Monthly Archives: May 2015

CEO’s Message: Some good advice from an unlikely source

By Richard Yep May 28, 2015

Richard Yep, ACA CEO

A flurry of activity has taken place these past several months around your national ACA headquarters. I can remember in the “old days” when there was a bit of a lull for a few weeks after the annual conference. That was good because it allowed staff, leaders and members to take a deep breath, get organized and then prepare for the next project. But that was then.

As some of you know, after more than 30 years in the same location, ACA moved its headquarters to a building just down the block. Despite the short distance involved, this was a monumental task, requiring the concerted effort of all 60-plus staff members, as well as project managers, technology wizards and professional movers. Although the move was completed in November, we have continued to build, fix, assemble and “nest” in our new space. This past month, we finally had an official ribbon-cutting that included ACA President Robert Smith and the mayor of Alexandria.

This month, ACA launches its first Asia Pacific conference in Singapore, but it has been in the planning stages for several months. Although we won’t achieve nearly the number of attendees that we have for the ACA annual conference, the effort required to organize and work with those who live 12 time zones away has been both interesting and challenging.

In the midst of all of this, ACA has been very active on Capitol Hill, seeking to have licensed professional counselors included as independent practitioners under TRICARE (see p. 10). In addition, our advocacy on behalf of the Elementary and Secondary School Counseling Programs resulted in having funding restored after being threatened with zero dollars. While this was occurring on the federal level, our grass-roots and state legislative staffers were busy with various states’ “religious freedom restoration” bills and legislation concerning reparative “therapy” for minors.

Sometimes in life, things happen that can’t really be explained, yet they seem so prophetic. For instance, in the rush to get so much done, I found myself running over to the little deli near our office to grab something for lunch. I happened to buy one of those drinks that has some type of saying under the bottle cap. When I unscrewed the cap, there was only one word — RELAX. Was someone trying to tell me something or, given all that was happening, was it just a cruel joke? My thinking is that whatever the explanation, that bottle cap is a keeper.

Too often in our daily activities, we simply do not take the time to find a relaxing moment. I know I am preaching to the choir on this topic, but I strongly suggest that you follow the advice on my bottle cap. With the important work that all of you do, it is critical that you make the time to relax, recharge and reenergize. I hope you will remind your colleagues to do the same.

One example of this took place during the ribbon-cutting that I mentioned earlier. In my brief remarks, I said, “One last very special group of people I want to acknowledge are members of the ACA family who are in that esteemed category of being former or retired employees. The fact that so many of you are here today speaks volumes about your connection with the association. I thank you for joining us today, and I say, ‘Welcome home.’” Seeing so many of these former employees moved me and reminded me of the specialness of ACA. And that made me relax.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800.347.6647 ext. 231 or email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.

From the President: Recognitions, intentional collaboration and recommendations

By Robert L. Smith

Robert L. Smith, Ph.D., ACA 63rd President

The 2014-2015 year as the 63rd president of the American Counseling Association has moved at a rapid pace. It has been an honor to serve as your president during this fantastic year, highlighted by the ACA Conference & Expo in Orlando, Florida. Special for me are the relationships established during this time. My interactions with you have been both meaningful and humbling in the most positive sense. Memories of the dedicated professionals who are passionate about empowering others and the profession of counseling will be forever etched in my mind. Thank you!

Intentional collaboration both within and outside of the ACA community has been a theme during the past 12 months. It has been characterized by openness and honesty, yet tempered with the salient relationship conditions of respect, genuineness, congruence, caring, concreteness and understanding that we teach our students and that our mentors taught us. Collaborative experiences within and outside of ACA affirm that:

The American Counseling Association is the home for individuals in the helping professions. ACA’s exemplary CEO, Richard Yep, is at the top of those serving in this position. And the ACA staff is the best — unbelievably competent and caring.
Equifinality is alive and well, proving that we can find many options to the challenges facing individual members of ACA and its divisions, regions and branches. The creativity demonstrated by ACA members and leaders adds to the credibility of this concept.
We have more in common than we have differences. We are dedicated to advocacy in its broadest sense for the fair and equitable treatment of all humans. We advocate for what is best for students, new professionals, practicing counselors, counselor training programs and the future of the counseling profession.

My recommendations pertaining to the future of the counseling profession include:

Continued collaborative advocacy on behalf of all counselors with TRICARE (see p. 10), the Department of Veterans Affairs (VA) and licensure board rules and policies
Continued collaborative advocacy for licensure portability
Support and advocacy for the Council for Accreditation of Counseling and Related Educational Programs, the accreditation body in counseling that is nationally and internationally recognized by the Council for Higher Education Accreditation, the Institute of Medicine, the VA and a number of state licensure boards
Support and advocacy for extensive grandparenting provisions for counselors to meet any changes brought about by federal and state agencies (again, see p. 10) and support for similar grandparenting provisions for counselor preparation programs to meet accreditation standards

It is important for all parties affected by the changes that are, and will continue, taking place in the counseling profession to look within and proceed prudently with those activities that will best benefit counseling and the future of our profession.

