Tag Archives: therapeutic alliance

Counselor self-disclosure: Encouragement or impediment to client growth?

Written and compiled by Bethany Bray January 29, 2019

W. Bryce Hagedorn once counseled a client who was wrestling with intense feelings of shame regarding things he had done during the Vietnam War. The client, a veteran of the U.S. Marine Corps, felt responsible for the soldiers he had lost during combat. He never expressed any details connected to these painful and complicated memories, however, until Hagedorn used a pivotal therapeutic tool: self-disclosure.

Hagedorn is also a Marine Corps veteran who has served in combat. The disclosure of his military service “opened the door to share things that the client had never shared before, even with going to the Department of Veterans Affairs [for treatment] for years. Before he was able to share, he wanted to know if I would be judging him,” says Hagedorn, a licensed mental health counselor and director of the counselor education program at the University of Central Florida.

When used sparingly, professionally and appropriately, counselor self-disclosure can build trust, foster empathy and strengthen the therapeutic alliance between counselor and client. However, counselor self-disclosure also holds the potential to derail progress and take focus off of the client. It is a tool that should be used with care — and in small doses, according to the ethics professionals working at the American Counseling Association (see sidebar, below). Learning how, when or whether to use self-disclosure with clients is best achieved through training, experience and supervision.

Hagedorn notes that once a clinician self-discloses, the client may naturally be inclined to ask questions seeking additional personal information about the counselor. “If you’re going to self-disclose, know ahead of time where your bailout point is,” says Hagedorn, a member of ACA. “Once you open the self-disclosure door, where are you going to stop? When I worked with couples, they could see that I was wearing a wedding ring. I was often asked how long I had been married, if I had kids or if I ever struggled like [the clients were] struggling. Know where you’re going to stop answering questions.”

Hagedorn doesn’t believe that self-disclosure should be an automatic, out-of-the-gate technique for counselor practitioners. Rather, he advises, counselors should consider it a tool to keep in reserve, using it only when appropriate — and with clear intention.

“I’m in favor of less is more with self-disclosure,” Hagedorn says. “If you’re going to self-disclose, you have to do it with dignity and understand the reasons why a client is asking [for personal information from a counselor]. Explain to the client, ‘Even if I have walked down a similar path, it doesn’t mean I have walked down your path.”

 

The many aspects of self-disclosure

Counseling Today recently collected insights about counselor self-disclosure from American Counseling Association members of varied backgrounds and practice settings. Read their thoughts below.

We encourage readers to add their own thoughts to this discussion by posting comments at the bottom of this article.

 

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Kimberly Parrow is a doctoral student at the University of Montana. She is a licensed clinical professional counselor who specializes in working with clients to address grief and posttraumatic growth.

Client comments often spark the urge for self-disclosure. The feelings of connection in a professional counseling relationship tempt counselors to self-disclose, sometimes without warning. I think the consideration of providing personal details to clients occurs regularly [but] believe situations when such disclosures are appropriate are few. Appropriate self-disclosure is client-focused, validates the client’s experience and spurs further exploration. A constructive disclosure is brief, focused on meaning and light on story.

Professional counseling relationships require a harmony of the necessary theoretical and relational components. When the pull to disclose occurs, I take a moment and ask myself three things:

a) Is the disclosure grounded in theory?

b) Is there any other way to keep the locus of the experience within the client’s world?

c) How will the disclosure affect the therapeutic relationship?

For these reasons, I think it is important to keep in mind that the decision to disclose should not be made in the moment. An appropriate disclosure is the product of thoughtful planning.

I once had a young adult client recovering from a tragedy that killed several people and left him clinging to life. Our work began after several months of hospitalization and physical therapy. A number of sessions became focused on his feelings of dissociation regarding his own near-death experience. He would make statements such as, “I almost died, and it feels like I don’t care.” He explained the feeling was getting in the way of connecting with his family and friends. His support people couldn’t understand why he wasn’t more thankful to be alive, and neither could he. Feelings of isolation and confusion were becoming a sticking point in his recovery. He felt alone in a rare experience. However, he wasn’t and isn’t alone; I have had a near-death experience too.

My decision to disclose took several days. The disclosure would be tied to our treatment goals, but keeping the locus on the client was a challenge. A discussion of my experience might be too alluring and could pose a threat to our therapeutic relationship and focus. Eventually I decided on a very brief statement, [saying], “I almost died once too,” and waited for the subject to surface again. When it did, I shared my brief statement. It was simple and powerful. In that moment, he was able to trust that my validation of and explanation for his dissociation was real, because I had also lived it. As a result, our therapeutic bond deepened, and our trauma recovery work gained traction.

 

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Benjamin Hearn is a school-based counselor in Columbia, South Carolina.

Self-disclosure is something that we all do with our clients from the moment we begin interacting with them. Our clothes, offices and other nonverbal communications all disclose things about [us], either intentionally or unintentionally.

Our more common notion of self-disclosure, however, centers on information we share about ourselves verbally with our clients. One piece of information that I have found myself often considering whether to disclose is my identity as a gay male. I most often disclose this information when I have sufficient client rapport and a client voices an incorrect assumption about me, such as asking about my wife. At other times, I may use disclosure to model a healthy gay identity or to promote a sense of similarity between myself and a client.

This latter approach was particularly helpful with a teenage client who had recently come out as gay but did not know other gay people and conceptualized them using common stereotypes. In order to keep the focus on him while disclosing, I framed my disclosure with a question afterward, saying, “I’m not sure if you know this, but I’m also gay and wonder if you see me as fitting within these stereotypes?” This allowed my client to explore differences in gay identities, as well as modeling a secure identity. He noted that he was surprised at how casual I had been in my statement, after which I was able to assist him in exploring reasons that he was anxious about his own disclosure to others.

Regardless of the content being self-disclosed, counselors should consider the possible risks and benefits of disclosure prior to disclosure and how they will keep focus on the client afterward. This can be done by questioning how a client responds to the information or by ending the disclosure using an empathy statement such as, “I remember when my own child left for college. You feel like the house and your life is just emptier.” Though this statement contains a self-disclosure, it is framed in a way that acts as an empathy statement, which the client is then able to evaluate according to their own experience.

Overall, mindful and intentional self-disclosure can act as a powerful technique in the therapeutic relationship [that] can normalize client issues, model healthy behaviors and increase clients’ own self-exploration.

 

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John J. Murphy is a licensed psychologist and professor of psychology and counseling at the University of Central Arkansas. He is the author of the book Solution-Focused Counseling in Schools, published by ACA.

The decision to self-disclose, like any counseling decision, is based on my judgment of its potential to enhance clients’ goals. For me, self-disclosure is never planned but occurs spontaneously, just as it does in other relationships and conversations. Self-disclosure can help convey our humility, humanity and understanding. Research indicates that the most effective counselors are seen by clients as genuine, compassionate and accessible, and self-disclosure can help foster such perceptions.

The following examples of self-disclosure occurred in a psychoeducational group that I led for parents and guardians of children with behavioral difficulties:

  • We started the first meeting by stating that some parents describe parenting as one of the most joyful, gratifying and challenging experiences of their lives. I commented that parenting was much more draining and humbling than I ever expected, adding that “if I made as many mistakes on a job as I do as a parent, I’m pretty sure I’d be fired within a week.” They liked that metaphor and brought it up a few times in subsequent meetings.
  • I made the following comments in a meeting during which a parent stated how hard it was to change her parenting style: “Some of my parenting habits have been really hard to break. One that comes to mind is the use of those short ‘precision requests’ we discussed last week. Even though I teach it to parents, it’s hard for me to do it with my own kids. So, I have these times when I can almost see the words traveling from my mouth toward one of my kids, and I just want to reach out and pull them back before they get there. I’m not sure why I expect these words to work now when they haven’t worked the last 100 times. It’s frustrating and embarrassing.”

Both examples framed the experience of making and accepting mistakes — a valuable skill for any parent — as a shared, inevitable part of any major life journey, parenting or otherwise. While neither example was deeply personal or self-revealing, I hope that acknowledging my own parenting blunders and frustrations helped level the relationship and enhance my approachability.

Self-disclosure, like anything else we do as counselors, is only as useful as clients’ response to it. Obtaining regular client feedback on their experience of the alliance can also help detect a client’s response to self-disclosure and other aspects of our overall counseling style and approach.

 

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Catherine Beckett is an adjunct faculty member in the doctoral counseling program at Oregon State University. She also has a private practice in Portland, Oregon, specializing in grief counseling.

