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Counselingskillsandprocesspsych410.pdf

Counselingskillsandprocesspsych410.pdf

Learning the art of heLpingBuilding Blocks and Techniques

S i x t h E d i t i o n

Mark E. YoungUniversity of Central Florida

330 Hudson Street, NY, NY 10013

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Copyright © 2017, 2013, 2009 by Pearson Education, Inc. or its affiliates. All Rights Reserved. Printed in the United States of America. This publication is protected by copyright, and permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise. For information regarding permissions, request forms and the appropriate contacts within the Pearson Education Global Rights & Permissions department, please visit www.pearsoned.com/permissions/.

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Library of Congress Cataloging-in-Publication Data

Names: Young, Mark E., author. Title: Learning the art of helping : building blocks and techniques / Mark E. Young, University of Central Florida. Description: Sixth edition. | Boston : Pearson, [2017] | Includes bibliographical references and index. Identifiers: LCCN 2016012245| ISBN 9780134165783 (alk. paper) | ISBN 0134165780 (alk. paper) Subjects: LCSH: Counseling. | Psychotherapy. Classification: LCC BF636.6 .Y68 2017 | DDC 158.3—dc23 LC record available at https://lccn.loc.gov/2016012245

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To SKSJM

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ABOUT THE AUTHOR

Mark E. Young is Professor at the University of Central Florida. He received his bachelor’s degree from Miami University, his master’s from Wright State University, and his doctorate from Ohio University. He has trained helpers for more than 25 years and worked as a therapist in community mental health, private practice, college counseling centers, and corrections for more than 15 years. Since 2003 he has been affiliated with the Marriage and Family Research Institute teaching relationship skills to low-income couples. His professional writing has focused mainly on therapeutic methods and techniques, wellness, and couples. If you have comments or suggestions on what you have read, please send an e-mail to meyoung3000@gmail.com.

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PREFACE

HOW IS THIS BOOK DIFFERENT FROM OTHER BOOKS ABOUT HELPING SKILLS?This book is unique in five ways. First, it is based on lessons learned through years of practice and supervision. I have tried to infuse what I learned from my clients, my stu-dents, and my teachers about the practical aspects of helping. For example, we will talk about what a therapeutic office environment should look like and how to appropriately terminate a client. My work with students has helped me understand the common prob-lems in learning the art of helping and how to overcome them.

Second, the most important innovation of this book is that it involves you person-ally in your learning. Throughout the book you are asked to “Stop and Reflect,” to con-sider thorny issues and challenges that you will face. If you wish, you can journal using Journal Starters or do outside homework to deepen your interaction with the material. In addition, you will have the opportunity to practice on your own by watching videos of helpers and clients and then identify the best helping responses. Every chapter contains Application Exercises in which you can follow the steps of a particular technique and get feedback on your answers.

Third, this book emphasizes that the relationship between helper and client is the most powerful ingredient for success. The relationship (Vitamin R) potentiates all the basic techniques that you will learn. If you and the client are on the same wavelength, progress is possible. When the relationship fails, the helping process falters. In this book, I talk about how to develop a therapeutic relationship and how to repair ruptures that threaten it.

Fourth, I have tried to incorporate the latest research on effective treatments. Stay-ing close to the research can be called “evidence-based practice.” At the same time, we must recognize that there is such a thing as clinical wisdom or “practice-based evidence.” Not every method, technique, or client problem has been researched or even discovered. Thus the helper-in-training needs to learn from his or her clients about what is working for that specific person. I suggest that in every session, the helper should elicit feedback from the client about the relationship and progress toward goals.

Finally, this is a book with an integrative perspective. That means that I have drawn from the techniques of many different theories rather than presenting a purely person-centered or cognitive behavioral approach. At first this may sound like chaos. How can we possibly learn to arrange treatment by blending so many competing theo-ries? In this text, we do not blend theories but instead take a common factors approach to organizing the techniques using the REPLAN method. Common factors are those therapeutic effects that underlie the various theories. REPLAN is an acronym that describes each of the healing factors. R stands for establishing and maintaining a thera-peutic Relationship, E is Enhancing efficacy and self-esteem, P means Practicing new behaviors, L is Lowering and raising emotional arousal, A is Activating expectations, hope, and motivation, and N is providing New learning experiences. Every theory emphasizes one or more of these common factors and even advanced therapeutic techniques tend to fall into one of these categories. We have found that categorizing the techniques in this way provides a rational basis for deciding what kind of help the client

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vi Preface

needs. Is it important to raise self-esteem or practice new behaviors? This forms the skel-eton of our treatment plan and is guided by the goals that are collaboratively formed between helper and client. This approach can incorporate both time-honored methods and cutting-edge techniques.

WHAT IS NEW IN THE SIXTH EDITION?

• The Sixth Edition of Learning the Art of Helping has additional coverage of cultural issues. Throughout the book are new Culture Check sections that highlight issues of culture in research and in personal experiences as they relate to helping skills.

• In addition, Chapter 12 focuses specifically on learning to help those who are cul-turally different from you.

• For the first time, we have identified helping skills you should develop when you work with children.

• We address the issue of gender differences and how they can challenge the helping relationship.

• The book now includes two new self-assessment tools to help you evaluate recorded sessions or transcripts. They are the Helper Competency Scale, which assesses the basic skills, and the Depth Scale, which looks at the depth of helper responses.

• In addition to the end of chapter activities, such as homework, activities, exercises, self-assessments, and journal starters, we now identify specific points of practice where you can watch a video of the skill you are learning or complete written exer-cises and receive feedback on your answers. You can now access these ancillary materials at the same time you are reading about them.

ACKNOWLEDGMENTSIn my own journey, there have been many who have taught and inspired me to be a better person and a better helper. I must acknowledge my teachers Rajinder Singh, J. Melvin Wit-mer, Harry Dewire, and James Pinnell, my first supervisor, who took me as a raw recruit in a mental health clinic, sacrificing his time and talent to teach me as an apprentice. We shared a zeal and passion for the profession, and his wisdom infuses every chapter of this book. I must also mention those who have encouraged me in my writing, Sam Gladding, Gerald Corey, Jeffrey Kottler, Adam Blatner, James Framo, John Norcross, and Jerome Frank. I appreciate the feedback from my colleagues at Ohio State University, Darcy and Paul Granello, and Daniel Gutierrez at the University of North Carolina at Charlotte. Tracy Hutchinson deserves special mention for reading every chapter and giving feedback at every step. I also recognize the helpful comments of those who reviewed various drafts of the manuscript including Hannah Acquaye and Shainna Ali. In addition, the following reviewers supplied insightful feedback for updating this edition: Valerie G. Balog, University of North Carolina at Charlotte; Daniel Bishop, Concordia University Chicago; Natalie Arce Indelicato, University of North Florida; Kristin Perrone McGovern, Ball State University; David A. Scott, Clemson University; and Heather Trepal, University of Texas at San Antonio.

I would like to thank my editor, Kevin Davis, who has believed in this book since its first edition. Finally, I recognize the contribution of my wife, Jora, who remains my most demanding critic and my staunchest supporter.

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BRIEF CONTENTS

Chapter 1 Helping as a Personal Journey 1

Chapter 2 The Therapeutic Relationship 31

Chapter 3 Invitational Skills 60

Chapter 4 Reflecting Skills: Paraphrasing 85

Chapter 5 Reflecting Skills: Reflecting Feelings 101

Chapter 6 Advanced Reflecting Skills: Reflecting Meaning and Summarizing 121

Chapter 7 Challenging Skills 147

Chapter 8 Assessment and Goal Setting 175

Chapter 9 Change Techniques, Part I 208

Chapter 10 Change Techniques, Part II 243

Chapter 11 Evaluation, Reflection, and Termination 276

Chapter 12 Skills for Helping Someone Who Is Different 297

Glossary 315References 323Index 349

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CONTENTS

Chapter 1 HELPING AS A PERSONAL JOURNEY 1The Demands of the Journey 1Becoming a Reflective Practitioner 2

Using Reflection to Help You Overcome Challenging Helping Situations and Enhance Your Learning 3Using Reflection to Help Clients with Backgrounds Different from Your Own 3Using Reflection to Accommodate New Information about Yourself 4Learning to Reflect through Exercises in This Book 6

What is Helping? 6Psychological Helping 8Interviewing 8What Are Counseling and Psychotherapy? 10Coaching 11

Challenges You Will Face in Learning the Art of Helping 11The Challenge of Development 12Taking Responsibility for Your Own Learning 12Finding a Mentor 14Finding the Perfect Technique 14In Limbo 14Accepting Feedback and Being Perfect 15Following Ethical Guidelines 15Individual Differences 17

Who Can Be an Effective Helper? 17What Can You Bring to a Client? 19

The Nuts and Bolts of Helping 21Learning Basic Skills and Common Therapeutic Factors 21Therapeutic Building Blocks 22Change Techniques 24The Importance of the Building Blocks 24

The Stages of the Helping Process: A Road Map 24Summary 26Exercises 27

Group Exercises 27Group Discussions 28

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Written Exercises 28Self-Assessment 29Homework 29Journal Starters 30

Chapter 2 THE THERAPEUTIC RELATIONSHIP 31The Importance of the Therapeutic Relationship in Creating Change 33

What Is a Helping Relationship? Is a Professional Helping Relationship the Same as a Friendship? 34The Unique Characteristics of a Therapeutic Relationship 36What Clients Want in a Helping Relationship 38