I close this column by welcoming Thelma Duffey as the 64th president of ACA. She will serve ACA very well because she is a leader, an innovator, a caring professional and a friend and colleague to us all.

Peace and happiness,

Robert L. Smith, Ph.D., NCC

Counseling is a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals.

Self-care in the world of empirically supported treatments

By Dolores “Lori” Puterbaugh

One of the many profound changes within the counseling profession for mental health counselors has been a gradual shift from psychodynamic and person-centered therapies to an emphasis on the medical model. The full history of this shift is an interesting one, featuring as much sociopolitical influence as scientific influence, but that is beyond the scope of this article. The end result of this shift is a focus on diagnosing and matching treatment interventions to the diagnostic criteria. Those who were focused on efficacy and efficiency in the early stages might never have imagined the unintended consequences of their best intentions.

Today, our graduate students are preparing to work in a world in which diagnosing according to the latest established criteria and then matching the appropriate brief, empirically supported interventions to those diagnoses are paramount. For students and new professionals, this reductionist approach might make it seem as if mental health treatment is a very straightforward process of applying Technique A to Problem B.

Medicalized mental health frames diagnostic criteria as signs of illness to be wiped out rather than indicators of pain to be uncovered, addressed and integrated. Symptoms are problems in themselves rather than signs of problems of being. This mechanization of mental health care can have strange effects on counselors. One in particular — the focus of this discussion — is the stultifying effect that reductionism can have on self-care.

Self-care is a standard topic in introductory graduate counseling courses, practicum courses, internship supervision sessions, professional trainings and the professional literature. Nearly every week, I receive invitations to participate in a survey on self-care for dissertation research and receive several offers of continuing education courses on the same topic. Ubiquitous a topic as self-care may be, the definition seems to be so broad that, as with a client’s complaint of depression, no two people can be sure that they really understand what the other is subsuming when the murky phrase “self-care” is introduced.

In recent research focused on grief counseling, not yet published, I surveyed counselors ranging from new professionals (less than five years of postgrad experience) to the seasoned (20 years of experience or more). The sample size was quite small, minimizing the generalizability of the findings. Still, one aspect in particular piqued my curiosity: the tendency among less experienced practitioners to confound recreation with self-care. Although recreation is part of self-care, it is not synonymous with the full range of internal and external attention that constitutes all of self-care.

Another pattern in the research was the assertion, most common among newer professionals in my small pool of respondents, that the right intervention (in this case, within grief counseling) would come naturally and they would know what to do or say in session without concern. More experienced therapists were far less likely to subscribe to this option because they shared an awareness that within (grief) counseling there is no single “right” answer that will naturally come to the foreground. In short, the less experienced counselors were more likely to oversimplify self-care and to have a great deal of confidence that they would simply know what to do when faced with client issues in grief counseling. More experienced counselors were more likely to cite a variety of self-care strategies and to be less confident that the correct intervention would simply rise to the surface during counseling.

I suspect the disparate attitudes between cohorts rests in part on the increasing emphasis on empirically supported interventions and psychiatry’s ongoing reductionist approach to the richness of human experience. We do very well in ensuring that our students know the diagnostic criteria and the most recent research-supported, efficacious interventions that match those criteria. However, we are into perhaps a second generation of counselors who are proceeding with protocols developed by others who are blind to the section of the Johari window that comprises all that is unknown.

Taking a shallower approach

A mere two counselor generations ago, our education and training were solidly grounded in psychodynamic theories, with a tremendous emphasis on self-awareness, therapy for therapists and a profound respect for the depth and breadth of the field of therapy. The power of the relationship was emphasized, and this has not lost its importance, as evidenced by the keynote session presented by Jeffrey Kottler and Richard Balkin at the 2015 ACA Conference & Expo in Orlando, Florida. The developers of what comprise the brief therapies were well-grounded in psychodynamic theory.

Subsequent generations of counselors more often give a drive-by nod to theories that involve the unconscious aspects of experience. They can easily be misled to believe that the readily accessed cognitions are all there are to the client’s misconceptions. Unaware of how a leader such as Donald Meichenbaum’s deep knowledge of psychodynamics colors his current research and work with posttraumatic stress disorder, the new practitioner is prone to merely parroting technique. Meichenbaum, or a therapist with a similar depth and breadth of knowledge, will hear subtle cues about the client’s stability, insecurities, capacity for abstract thought and ability to tolerate frustration or ambiguity and then make nuanced adjustments to interventions on the basis of these minute variations in individual functioning. Meanwhile, a counselor whose education has been aimed at providing empirically based interventions for specific diagnoses is tightly gripping the hammer of cognitive-based therapies, in which every problem is a simple case of irrational belief or cognitive distortion to be thumped into a more logical shape.

Is there a risk that a superficial approach in one area will ineluctably contaminate others? Will the new counselor, ill-prepared to wade into the depths of the client and holding an empirically defended disregard for the importance of those depths, mirror this with a lack of insight into the depth of the self?

