimes we’d have conversations about it [the client’s toughness] that would put half a smile on his face. I’d like to think that he looked back on those conversations later and thought, ‘Hey, maybe that guy was on to something and I can use this thing that I’ve got for a different purpose.’”

At the same time, Martin cautions that a counselor’s interest in and excitement about clients has to be sincere, particularly with those who don’t want to be in counseling in the first place. “If you fake it, they will smell it, and they will hate you more than ever,” Martin says.

At the end of the day, a counselor’s authentic desire and determination to connect may be at the heart of the therapeutic alliance.

“Maybe I am young and naïve, but I think that you can really find something intriguing, redeemable or enjoyable about any client,” Martin asserts. “If you dig hard enough, you’re going to find something about the kid that’s going to make you want to come back the next week. And once they sense that about you, it’s a game changer like no other.”

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Jeffrey Kottler and Richard Balkin will be giving a keynote on “The Power of Relationships in Counseling — and the Counselor’s Life” at the ACA Conference & Expo in Orlando, Florida, in March.

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To contact the individuals 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

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