How Can a Helper Create a Therapeutic Relationship? 38Relationship Enhancers 39

Other Factors That Help or Strain the Therapeutic Relationship 45Facilitative Office Environment 45Distractions 46Appearing Credible and Taking a Nonhierarchical Stance 46Therapeutic Faux Pas 47Transference and Countertransference 50

Summary 56Exercises 57

Group Exercises 57Small Group Discussions 57Homework 58Journal Starters 59

Chapter 3 INVITATIONAL SKILLS 60Listening to the Client’s Story 61Nonverbal Communication between Helper and Client 64

Regulation 64Intimacy 65Persuasion 65

Nonverbal Skills in the Helping Relationship 65Eye Contact 66Body Position 66Attentive Silence 67Voice Tone 67

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Facial Expressions and Gestures 68Physical Distance 68Touching and Warmth 69

Opening Skills: How to Invite 71Saying Hello: How to Start the First Session 72How to Start the Next Session 72Encouragers 73Questions 74

Summary 79Exercises 80

Group Exercises 80Small Group Discussions 82Written Exercises 83Self-Assessment 84Homework 84Journal Starters 84

Chapter 4 REFLECTING SKILLS: PARAPHRASING 85Reasons for Reflecting 86Reflecting Content and Thoughts, Reflecting Feelings, and Reflecting Meaning 86The Skill of Paraphrasing: Reflecting Content and Thoughts 89

How to Paraphrase 89Paraphrasing: What It Is and What It Isn’t 90When to Paraphrase and the Nonjudgmental Listening Cycle 91

Common Problems in Paraphrasing 94Simply Reciting the Facts 94Difficulty Listening to the Story because of “Noise” 94Worrying about What to Say Next 95Being Judgmental and Taking the Client’s Side 95Being Judgmental of the Client 96Turning a Paraphrase into a Question 96

Summary 97Exercises 97

Group Exercises 97Small Group Discussions 98Written Exercises 99

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Self-Assessment 99Homework 99Journal Starters 100

Chapter 5 REFLECTING SKILLS: REFLECTING FEELINGS 101The Importance of Understanding Emotions 101The Skill of Reflecting Feelings 102

The Benefits of Reflecting Feelings 102Why It Is Difficult to Reflect Feelings 103

How to Reflect Feelings 104Step 1: Identifying the Feeling or Feelings 104Step 2: Putting the Emotion into Words 104

Common Problems in Reflecting Feelings and Their Antidotes 110

Asking the Client, “How Did You Feel?” or “How Did That Make You Feel?” 112Waiting Too Long to Reflect 112Making Your Reflection a Question 112Combining a Reflection and a Question: The Error of the Compound Response 113Focusing on Other People 113Interrupting Too Soon and Letting the Client Talk Too Long 114Confusing the Words Feel and Think 115Missing the Mark: Overshooting and Undershooting 115Letting Your Reflecting Statements Go On Too Long 116

Summary 117Exercises 117

Group Exercises 117Written Exercises 119Self-Assessment 120Homework 120Journal Starters 120

Chapter 6 ADVANCED REFLECTING SKILLS: REFLECTING MEANING AND SUMMARIZING 121Meaning, Uncovering the Next Layer 122

Why Reflect Meaning? 124Challenging the Client to Go Deeper: The Inner Circle

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Strategy 126Worldview: Meanings Are Personal 129

How to Uncover Meaning in the Story 130Reflecting Meaning 130Using Open Questions to Uncover Meaning 133

Summarizing 134Focusing Summaries 135Signal Summaries 135Thematic Summaries 136Planning Summaries 136

The Nonjudgmental Listening Cycle Ends with Summarizing 137

What Happens after the Nonjudgmental Listening Cycle? 138A Questioning Cycle Typically Found Early in Training 138

Summary 140Exercises 141

Group Exercises 141Small Group Discussions 142Written Exercises 143Self-Assessment 145Homework 145Journal Starters 146

Chapter 7 CHALLENGING SKILLS 147When Should We Use the Challenging Skills? 149Giving Feedback 150

Why Is Feedback Important? 150How to Give Feedback 151

Confrontation 154What Is a Discrepancy? 154Why Should Discrepancies Be Confronted? 154Cognitive Dissonance and Confrontation: Why Confrontation Works 155Types of Discrepancies and Some Examples 156How to Confront 158Steps to Confrontation 159Common Problems in Confrontation and Their Antidotes 161Final Cautions about Confrontation 162

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Other Ways of Challenging 163Relationship Immediacy 163Teaching the Client Self-Confrontation 164Challenging Irrational Beliefs 165Humor as Challenge 166

Summary 167Exercises 168

Group Exercises 168Small Group Discussions 169Written Exercises 170Self-Assessment 170Homework 174Journal Starters 174

Chapter 8 ASSESSMENT AND GOAL SETTING 175Why Assessment? 176

Assessment Is a Critical Part of Helping 177Reasons to Spend Time in the Assessment Stage 178

Two Informal Methods of Assessment That Every Helper Uses: Observation and Questioning 181

Observation 181Questioning 183

Conducting an Intake Interview: What to Assess? 184A. Affective Assessment 184B. Behavioral Assessment 184C. Cognitive Assessment 1841. Developmental Issues 1852. Family History 1863. Cultural and Religious/Spiritual Background 1864. Physical Challenges and Strengths 186

Categorizing Clients and Their Problems 188Organizing the Flood of Information: Making a Diagnosis 188

Goal-Setting Skills 188Where Do I Go from Here? Set Goals! 188Why Must We Set Goals? 190When to Set Goals 191

What Are the Characteristics of Constructive Goals? 192Goals Should Be Simple and Specific 192

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Goals Should Be Stated Positively 194Goals Should Be Important to the Client 195Goals Should Be Collaboration between Helper and Client 195Goals Should Be Realistic 196

Resources for Identifying and Clarifying Goals 197The Technique of Using Questions to Identify a Goal 198

Questions That Help Make the Goal More Specific 198Questions That Help Turn a Problem into a Goal 198Questions to Determine a Goal’s Importance 199Questions to Enhance Collaboration on Goal Setting 199Questions That Help Confirm That the Goal Is Realistic 199

The Technique of Boiling Down the Problem 201Summary 203Exercises 204

Group Exercises 204Small Group Discussions 205Written Exercises 206Self-Assessment 206Homework 206Journal Starters 207

Chapter 9 CHANGE TECHNIQUES, PART I 208What Are Change Techniques? 209REPLAN and the Common Therapeutic Factors 210

Understanding the Factors or Major Components of the REPLAN Model 210How the REPLAN System Helps You Plan Treatment 211Using the Common Therapeutic Factors 212Steps in Treatment Planning Using the REPLAN Model 212

Enhancing Efficacy and Self-Esteem 214Sources of Low Self-Esteem 216Silencing the Internal Critic: The Technique of Countering 218

Practicing New Behaviors 221Role-Playing 223Giving Homework Assignments as Practice 226

Lowering and Raising Emotional Arousal 230Reducing Negative Emotions 230

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Reducing Anxiety and Stress 231Raising Emotional Arousal and Facilitating Expression 234Creating Positive Emotions 236

Summary 237Exercises 238

Group Exercises 238Small Group Discussions 240Self-Assessment 241Homework 241Journal Starters 242

Chapter 10 CHANGE TECHNIQUES, PART II 243Activating Client Expectations, Hope, and Motivation 244

The Demoralization Hypothesis 244Motivation and Readiness 245Increasing Expectations and Fostering Hope 246

Providing New Learning Experiences 256Definitions of New Learning Experiences 256What Client Problems Are Helped through New Learning? 257Common Methods for Providing New Learning Experiences 257

Summary 272Exercises 272

Group Exercises 272Small Group Discussions 274Written Exercises 274Self-Assessment 275Homework 275Journal Starters 275

Chapter 11 EVALUATION, REFLECTION, AND TERMINATION 276Evaluating the Effectiveness of Helping 277Basic Outcome Evaluation Methods 279

Use Progress Notes to Track Improvement on Goals 279Use a Global Measure to Detect Overall Improvement 279Consistently Assess the Client’s View of Progress and the Therapeutic Relationship 280Use a Specific Measure 281Use Subjective Scaling and Self-Report to Measure

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Improvement 281Use Another Person to Monitor Change 282Use Client Satisfaction Scales 282Use Goal-Attainment Measures 282

Termination 283How to Prevent Premature Termination 283How to Tell Whether Termination Is Needed 285How to Prepare a Client for Termination 286Dealing with Loss at Termination 286The Helper’s Reaction to Termination 287

How to Maintain Therapeutic Gains and Prevent Relapse Following Termination 287

Follow-Up 288Booster Sessions 288Engaging Paraprofessionals 288Self-Help Groups 288Continue Self-Monitoring Activities 288Role-Playing for Relapse Prevention 289Letter Writing 289

Summary 289Exercises 289

Group Exercises 289Small Group Discussions 290Written Exercises 290Self-Assessment 291Homework 291Journal Starters 296

Chapter 12 SKILLS FOR HELPING SOMEONE WHO IS DIFFERENT 297Differences Make a Difference 297

Mismatch between Client and Helper 298How Can You Become Culturally Competent? 298What Is Culture, and What Should We Do about It? 299