Many graduate students and new practitioners have taken advantage of personal therapy and other opportunities for reflection and growth. However, when I review a taped session with a counselor-in-training and my question “What was/is going on for you right now in the session?” is met with a blank stare or a recitation of the relationship between the intervention and the client’s issue, I suspect that insight into the internal experience of the counselor was a chapter only skimmed during formation. Likewise, countertransference was reduced to a mere vocabulary word or reflexively described as a source of ethical violations. It is rarely considered a source of useful insight when handled properly and brought to supervision, consultation or the counselor’s own therapy session.

When I encounter insufficiency in attending to internal experiences (in counselors and in clients), that insufficiency often co-occurs in the realm of self-care. How, then, do we bridge the gap for students, interns and new practitioners who are attempting to meet the self-care needs of a counselor’s heart, mind and soul through lighthearted socializing or with a stroll in the park?

A superficial model of self-care

The awareness of a need is required before any meaningful attempt to meet that need will be taken. The counselor who has decided that emotions regarding clients are “wrong” because they signify “countertransference,” and subsequently attempts to ignore or suppress those responses to the client, is at risk for the very problems that countertransference can spur. Similarly, self-care requires quiet times for reflection, but a counselor who has absorbed the societal bias against introverted behavior may mislabel these quiet times as “isolating.” Busy students and practitioners — like so many of our clients — can no doubt find multiple reasons, from lack of time to lack of finances, to postpone individual therapy, spiritual guidance and peer supervision.

Yet lack of reflection feeds into a deeper ocean of lack of insight. Meanwhile, self-care, dumbed down to socializing and recreational pursuits, skips lightly over the surface, not sinking into the opportunity for deep reflection and its rewards, including insight into self and others. Self-care gets reduced to time spent relaxing with television or friends or, more rarely, exercising or playing outdoors. These are aspects of self-care, but they elude the essence and responsibility we have for a well-rounded and consistent habit of true self-care.

Our professional literature and conferences are rich with articles and experiential trainings on the importance of deep, well-rounded self-care that addresses the whole person: body, mind and spirit. One suspects that, overstretched and desperately in need of self-care, a great many counseling graduate students, interns and professionals are failing to give more than a cursory glance at these offerings because life is overwhelming. Using a superficial model of self-care, they throw interventions at themselves the same way we are trained to toss interventions at client complaints. As with the empirically supported interventions of therapy, many self-care interventions are focused on the immediate, conscious needs — for example, I need to unwind/blow off steam/throw my head back and laugh until my sides ache. These are indeed real aspects of self-care, but they are not sufficient on their own.

I suggest, then, that frequently shallow practices of self-care and the potential problems of relying on menu-driven, empirically supported interventions are not random parallel processes. They are one regrettable, predictable outcome of an efficiency-focused, reductionist approach to mental health that is not reflective of mental health counseling as a profession. Counselors are historically holistic, incorporating relationships, client strengths and insight into development with an understanding of pathology and treatment.

The current reductionist approach has been imposed on us by larger forces: third-party payers and the American Psychiatric Association. Meanwhile, our accreditation boards continue to emphasize proper formation, and mental health counseling graduate programs always feature foundational courses that include self-care. We must frequently revisit what is meant by self-care, as well as the implications of the various aspects of self-care for personal and professional functioning.

Client care and self-care ought to be rooted in a deep understanding of the human experience and a profound respect and reverence for the unknowable in each of us. A comprehensive self-care practice feeds our deep need to reflect, make meaning from the events of our lives and develop deep connections with others. Information on self-care and its many vital facets is readily available; we must ensure that the next generations of counselors integrate holistic care of the self into the fabric of their beings and the texture of their lives.

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A whole-person approach to self-care

The ways in which we meet our self-care needs will vary. The unique preferences, temperament and style of each counselor require a nuanced approach to self-care. Whatever your style, good self-care will encompass the following elements.

Physical: Strive for good nutrition, regular medical care, adequate sleep and appropriate exercise on a regular basis. Choose a few activities that suit your physical condition and temperament. For example, an extrovert might not enjoy long solo runs, whereas an introvert may relish the alone time for reflection and time in nature. Frequency: Daily practices.

Psychological: Have colleagues with whom you can meet and debrief on a regular basis. Consult with others. Have a therapist or supervisor to help you process the issues raised by your work with clients. Frequency: Weekly, meaningful interaction with colleagues or supervisors.

Social: Meet your social needs in the ways that suit your personality. Failure to meet your social needs outside of therapy will leave you vulnerable to meeting your needs in the therapy room. Frequency: Know your personality and adjust accordingly. Extroverts will need more contact to feel refreshed, whereas introverts will need more quiet after a day of interaction.

Emotional: Have a few people with whom you can be emotionally honest and feel the safety of mutual support. Frequency: Daily contact of some kind with a member of your inner circle.