Like many other aspects of counseling, clients are going to have different experiences with different approaches. One question I always ask during the intake process is, “If you have had counseling in the past and it worked well, what was it about the therapist’s approach or style that was positive for you? Or, if it did not work well, were there aspects of the approach or style that contributed?”

Some clients say, “That therapist shared too much; I didn’t like it.” Whereas others may say, “That therapist wouldn’t even answer basic questions about him[self] or herself, and I found it hard to have a relationship with somebody I didn’t know at all.” So, within the bounds of what I believe is ethical and what I feel comfortable with, I will try to be respectful of a client’s preferences in the service of building a positive alliance.

The second principle I have found useful is the practice of requiring myself to have clarity about the purpose of a disclosure prior to making it. I suggest to clinicians whom I supervise that they be able to follow any disclosure with, “The reason I am sharing this is …” This serves two purposes. First, it holds counselors responsible for clarity around intention. Second, it makes the purpose or intention clear to the client, as opposed to — and guards against the possibility of — a disclosure coming across as chitchatty, or as the counselor making the session about him/her.

I also believe that counselors need to be very cautious about using disclosures to convince a client that we understand how she or he feels. Even if we have had an experience similar to what that client is going through, the reality is that we don’t know how she or he feels. We had our own experience, and the experience of our client may be quite different.

 

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John Sommers-Flanagan is a professor of counselor education at the University of Montana and the author of eight books, including Tough Kids, Cool Counseling, published by ACA.

My first thought about self-disclosure is that it’s a multidimensional, multipurpose and creative counselor response (or technique) that includes a fascinating dialectic. On one hand, self-disclosure should be intentional. If counselors aren’t aware that they’re using self-disclosure and why they’re using it, then they’re probably just chatting. On the other hand, self-disclosure should be a spontaneous interpersonal act.

Self-disclosure is an act that involves revealing oneself. As Carl Rogers would likely say, if your words aren’t honest and authentic, then your words aren’t therapeutic. From my perspective — which is mostly person-centered — the purest (but not only) purpose of self-disclosure is to deepen interpersonal connection. As multicultural experts have noted, self-disclosure can facilitate trust more effectively than a blank slate, because transparency helps clients know who you are and where you stand. What’s less often discussed is that it’s impossible to not self-disclose; we’re constantly disclosing who we are through our clothing, mannerisms, informed consent form, office accoutrements and questions.

I remember working with a 19-year-old white, cisgender, heterosexual male. He told me he was diagnosed as having reactive attachment disorder. After listening for 15 minutes, I was convinced that there was no possible way he could meet the diagnostic criteria for reactive attachment disorder. First, I used an Adlerian-inspired question/disclosure: “What if it turned out you didn’t really have reactive attachment disorder?”

You might not consider a question as self-disclosure, but every question you ask doesn’t simply inquire, it simultaneously reveals your interests.

Later, I disclosed directly, using immediacy: “As I sit and listen to all your positive relationships, it makes me think you don’t have reactive attachment disorder.” Despite my interpersonally clever use of an educational intervention embedded in a self-disclosure, my client didn’t budge, countering with, “That doesn’t make any sense, because I’m diagnosed with reactive attachment disorder.”

At that point, I wanted to use self-disclosure to share with him all the ways in which I was a smarter and better health care professional than whoever had originally misdiagnosed him. Fortunately, I experienced a flash of self-awareness. Instead of using disclosure to enhance my credibility, I spontaneously disclosed, “I’ve been talking way too much. I’m just going to put my hand over my mouth and listen to you for a while.”

As I put my hand over my mouth, my client smiled. The rest of the session was — in both our opinions — a rousing success.

 

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Zachary R. Taylor is a licensed professional counselor (LPC) and behavioral health director at a health center in Lexington, Virginia.

I specialize in working with patients who have chronic anxiety and panic, and I regularly disclose that I suffered from these disorders myself for more than 10 years.

The key is being specific about my experiences because many anxious patients feel no one understands what they are going through. Simply saying, “I too was anxious” often doesn’t connect. Instead, I choose specific stories about my many trips to the emergency room, my phobia of checking the mail, the clutching on to my Xanax and my sophisticated driving routes through town to avoid anxiety triggers.

When I share these things, it’s usually out of an effort to normalize their experience and get leverage because, if they know I’ve been there, they’re more likely to accept my help not only as a licensed counselor but also as a former anxiety sufferer who has used these same counseling principles to recover.

Second, I use self-disclosure to reinforce principles we are working on in counseling. For example, to this day, I still experience scary and sometimes tragic images that flash through my mind out of the blue. These used to send me into full-on anxiety spirals, during which I would go through all kinds of safety behaviors to reassure myself that I, and everyone I loved, was OK.

The only real difference between these images then and now is not that the images don’t come back anymore but that I learned how to do things many counselors know as cognitive defusion and psychological flexibility. This is the ability to recognize the imaginary quality of these images and learning how to have the courage to treat them as things I can safely ignore.

This example, in particular, is useful when patients believe every anxious thought, image or sensation and take them as something they need to either respond to or repress. It gives them a new vision that recovery doesn’t mean never having another anxious thought but learning to cope with them when they show up.

However, we must remember there’s a difference between showing patients our psychological scars versus our psychological wounds. There is a significantly greater risk in revealing hurts not yet healed. We must be judicious in self-disclosure, make it brief, always have a clear therapeutic purpose and have a reasonable expectation that the patient can manage the disclosure and that they never feel the need to care for us in the process.

 

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Richard S. Balkin is an LPC and the editor of the Journal of Counseling & Development. He is also a professor and doctoral program coordinator in the Department of Leadership and Counselor Education at the University of Mississippi.

In the second semester of my master’s program, my skills class was taught by a professor who followed a psychoanalytic orientation. She was clear that she would give feedback based on this orientation and that it was OK to reject her feedback as long as we supported any alternative with our understanding of theory. I do not recall any student rejecting her feedback. That being said, I do recall my first session with a client. When the client entered the room, I reached out to shake hands. When reviewing my initial session with the professor and class, I was asked [by the professor] why did I reach out to shake hands? When I indicated I thought that was the polite thing to do, I was told, “That’s about you, not the client.”

I remember being taken aback by this feedback, which seemed to me rather extreme. Not only did I listen to it at the time, but I was influenced by it for many years. Naturally, not shaking hands with the client easily extended to what I could possibly share with a client. If the initiation of a handshake was viewed as countertransference, I could only imagine what my professor would say if I were to self-disclose.

Of course, all of this was challenged in my first year working as a professional counselor, when I worked on a dual diagnosis unit with adolescents. Many members of the multidisciplinary treatment team were active in 12-step support programs, so self-disclosure as a means for teaching about addiction and working together was very natural. More importantly, the adolescents seemed to appreciate the candor and learn something from it.

No doubt, self-disclosure can be helpful, but it can also be self-serving for the counselor, contributing to an unhealthy dynamic in the counseling relationship. If the curative components of counseling truly are based on the counseling relationship, then counselors might do well to consider how self-disclosure will deepen the counseling relationship. In [the ACA-published book] Relationships in Counseling and the Counselor’s Life, my co-author, Jeffrey Kottler, and I mention ways that self-disclosure can be therapeutic, [including] communicating understanding and acceptance and promoting deeper reflection.

 

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Sidney Shaw is an LPC in Anchorage, Alaska, and a core faculty member in the School of Counseling at Walden University.

Researchers often describe two types of self-disclosure: immediate and nonimmediate self-disclosure. Immediate refers to process self-disclosures from the counselor about their own feelings or ways of experiencing the relationship with the client. Nonimmediate self-disclosure or counselor disclosure about their life, personal experiences or biographical information is often what counselors are referring to when they discuss self-disclosure. Immediate and nonimmediate self-disclosure both have potential to deepen the alliance and promote client wellness. That said, there can also be negative effects of indiscriminate self-disclosure. The litmus test of whether or not to engage in self-disclosure is to do so only when it will be therapeutic for the client.

In the spirit of self-disclosure, I’ll share an anecdote about nonimmediate self-disclosure from my own practice. Early in my counseling career, I worked with indigenous communities, and one of my first experiences was to co-facilitate groups on the topic of healthy families and communities. In preparing for the upcoming groups, my supervisor asked me, “Have you thought about what story you are going to share about yourself?” I replied that I had not considered it, and I could feel my anxiety rise as he mentioned it. As a recent counseling graduate, I was highly concerned about negative effects of self-disclosure — e.g., too much emphasis on me, communicating that how I dealt with a situation is how the client should deal with it, etc.