Skills for Helping Someone Who Is Culturally Different 300The Skill of Cultural Study and Cultural Immersion 300A Tutorial Stance: The Skill of Understanding the Client’s Culture by Listening 301

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Tapping Cultural Support Systems 301Achieving Credibility and Trust 301Culturally Adapting Treatment: Tailoring Your Approach to the Client 302Acknowledging Differences by Broaching 303

Skills for Dealing with Gender Issues 303Challenges Caused by Differences in Gender 303Skills for Addressing Gender Issues 304When the Difference Is Gender 305

Skills for Helping a Child 306Identifying Helping Skills for Working with Children 307Using Basic Skills as a Guideline for Working with Children 311The Case for Play Therapy 311

Summary 312Exercises 312

Group Exercises 312Small Group Discussions 312Self-Assessment 313Homework 313Journal Starters 313

Glossary 315

References 323

Index 349

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1

The Demands of the Journey

Becoming a Reflective Practitioner• Using Reflection to Help You Overcome

Challenging Helping Situations and Enhance Your Learning

• Using Reflection to Help Clients with Backgrounds Different from Your Own

• Using Reflection to Accommodate New Information about Yourself

• Learning to Reflect through Exercises in This Book

What Is Helping?• Psychological Helping• Interviewing• What Are Counseling and

Psychotherapy?• Coaching

Challenges You Will Face in Learning the Art of Helping• The Challenge of Development• Taking Responsibility for Your Own

Learning• Finding a Mentor• Finding the Perfect Technique• In Limbo• Accepting Feedback and Being Perfect• Following Ethical Guidelines• Individual Differences

Who Can Be an Effective Helper?• What Can You Bring to a Client?

The Nuts and Bolts of Helping• Learning Basic Skills and Common

Therapeutic Factors• Therapeutic Building Blocks• Change Techniques• The Importance of the Building Blocks

The Stages of the Helping Process: A Road Map

Summary

Exercises• Group Exercises• Group Discussions• Written Exercises• Self-Assessment• Homework• Journal Starters

LEARNING OUTCOMES

By the end of this chapter, you will be able to:

1.1 Identify ways of reflecting that you can begin implementing to deepen your learning of helping skills.

1.2 Recognize that there are personal challenges in learning helping skills such as recognizing the time factor needed to master skills and dealing with ethical dilemmas as you train with fellow learners.

1.3 Identify the therapeutic factors, the building blocks, and the stages of the helping relationship.

THE DEMANDS OF THE JOURNEY

Learning to be a professional helper is a journey that takes years. Besides gaining a basic fund of knowledge about people and their strengths and challenges, one must be constantly learning

Helping as a Personal Journey

C H A P T E R 1

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2 Chapter 1 • Helping as a Personal Journey

and updating knowledge just as a physician needs to know about new treatments and new diseases. But helping is also a personal, “interior” journey because you must be committed to understanding yourself as well as your clients. In this book you will learn the essential helping skills, but it is not enough to be skilled; at every turn, you face self-doubt, personal prejudices, and feelings of attraction, repulsion, and frustration. You will experience self-doubt when your clients encounter complex and unfamiliar problems; you will experience attraction and repulsion because of your personal needs and prejudices based on your cultural conditioning. Moreover, all helpers become frustrated at times when clients fail to reach the goals we expect of them. These reactions can be roadblocks on our journey if they interfere with the ability to form a vibrant client/helper relationship or when we see the client as a reflection of ourselves rather than as a unique human being. Irvin Yalom, in his book Love’s Executioner (1989, pp. 94–95), describes his treatment of an obese woman who is depressed. From the moment he meets her, he is disgusted by her body and realizes his reaction is extreme. It makes him think about the rejection he received for being Jewish and white during his childhood in segregated Washington, DC. He thinks that his repulsion is perhaps a historical attempt to have someone to reject as he was rejected. It makes him wonder why he cannot accept fatness even though he was able to easily counsel people who were criminals when he worked in a prison. All of these reactions flood into his mind before the client ever even opens her mouth. Becoming aware of our prejudiced responses to others is part of the journey of the professional helper. This journey is difficult because it requires that we simultaneously try to focus on the client while keeping a close watch on our own tendencies to judge, to boost our egos, or to force our viewpoint on others.

BECOMING A REFLECTIVE PRACTITIONER

Because of the challenges caused by our personal reactions and unique client character-istics, we believe that helpers need a method of integrating new learning and coping with moments of indecision and doubt. In this book, we teach one method of dealing with the dilemma of understanding the client and monitoring the self. This is an approach called the reflective practitioner. Being a reflective practitioner means that you make a com-mitment to personal awareness of your automatic reactions and prejudices by taking time to think back on these reactions and perhaps to record them in a journal or discuss them with a supervisor or colleague. In other words, the reflective practitioner consciously reviews what has happened and decides on a plan of action. Jeffrey Kottler (2010) con-siders reflection to be not only a necessary characteristic of an effective helper but also a form of training. Reflection trains one to be open to contemplation, to consider alterna-tive plans of action, to become resourceful, and to be inquisitive in one’s lifestyle as well as in one’s work.

You may find that your teachers ask you to use reflective methods in class and on your own. For example, the teacher might use such techniques as Socratic questioning (asking leading questions), journal writing, watching and then reflecting on video seg-ments, conducting small groups to react to case studies, or even reflecting teams (Griffith & Frieden, 2000; Magnuson & Norem, 2002; Willow, Bastow, & Ratkowski, 2007). Just as every client will respond to the same technique or skill in a different way, you, as a stu-dent, will react to different learning situations based on your history and favored learning

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Chapter 1 • Helping as a Personal Journey 3

styles. Some students learn best by listening and then reflecting, others need to write down what they are learning, and some do best when they can have hands-on experi-ence and then talk about the theory. Thus, you will respond differently to different assign-ments throughout your program of study based on your individual preferences. Still, reflection can help you even when a teacher’s method does not suit your learning style. You can record what is said and then write your reaction and rebuttals in the margins. You can come to class with questions and concerns based on the previous week’s lesson. In short, the method of the reflective practitioner challenges you to be more than a recep-tacle of knowledge. It asks you to chew everything thoroughly before you swallow it, rather than to merely remember and give back just what you have heard or read.

Using Reflection to Help You Overcome Challenging Helping Situations and Enhance Your Learning

If you are engaged in a course of study to become a professional helper, you will be confronted with many challenging experiences both in the classroom and when you actu-ally meet your clients. For example, a client may be hostile and uncooperative. Your training may tell you to encourage clients to articulate their concerns more fully. But sometimes this seems to make the client even madder. The process of reflection can help at such times when tried-and-true methods are not working. Let me give an example from my own experience. When I was first learning group counseling, I read in several text-books that clients should never receive both group and individual therapy at the same time. As I began to practice group counseling, I found support for this rule in the fact that when clients received both forms of treatment, they did not contribute to the group, sav-ing their most personal issues for their individual sessions. One day, I received a new client for my group who had undergone a number of very traumatic events and was still being seen individually by another therapist. She performed beautifully in group, and she felt that individual counseling was a vital support in her life. She seemed to be profiting from both forms of treatment. Normally, I would insist on the client dropping out of indi-vidual counseling while she attended my group, but now my rule of thumb was in jeop-ardy because it did not seem to be limiting her progress or the group. In fact, she was applying the insights of individual counseling to her interpersonal world! I went to my supervisor with my dilemma, and she helped me put my old rule and my new experience together. With her help, I constructed a revised rule: “Most of the time, clients will not benefit from both forms of treatment; however, there are times, especially when the client is in need of a great deal of support or has been traumatized, when both modalities might be beneficial.” I have found that the process of reflection allows me to better accommo-date new information rather than rejecting it out of hand. You will undoubtedly experi-ence similar moments as you study the skills of helping. You may be shocked when you discover that the methods you have always used to help your friends are not recom-mended in a therapeutic relationship. At times like these, reflection can help you meld old and new information.

Using Reflection to Help Clients with Backgrounds Different from Your Own

An important and frequent challenge occurs when you encounter people who are com-pletely different from you in one or several ways: culture or ethnicity, socioeconomics,

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education, race, religion/spirituality, and family rules and relationships. For example, you will encounter family situations where people openly express their thoughts and feelings and others where they rarely if ever reveal their inner lives to each other. Because of your own upbringing, you might be shocked by or you might disapprove of a particular family dynamic. If you undertake the challenge of becoming a reflective practitioner, allow yourself to register surprise and all the other emotions as you encounter these novel situ-ations. Later, take time to think back on what you know and what you have learned and compare it with your new experience. Through reflecting, you will be better able to separate your personal prejudices about what seems normal and perhaps look at the situ-ation from an alternate viewpoint. The ability to see another perspective is enhanced when you have the opportunity to reflect with teachers, fellow students, and supervisors. Growth means that we consciously stretch and are able to see multiple viewpoints. That is why we think of helpers as expanders rather than as “shrinks.”