Creativity: Seek a regular outlet for creativity that is wholly separate from the creativity required in the therapy room. Thinking outside the box in one area will enhance your creativity in the professional area, and investing energy into this kind of play is a way to refuel your spirit. From gardening, woodwork and music to haiku, drawing and cake decorating, the options are endless. Frequency: At minimum, a session of at least a couple of hours once per week.

Intellectual: Years ago, an instructor advised me to expect to spend 10 percent of my professional time reading and learning for the rest of my career. Make a habit of trying to learn something new about the profession every week. Frequency: Ten percent of the time you spend working, which includes reading, watching truly educational video presentations and earning continuing education units.

Spiritual: Nurture this aspect of yourself through whatever discipline is appropriate, whether it is the observation of an established religion or spending adequate time for reflection, meditation and quiet separateness from the busyness of life. Frequency: Daily.

Sound like a lot? We ask this of our clients; perhaps asking less of ourselves is not asking enough.

Imagine yourself well-fed, well-exercised and well-rested. You are regularly surrounded by supportive and insightful colleagues and have a safe place in which to explore your thoughts, feelings and memories as affected by counseling clients. You enjoy regular, meaningful contact with the people you love. You find your creativity blossoming in ways you may not have enjoyed since childhood — or certainly not since graduate school — and your counseling skills seem rejuvenated. At the same time, a regular stream of new ideas and research informs your work and challenges you to stretch your portfolio of techniques. With all this constant growth and change, the quiet time you spend in reflection, meditation, prayer or journaling becomes all the more precious as a way to integrate the totality of your life.

This is the self-care we want for our clients, our loved ones, our students, our colleagues and, yes, for ourselves.

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Dolores “Lori” Puterbaugh is a licensed mental health counselor and licensed marriage and family therapist who has been in private practice since 1999. She is an approved supervisor for registered mental health counseling and marriage and family therapy interns in Florida and teaches undergraduate and graduate courses in counseling and psychology. Contact her at puterbaugh@mindspring.com or visit her website at drloriputerbaugh.com.

Letters to the editor: ct@counseling.org

Incorporating feedback-informed treatment into counseling practice

By Sidney Shaw and Kirsten Murray

How do you determine your level of effectiveness in your work with clients? In everyday practice, counselors typically rely on clinical judgment and their own assumptions about the therapeutic alliance and client progress. Few would argue against the importance of good clinical judgment, but there is persistent evidence that counselors’ views of the alliance and client outcomes are often at odds with the views of clients.

In regard to helping clients attain positive outcomes, research evidence and clinical wisdom converge strongly on the therapeutic alliance. However, while research and meta-analyses have repeatedly demonstrated the power of the alliance, an important nuance in those findings is that the client’s view of the alliance is consistently found to be a better predictor of counseling outcome than is the counselor’s view. Additionally, counselor views of the alliance frequently do not correlate well with the views of the client.

Because client perceptions of the alliance are a better predictor of outcome than the counselor perceptions are, a validated model for collecting continuous feedback from the client is needed. Furthermore, integrating client feedback into counseling services can help counselors check their assumptions, increase counseling’s effectiveness and privilege the client’s voice. This article is a review of a systematic, validated and practitioner-friendly method for monitoring the client’s view of the alliance and outcome known as feedback-informed treatment (FIT).

Formal client feedback

Collecting feedback from the client emphasizes counseling tenets related to understanding clients’ subjective experiences, cultivating a quality relationship, supporting clients’ abilities to choose their goals and how to meet them, and working in service of a positive outcome for clients. In counseling practice, counselors typically evaluate these important factors informally, but this is an area in which counselors — and clients — can benefit from formal feedback. Indeed, numerous studies have found that counselors, despite their confidence that they accurately appraise the strength of the alliance and client progress, are poor at gauging these elements when using clinical judgment alone.

In a representative study from 2009, researchers Morten Anker, Barry Duncan and Jacqueline Sparks conducted a randomized clinical trial of couples counseling in a naturalistic setting. Clients were randomly assigned to either a feedback group (in which the counselor would obtain session-by-session feedback from clients using a brief alliance measure and an outcome measure) or to a “treatment as usual” group. Pre-study surveys showed that all the counselors believed they were already acquiring outcome and alliance feedback from their clients without the use of a formal feedback process and that formal feedback would not improve their effectiveness. In contrast to those pre-study beliefs, findings revealed that 90 percent of the counselors improved their outcomes with clients after integrating formal client feedback using brief measures of alliance and outcome. This finding, coupled with findings from similar studies, illustrates the tendency for counselors to assume that their informal method of checking in with clients is as useful as a formal feedback process.

Because of cumulative research on the client’s view of alliance as a predictor of outcome, research on formal client feedback has burgeoned during the past decade, and the evidence is compelling. In 2010, outcome researcher Scott Miller conducted a review of existing research on integrating client alliance and outcome feedback into counseling services. At that time, 13 randomized trials with more than 12,000 ethnically and diagnostically diverse clients had found that simply incorporating client feedback improved counseling outcomes by as much as 65 percent, decreased client dropout rates by half and decreased deterioration (clients who got worse) by 33 percent. The act of consistently engaging with clients about their experience of the alliance and the degree to which the sessions were helpful had a profound influence on client outcome.