As my supervisor pointed out, and as supported by my subsequent experience and broader research findings on the topic, self-disclosure is frequently an important element of developing trust in working with indigenous clients. One of the groups that I co-facilitated was on the topic of male family relationships. With this in mind, I shared a brief story about my father, how we had been through a long period in which our relationship was conflictual and how we eventually worked to move toward a more harmonious relationship. Cultural context is an important factor to consider in terms of how and to what degree to engage in self-disclosure. Thoughtful and intentional self-disclosure can help counselors build alliances with individual clients and with communities outside of their own.

As counselors, we may initially intend to self-disclose in order to promote client well-being, but self-disclosure can subtly and unwittingly begin to creep toward serving our own needs. The question of whether or not our self-disclosure is therapeutic for the client is not one that counselors should answer in isolation. Ongoing consultation with skilled, wise and competent supervisors and peers is an essential element of helping counselors answer this question.

 

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Caitlyn M. Bennett is a licensed mental health counselor and an assistant professor at the University of North Texas.

One of my areas of clinical expertise is anxiety, especially in adolescents and young adults. Anxiety has a way of making people feel out of control, and oftentimes, clients have told me that they “feel crazy.” Because of this, I have found when processing and making sense of the physiological aspects of anxiety — i.e., racing heart, tightness of chest, etc. — with clients, it can be empowering and validating to self-disclose my personal physical expressions of anxiety.

Prior to this self-disclosure, I find that general psychoeducation about anxiety [and its effects on] the brain and body serves as a catalyst to making sense of anxiety as well as serving as a bit of a normalizing factor. This helps me to gauge whether clients feel connected and understand the physiological impacts of anxiety. For example, their experience of anxiety may not involve as much of the physical experiences. Thus, me expressing my personal physical experiences of anxiety would not be helpful for the client.

After exploring psychoeducation, I begin to encourage clients to share about their personal physical experience of anxiety. If clients have a hard time identifying where in their body they experience anxiety, this is where I introduce self-disclosure by sharing, “When I feel anxious, I may feel my anxiety in my chest or my shoulders tense up. What about for you?”

I have found that this softens and makes exploring anxiety safer and more relatable without taking away from the counseling space being for the client. It also creates an added layer of connectivity for the therapeutic relationship. I have found that some of the most powerful sessions have been when clients feel understood by me as their counselor and also realize that I am only human too.

In all aspects of self-disclosure, I reflect on rapport and encourage my students to do the same. For example, I don’t make it a point to self-disclose prior to establishing a working therapeutic relationship. Self-disclosing prior to creating this relationship may create misunderstanding of what counseling will or will not look like for the client.

It is also important for counselors to remember that self-disclosure can be such a powerful tool. In my personal process of integrating self-disclosure with a particular client, I reflect on the pros and cons of self-disclosure, the difference of impact in emotional (personal feelings) versus content (facts) self-disclosure, the development of the client and multicultural factors. When I have explored this with counselors-in-training, we often focus on using self-disclosure “for good and not for evil.” That is, will the self-disclosure I choose to use be helpful for my client and their process or only benefit myself?

 

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Carol ZA McGinnis is a licensed clinical mental health counselor and approved supervisor. She is a pastoral counselor and clinical director for the AWI Counseling Center at the Fairview United Methodist Church in Phoenix, Maryland, and an associate professor and clinical mental health track coordinator in the graduate counseling program at Messiah College.

As a person-centered [counselor], I rarely self-disclose and only after professional consultation and deep reflection on how that content may be of significant help to the client.

One client who had decided to drop out of high school and pursue her GED received a brief self-disclosure from me at our termination session. I considered the fact that I had dropped out of high school and earned my GED many years prior to completion of my Ph.D. sufficient to disclose. [In doing so, I] meant to encourage and challenge the client to stay the course.

Another client I can recall self-disclosing to was a Muslim adolescent whose parents had asked with concern about my religious orientation. After consultation with my site supervisor and fervent prayer, I decided to disclose my faith tradition along with reiteration of my work that would focus on the client’s beliefs and not my own. It was rewarding to receive a copy of the Koran at our termination session in appreciation from the client and his family.

I do, however, use emotional self-disclosure fairly frequently to validate and normalize client anger. Oftentimes, people who come to me for help with their anger feel shame, guilt or fear, and it has been helpful for them to hear that I am in alignment with them when they report an unfair or unjust event as the source of that emotional response. This disclosure does not include circumstances or stories from my life but instead remains strictly within the realm of emotion in the moment.

One client example of this type of disclosure involved a [client’s] vague memory of an unidentifiable doctor who had engaged in questionable behavior during a medical physical when she was a teenager. The client could not recall what had happened beyond [the doctor’s] request to have her strip naked and do jumping jacks, yet the anger she held toward him was fresh. When this client cursed through tears at this person in the counseling session, I disclosed my own feeling of anger toward this person because he had violated her trust and his professional mandate to act in an ethical manner. Efforts to report this professional were largely unsuccessful due to the client’s blocked memory, yet the client reported feeling affirmed and validated by our work that focused on mitigating that traumatic event.

 

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The ethics of self-disclosure

Practitioners who choose to self-disclose information about their personal lives in counseling sessions often walk a fine line between using it as a tool to connect with clients and diverting attention away from clients and on to themselves.

When used incorrectly, self-disclosure can take focus away from the therapeutic work and the needs of the client. When used appropriately, however, practitioner self-disclosure can build trust, strengthen the therapeutic relationship and help a counselor to express empathy.

So, how much self-disclosure is too much? Practitioners must always put the client first when using any intervention, including self-disclosure, says Joy Natwick, ethics specialist for the American Counseling Association. Counselors should carefully consider their client’s needs and presenting issues and whether the self-disclosure could trigger an issue with which the client struggles, such as excess worry or caretaking behavior, she says.

In addition, self-disclosure should never be used as a response to the counselor’s emotional needs or in situations in which self-disclosure would jeopardize the quality of care to the client, Natwick emphasizes.

Self-disclosure should be regarded as a tool to engage clients and help move them toward their treatment goals. If it would have any other outcome, it is unlikely to be the correct intervention to use, Natwick says.

For additional guidance, consult the following standards in the 2014 ACA Code of Ethics:

  • A.1.a. Primary responsibility
  • A.4.a. Avoiding harm
  • A.4.b. Personal values
  • A.6.b. Extending counseling boundaries
  • B.7. Case consultation
  • C.2.g. Impairment
  • C.6. Public responsibility
  • H.6. Social media
  • I.1.b. Ethical decision making

 

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Related resources from ACA

Books (counseling.org/publications/bookstore)

Counseling Today (ct.counseling.org)

 

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

Letters to the editorct@counseling.org

 

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

Volcanic adolescence

By Chris Warren-Dickins January 14, 2019

In the early days, Caroline, a 14-year-old girl, started each session with a chin thrust indignantly at her counselor. She wanted to be seen as a warrior, and she offered answers that were blunt as a sledgehammer.

And why should she drop her defenses? She had seen too many adults — teachers, social workers, friends of the family — try to engage with her at first, and then seemingly lose interest. In the end, she felt that she was just an inconvenience to everyone around her. Why should Caroline believe that this counselor would offer a different type of relationship?

With any new client comes the challenge of forming a therapeutic relationship, but when that new client is an adolescent, there are additional factors to consider. Aside from the legal issues of capacity and consent, I discuss 10 of those therapeutic factors below.

 

1) A holistic assessment: It is important to adopt a strengths-based approach to assessment of adolescents. In addition, it is worth reviewing that assessment more regularly than with an adult client because more things are likely to change with a growing adolescent. As Urie Bronfenbrenner pointed out, a young person’s development is the result of a complex system of relationships that constitute the child’s environment. Therefore, assessments of young clients will include their developmental needs, the extent to which caregivers are meeting their needs, and their family and environmental contexts, including the influence that their school and peers have on them. The assessment should also gauge the influence of technology in the young person’s life.

2) Emotional “distance” from problems: As an adolescent, Caroline needs her counselor to appreciate that she does not have the same “distance” as adults experience from their problems. Adolescents have little control over their lives. They have to stay in the same home or school, even if these things might be the source of their depression, anxiety or other presenting issue.

3) Grasp of emotional language: As a 14-year-old, Caroline still has not developed her emotional language, so volcanic eruptions of anger or shoulder shrugs of apparent indifference are her only means of expressing how she feels. We have to see past the shoulder shrugging, which can easily be interpreted as nonchalance, and open ourselves to the possibility that young clients want to express themselves but just don’t know how to yet.