Using Reflection to Accommodate New Information about Yourself

Perhaps more than any other profession, helping requires helpers to become aware of their own personalities, preferences, values, and feelings. Reflection can help you inte-grate new discoveries that you make about yourself. It allows you to carefully consider the feedback you are getting from supervisors, teachers, fellow students, and even your clients. In the course of your training, others will comment on your interpersonal style (the typical way you interact with others), your words, and even your gestures and pos-ture. You will frequently become defensive, rationalizing your mistakes, discounting the giver of feedback, or blaming the client for a lack of progress. These are natural reflexes to the threat of feeling uncertain, impotent, or incompetent. Yet the reflective practitioner is one who examines and reflects on critical incidents and strong personal feelings in the course of supervision, rather than making excuses or blaming others. He or she learns from difficult clients, unpleasant interactions, failure of a technique, and unexpected suc-cesses (Gordon, 2004). So, being a reflective practitioner also means having the courage to ask for feedback from others and then to reflect on how you can work more effectively in a particularly difficult situation (Kinsella, 2010; Schön, 1983, 1987).

The following are some ways that you can be proactive in reflecting on your prac-tice, including asking for supervision, developing a support group of fellow learners, becoming a client yourself, and keeping a personal journal. In addition, this book pro-vides a number of opportunities to personally respond to the material, including exer-cises to help you become accustomed to the reflective process.

ASK FOR SUPERVISION Supervision is the practice of a helper and a supervisor sitting down to review the helper’s problems and successes with his or her clients. In supervi-sion, you will reflect on possible courses of action, ethical issues, and personal reactions. Everyone in the helping field needs periodic supervision whether he or she is a student or an experienced practitioner. Professional helpers are required to be under supervision while they are students and during their post-degree internships. Lawrence LeShan (1996) reported that his own mentor still sought supervision for herself, even when she was in her 80s, indicating that the reflective process is necessary at all stages of the journey. This approach abandons the view of supervision as a dependent relationship and guidance as the main purpose of the meeting. Supervision’s real value is that it is a time set aside for

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you to listen to yourself as you explain your situation to someone else. As a student, you may have the opportunity to ask supervisors and faculty members to look at your videos and discuss cases with you. Make use of this valuable opportunity to reflect on your work. Schön (1987) indicates that having a “master teacher” is important, but it must be in a setting where you have the chance to face real problems, try out various solutions, and make mistakes. The best learning environment involves reflection in action.

DEVELOP A SUPPORT GROUP OF FELLOW LEARNERS Another golden opportunity for reflecting on your new learning is to develop a supportive group of co-learners with whom you can discuss your personal reactions to the material. Many therapists in private practice are members of such groups. In some training programs, students are part of a cohort or group that goes through every class together. If you are not part of a cohort, you can still develop a supportive group that meets regularly, shares information, and studies together.

BECOME A CLIENT Another way of building a reflective component into your learning plan is to enter a counseling relationship as a client. More than half of therapists become clients after their advanced training and about 90% consider it to be very beneficial ( Norcross, 1990). Many universities offer free services to students, and this can be a way for you to experience what it is like to sit in the other chair. You should be aware that some schools restrict their counseling centers to people who are in critical need.

KEEP A PERSONAL JOURNAL One of the most popular methods for reflecting is to keep a personal journal. Some helpers even use journals as a therapeutic technique and a way of assessing the client’s feelings, relationships, and dreams (Stone, 1998). They write their reflections to clients in letters, or client and helper journal together and compare notes. There is a boom in blogging and online Internet journals. Personal journaling is also available on your smartphone using applications such as Day One, Momento, My Day Journal, and Journie.

OTHER METHODS FOR REFLECTING Reflection does not have to be a separate activity. It can be incorporated into your daily life as a student or practitioner. A number of writers (e.g., Gordon, 2004; Sax, 2006) have compiled lists of opportunities for reflection. The examples that follow were submitted by helpers working in the field. They found that reflecting can take place:

• When writing case notes• During group supervision• During individual discussion with a supervisor• In personal therapy• While journal writing• During meditation• As a part of course assignments such as papers• While listening to recorded sessions• When talking informally to fellow practitioners• When unexpectedly thinking about a client• In online groups, synchronously or asynchronously

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Learning to Reflect through Exercises in This Book

As you read this book, we will offer several opportunities to develop this reflective habit. In every chapter, we have included “Stop and Reflect” sections that ask you to consider your reaction to real cases or situations. These sections have no right or wrong answers. Instead, they ask for personal reactions and hopefully stimulate your thinking. They can make your learning more interactive if you take the time to respond as authentically as you can.

You will also have opportunities to receive feedback from your fellow students and to reflect on your own progress when you practice new skills. Finally, we have included suggested journal questions at the end of each chapter. These questions are meant to kindle your thinking, but do not feel that answering these questions is your only journal-ing option. If you do not find the stimulus question to be relevant, design your own or, instead, record your reaction to your practice sessions each week.

Next we look at helping and the different emphases of counseling, psychotherapy, interviewing, and coaching in helping clients. Being a skilled reflective practitioner is a benefit in each field and in each helping relationship.

MyCounselingLab Application Exercise 1.1 A Reflection Plan

WHAT IS HELPING?

Helping is a broad term that encompasses all the activities we use to assist another person, whether we have a therapeutic relationship or not. For example, a school administrator who takes time to listen to a crying first grader can utilize helping skills. A foster parent can learn to listen to the child and to the biological parents. A teacher’s aide in a sixth-grade classroom can take a nonjudgmental stance when a child talks about why homework is late. Marital partners can help each other deal with disappoint-ments and frustrations. Helping does not require a contract or a professional, confiden-tial relationship. Helping only requires a person desiring help (a client), someone willing and able to give help (a helper), and a conducive setting (Hackney & Cormier, 2005). You can learn helping skills and use them whether you are on the way to becoming a professional or you simply want to help those with whom you live and work. In Table 1.1, we identify some of the major ways that we can help another per-son, whether physically, financially, spiritually, psychologically, or through advocacy. The table provides examples and cautions, and briefly describes the role of the helper. One of the current controversies is how much emphasis should be placed on advocacy, or seeking to change unfair social and political systems, rather than on merely helping an individual client. Consider the anecdote about a group of people pulling accident victims from the river without sending anyone upstream to see why people were end-ing up in the river in the first place. The apparent moral is that we need to prevent people from falling in rather than just treating the victims. The problem is that there will always be people falling in the river, and someone still needs to pull them out. Efforts to make our social systems more responsive and just will not entirely replace the need to help individual clients. So, we take the stance that although all helpers should have

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TABLE 1.1 Ways of Helping

Ways of Helping Example Cautions

Help That Is Not Helping

Role of the Helper Comment

Physically Joining Habitat for Humanity to build houses

None Doing things for people that they can do for themselves makes them dependent.

Laborer

Financially Giving money to the Red Cross

Not all organizations make the best use of donated funds. Be sure your donations are used effectively.

Giving money to a person on the street can assuage your conscience but may not actually be helping.

Donor

Advocating at agency or school level

Calling Social Security to understand application procedures and explaining them to the client

This kind of help is only useful if clients then learn more about how to work the system themselves.

The client may be helped in one situation but not empowered to deal with future situations.

Client Advocate

This is a normal part of every helper’s daily work.

Advocating at the sociopolitical level

Writing letters of complaint or concern to the Veterans Administration about gaps in service; helping client get on Medicaid

You must have client’s permission if advocating for a specific client.

Professional helping requires a client. Most clients are not looking for this kind of help.

Activist More educators are recommending additional training for helpers in this area.

Spiritually Encouraging client to pray or meditate; read scriptures; go to church, mosque, or temple; or utilize spiritual beliefs to aid treatment

Helpers must be aware of their client’s background and their own personal biases.

Client may be seeking to avoid or oversimplify problems rather than address them.

Spiritual Advisor

Helpers are becoming more aware of their responsibility to consider this aspect of a person’s life and help or refer.

Psychologically Counseling or psychotherapy to aid client in changing, thoughts, feelings, and behaviors

This kind of helping requires a commitment to personal growth and a long period of training and supervision.

Clients can become dependent on the relationship, and the helper must stay alert to when the client needs to go it alone.

Professional Helper

This book is about helping psychologically.

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advocacy skills, they must also have the skills to help the individual, couple, group, or family member. Some helpers are better at working with agencies and institutions, and some helpers are better with families, couples, or children, but both avenues are equally important.

Psychological Helping

Although helping in the psychological realm is the term we use in the last row of Table 1.1, different settings and different contracts between helper and client mean that this kind of helping can be defined in a variety of ways (see Figure 1.1). To the newcomer, this can be confusing. The following sections will clarify some of the most common terms, includ-ing interviewing, counseling, psychotherapy, and coaching.

Interviewing

According to the simplest definition, interviewing is a conversation between an interviewer and an interviewee. During the conversation, the interviewer gathers and records information about the interviewee. In essence, during an interview, the inter-viewer is eliciting data, not trying to improve the situation of the interviewee. Thus, interviewing is one method of assessment, as is giving a client a paper-and-pencil test. Both assessment methods can utilize simple and direct questions or use a fill-in-the-blank approach. Interviews can be structured with a series of predetermined ques-tions or unstructured with the helper fitting questions in during the flow of the session. There are published structured interviews for a variety of psychological con-ditions and problems, from eating disorders to depression. If you utilize an intake or history form during the first session with a client and fill in all the spaces, you are conducting an interview. Interviewing is part of the assessment process that we dis-cuss in more detail later. But it is important to talk about the relationship between

CounselingMore emphasis on the therapeutic relationship and overcoming normal developmental hurdles. Growth- oriented.

PsychotherapyMore emphasis on pathology and accurate diagnosis.

InterviewingMore emphasis on gaining information.Information may be used to help another person rather than the client.Coaching

A strong dose of encouragement.