Barriers to formal feedback

The term formal in this case refers to using validated tools for eliciting client feedback about their perception of the alliance and outcome. We acknowledge that the notion of using a form to obtain client feedback can create resistance among counselors. The method might sound reductionistic to some clinicians, or they might regard it as having the potential to trivialize the alliance by assigning a number value to it.

Although these concerns are understandable, it is important to remember that client feedback tools are not for assessment in the traditional sense. Rather, they are primarily dialogue tools. The aim is to open dialogue and put clients in the driver’s seat to express their experience of the alliance and whether progress is being made. This in turn enables the counselor and client to work collaboratively to make adjustments and individualize the services being delivered.

When we present this information at conferences, there are sometimes counselors who indicate that they check in with their clients verbally or informally about the alliance and outcome. Counselor intentions to check in with clients are no doubt rooted in an aim to truly understand clients’ experiences. Some research has indicated, however, that counselors think they check in with clients far more frequently and consistently than they actually do. Indeed, our own experience of first beginning to use an alliance measure was that sometimes we would give the measure at the end of the session and sometimes we wouldn’t. The problem with counselors choosing whether or not to check in formally about the alliance is that it places the decision in the wrong hands.

FIT alliance and outcome tools

FIT involves incorporating the client’s perspective about the therapeutic alliance and outcome. Specifically, FIT includes the use of two ultra-brief, validated measures that are used to open and broaden conversation about the alliance and outcome.

The Session Rating Scale (SRS) is a four-item measure of the therapeutic alliance that the counselor administers at the end of each session. This takes only about one minute to do. The first three items of the SRS correspond directly with the domains of the alliance found in the dominant definition in the mental health field. The fourth item simply asks how the client felt about the session overall. The four items of the SRS are as follows:

1) Relationship (degree to which the client felt heard, understood and respected)

2) The goals and topics (degree to which the client was able to focus on what he or she wanted to in session)

3) The approach or method (how the client felt about the counselor’s approach)

4) Overall (degree to which the overall session felt right and on track for the client)

Each of the items is on a 10-point visual analog scale. Clients are asked to reflect on the session, complete the brief form and then discuss their feedback with the counselor.

The Outcome Rating Scale (ORS) is a brief four-item tool for measuring the client’s perspective of change or improvement (or lack of improvement) in relation to the initial score at intake. The counselor administers the ORS at the beginning of each session. This takes about one minute. The first three items are based on three domains of the much longer Outcome Questionnaire-45, while the last item refers to the client’s general sense of well-being. The four items of the ORS are as follows:

1) Individually (personal well-being)

2) Interpersonally (family, close relationships)

3) Socially (work, school, friendships)

4) Overall (general sense of well-being)

In 2012, the Substance Abuse and Mental Health Services Administration (SAMHSA) designated the systematic use of the SRS and ORS to monitor and improve alliance and outcome as an evidence-based program and practice. These measures have good reliability and validity for such brief measures and, unlike longer measures geared toward research, they are designed to be used in everyday practice.

Introducing formal feedback in counseling sessions

With most any intervention, process or method in counseling, simply going through the motions doesn’t translate into effective, competent practice. The same applies to the use of the ORS and SRS. These tools are intended to privilege the client’s voice and provide a reference point for the client’s experience. Intention, openness to feedback and clarity of purpose are required of counselors to truly engage clients collaboratively. With this in mind, sample scripts for introducing the measures are provided below. Keep in mind that the ORS is administered at the beginning of each session and the SRS at the end of each session.

Introducing the ORS

“A primary focus of mine in working with you is to make sure that you are getting what you want and need out of our sessions. So, it is really important that we are discussing and tracking how you are doing and whether things are improving in your life. I have a really brief form that I use every session just to get a snapshot of how things are going. This form allows us to get a sense of important areas of your life and how things are changing or not changing over time. It also helps me to figure out if I am being helpful or not, and that is really important for me to know. It will only take a minute or so to complete. On each of these four scales, just place a hash mark indicating how things have been for you over the past week, with lower scores to the left and higher scores to the right.”

The client then completes the ORS and, afterward, the counselor attends to and mentions any particular domain that is lower than the rest. The session then progresses in a traditional counseling format.

Introducing the SRS

“Before we wrap up today, I would like to ask you to fill out another really short form. This one deals directly with how our session was today. It is really important to me that you are getting what you want and need from coming here, and how well we work together directly relates to how well things go for you overall in counseling. I truly want to hear any feedback you have about our session, especially if it is feedback that you might think is not positive or about something that was lacking in our session. Sometimes it may be something big that I missed or that wasn’t right in our session, and I want to hear about that. However, it could also be something seemingly small that wasn’t quite right about our session today. It may seem so small that it’s not worth mentioning, but I’d like it if you would mention it. I also want to emphasize that you don’t have to be concerned about hurting my feelings and that I really welcome your feedback. Like with the other form, there are four different scales, with lower scores to the left and higher scores to the right. Just put a hash mark on each line indicating how the session was for you today. Thanks!”