Images are a useful starting point, even if it is just looking at a series of facial expressions to try and help these clients identify the emotions they are experiencing.

4) The dominance of transition: Transition features heavily in adolescents’ lives. Each year, they are at a different stage of educational development and, each year, they experience bodily changes. On top of all of this, their ideas about who they are and how they fit in with their peers and wider society are in a constant state of flux.

At this level of fluidity, a counselor can offer Caroline some sort of stability. One source of this stability can be the therapist’s professional boundaries. The counselor can also offer Caroline the benefit of his or her life experiences, providing a deeper context than Caroline’s young perspective. But the counselor’s older years and life experience do not provide complete insight, no matter what the client’s presenting issues is, so a person-centered approach is crucial. We, as counselors, do not know Caroline’s worldview until we explore it with her, and we have to be careful not to make too many assumptions.

5) Disruption tenfold: It is hard for adolescents to experience so much transition, but it is even harder to manage at the same time as dealing with mental or physical health challenges, a chaotic home life or a sudden major change experienced by the adolescent’s parents (e.g., job loss, divorce, bereavement).

Because of the volcanic eruptions of adolescence, there is a danger that adolescents will become scapegoats in these situations. Just because adolescents may shout the loudest does not mean they are the source of the problems. Often, parents bring their adolescents for therapy, and these adults are completely unwilling to consider that the need for change might also rest on their own shoulders, rather than expecting just the adolescent to change and the whole family dynamic to become settled.

6) Discrimination experienced by minority adolescents: If an adolescent client is a member of the LGBTQ community or is an ethnic minority, it is likely that they have endured some sort of discrimination. If adolescents have to make sense of this — in addition to the transitions they are experiencing in their bodies, at school and at home — it can be challenging to deal with.

Is it any wonder that we sometimes see volcanic behavior in adolescents in the form of outbursts and defiance, screamed at us in a burning rage? If we are to help these youngsters, we have to see past the behavior that spews out like lava. We must dare to imagine what unmet needs might be fueling this volcano.

To help us, we can consider Abraham Maslow’s hierarchy of needs, and we can assess to what extent our adolescent clients may be getting their basic physiological needs met. Perhaps they are hungry, or there is the constant threat of homelessness hanging over them. Or perhaps their basic safety needs aren’t being met because domestic violence is present in the home. We can continue working our way up Maslow’s hierarchy (love/belonging, esteem and, ultimately, self-actualization) to understand what unmet needs may be fueling what appears on the surface to be irrational and unacceptable behavior.

7) Trauma-informed care: If the adolescent has a history of trauma, it is especially important to see past his or her volcanic eruptions of anger. In a 2017 article in Counseling Today about young clients in foster care (“Fostering a brighter future”), Stephanie Eberts states that therapists need to “help these children heal” by acting as a “translator” of the child’s behavior: “This includes explaining what a child’s behavior means and what motivates it, and then equipping both the child and the parents … with tools to redirect the behavior and better cope with tough emotions.”

8) Testing (to discover and take reassurance from) the boundaries: Adolescents may test boundaries more than adult clients do. Modeling behavior is important, and this is where congruence comes into play. If young clients are constantly pushing the boundaries by turning up late to sessions or missing them entirely, you can communicate the resulting emotion you are experiencing as a result of their behavior.

I like to think of this like a sonar device: Young clients are checking to see if you are still emotionally there and whether they are also still present in the interaction. You can share this with young clients, showing that certain behavior has consequences. Then you can jointly look for a way to resolve the matter.

Psychotherapist Rozsika Parker wrote about parents’ relationships with their children, but the following statements could apply equally to counselors and their young clients. Young clients “need to learn that they have an impact, that it’s possible to hurt” an adult, but it is also possible to “make it up with them.” Parker encourages adults to “show joy, hate, love, satisfaction — the full range of emotions — that will help the child to know themselves.” Parker wrote that she “heard the same note of reproach in their wails when they teethed, as in the studied criticism of me they could launch as teenagers.”

9) The resistant adolescent: As with any resistant client, adolescents need to feel that they are choosing to be in the sessions. But what happens if they are given no choice? If a therapist is working with a young client and the client’s family, and the young client chooses to leave the session early, what should the approach be?

I have heard some therapists adopt the following approach: They tell young clients that they are free to return to the session at any time but that the session will continue with the other family members. I quite like this approach because it avoids sessions becoming hijacked and held hostage by young clients, which might be a parallel process to other times in which these young clients have held more power than they knew how to handle. For example, they might have been forced to adopt a parental role with a younger sibling, or even a neglectful parent, at an inappropriately young age.

10) Mindfulness and meditation: I have seen and heard some of the criticisms of mindfulness and meditation. I struggle with this because, when I was starting out in this profession, my mentors raved about mindfulness and meditation. I need to see where this debate goes, but in the meantime, I cannot help but believe that there might be some value in mindfulness and meditation in our work with young clients.

Everything we offer our clients involves a balancing act between thoughts, feelings and bodily sensations. Society is built to engage the thinking side of our awareness, and this casts a shadow over our feelings and bodily sensations. Yet all three are important sources of information. If we focus solely on our thoughts, we are arguably functioning at only a third of our capacity. Short and simple mindfulness or meditation exercises can help young clients tap all sources of information, while also giving them a moment of relief from the constant demands of life.

 

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Chris Warren-Dickins is a licensed professional counselor in Ridgewood, New Jersey. Contact him through his website at exploretransform.com.

 

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

The beauty of client and supervisee resistance

By Michelle Backlund and Veronica Johnson August 8, 2018

In the counseling profession, resistance is essentially considered a four-letter word. Actually, many counselors probably feel more comfortable using a four-letter word than they do talking about a client’s or supervisee’s resistance. There are good reasons for this aversion.

Traditionally, resistance shown by clients or during supervision was considered a type of pathology. It was akin to victim blaming. As a profession, we have come to understand that resistance to change or to feedback is often a normal reaction to anxiety, stress, evaluation, trauma or even the learning process. Counselors have substituted many names, including ambivalence and self-protection, in place of resistance to avoid pathologizing normal behavior. As counselors and supervisors, we must choose our words wisely, understanding that every word has unspoken meaning.

History is full of negative references to resistance. Most of these denote the effect of some form of rejection — an idea is discarded, a form of government is found offensive, love has bloomed unrequited in someone’s heart, advice is unwanted, and on and on. However, resistance also has a beautiful aspect: the formation of diamonds as they respond to the pressure of the earth, muscles gaining tone and strength under the resistance of weight, the violinist’s fingers sturdily pressing the strings of her instrument as she then presses her bow to produce the sound.

Taking it a step further, here is an object lesson: I (Michelle Backlund) was visiting with a colleague who previously taught ballroom dance for 30 years, and he recognized how physical resistance could create connection, spontaneity and fun within a dance partnership. I was sharing with this colleague the many negative effects of resistance on relationships.

He asked me, “Did you know that resistance is really a great tool to make relationships strong?”

I said, “How?”

He said, “Put your hand up, with your palm facing me.”

I did, and he placed his hand against mine, then gently pressed. I automatically pressed back. He showed me how the pressure in the form of resistance connected our hands and held us together. The resistance allowed him to move his hand from place to place; it allowed me to feel that movement and follow him. Then he said, “With no resistance, there is no connection — you cannot move together.”

This simple object lesson created a paradigm shift for me as a counselor and as a supervisor. I began wondering how to harness client and supervisee resistance to create stronger, more collaborative, nonpathologizing relationships. This is the beauty of resistance.

Most humans use resistance to assure their physical and emotional safety. The reality is that the world can be truly threatening, and resistance is a means of reducing that threat. Whether we are discussing resistance as it relates to a client who has taken the risk to attend counseling or a supervisee who understands that supervisors serve as gatekeepers to the counseling profession, their anxiety and protection of identity should be regarded as normal reactions to a perceived threat.

An obvious question then arises: How do we recognize resistance that is showing up in our counseling or supervision sessions? You might laugh at this question, feeling that you know all too well how to recognize resistance. Resistance can be difficult to identify, however, especially for new counselors and new supervisors. Responding to the many threatening experiences that humans face from childhood through adulthood, people may unknowingly develop very artful and socially acceptable methods of manifesting their resistance. Of course, some methods are less artful.