FIGURE 1.1 Different Emphases among Psychotherapy, Counseling, Interviewing, and Coaching.Despite these differences, there are many common theoretical underpinnings as well as common skills. The area overlapped by all four circles depicts this shared base.

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assessment and helping early on, so that you can begin to distinguish their separate but complementary roles.

The purpose of an interview may be to help an interviewee or to make a decision about that person. For example, many counseling centers hire intake interviewers who talk with clients and then assign them to the appropriate counselor or refer them to another service or treatment facility. Employers interview applicants for jobs, promotions, or entrance into special training programs. An interview may also be used to test the interviewee’s skills, poise, or ability to think in a “live” setting. This is called a situational interview. For example, some companies use a stress interview (a type of situational interview) to determine which of their employees can operate best under pressure. The interviewee is “grilled” and even treated disrespectfully to gauge his or her reaction. Many people think that this kind of interview is unethical, but the point is that an interview can provide an opportunity to observe the reaction of a student or employee in a contrived situation similar to actual situations that he or she may encounter. Whenever we inter-view someone, we want to watch the person’s reaction to the interview because we can learn about how he or she responds to people.

Helpers interview to determine the appropriateness of services for an individual, to assess some skill, or to confirm a diagnosis. These interviews are designed to ultimately benefit the client, but in business settings, the interview is primarily for the benefit of the organization. In clinical settings, interviewing and counseling are rarely separate pro-cesses. For example, I was recently seeing a couple for counseling. During the first ses-sion, they both wanted to talk about their anger and frustration related to financial difficulties. It seemed clear that they blamed each other for these problems, and each wanted to unload. Although I felt that it was important that they be allowed to express some of these feelings, I had other items on my agenda. I needed to know whether financial problems were the only issues. In my experience, couples most frequently complain about the following concerns: their inability to communicate, children, in-laws, sex, and finances. I wanted to make sure that I covered each of these areas and that I was not missing something important. It is also essential to know whether there has been violence in the relationship, whether substance abuse is involved, or whether either party suffers from a mental disorder. So I frequently stopped their argument about finances to insert a question about these other areas. In the middle of the session, the wife revealed that she was concerned about her husband’s drinking. I immediately took time to ask the husband several questions about his drinking and looked back at the OQ-45, a short test we give to all our clients during the first session. He had marked several of the questions that indicate substance abuse problems. I used the data from the test, from his spouse, and from the client himself to determine the extent of his problem. By the end of the session it was clear that his drinking was a serious problem that needed treatment before we could solve any other concerns, even their finances. This case demonstrates several important issues. First, helping and interviewing frequently occur during the same therapeutic session. Second, interviewing, as part of the assess-ment process, can make your helping more effective because it is a way of making sure you are going in the right direction and treating the right problems. Finally, interviewing can be disruptive of the relationship. Clients want to tell you their version of the story, and interviewing is experienced as an intrusion. A helper must go back and forth between helping and interviewing in almost every session because clients bring up new

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issues as the relationship deepens. It is up to the helper to repair the relationship when clients feel disrupted and to explain the reasons for the interview so the clients under-stand your need to get the whole picture.

In summary, interviewing is utilized in a variety of settings, not all of which are designed to directly help the interviewee. Interviewing is an art whose medium is the relationship; it is not merely a mechanical process of filling in the spaces. A skilled inter-viewer knows how to quickly develop a working relationship with an interviewee in order to obtain the most relevant information for the decision-making process. The inter-viewer creates a climate where the interviewee will feel like talking and asks relevant questions to gain vital information. The basic helping skills you learn in this text will help you create this climate of openness, warmth, and acceptance needed for an effective interview. This atmosphere increases the quantity and quality of information obtained. In the assessment chapter, you will have an opportunity to utilize your helping relationship skills and also learn to interview for key data.

What Are Counseling and Psychotherapy?

Counseling and psychotherapy are professional helping services provided by trained individuals who have contracts with their clients to assist them in attaining their goals. Counselors and other psychotherapists use specific techniques to persuade, inform, arouse, motivate, and encourage their clients and to thoroughly assess their issues and backgrounds. Sessions with a counselor or psychotherapist take place on a regularly scheduled basis, usually weekly, and last about 1 hour. A therapeutic relationship will last several months or even several years. Although counselors and psychotherapists may help clients deal with emergencies, they also try to empower clients to address persistent problems in living and make changes that will lead to overall improvement rather than temporary relief. In most states, counselors, clinical social workers, psy-chologists, marriage and family therapists, and psychiatrists can all practice counseling and psychotherapy in private practice when they have a license. Other individuals without these licenses, such as individuals certified in treating substance abuse or with a background in human services, can usually practice within an organization under supervision.

In the literature and in practice, the words counseling and psychotherapy are now used interchangeably. Historically, however, different professional groups have tended to prefer one or the other, creating confusion for professionals and clients. Between 1920 and 1950, psychotherapy was used to describe the process of helping clients who were troubled by mental disorders. Mental disorders are defined as severe disturbances of mood, thought, and behavior for which there are specific diagnostic criteria. Examples include major depressive disorder, schizophrenia, and panic disor-der. For each disorder, there is a list of criteria that the client must meet to possess the diagnosis. The criteria for more than 300 mental disorders are outlined in the Diagnos-tic and Statistical Manual of Mental Disorders (DSM), which is the bible of mental disorders (American Psychiatric Association, 2013). Even today, these are the only problems that most health insurance companies recognize as reimbursable. From the beginning, the processes of assessment, diagnosis, and treatment planning have been integral aspects of psychotherapy.

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Counseling was developed in the early 1960s as psychotherapy for “normal peo-ple.” Medical terminology was shunned by counselors, along with words such as treat-ment, patient, and diagnosis. Counselors believed in seeing each individual as a unique person, rather than as a diagnostic label. For that reason, personality tests and other assessment activities were minimized, and identifying areas of growth rather than dys-function was emphasized. Counseling was focused more on the counselor/client relation-ship as the medium for change rather than on the tools and techniques. Although these values are still common among counselors today, the distinctions between counseling and psychotherapy have blurred. Now, counseling includes helping people with mental disorders as well as those experiencing normal developmental problems. Modern coun-selors routinely use assessment tools, learn diagnostic methods, and engage in treatment planning. By the same token, professionals such as psychologists and marriage and fam-ily therapists who prefer the term psychotherapy or therapy also help clients with difficul-ties such as adolescent adjustment, marital issues, and the transition to college or work—what we might call “normal problems.” Although some may still feel there are good reasons to make distinctions between the terms counseling and psychotherapy, they will be used interchangeably in this book. Both will refer to the contractual and profes-sional relationship between a trained helper and a client.

Coaching

Coaching is a new term on the mental health scene. Coaching practices are springing up because coaching is not yet regulated by licensing boards and state legislatures, and because there is a market for a helper who is not therapeutic but mostly supportive. Coaching allows individuals without therapeutic degrees to practice professional help-ing, and “coaching” sounds a lot more pleasant than counseling or therapy. But coach-ing is mostly counseling by another name. Here is a definition provided by Cummings and Worley (2009): “Coaching is a development process whereby an individual meets on a regular basis to clarify goals, deal with potential stumbling blocks and improve their performance. It is an intervention that is highly personal and generally involves a one-on-one relationship between coach and client” (p. 451). DuBrin (2005) identifies the following elements of an effective coach: “empathy, active listening, ability to size up people, diplomacy and tact, patience toward people, concern for the welfare of oth-ers, self-confidence, non-competitiveness with team members and enthusiasm” (p. ix). About 90% of this definition overlaps with counseling and psychotherapy. What may be different is that the definition of a coach frequently includes a very encouraging cheer-leader sort of attitude and the focus on specific achievable goals that the client wants to pursue (Biswas-Diener, 2009). Later in this book, we will talk about this issue more. Under what circumstances is this kind of enthusiasm helpful or potentially detrimental? Determine for yourself whether you think coaching is a new approach or merely a mar-keting strategy.

CHALLENGES YOU WILL FACE IN LEARNING THE ART OF HELPING

A major feature of this book is that I have included input from students about specific hurdles they have faced on the road to becoming a helper. In this section, we look at the normal challenges that you will probably face in your training.

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The Challenge of Development

An immediate challenge, as you encounter the seemingly endless flood of information and skills that you will need to learn, is a feeling that you should be effective right away. It is difficult to accept that considerable time and training is necessary. One cannot master the art of helping in one semester or even 2 years of formal training. Although becoming a master of the helping arts is a lifelong journey, we sometimes expect to have some measure of competence quickly. If you are a beginner, there are many stages ahead of you on the journey, and feeling effective may elude you for quite some time. The concept of levels of expertise is a commonsense approach that has been around for centuries, especially in the skilled trades. You have probably heard of master plumbers or master electricians. Hoffman and his colleagues use traditional “guild” terminology from the trades to divide expertise into seven stages. In Table 1.2, you will see this concept applied to the development of expertise in helping (Young, 1998). In essence, it maps the journey from entry level to master level.

One implication of this developmental concept is that, despite what state legislatures allow, a new helper is probably not permitted to handle all of the day-to-day decisions independent of supervision until after 2 years of education and 2 more years of supervised experience. A journeyman still needs ongoing contact with an expert or master counselor. Supervision (a reflective process) is a vital part of the journey because when you are a working professional, it may be the only time when you are able to reflect during the day.