After the client completes the SRS, the counselor inquires about and attends to scores in any domains that are lower. The counselor needs to maintain a stance that communicates not just openness to feedback but also that the counselor will attempt to incorporate the client’s feedback to guide treatment.

Creating a culture of feedback

On the surface, the use of these brief measures may seem simple. In fact, this is often the initial response of counselors when they begin using the SRS and ORS. However, it quickly becomes apparent that these tools can be used in a manner that makes them little more than a meaningless ritual at the beginning and end of sessions. To use these tools in a way that yields truly beneficial results for clients, counselors need to create a culture of feedback.

The first, and perhaps most challenging, step in this process is for counselors to become very clear about whether they really want client feedback and if they are prepared to handle feedback with openness and receptivity. In essence, the counselor’s goal with the SRS is to strive hard to encourage clients to share even small things that were not to their satisfaction about the session. Indeed, research findings on top-performing counselors (that is, counselors whose outcomes are significantly greater than those of the average counselor) indicate that they typically receive lower SRS scores in the early stages of treatment. These counselors are very adept at getting clients to share feedback about elements of the alliance that are weak. In fact, when counselors receive consistently high SRS scores from clients, it is often an indication that they have not adequately created a climate in which clients feel comfortable providing truthful feedback.

Creating a culture of feedback with clients essentially means that counselors are very receptive to feedback and will use this feedback to guide and adapt services. Soliciting feedback effectively requires that counselors clearly explain the ORS and the SRS as well as the purpose of these two tools. When counselors communicate openness to feedback (especially critical feedback) and responsiveness to client preferences, they are more likely to receive the feedback they need to individualize services.

Summary recommendations

There is strong evidence that integrating alliance and outcome feedback into counseling improves overall outcomes. FIT is pan-theoretical and can be used in conjunction with any treatment approach. Key considerations to start integrating client feedback into counseling services are as follows:

Download the ORS and the SRS from the International Center for Clinical Excellence at centerforclinicalexcellence.com. This is free for individual practitioners.
When downloading the performance metrics, read the information on how to score and introduce the measures.
Practice administering the measures with a colleague. Use your own language, but hit the key points highlighted in the sample introductions in this article.
Seek internal clarity on your openness to hearing and responding effectively to client feedback. Remember that a characteristic of top-performing counselors is that they often solicit negative alliance feedback (and receive it nondefensively) and are able to modify treatment according to that feedback.
Read additional articles on this topic, a number of which can be accessed on Scott Miller’s website (scottdmiller.com).
Work to create a culture of feedback with clients. Don’t use the ORS or the SRS with existing clients, but begin to use the measures in every session with new clients.
Track client ORS scores on a graph for visual indication of the client’s outcome over time.
If clients are not improving (by an increase of five points from the initial intake score) on the ORS by session four, have a conversation with the client about the alliance and what could be done to improve treatment.
Seek supervision or consultation from someone who is familiar with FIT.
Keep in mind that even the best counselors have clients on their caseloads who are not progressing or improving. Having a reference point for clients’ experiences of change allows you to individualize services and improve client outcomes.

Conclusion

As counselors, we have been trained to build and invest in an alliance with our clients. The therapeutic factor of the alliance itself has been found to be a better predictor of client outcomes than client diagnosis, the professional discipline of the clinician, years of clinician experience, the client’s previous treatment history and the specific treatment approach. Attending to the therapeutic alliance is critical for successful counseling, and given that counselors’ and clients’ views of the alliance are often at odds, a method for aligning those perspectives is needed. Integrating FIT practices is a way to create a consistent culture of feedback, privilege the client’s voice and individualize treatment needs for the people we serve.

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Those interested in more information on this topic can refer to Sidney Shaw and Kirsten Murray’s article, “Monitoring alliance and outcome with client feedback measures,” published in the January 2014 issue of the Journal of Mental Health Counseling.

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

Sidney Shaw is a core faculty member in the clinical mental health counseling program at Walden University and a certified trainer for the International Center for Clinical Excellence. Contact him at sidney.shaw@waldenu.edu.

Kirsten Murray is an associate professor and chair of the Department of Counselor Education at the University of Montana. Contact her at kirsten.murray@umontana.edu.

Letters to the editor: ct@counseling.org

Dispatches from Nepal: A drop in the bucket

By Bethany Bray May 27, 2015

The 10 days that Jeffrey Kottler spent in earthquake-ravaged Nepal this month were exhausting and painful but also some of the most worthwhile work of his career, he says.

Kottler served in a medical team with Empower Nepali Girls (ENG), the nonprofit he founded 15

Jeffrey Kottler plays with some Nepali youngsters near an Empower Nepali Girls medical tent.