Recognizing forms of resistance

Some forms of resistance are easier to detect than others. My interest in this subject came from my experiences as a counselor and as a supervisor. I noticed that sometimes I would come out of a session feeling what I called “yucky,” but I didn’t really know why. Things seemed fine, but for some obscure reason, I did not feel good about the session.

Then I came across some old literature about how resistance manifests in supervision, written by Cheryl Glickauf-Hughes, that changed my world. First, I started saying things like, “I do that to my supervisor,” and “I feel like that.” Then, when I was counseling or supervising others, I suddenly heard what I had not been able to hear previously: resistance. In my new exuberance, however, I quickly picked up on an attitude from other professionals of “We don’t use that word.”

The conclusion I finally reached after an extensive literature review on the different linguistic substitutes for the word resistance is that no word stands alone without using resistance to help define it. To me, this says that turning away from use of the word resistance is not really feasible. However, it is feasible to harness the constructive power of resistance by using it to create relationship. But to use this tool, we need to be able to identify resistance in its various forms.

Game playing

Game playing may be used as a form of resistance either consciously or unconsciously. Either way, it is deployed as an attempt to maintain control. I think of it as a type of shell game in which attention is drawn elsewhere to get the player (i.e., the counselor or supervisor) to lose his or her place. Esteemed social worker Alfred Kadushin wrote about game playing; what follows in this section is a synthesis of some of his ideas combined with some of my own.

One game-playing technique is flattery, which is used to deflect counselors or supervisors either from confrontation or their evaluative agenda. Flatterers are the clients or supervisees who can talk for 20 minutes about the counselor’s or supervisor’s outfit, the office décor or even the “game” the other night, secretly hoping that the counselor will run out of time to address some important aspect of the prior session or the supervisor will run out of time to look at their session recording.

Other types of game playing may include:

  • Redefining the relationship, in which the client or supervisee creates ambiguity.
  • Self-disclosure, in which the client or supervisee talks about himself or herself through telling stories. Clients might do this by skipping from one story to another, giving no time for reflection or comment. Supervisees might use storytelling about self or clients, engaging the supervisor so there is no time for skill correction.
  • Trying to reduce the counselor’s or supervisor’s power, in which clients or supervisees attempt to show that they are more intelligent than the counselor or supervisor.
  • Working to control the situation with the direct use of questions that can steer conversation away from the client’s or supervisee’s areas of anxiety.
  • Focusing on failure and seeking reassurance.
  • Allowing helplessness to feed into dependency by working to implement every single word that the counselor or supervisor shares in session.
  • Practicing self-protection by externalizing blame for their lack of growth on the counselor or supervisor.

It is important to remember that playing games is designed to create safety and protect the self.

One simple way to work with game playing is role induction. Clients and supervisees have constructed coping strategies (resistance) that have served them well. Typically, these strategies have evolved in an organic way and are outside of the client’s or supervisee’s awareness. We can help these individuals understand that counseling or supervision can be stressful and that clients or supervisees may develop certain behaviors as a way of dealing with their anxiety or stress. In normalizing this process, it becomes less threatening.

You could provide your clients or supervisees with a list of behaviors, thoughts and feelings that they might experience during your work together, then invite them to freely point out these behaviors, thoughts and feelings to you as they notice them. This broaching process becomes a step toward creating a collaborative relationship. As they point out their own resistance, you can be appropriately curious about it and then thank them for bringing it to your attention. Often, clients and supervisees will not call attention to their own resistance. However, as they grow more aware of it, they may choose to lay these behaviors down in an effort to use their time more wisely.

Developmental causes of resistance

Another way to look at resistance is through a developmental lens. It has been proposed that manifestations of resistance can have roots in the unsuccessful completion of Erik Erikson’s developmental stages. What would we listen for if we used this framework in our counseling or supervision sessions?

Trust versus mistrust: When clients or supervisees have not fully learned to trust others, the anxiety produced in an ambiguous setting such as counseling or supervision may create enormous tension. In many instances, those who have not successfully navigated this stage have experienced parents, guardians or other authority figures as harsh, critical or unaccepting of them. Often, they expect to be rejected by their counselor or supervisor.

This lack of trust can be recognized by clients’ or supervisees’ maintenance of distance in the relationship; they may seem closed, guarded, defensive and extremely self-sufficient. Identifying these traits is essential to using this information to strengthen the relationship and create collaboration. Glickauf-Hughes suggests that when working with those who are distrustful, taking a person-centered, nondirective approach can help them to feel safe and may provide a corrective experience. Consider letting them know that you can tell they are a bit guarded; ask them whether they have been hurt in the past and whether they are concerned that you might also hurt them.

Autonomy versus shame and doubt: Clients or supervisees who struggle with issues surrounding the need for autonomy can be confusing for counselors and supervisors. Erikson warned that controlling others helps those without a sense of autonomy to feel in control of their own lives.

Often, those who struggle with autonomy cannot quite put a name to what they want, but they can clearly identify what they do not want. They often vacillate between seeking direction and then dismissing the very information they sought. An exchange with someone who struggles with autonomy might sound something like this:

Counselor: “Mary, I hear you saying that this situation is irritating you.”

Mary: “I’m not irritated, I’m frustrated.” 

To protect their personal freedom, these individuals may mince words or say things like “yes, but …” — anything not to accept influence from others.

Glickauf-Hughes and Linda Campbell suggested three ideas for working with those who struggle with autonomy: Socratic questioning, homework, and healing stories or puzzles. These strategies put power directly into the hands of clients or supervisees, allowing them to arrive at the answers they seek without things being laid out for them explicitly. Interestingly, this is helpful even when resistance is not present. Most people enjoy finding their own answers; it increases their self-efficacy and helps them to feel autonomous. This is exactly why it works so well for those with issues of autonomy.

Those who have not successfully navigated the aspect of shame versus doubt are particularly sensitive to any confrontation or feedback, even when it is done with extreme care and sensitivity. Issues of shame originate within relationships and indicate to the individuals being shamed that, somehow, they themselves are unworthy or defective. Unfortunately, shame can be so internalized that it becomes self-activated and no longer attached to an interpersonal event. This may present as clients or supervisees being so hard on themselves that it preempts any possible feedback from others.

This ultra-vulnerable type of person is, in some ways, reminiscent of a sensitive child. This makes sand tray therapy or sand tray supervision an excellent tool for working with clients or supervisees who have internalized shame. For those who believe intrinsically that they are somehow unworthy or defective, the sand tray is a wonderful avenue for them to look at issues and dynamics in a nonthreatening way. The figures become a buffer between these individuals and the counselor or supervisor, protecting the ego from further damage. This is less threatening for supervisees because they can work out the dynamics they are witnessing with their clients. Sand tray therapy or sand tray supervision can also create self-awareness. When incorporated with Carl Rogers’ core conditions, this can cause confidence to grow and doubts to recede among clients and supervisees.

The use of positive reframes can also be used to reduce anxiety and increase receptivity to change. Mark A. Masters suggests that positive reframes should be designed to emphasize the client’s or supervisee’s experience of personal power and self-esteem. The use of positive reframes is most useful when three different components are present.

First, the reframe empowers clients and supervisees by improving their self-reliance and motivation. Second, most behaviors can be asserted in a positive connotation. This can increase clients’ and supervisees’ sense of safety within the counseling or supervisory relationship, thereby promoting reflectivity and growth. Finally, the positive reframe is most useful when it models more effective ways of dealing with the person’s thoughts, feelings and behaviors. When all three of these components are applied together, they can create a powerful alliance that furthers clinical development. Glickauf-Hughes emphasizes that when reframing, the counselor’s or supervisor’s word choice needs to be mild and should evoke curiosity in the client or supervisee.

Identity versus role confusion: What about the client or supervisee whose fundamental issues with others involves the developmental stage of identity versus role confusion? This fragile sense of self can come into play as clients and supervisees strive to find their confidence or shift their already-fragile identity. In this case, learning from the counselor or supervisor would mean merging with him or her, so clients and supervisees in this developmental stage steadfastly hold to their current identity. Signs of this resistance can come through expressions of contempt (such as eye rolling and other demeaning behaviors and statements), often appearing argumentative or expressing directly or indirectly that all other modes of being (for the client) or all other theories (for the supervisee), other than their own, are without value.

Metaphors can provide a means to use what a person already knows and relate it to even more complicated information in a way that transfers the learner’s original understanding to the new situation. The use of metaphors, or the process of transferring information from the known to the unknown, can enhance the learning process and create an atmosphere in which resistance improves emotional connection. For those who feel their identity threatened, the use of metaphors, jokes or Socratic questioning can help them find their own answers. This maintains their identity and prevents them from rejecting the information.