Another implication is that people enter this training with varying levels of expertise. A significant number are already journeymen when they register for basic helping skills training (McLennan, 1994). If you are in this situation, you may feel that your time is being wasted going back over the basic skills. I have frequently taught basic skills to students who have been working as helpers for several years. Invariably, the more experienced students eventually feel that the course has been extremely valuable. They report that it was benefi-cial to reexamine their basic positions on important questions such as “Under what circum-stances should I give advice?” and they feel that they may have not been as thoughtful as needed about treatment alternatives when working in a system that prescribes the way that clients are helped. If you already have some helping experience, you may find that on-the-job training has not been systematic and that this course can help fill in the gaps. You may also discover that your experience allows you to make connections not available to you the first time you learned these skills. If you feel that this course is repetitious, ask your instruc-tor for more challenging assignments. Also, with your instructor’s permission, find ways to help other members of your training group by giving them detailed feedback. Encourage them to reflect on their learning. You will be learning supervision skills as you do so.

Recognizing and normalizing where you are at this moment—whether journeyman or beginner—can help you focus on the next step ahead and alleviate some of this feeling that you should swiftly ascend to a higher level of helping. Take comfort in the small victories when your instructor or fellow students notice your progress—even if it is hard for you to see.

Taking Responsibility for Your Own Learning

In other course work, you may have found that memorizing the text and attending class were sufficient for success. Unlike traditional classes, helping skills training requires that you perform skills in front of other people in practice situations. To receive the maximum

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benefit from practice sessions, you must open yourself up to feedback and suggestions. There is a strong tendency to compare oneself with others and to view training as a com-petition. Although that may be a good strategy in some classes, it can be a detriment in learning helping skills because it may keep you from volunteering to practice in class and receiving the feedback that will help you grow. For example, you may appear to be ahead of or behind your classmates as you learn a particular skill in this book. If the class moves ahead, you may need to continue to work on that skill by practicing with fellow students, watching videos of your performance, reading, or getting special help from the instructor. You must take responsibility for educating yourself and request the training that you need, rather than seeing the process of learning as a “mug and jug” phenomenon, in which the teacher pours from the jug of knowledge into the student’s mug. You must

TABLE 1.2 “Guild” Terminology for Helper Development (Based on Hoffman, Shadboldt, Burton, & Klein, 1995)

Naivette One who knows nothing about the practice of counseling or psychotherapy—a layperson. This term was coined by Hoffman to identify a person who is completely naive to the trade.

Novice The word novice means one who is new. The novice is a new trainee who is on probation; for example, someone beginning the first class in basic helping skills but not yet accepted into a program of study.

Initiate A person who has been selected for a program and has begun introductory training—a new student in his or her first semester.

Apprentice A student still undergoing instruction but who is beyond the introductory level. The apprentice is fully immersed in professional helping and works as an assistant. Students in practicum and internship experiences are apprentices. In the trades, apprenticeship lasts from 1 to 12 years.

Journeyman The term journeyman comes from the French word for day, journée. A journeyman is one who can do a day’s work unsupervised. A journeyman works on orders from his or her supervisor. This period of training may last for many years, even beyond the 2 to 3 years postgraduate experience required by the supervisor or the licensing state.

Expert An expert is an exceptional journeyman who is highly esteemed by his or her peers, whose diagnostic and therapeutic skills are exceptionally accurate, and who can quickly and effectively deal with normal professional situations. In addition, the expert is one who can handle “tough cases” and may have some particular area of expertise based on considerable experience with a certain type of problem—for example, substance abuse, crisis intervention, domestic violence, and so on. Expert status is by no means inevitable. Some helpers stay at the journeyman stage for life.

Master A master is one of a select group of experts who are qualified to teach others. A master is one whose judgments and practices become standards for others to follow. One way to identify a master is that he or she is regarded as an expert by other experts. Frequently, this is because the master is thought of as “the expert” in a particular area within the field.

Source: Young, M. E. (1998). Skills-based training for counselors: Microskills or mega-skills? Counseling and Human Development, 31(3), 2. Reprinted with permission of Love Publishing.

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move from teacher-directed learning to self-directed learning (Caffarella, 1993; Canipe & Brockett, 2003). In your training, this may mean that you face embarrassment if you are honest about what you do not know or cannot do. Although you may be able to keep your skill level hidden for a little while, eventually you will be alone with a client, and you will need these skills to really be effective.

Finding a Mentor

Earlier, we talked about the value of a master therapist for reflecting or supervision. But learning from models is not restricted to only those in the highest altitudes of therapeutic expertise. One of the best ways to learn the helping skills is to watch effective models and to receive feedback from teachers even if they are only a few steps beyond you. It is a challenge, however, to find experienced helpers who have the time to act as mentors or who will allow you to observe. Once I watched one of my own teachers in a session with a client. I remember saying to myself, “He acts like being with that person is the most important thing in the world.” Although I had read about “eye contact,” “empathy,” and “unconditional positive regard,” when I saw the quality of his presence, I grasped, for the first time, how powerful such attention can be. How few are the times when someone really stops to listen wholly and solely. Teachers and supervisors are vital guides through-out the journey, especially in the beginning, and you must seek them out. As time goes on, it is true that one learns to have more faith and confidence in one’s own judgment and abilities (Skovholt & Ronnestad, 1992), but even then, supervision and mentoring are essential for self-assessment and reflection.

Finding the Perfect Technique

Beginning helpers are extremely anxious to learn specific techniques and interventions. They gather techniques and tricks of the trade at workshops, hoping that one of them will be the magic pill that cures all clients. When you feel anxious or ineffective, it is normal to experience a desire to learn every method available and assume a sort of “cookbook” approach to helping. There is nothing wrong with learning all you can. It is unlikely, however, that you will find the perfect technique that will work for every client. As we will discuss later, techniques account for only a portion of being successful in helping. If you abandon the therapeutic relationship in favor of an exciting technique, you may be learning, but you may not necessarily be helping the client.

In Limbo

As you begin the process of learning to help, you may find that you abandon your natural helping style. Although beginning helpers are often naturally therapeutic, they typically find that they must temporarily set aside their old ways of helping. You may find that the new techniques and interventions feel artificial or “not like me” at first. Do not be sur-prised to hear yourself say, “I used to know what to do when a friend was upset. Now that I’ve begun to study helping, I no longer know what to say.” Even your attempts to regain your old self seem awkward and artificial. As you consciously learn the helping process, it may be difficult to be natural.

Arnold Lazarus, the founder of multimodal therapy, cautions us that training can sometimes undermine our native talents (1990). He tells the story of his friend, a dentist,

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who was a natural listener and was very therapeutic with his patients. But the dentist went back to school to become a therapist. Lazarus felt that the result was a rather phony person who resorted to jargon instead of listening. Perhaps Lazarus’s friend was going through a stage characterized by overzealousness and insecurity. But the story is there to remind us that we have much to lose. If we abandon our genuineness, personal warmth, and all the other qualities that make people feel we are listening and caring, our training will be something to overcome rather than to rely on. Hopefully, as you give up old hab-its and learn new skills, you will find a way to integrate the old “therapeutic friend” with the new “therapeutic helper.”

Accepting Feedback and Being Perfect

Your willingness to accept feedback will be another indicator of developmental change. Early on, students accept feedback but feel discouraged about being “wrong.” When faced with feedback, they attempt to justify their actions rather than listening to critiques and suggestions. As you gain confidence and see how different responses take clients in different directions, it is easier not to react personally because you feel confident in your basic skills, and it is as if someone says, “There are a number of different paths. Which one is better?”

Following Ethical Guidelines

We are all familiar with errors in medical treatment. However, we may fail to recognize that clients in a helping relationship can also be harmed by inappropriate advice, humiliation, emotionally arousing techniques, and subtle messages of contempt when we do not under-stand their cultures, religions, families, or beliefs. The challenge of the Hippocratic oath to all practitioners of the healing arts is primum non nocere—first, do no harm. Ethical guidelines help us avoid harm to clients by asking us to adhere to some general rules.

Ethical guidelines have been proposed by virtually every professional organization in the helping professions. These standards can be found in recent publications, and updated versions are available online. Ethical guidelines and codes largely deal with the work environment; however, ethical dilemmas are just as likely to arise in your training group. The following are some guidelines you may wish to adopt as a group during your class. Optimally, you should discuss these thoroughly, so that everyone is in agreement. On the other hand, rules are inadequate to deal with every problem that arises. In many cases, it will be necessary to talk with your instructor about how to handle these conflicts. Although many of the issues described in these guidelines will not surface in your train-ing group, you should still be prepared. Make sure everyone is in agreement to abide by the ethical guidelines.

Guideline 1: Do not reveal what other training group members say about

themselves during role-playing and practice sessions.This means that you should not tell your best friend, your father, or your spouse. Although there may not seem to be any serious harm in doing so, forming these boundaries will set up an atmosphere of trust and allow for more freedom for all participants. It may be your first experience in keeping professional secrets. Try thinking of it as a sacred trust, similar to the seal of the confessional taken by Catholic priests.

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Guideline 2: Avoid giving advice.This is a practical suggestion as well as an ethical guideline. From the practical standpoint, you may find that giving advice, especially early on, can damage the relationship and slow client progress. From the ethical perspective, are you really competent and knowledgeable enough to give advice? Could your advice be dan-gerous to a person’s relationships or his or her academic or professional life? Could it undermine the client’s self-confidence? These concerns suggest that you might wish to resist giving advice during this part of your training and develop some alternative skills.