Jeffrey Kottler plays with some Nepali youngsters moments before a 7.3-magnitude quake hit on May 12. (Click on photos to see full size)

years ago. The help the team members provided, including treating both physical and mental wounds and distributing donated supplies such as tents, is just a “drop in the bucket” toward what is needed, says Kottler, an American Counseling Association member and professor of counseling at California State University Fullerton.

Over the course of 10 days, the ENG team treated more than 500 people, including some in the hardest-hit areas of the country that had yet to see international aid. A 7.8-magnitude quake left much of Nepal in ruins on April 25; the destruction was made worse by a 7.3-magnitude quake on May 12.

Kottler is CEO of ENG, a nonprofit that develops mentoring and supportive relationships with children at greatest risk of being forced into early marriage or sex slavery.

Kottler and an ENG translator wait for their next patient in the "counseling corner" of a makeshift ENG medical center setup in a school.

Kottler and an ENG translator have their counseling tools ready as they wait for the next patient in an ENG medical center setup in a school.

Counseling Today has posted a series of online articles about the conditions in Nepal via Kottler’s travel journals. This journal entry from May 19 is the final installment.

Find more photos and information in earlier articles here and here.

Jeffrey Kottler’s travel journal: May 19

Mount Everest area

I had already seen four families in a row without a break, and my energy was faltering. Many cases are similar: One or more of the children has a headache or stomachache or sleep problem, and the parents are worried; or an adult is hypervigilant and overreactive to any noise or movement, unable to sleep or eat; or some preexisting medical condition like hypertension or heart problems are now far more serious. With such a long line of people waiting to be seen, most of our sessions are 20

Kottler and one of his students (far left) in the middle of a counseling session with a Nepali family.

minutes. During that time my team of students and I have to figure out what’s going on and attempt some form of reassurance or intervention. I’ve been teaching deep breathing, a simplified form of self-talk, but mostly explaining and normalizing their reactions as typical of trauma symptoms and chronic, unrelenting fear.

One mother brought in her boy after seeing our doctor because of an eating disorder. She had taken him to hospitals trying to figure out why he wouldn’t eat and complained of stomachaches when he did eat. The doctors recommended giving him vitamins and energy drinks to maintain his nutrition. But the mother was beside herself with worry and didn’t know what to do, especially since the earthquakes, when the boy had become even more unwilling to eat at the family meals.

I asked the social work students to do an assessment while I worked with an older girl, one of our [ENG] scholarship students who wanted to attend medical school next year but whose father thought that it was time for her to be married now that she was 18. He insisted girls didn’t belong in school and tried to sabotage her studies as much as he could. What should she do? Can she disobey her father and pursue her studies? Or should she follow her dreams and risk being disowned? I had spoken to her a few months earlier when I was in Nepal with several of my counseling students and had told her that the choice was hers and promised her that if she wanted to continue medical training, we would provide alternative housing and support her. I had directed my counseling students (after only one semester) to talk to her, and one student, Karla, shared her own story of immigrating from Mexico when she was 12, unable to speak English, leaving everything behind, and also showing resolve to be the first in her family to ever attend university, much less graduate school. This seemed to strongly impact the girl, and now I was following up with her.

I returned to our therapy room to find the social work students still trying to engage the boy who would not speak and deferred all questions to his mother. Yes, in other ways he is normal and happy, although since the earthquakes his eating problems have worsened. Yes, the family is intact and they are all healthy. Yes, their home had been damaged and they were living outside, but they planned to move back inside if there were no further quakes in the next few days. The students looked at me and shrugged, unsure what to do next. They are smart and capable and awesome, but this was really confusing, and I was also puzzled. Time was running short, and we had barricaded the door against the crowd fighting to get their turn.

I told the boy I had a test for him and wondered if he would pass. He looked intrigued, so I told him that I bet I could find something that he would eat. He barely looked at me, but I could see the beginning of a smile. I pulled out a Snickers bar and handed it to him. Out of pure obstinacy, he

Two Empower Nepali Girls scholarship children stand in front of their damaged house near Lukla in the Mount Everest region of Nepal.

shrugged and passed it to his mother, pretending he wasn’t interested. He looked back at me defiantly, the glimpse of a smile now gone.

“What DO you like to eat?” I asked him. “Smoothies?”

He nodded his head affirmative, or rather waggled it back and forth in that characteristic Nepali way.

“KFC?”

Another nod.

“Kabobs?”

Again, a nod.

“So, what don’t you like to eat?”

He whispered something I couldn’t hear. “Say that again,” I asked him.

“Dahl baht.”

“I see.” And now I did see. Most Nepalis eat rice and lentils for both meals of the day, every day, even when they are given other choices. It is perhaps the single most nutritious meal that the human body can metabolize and provides a cheap and efficient source of protein and energy. It turned out he really didn’t have an eating disorder; he just didn’t like dahl baht. But he LOVED fast food.