Externalizing issues can also reduce stress in the client or supervisee, again allowing both learning and a better relationship. For example, let’s say your client with a talent for writing music has a goal to develop relationship skills to create a more satisfying social life. Relating the client’s goal to something with which the client is familiar may transfer his or her understanding of one skill to another. In this case, you might first create a theme for the type of song or type of social life the client wants. Let’s imagine it will be a ballad because the client is looking for an intimate relationship. Next, a basic melody is plotted out (what type of person is the client looking for?). Then the lyrics are sketched in (does the client believe this type of person already exists in the client’s current social circle?). Add some harmonies (how can the client enlarge his or her social group?). Once the basic song is set, the addition of instrumentation, percussion and orchestration develops the song into a masterpiece, with all of the different pieces adding to the complexity and beauty of the finished product (how might the client expand the types of activities that he or she enjoys — sports, theater, reading, dancing, outdoor recreation and so on?).

Metaphors, in the form of stories or drawing activities, allow clients and supervisees to depict themes, issues and relationships in their lives or their clients’ lives. At the same time, the use of metaphors leaves the identity or newly emerging identity of the client or supervisee intact.

Motivational interviewing

Motivational interviewing can broaden our view of resistance in a way that can be applied to the supervisory relationship. William R. Miller and Stephen Rollnick, the primary developers of motivational interviewing, explore using resistance to increase connection. Rolling with resistance — which simply means being curious about it — can strengthen relationships and depathologize resistance as normal. Supervisors can easily detect resistance in supervision and can choose to employ some basic motivational interviewing responses to join with the supervisee and open the door to exploration.

Developing the discrepancy: Imagine a supervisee who presents as needing assistance and guidance in working with a difficult client, but when provided with that guidance, responds with, “I don’t think that will work because I already tried ________” or “I don’t think the client will respond well to that because of ________.” 

Developing the discrepancy involves acknowledging what the supervisee wants and then also acknowledging the difficulty the supervisee has in accepting this help or guidance when it is offered. The supervisor’s response might be along these lines: “This sounds like a really challenging client. I hear that you really want help moving forward with the client, and I notice that it’s hard to hear some of the suggestions that I have.”

The specific use of and instead of but in this example is important. And creates the possibility that the supervisee can exist in both worlds — one of wanting help and another of rejecting it. Embracing the ambivalence that a supervisee might feel in supervision can open the possibility for the supervisee to explore what it feels like to be needing connection and resisting it at the same time. And it’s also possible that the supervisee’s client feels the same way — an example of parallel process.

Agreeing with a twist: Being a supervisee is hard work. The courage it takes to present clinical work that is mediocre and the vulnerability required to sit with a supervisor and watch the “magic” unfold can be unnerving. “Agreeing with a twist” refers to reflecting on the risk that a supervisee takes when sharing difficult sessions with a supervisor (especially when the supervisee is not yet in a place to be vulnerable and courageous) and then providing a reframe that opens discussion.

Imagine a supervisee who seems to select sessions or cases to discuss in supervision that aren’t of substance or that don’t allow many opportunities for constructive feedback. This behavior could indicate that the supervisee is protecting his or her already-fragile ego from potentially critical or damaging feedback. Addressing this in supervision is tricky. Agreeing with a twist might sound something like, “It can be so hard to watch sessions that you don’t think are great. I remember what that felt like when I was in training. What are some of your concerns about showing me your not-so-great sessions?”

This example is a three-part equation:

1) Acknowledging and validating the supervisee’s experience.

2) Offering a simple self-disclosure that deepens the reflection.

3) Asking an open-ended question that gets at the heart of what is happening, apart from the actual case the supervisee has brought to discuss.

This method of “caring confrontation” serves to invite the supervisee to share his or her fears of negative evaluation. It also allows the supervisor to assuage those fears and build the kind of relationship in which a supervisee can share “not so great” work without sacrificing a piece of his or her ego.

Using OARS as a basic model for resistance-free supervision: At its core, motivational interviewing is person-centered. Simple strategies for supporting, inviting and engaging supervisees early in the supervisory relationship are often overlooked. OARS is an acronym that can serve as a reminder to supervisors (and counselors) that the basic skills of open-ended questions, affirmation (support, appreciation and understanding), reflective listening and summarizing are absolutely essential and can foster connection, openness and curiosity in both supervisees and supervisors (and clients and counselors).

 

Conclusion

The usefulness of any tool involves its accessibility and effectiveness. The beautiful aspect of resistance as a tool is that it is consistently present in some form. It is always available to strengthen the counseling or supervisory relationship. Try using the tools we have suggested in this article and working to identify strategies that can reframe resistance in positive, collaborative and nonpathologizing ways. Resistance provides opportunities to connect, engage, be curious and, ultimately, foster the kind of counseling and supervisory relationships that create growth and change.

 

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Special thanks to Ray Backlund, coordinator of the New Mexico State University dance program, who holds a doctorate in counselor education and supervision, for sharing his connection between ballroom dance and positive uses of resistance with supervisees.

 

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Michelle Backlund is an assistant professor and clinical director of the master’s program in the Counseling and Educational Psychology Department at New Mexico State University. Identifying positive uses of resistance to enhance all types of relationships is a major part of her research agenda. Contact her at micback@nmsu.edu.

Veronica Johnson is an associate professor and chair of the Department of Counselor Education at the University of Montana. Her research interests are intimate relationship development and maintenance, forgiveness in intimate relationships and clinical supervision. Contact her at veronica.johnson@mso.umt.edu.

Letters to the editor: ct@counseling.org

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

 

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

The high cost of human-made disasters

By Lindsey Phillips March 1, 2018

The stories of the aftereffects of human-made disaster have become all too familiar: a refugee forced to make a dangerous journey to find a new home; the soldier deployed thousands of miles from home for months at a time; the person who finds his or her world turned upside down when a shooter enters the room and begins firing. It’s not surprising, then, that according to a report by the American Psychological Association, in 2017, 60 percent of Americans felt stressed about terrorism and 55 percent felt stressed about gun violence.

In addition, refugees fleeing war-torn countries have created an international crisis, and, among other things, they aren’t getting the mental health care they need. The International Medical Corps found that 54 percent of Syrian refugees and internally displaced populations in Syria, Lebanon, Turkey and Jordan suffered from severe emotional disorders, including depression and anxiety.

The increase in human-made disasters raises a question for counselors and others: Does the type of disaster — natural, human-made or technical — affect the severity of the trauma or the counseling approaches used to treat it? Devika Dibya Choudhuri, an associate professor at Eastern Michigan University, says sufficient research indicates that when human agency is involved, the disaster has a more traumatizing effect. Although natural disasters are traumatizing, there is often a huge response of communities taking care of one another, which tends to be a restorative factor, she explains.

“With human-made disasters … the aftermath is also conflicted,” says Choudhuri, a licensed professional counselor and American Counseling Association member who presented at the ACA 2017 Conference & Expo in San Francisco on group interventions in the aftermath of violence, terrorism and dislocation. “Most [refugees’] … traumatizing stories are not just [about] the original trauma. … The journey after is so profoundly traumatizing as well because not only are they ungrounded from the loss of home, but then all of these additional wounds are made. There is no safety anywhere, as opposed to that sense [after a natural disaster that] people are coming forward to help.”

Rebuilding trust, regaining control

Choudhuri, who worked with Cambodian and Bosnian refugees in the 1990s and has worked with Iraqi and Karen refugees since the 2000s, points out that survivors of human-made disasters are fighting on two fronts: struggling to survive in their environment and engaging in an inner conflict where the original strategies for survival during the trauma are no longer helpful. Thus, when it comes to trauma and human-made disasters, counselors should focus on restoring a client’s sense of control, not safety, she advises.

Hannah Acquaye, an assistant professor of counseling at Western Seminary in Portland, Oregon, works with refugees from war-torn countries such as Afghanistan and Iraq and parts of Africa. She finds that for refugees from countries where neighbors are fighting neighbors, the trauma is unique in terms of feeling a sense of betrayal. If the person holding the gun and causing the devastation is someone they know and used to play with growing up, then the trauma becomes especially troubling, she says. “It affects the way they trust people … and makes it harder to build a community back,” explains Acquaye, an ACA member whose research focuses on refugee trauma and growth.