Guideline 3: Do not impose your values on others.Avoid making value judgments on a person’s lifestyle, life experiences, or philoso-phy of life. Similar to giving advice, your judgments may be based on inadequate knowledge, may reflect your own limited experiences, or may communicate con-tempt or lack of acceptance of the other person. Learning to be sensitive to the cul-tural and religious differences and honoring the unique experiences of clients help us to avoid the trap of subtly communicating that a person’s values and worldview are unacceptable.

Guideline 4: Be careful with feedback to clients and to fellow students.Give feedback only when asked and package it in a way that the other person can accept. Give only specific and constructive feedback. Giving vague or very nega-tive feedback can be damaging. Give feedback on areas where the person wants more information. We give feedback not to show how clever we are but to provide something useful to the client. I am sure you have heard of an “empathy sandwich.” It means giving the bad news in between two positive statements. In fact, this kind of sandwich is not a bad idea for training situations. In couples communication, Gottman (2000) has found that it takes five positive statements to counteract one negative statement in a couple’s conversation. Similarly, specific, simple positive feedback will be the most helpful here because one negative statement is heard five times louder than a compliment.

Guideline 5: Stay mainly with the techniques described in the book or those taught by your instructor.Using an unfamiliar and potentially harmful method should only be attempted with the guidance and permission of your teacher or supervisor. A powerful technique can cut both ways; it may have an equally powerful negative effect when misap-plied. Generally speaking, reading about a technique or seeing it demonstrated at a workshop is not sufficient training. Practicing new techniques is only ethical when you are under supervision.

Guideline 6: Notify your instructor or supervisor at once if a member of your training group or a client is contemplating suicide or is considering harming others.Even if you are relatively sure that the probability of violence is low, it is vital that you discuss any suggestion of violence with someone in authority. A few years ago, Michael Mahoney, one of the most prolific writers and most innovative thinkers in cognitive therapy, committed suicide. It makes us realize that we have the obligation to be sensitive and to receive training in suicide assessment and prevention, and even be aware of these issues in our esteemed colleagues (cf. Granello & Granello, 2007).

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Learning to talk about suicide and violence with your fellow students and your instructor is good training for your later work when you must learn to disclose to supervisors or other authorities.

MyCounselingLab Application Exercise 1.2 Following Ethical Guidelines in Your Training

Individual Differences

If you are a member of a minority group, have a disability, are one of the first in your family to attain higher education, or are going through a particularly stressful life stage (for example, getting married or divorced, leaving home, or having children), you may face additional challenges in the process of becoming a helper. Students facing outside stressors may also have difficulty maintaining the flexible schedule that is required (Gaff & Gaff, 1981; Quimby & O’Brien, 2006). Specifically, consider how the following indi-vidual differences may have an impact:

• Minority students may have fewer same-race peer interactions (less support) and fewer minority role models (Cheatham & Berg-Cross, 1992).

• Female students raised in traditional families may have difficulty trusting in an internal authority (their own thoughts, feelings, and conclusions; Bernard, 1981; Marx, 1990).

• Some male students may not be as attuned to relationships and feelings as their fe-male counterparts.

• Hypermasculine upbringing may cause male trainees to be “fixers,” seeking solu-tions quickly, before understanding the client. They may fail to recognize and accept feelings of fear and helplessness in themselves and may therefore have difficulty recognizing them in others.

Such considerations should serve to illustrate that development is not the same for each person, rather than to discourage those with special situations. A student’s progress in learning the art of helping cannot be confined to a timetable (Barrow, 1987), nor is it necessarily a linear process. Sometimes you may feel that you are taking two steps forward and one step back. Allow yourself time to develop and move at your own pace. Development is not a competition with your classmates; it is a personal journey.

WHO CAN BE AN EFFECTIVE HELPER?

Questioning whether you are really cut out for a job is to be expected when you enter a new field. Are you similar to the professionals you know? What must you know, and what abilities must you possess going in? Although there is no single personality configu-ration that defines the perfect helper, various writers have looked at specific traits that lead to effective helping. They have also looked at the beliefs and attitudes most condu-cive to learning and working in the profession. Knowing more about these may help you because many of these qualities can be acquired.

The writings of 15 different authors described 55 characteristics, attitudes, and beliefs of effective helpers. In this section, I have tried to consolidate these into five key elements (Combs, Avila, & Purkey, 1971; Corey, Corey, & Callanan, 2015; Gladding, 2008;

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Kottler, 2010; McConnaughy, 1987; Patterson & Eisenberg, 1983; Spurling & Dryden, 1989; Truax & Carkhuff, 1967).

First and foremost, an effective helper has a positive, accepting view of other peo-ple. He or she accepts people who are different from himself or herself and is not judg-mental about other people’s lifestyles, values, cultures, and religions. He or she wants to help others and believes that people have the desire to change. The helper must be able to communicate his or her nonjudgmental attitude as well as warmth and caring.

Second, the effective helper has good self-esteem and is a secure and mentally healthy person. Learning to be a helper because of a personal mental disorder is not the correct motivation, nor should it be a way to experience power over others or to feel superior to those with more serious problems. Does this mean that if you have a serious mental disorder you should not be a professional helper? I think the answer is yes. Fre-quently, clients who have been helped want to return the favor. Although the process of recovery may intrigue the recovering alcoholic or addict, recovery is not the only creden-tial one needs. The addicted client needs to be well beyond the thrall of his or her addic-tion before becoming a counselor. Similarly, individuals who have received help themselves may be attracted to the field that helped them so much. Yet before entering the field of professional helping, every person should not only evaluate his or her own personal mental health and stamina but also get a second opinion from a professional. Effective helpers appreciate their strengths but know their limitations, too. They are able to examine themselves critically. They have the courage to look at themselves under a microscope and can separate helping the client from boosting the ego of the helper. They make reflection and personal growth part of their lifestyle.

Third, most writers agree that the effective helper has good self-care skills. Many who are attracted to this profession want to help others, but soon find that doing so can be depleting. It is easy to become emotionally “bankrupt” and “burned out” if one does not develop techniques for stress management, time management, relaxation, leisure, and personal self-renewal. The effective helper has a stable and fulfilling personal life with close family and friends to provide support as a buffer to the stress of helping.

Fourth, the effective helper is both creative and intellectually competent, a Renais-sance person who appreciates both the science and the art of helping. The effective helper has specialized knowledge of human relationships, human motivation, and human development and understands how to create change. Those who remain vital in the pro-fession have an “insatiable curiosity” to learn and grow in their skills and knowledge (Spurling & Dryden, 1989); they are lifelong learners. Creativity and flexibility are equally important. Helping requires one to devise innovative ideas with different clients in differ-ent situations. A helper must be able to deal flexibly with ambivalence, unfinished busi-ness, and moral dilemmas. He or she has to allow clients to work through difficult situations without moving them to premature decisions.

When J. L. Moreno, the founder of psychodrama, was once asked what the most necessary quality was for a group leader, his unexpected response was “courage.” This fifth characteristic of an effective helper has two facets: First, the helper must be able to listen unflinchingly to stories of great pain. Like a physician who sets a broken arm, he or she must be able to look with a detached eye at human destruction and see where the healing can be started. Second, the helper’s job requires risk taking and action, without the security offered by other sciences. Individuals who believe that they can control every circumstance and that there is a procedure and a solution for every crisis have a difficult

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time as helpers. For example, there are no psychological tests that accurately predict a person’s tendency to be violent. Helpers’ decisions must be based on experience, train-ing, and even intuition. Because human behavior is relatively unpredictable, effective helpers must have the courage to help in situations of uncertainty.

What Can You Bring to a Client?

Although the preceding list identifies some basic characteristics of effective helpers, there is no one set of personal qualities that defines the ideal helping professional. There is room for many types of individuals, each of whom brings significant strengths and unique limitations. The example of a former student may help to illustrate this. Maria, a graduate student, got under my skin sometimes because she had little patience for long theoretical discussions and did not like studying anything that did not have immediate application. She seemed to roll her eyes when the discussion became too intellectual. She was practi-cal and concrete and liked people who were “down-to-earth.” She wanted to solve prob-lems and make a difference in the lives of children. It seemed to me that sometimes she tended to be too quick to come to closure with adult clients when they became stuck or were indecisive. Sometimes she pushed them to make decisions and seemed insensitive to their turmoil.

However, Maria now works effectively as a school counselor. Her particular strength is that she knows how to manage crises. She instantly grasps what has to be done and takes bold and concrete steps to accomplish it. She has excellent judgment and is indis-pensable to her school because she knows how to take quick action and exudes calm and poise in times of confusion. Maria’s case illustrates that each of us brings strengths to the helping role. Much depends on knowing our own abilities and finding an environ-ment where they can be put to good use.

As you consider the characteristics of effective helpers that we have identified, remember two things. First, many of the characteristics can be developed. They are not necessarily inborn. Second, each person brings unique characteristics to the helping pro-fession and, as in Maria’s case, the challenge is to find a place where these gifts will help others. Do not look at the characteristics of effective helpers in order to identify those you do not have. Helpers should not be clones. Build on your own strengths and add new skills as you go along.