My head hurt with concentration. I desperately needed a break and to use the restroom. Before I could get out of my chair, a tiny girl was carried into the room by a man, accompanied by what I assumed was the girl’s mother. They were followed by the principal of the school we were using as our clinic, and Pasang Sherpa, the president of our (ENG) foundation in Nepal.

Because confusion was my usual state of mind, I just sat and waited for the drama to unfold. I wondered what could possibly surprise me next.

“This is Pramisa,” Pasang said to me, pointing to this absolutely adorable girl who was looking around the room, studying all of us carefully. “She is 3 years old.”

I nodded, waiting. Pasang and the principal explained to me that these were her aunt and uncle.

“Where are her parents?” I asked.

Everyone looked at one another after the translation. Her mother was at the hospital. “She is dressed in white,” the uncle said.

“She is dressed in white?” I repeated, now completely confused.

“Yes,” Pasang agreed. “Her husband, the girl’s father, died yesterday. He was hit on the head during the last earthquake. He was in the hospital and he died. The mother is with the body, dressed in white as she is [culturally] required. This girl, she doesn’t have a father, and we haven’t told her yet.”

I looked at this little girl, Pramisa, and she was smiling and playing with a stuffed animal I had just given her. My heart just broke. I could feel myself losing control, tears running down my cheeks, and so excused myself for a moment and walked out of the room to regain my composure. Were we now going to tell this 3-year-old that her father was never coming home? I had already seen and done so much, but this I could not do. But I knew I had to go back in the room.

Once I was back in my chair, Pasang asked if we might offer this girl a scholarship, support her now that she had lost her father and her home. They had no money, no place to live, no way to earn an income. The mother would spend a year in mourning, and that would be her job.

I thought to myself how fate had put me in this place, at this moment in time. My chest hurt. I felt so flooded with emotion from all the accumulated stress, all the stories I had heard and all the people I

had seen. I had felt so helpless at times, so inadequate to provide the help and support that everyone needed. And now I was given this gift: I could save this child — literally save her life and give her a future — by agreeing to provide her with a scholarship so she could have an education and a future.

I could barely speak, but I nodded my head, once, twice, then up and down so vigorously that everyone looked at me curiously. “Yes, of course,” I finally spoke aloud. I looked at the aunt and uncle and told them that although this was a terrible tragedy, I would do everything in my power to make certain that Pramisa was provided an education, to go as far as she could in life, maybe even to become a doctor or an engineer, professions that were rarely possible for girls in Nepal.

Then I fled the room, went into the restroom, shut the door and started sobbing. In fact, I am crying now as I try to tell this story.

Kottler (upper right) with his ENG medical team.

We are now heading home after 10 days of exhausting, overwhelming work. During this time, we have treated more than 500 patients, as well as distributed and prescribed $30,000 worth of medications and medical supplies that have been donated by doctors and hospitals in the U.S. We reached areas that have still not received any government help or assistance by any nongovernmental organization three weeks after the first earthquake.

It has been among the most painful and yet the most interesting experiences of my professional life. I have known many of our ENG scholarship girls for over 10 years, some for almost 15 years. During that time I have spent time with their families, shared tea in their homes, visited with them at school and walked on the trails, listened to the stories of their lives and the daily challenges they face. Now many of their homes are destroyed. Their schools are gone and their teachers have disappeared.

My heart still hurts. I can barely sleep. I’ve probably lost 10 pounds in the last week. I can’t tighten my belt any farther. I know this is the result of compassion fatigue or vicarious trauma, as well as primary trauma of surviving two major earthquakes and dozens of smaller ones. I know it is the result of working insane hours and seeing so many people compressed in a day. I know it is the result of seeing so much devastation and despair, so much sickness.

I know that what we have done is just a drop in the bucket compared to the millions of people who still need help, need tents and food and water, need support. But after a life devoted to service, a life dedicated to teaching and helping others, I am certain that everything I have ever done, everything I have ever prepared for, was to be here now.

Kottler walks along a trail in the Mount Everest region with a nurse, Pema. They took the walk to take a break and talk about the trauma and flashbacks they had been experiencing themselves. "Pema is a nurse who was at ground zero after the first earthquake. She saw headless bodies, saw hundreds of corpses crushed and listened to the wails of desperate mothers begging her to save their injured children. We talked about secondary trauma and how so many health professionals will experience problems once they fully metabolize everything they’ve witnessed," Kottler says.

Jeffrey Kottler walks along a trail in the Mount Everest region with a nurse, Pema. They took the walk to take a break and talk about the trauma and flashbacks they had been experiencing themselves. “Pema is a nurse who was at ground zero after the first earthquake. She saw headless bodies, saw hundreds of corpses crushed and listened to the wails of desperate mothers begging her to save their injured children. We talked about secondary trauma and how so many health professionals will experience problems once they fully metabolize everything they’ve witnessed,” Kottler says.

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For more information on Empower Nepali Girls, see empowernepaligirls.org

See recent photos and updates from Nepal at ENG’s Facebook page

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

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