Thus, rapport and trust are crucial for survivors of a human-made disaster. According to Mark Stebnicki, professor and coordinator of the military and trauma counseling certificate program in the Department of Addictions and Rehabilitation Studies at East Carolina University (ECU), empathy and listening are critical elements of establishing rapport and gaining the trust of these clients.

Establishing a therapeutic alliance can be problematic, however. Counselors often learn to build a therapeutic alliance by offering warmth and connection and by encouraging clients to tell their stories, Choudhuri points out. But for individuals who have experienced a “traumatizing offense through human agency … the betrayal and abandonment and loss of trust during the process gets triggered by the very warmth of the connection,” she explains. Counselors will often experience that after making a connection and getting the client to open up, the client never shows up again or ends up in the hospital, Choudhuri says.

Before uncovering the trauma, counselors must help rebuild and ground clients so that they will have resources to address the trauma, Choudhuri argues. “Rather than creating a therapeutic alliance, it’s about rebuilding the kinds of ways in which people can take care of themselves so that they don’t require the therapist to do that,” she explains. In fact, she advises that counselors should work with survivors of human-made disasters as if they will have only one session together. The first few sessions should focus on techniques that will help clients function in case they don’t return, she says.

One way counselors can help clients become autonomous is by providing them with tools to regulate their emotions. Somatic and emotion regulation techniques allow survivors of human-made disasters to notice their triggers on a sensorial basis and use their brain to counter this negative trigger, says Choudhuri, a certified eye movement desensitization and reprocessing (EMDR) therapist. In a sense, their brain becomes an ally, rather than an obstacle or hindrance, in their recovery.

One of Choudhuri’s clients suffered trauma after being held captive and tortured for several days. Smelling the cologne worn by one of his captors would trigger the client. After identifying this sensorial trigger, Choudhuri set out to counter it. She discovered that the client found lavender essential oil calming, so she directed him to take in the lavender scent anytime that he encountered the smell of cologne. The process works on two levels, Choudhuri notes, because “it’s addressing the sensorial piece, but it’s also giving control back [to the client].”

Choudhuri also finds that traumatic resilience is important when working with survivors of human-made disasters. Many resourcing and grounding techniques that counselors use can also make clients more resilient in the face of ongoing trauma, she notes. For example, Choudhuri finds the container technique helpful for her clients: She tells clients to think of a container with a secure lid (e.g., a jar, a jewelry box) and then to use that container to mentally store the parts of the trauma that get in their way and prevent them from moving forward.

Group work is another resource that can help survivors of human-made disasters rebuild a sense of trust. At the same time, Choudhuri says, “group work is really challenging, particularly for [people] who have had human-made disasters, because other human beings are a source of threat [to them].”

In fact, Choudhuri is careful to avoid touching clients who have been hurt by other human beings. Instead, she teaches clients how to give themselves a comforting touch. For example, she uses the butterfly hug method (clients cross their hands over their chest and alternately tap their hands to a heartbeat cadence) while she facilitates thoughts of being safe and loved. This technique works well with children and is one that clients can do themselves when they are upset, she adds.

Rather than asking individuals to share their trauma in groups, Choudhuri suggests having them process it in a way that allows group members to provide comfort to each other, thereby helping restore a sense of control, trust and efficacy. For example, counselors could have individuals teach each other how to engage in deep breathing. “It allows for people to feel empowered to … not just be on the receiving end but also on the giving end,” Choudhuri explains, “and then they’re giving something that they themselves are learning, which helps them learn it better.”

From Stebnicki’s perspective, groups not only allow counselors to identify people who need more individualized treatment but also provide a safe space to verbalize and normalize survivors’ feelings (e.g., anxiety, depression, grief, sleeplessness) about an event and prepare them for the forthcoming weeks. “If you get [clients] to open up and share feelings [in a group], then the group itself is your own best source of support because they can normalize what that scary event was like,” he says.

Bridging cultural differences

Stebnicki acknowledges that working with people who are culturally different from the counselor can be challenging. Clients who are refugees, immigrants and asylum seekers may pose an even greater challenge because American counselors are often far removed culturally from individuals from war-torn countries such as Syria and Afghanistan, he adds. But successful treatment relies on understanding clients’ cultures and how they heal, he asserts.

In some cultures, counseling as generally practiced in the Western Hemisphere doesn’t exist, so counselors shouldn’t force clients to share their stories, Acquaye says. Instead, counselors should focus on providing a safe, supportive environment and inform clients that they are in the moment with them, she advises.

Stebnicki, a member of both ACA and one of its divisions, the Military and Government Counseling Association, says that he distinguishes between civilian and military responses to human-made disasters. “Military is a culture unto itself,” he says. “Military personnel experience person-made disasters differently in that instead of detaching, isolating, running and going into shock like civilians do, they adapt and survive, and they aggress … [not] stress.” Unlike civilians, who typically respond to a shooting by running away, military personnel are generally running toward the gunfire, he points out.

At the same time, civilians and military personnel experience similar physiological, psychological and emotional responses to human-made disasters. However, military personnel also experience ongoing trauma stressors (such as multiple deployments) and generally do not undergo the full range of posttraumatic stress disorder (PTSD) symptoms until after their deployment or military service ends, Stebnicki says. Thus, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders “measures PTSD, but mainly in civilian life because it doesn’t take into account this … repeated exposure to trauma which military [personnel] are exposed to,” he argues.

In addition, military personnel often cannot easily take advantage of mental health services in the same way that most civilians can because of the stigma that military culture places on it, Stebnicki says. Using these services can sometimes put their security clearances at risk, cause them to get demoted or have others in the military lose faith in them and their ability to lead, he explains.

Despite these difference, many counselors try to treat military personnel as civilians and do not recognize the distinctions between civilian and military mental health, Stebnicki says. To help address this issue, he developed the certificate in clinical military counseling at ECU. The course trains professional counselors on some of the unique cultural differences in diagnosis, treatment and services for members of the military.

Making meaning of human-made disasters

In the face of a human-made disaster or a large-scale political event, people often feel helpless, like a small cog caught in a big wheel, Choudhuri says. In such cases, the counselor’s aim is not to help clients find an answer to existential/spiritual questions of why the disaster happened but to help them figure out a meaning to these events that they can live with, she says.

Meaning making should also involve some degree of personal growth, Stebnicki notes. He says that counselors can determine whether clients have experienced posttraumatic growth by their actions: Are they taking their medications? Are they going to counseling? Have they reconnected socially? If the answer is no, then there is no growth, he says.

The counselor’s job, Stebnicki contends, is to provide tools and resources to help clients take responsibility for finding meaning and growing from the trauma. However, he points out, growth is painful, so counselors must prepare clients to take small steps toward identifying ways of feeling safe and ultimately finding meaning.

Acquaye actively celebrates her clients’ small victories because she believes it encourages them. She had one client who was a refugee who was depressed because she didn’t know how to communicate in her new culture. Acquaye asked her to try to leave her apartment each day and walk around for five minutes. When her client was successful, Acquaye jumped up and down in front of the woman to celebrate her progress. Taking this small step forward helped her client begin to sleep regularly again, Acquaye says.

Choudhuri looks for ways to address clients’ despair without trying to change their beliefs about what happened. She finds EMDR helpful because it allows people to process internally without having to give the counselor details about their trauma. At the same time, clients are able to arrive at a meaningful narrative about their experience. “It may not be my answer, but it’s their answer,” Choudhuri adds.

Choudhuri provides an example of a Syrian refugee who participated in EMDR therapy that involved drawing and processing his trauma. At the end of the session, he said that regardless of the terrible things that had happened to him, he realized that every night has a morning. “It wasn’t that he got an answer or that he had a solution,” Choudhuri says, “but he got what he needed — hope.”

For many clients, spirituality plays a large role in meaning making. If the client’s and counselor’s spirituality differ, then the counselor should find common ground to discuss spirituality, Acquaye advises. The majority of her clients are Muslim and Acquaye is Christian, so in session, they discuss the general concept of God and who is in control of everything. “We can’t explain why people do what they do, but we can hold on to somebody who is greater than people and know that some good may come out of that,” she explains.

Self-care and counselor fatigue

Clients’ stories of trauma, suffering and loss can take a toll on counselors, resulting in counselor burnout, compassion fatigue or empathy fatigue. The cumulative effect of seeing multiple survivors of human-made disasters and other traumas can start to deteriorate counselors’ spirit to do well and damage their own wellness, Stebnicki notes. For that reason, counselor self-care must become a priority when working with survivors of human-made disasters.

Stebnicki differentiates between empathy fatigue, a term he coined, and other fatigue syndromes such as burnout and compassion fatigue. He explains that empathy fatigue results from a state of physical, emotional, mental, spiritual and occupational exhaustion that occurs as the counselor’s own wounds are continually revisited through a cumulation of different clients’ stories of illness, trauma, grief and loss.

The major difference between these types of fatigue syndromes is that empathy fatigue has an added spiritual component, Stebnicki notes. Horrific experiences such as genocide and torture go beyond the range of ordinary human experience and affect the mind, body and spirit, he explains. Thus, it is crucial that counselors are properly trained to be empathetic and compassionate, he says. In addition, because people experience and define spirituality in their own individual ways, counselors must understand their clients’ views of spirituality to assist them in cultivating hope and psychosocial adjustment to their trauma.

Acquaye acknowledges that she didn’t initially realize how much the stories of her refugee clients would affect her. If counselors are struggling with counselor fatigue, they need to seek help to avoid harming their clients, she advises. “It’s not about me. … If I claim I’m an advocate for my refugee clients, then I should get over myself and ask for help, so I’ll become a better person for them,” she says.

Choudhuri says counselors must also guard against making another common mistake. Because refugees often have little meaningful support, they are incredibly grateful when they do receive it, and there can be a danger in that for counselors. “If [counselors] work long enough with [refugees], it gets really easy to feel like a savior,” Choudhuri admits.

“One of the things that trips [counselors] up is this belief of indispensability — that there is nobody else, so I have to keep doing it even if I don’t want to,” Choudhuri adds.

She also finds that working with clients who have survived a human-made disaster can bring out something of a competitive nature in counselors: They assume (often incorrectly) that if the client can deal with the trauma, then they can too because they are the counselor.

Among the possible signs of counselor fatigue syndromes that Stebnicki notes are having diminished concentration, feeling irritable with clients, feeling negative or pessimistic, and having difficulty being objective or compassionate. “We’re good as counselors at giving advice to others and helping facilitate self-care strategies, but we don’t do it ourselves. We need to take our own best advice and get help,” he advises.

Stebnicki has found peer support helpful when dealing with fatigue syndromes. He and other colleagues meet once or twice a month to vent and share their stories. In fact, he notes that it is common to have ongoing peer support on-site for counselors and first responders at large-scale human-caused disasters. These support groups allow counselors to discuss what they saw, how it affected them, how they are responding and how they are going to overcome it, he says.

Acquaye is thankful for her supervisors and own personal counselor who help her guard against burnout. “I have to remind myself all the time that I’m not God … so I can’t carry my client because sometimes the stories are so heavy that you can’t sleep at night,” she says. She realizes that carrying the burden of her clients’ stories will serve only to make her negative and ineffective as a counselor.

Many counselors are drawn to working with refugees because they want to help, but before jumping in, Acquaye says, counselors should understand what their strengths and limitations are. “Ask yourself [if] you have enough strength for the kind of stories they will throw at you. [If not], it doesn’t mean you are not good enough. It just means that that is not your area,” she says. “When it comes to refugee work … you are going to go through the trauma yourself, so you have to ask yourself, ‘Do [I] have what it takes to go through that?’”

Lessons learned

How can counselors prepare to handle the specific needs of survivors of human-made disasters? “Training to be trauma informed becomes key. … There shouldn’t be counselors coming out of counseling programs who don’t have a basic understanding of trauma,” Choudhuri asserts. Yet, she finds that counselors often report not knowing how to deal with trauma and disaster mental health.

Choudhuri thinks that one area of disaster mental health where training needs to improve is clinical competency. Often, counselor educators aren’t practitioners, which can be problematic because they don’t see the chronic nature of clients’ issues and thus don’t prepare adequately, she contends. She argues that counselor educators should stay clinically active — perhaps even working with survivors of human-made disasters — to keep their finger on the pulse of what is happening.

Of course, Acquaye admits that counselors are never likely to have all of the training they need to handle disaster mental health straight out of school. Many of the skills must be learned on the ground. She recounts a time when despite her training on refugee trauma and posttraumatic growth, a client’s story scared her to the point that she was shaking. She had to remind herself that even though she had no idea how to treat the client’s many issues on the spot, she needed to start by listening to the client and then figuring it out as she went along by researching and assessing the client’s needs.

What people consider to be trauma or traumatizing changes over time, Choudhuri notes, so the symptoms that veterans displayed after the Vietnam War are not the same ones that soldiers returning from Afghanistan and Iraq have displayed. Today, counselors also have to take into account the fact that there is more aggression digitally, and digital aggression distances people from the trauma, she adds. For example, drone warfare has changed the rules of war, allowing people to kill from a distance. This makes killing more impersonal and affects the mental health of drone pilots differently.

“As conflict becomes handled differently, [so does] the kinds of betrayals and ways in which people can be hurt electronically. … [People’s] sense of danger and risk become different than if somebody broke into [their] house. They’re related, but they’re different,” she says.

One mistake that counselors often make when working with clients is expecting a more intense early disclosure of the traumatic incident, Stebnicki says. Stebnicki worked as a member of the crisis response team for the Westside Middle School shootings in Jonesboro, Arkansas, in 1998. In the aftermath, he witnessed a counselor go up to a student, take him by the shoulder and almost shake him to force disclosure of what the student had just experienced. Counselors must remember that everyone heals at his or her own rate, so survivors of human-made disasters may not want to discuss their experiences immediately after the event, he says.

Stebnicki has also found that people’s experiences vary based on their proximity to the disaster’s epicenter. “We all differ in stress and trauma in terms of the pattern, the frequency, the exposure, the magnitude/intensity. So, in other words, we all turn our stress response on differently,” he says.

In working with refugees, Choudhuri has learned that counselors can’t assume to know the trauma. One of her clients had been married off by her parents while in the refugee camp to a man who raped her. Was the worst part of her experience being in the refugee camp, losing her home or being raped? Choudhuri discovered that for the client, it was that her parents didn’t love her enough to have chosen a better husband for her.

“It wasn’t the violence that drove her from her home, it wasn’t the destruction of her life as a schoolgirl, and it wasn’t even the brutality of her experience in the marriage,” Choudhuri says. “It was the sense of being betrayed by her parents.” Thus, counselors should remember that the focus of the work is not about the trauma but about the client, she adds.

Choudhuri has also observed that although disaster mental health professionals have developed ways to work with people immediately after a disaster, they often fail to implement this guidance back home. She argues that counselors don’t respond to the ongoing, everyday disasters happening in their backyards — the microaggressions and microassaults that wear people down as they try to overcome obstacles of systemic racism, chronic poverty, violence and substance abuse — in the same manner as they respond to large-scale events.

“If we can point to the singular event, we can be horrified by it and [respond] with compassion and helping, but when we live in it, we numb ourselves … to it because we feel helpless,” Choudhuri says.

“It’s difficult because we all want a place of safety … so it’s easier to go away somewhere and work on [disaster mental health] and then come back [home] and be safe,” she points out.

Counselors need to resist the urge to let trauma and disaster response fade into the background because of the discomfort these events can generate, Choudhuri argues. Instead, they must keep disaster mental health in the foreground and help rebuild communities and individuals affected by disasters, including those less obvious disasters happening in counselors’ backyards.

 

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Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia. She has a decade of experience writing on topics such as health, social justice and technology. Contact her at lindseynphillips@gmail.com or through her website at lindseynphillips.com.

Letters to the editorct@counseling.org

 

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

Building better counselors

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

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

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

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

Evidence-based relationship factors

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

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

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

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

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

Evidence-based attitudes and behaviors

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

Congruence

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

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

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

Role induction

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

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

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

Unconditional positive regard

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

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

Empathic understanding

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

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

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

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

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

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

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

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

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

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

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

Cultural humility

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

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

2) Respect for client values and ways of being

3) An attitude of equality, not superiority

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

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

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

Scientific mindedness

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

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

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

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

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

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

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

Managing countertransference

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

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

The evidence-based therapeutic alliance

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

1) The emotional bond

2) Mutual goals

3) Collaborative tasks in counseling

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

The emotional bond

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

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

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

Mutual goals

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

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

Collaboration on tasks linked to goals

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

When applying techniques, relationally oriented counselors:

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

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

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

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

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

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

Progress monitoring

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

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

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

Rupture and repair

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

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

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

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

The relationally focused, scientifically based counselor

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

 

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

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

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

Letters to the editor: ct@counseling.org

 

 

 

 

 

 

 

 

 

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