STOP AND REFLECT

Helper Characteristics

The characteristics of effective helpers identified by the experts are listed in brief form in the follow-ing statements. Answer the accompanying questions as truthfully as possible, because your answers may point out areas you may wish to address later in your training. Which of these qualities do you presently possess and which do you want to improve? For those skills you need to develop, think for a moment about what you might do to challenge yourself. What extracurricular activities might help you to grow?

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Positive View of HumankindYou believe that most people are basically good and are striving for self-improvement. You enjoy people and believe that people can change.

How true is this for you?

How can you grow?

Stable and Mentally HealthyYou have good self-esteem and are basically a secure, mentally healthy person. (You may not be able to make a completely unbiased self-assessment, but friends and family can give you feedback on your coping ability.)

How true is this for you?

How can you grow?

Good Self-Care SkillsYou do not become overly involved with those you are helping. You know your limits and are able to set boundaries to protect yourself from burnout.

How true is this for you?

How can you grow?

Intelligent and Psychologically MindedYou are an intellectually curious person who is interested in the psychological world of other people. You can appreciate both a scientific and an artistic approach to learning about helping.

How true is this for you?

How can you grow?

CreativeYou are a creative person in some aspect of your life. You are not rigid or inflexible in your attitudes. You are not bothered by many prejudices about people, cultures, religions, and family customs that differ from your own.

How true is this for you?

How can you grow?

CourageousYou have enough courage to examine your own personal problems and to seek help and guidance for yourself when you need it. You are willing to admit that you need to change and grow. You are able, for the most part, to deal with the cruelties that other people inflict on each other without being so disturbed that it disrupts your own life or your ability to help.

How true is this for you?

How can you grow?

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THE NUTS AND BOLTS OF HELPING

In this section, you will be introduced to the basic skills, or “building blocks,” that make up the more complicated techniques that you will be learning. Your first challenge may be to incorporate new learning without abandoning your natural therapeutic abilities. It will seem awkward at first to use other skills instead of the ones that are most comforta-ble, but I have found that as time goes on, the old skills find their way back in a more therapeutic way as you discover that the nuts and bolts of helping must precede more elaborate interventions.

Learning Basic Skills and Common Therapeutic Factors

Basic helping skills are normally taught as small units that we call basic skills or building blocks. This makes learning easier, but it also creates problems. Individual skills often seem so elementary that students may be confused about why they are important. Stu-dents have trouble seeing the big picture because they learn first one piece and then another. One conceptual framework that may help to put these small pieces into the big-ger puzzle is understanding that these fundamentals are effective because they evoke common therapeutic factors, or “mega-skills” (Young, 1998).

These skills mostly originated as techniques embedded in theories of counseling and psychotherapy. It is estimated that there are between 100 and 500 different theoreti-cal orientations, from cognitive behavioral to psychodrama (Corsini, 2001; Corsini & Wedding, 2008; Herink, 1980; Parloff, 1979). The question is, “Are these different theories calling forth unique healing qualities or are there common things that all helpers do that work?” Common therapeutic factors are thought to be the basic healing properties that underlie all effective counseling theories and techniques (Duncan, Miller, Wampold, & Hubble, 2009; Karson & Fox, 2010). The lifetime work of Jerome Frank (1971, 1981) showed how different theories rely on these factors for their effectiveness. Although help-ers seem to be utilizing different techniques, they are actually drawing on similar meth-ods. Frank described six common therapeutic factors that seem to cut across theoretical persuasions (Frank & Frank, 1991):

1. Maintaining a strong helper/client relationship2. Increasing the client’s motivation and expectations of help3. Enhancing the client’s sense of mastery or self-efficacy4. Providing new learning experiences5. Raising emotional arousal and promoting emotional expression (Later, we make a

rationale to include techniques in this category that lower emotional arousal and create positive emotions such as relaxation training and meditation.)

6. Providing opportunities to practice new behaviors

Most therapies utilize these therapeutic factors to produce change and they are probably even more important than theory-specific techniques (Lambert, 2005). One of the best-researched and most potent common factors is the therapeutic helper/client rela-tionship. Because it is so central to what helpers do, we will examine it in more detail in the next chapter. The therapeutic building blocks or basic skills that you will learn are mainly aimed at helping you maximize this therapeutic factor. By learning to create a climate of openness and listening, you will have the foundation to develop more advanced skills and to implement the other therapeutic factors.

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Therapeutic Building Blocks

Therapeutic building blocks is the phrase we use to describe the basic helping skills. These are the most fundamental components of the helping interview, such as asking open-ended questions or maintaining eye contact. These building blocks are like the elements of the periodic table we all learned in high school chemistry (I apologize if this brings back traumatic memories). When elements are combined, they form more complex substances, such as oxygen and hydrogen coming together to make water. The therapeutic building blocks represent the foundational interven-tions used to create change, but they can also be combined into more complex tech-niques. In this book, we identify 19 therapeutic building blocks. They represent the combined wisdom of many theorists and helpers over time. Although this may seem to be an overwhelming number, 11 of the building blocks are quite simple (we call them invitational skills) and very easy to master. The therapeutic building blocks are divided into five categories (see Table 1.3). Each category represents an important helping activity as follows:

TABLE 1.3 The Building Block Skills

Skill Category Therapeutic Building Block

1. Invitational skills (two sub-categrories, nonverbal and opening skills)

Nonverbal skills Appropriate eye contactBody positionAttentive silenceVoice toneGestures and facial expressionsPhysical distanceTouching

Opening skills Encouragers Door openers Minimal encouragersQuestions Open questions Closed questions

2. Reflecting skills ParaphrasingReflecting feelings

3. Advanced reflecting skills Reflecting meaningSummarizing

4. Challenging skills Giving feedbackConfrontation

5. Goal-setting skills Using questions to identify a goalBoiling down the problem

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INVITATIONAL SKILLS (ELEVEN SKILLS—CHAPTER 3) Invitational skills are the basic means by which the helper invites the client into a therapeutic relationship. These skills encompass all the subtle verbal and nonverbal messages that helpers send to encourage a client to open up without applying pressure. For example, imagine how you would feel if the helper constantly checked her watch or looked out the window. You may think that paying attention is only polite, but it is also a skill. Eye contact and attentive body posture are two of the invitational behaviors you will learn and practice.

REFLECTING SKILLS (TWO SKILLS—CHAPTERS 4 AND 5) Invitational skills invite clients to tell their stories, and reflecting skills let them know that you have heard their sto-ries. Reflections are condensed versions of the facts and emotions the client has con-veyed. The helper shares these “snapshots” of the client’s story to let the client know that he or she is being understood both in terms of content and at the affective (emo-tional) level. When clients feel understood, they disclose more deeply and the important issues begin to surface. These skills take some time to develop. Recognizing and reflect-ing the gist of the client’s story and underlying emotions is something you will practice throughout your training.

ADVANCED REFLECTING SKILLS (TWO SKILLS—CHAPTER 6) Advanced reflecting skills help a client move even deeper than the reflecting skills do. They include reflecting meaning and summarizing. Advanced reflecting skills are hunches that helpers make and repeat to their clients to see whether they understand the unique impact of their cli-ents’ problems beyond the basic facts and feelings. For example, the loss of a job is not just the change in economic status and feelings of loss. Depending on the person, losing a job may also be seen as a sign of failure or evidence of incompetence. Understanding the unique meanings that people assign to events and helping them identify their beliefs about themselves, others, and the world are advanced skills that move clients to deeper self-understanding. Advanced reflecting skills help clients explore.

CHALLENGING SKILLS (TWO SKILLS—CHAPTER 7) Whereas invitational skills, reflecting skills, and advanced reflecting skills encourage deeper self-examination, challenging skills push clients to recognize discrepancies in their statements. Challenging skills identify incongruities in a client’s story and may give information on client strengths and weaknesses. For example, a client who says that he wishes to stop smoking but does not follow any of the suggestions made by the helper might be challenged about the discrepancy between words and behavior. Challenging skills can strain the relation-ship, but they may also remind clients that the helping relationship is a work project, not a social encounter. Giving feedback and confrontation are the fundamental chal-lenging skills.

GOAL-SETTING SKILLS (TWO SKILLS—CHAPTER 8) Up to this point, the aim has been to encourage the client to disclose in as much depth and breadth as possible. Goal-setting skills, however, begin to narrow the focus. The first key goal-setting skill is using ques-tions to identify a goal. The second key helping skill in this area is to “boil down” the problem, which involves shaping a client’s vague or unrealistic goals into specific and achievable targets. These building block skills of using questions to identify a goal and boiling down the problem are needed to help clients develop short- and long-term goals.

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Change Techniques

Beyond the therapeutic building blocks, this book also introduces you to some more advanced techniques in Chapters 9 and 10. We call these change techniques because they are interventions designed to help the client achieve a goal that has been identified using goal-setting skills. In Chapter 9, you will learn two cognitive therapy techniques: countering and thought stopping. You will also learn and practice role-playing, giving homework, deep muscle relaxation, meditation, gratitude, and some techniques for stim-ulating emotional arousal and expression. In Chapter 10, we address giving advice, a commonly misused change technique, as well as the use of change questions, encourage-ment, giving information, brainstorming, and reframing.

The Importance of the Building Blocks

We have said that one of the problems confronting most beginning helpers is that they learn elementary skills in isolation and cannot see how the skills fit into a grand scheme. They do not understand how flashy theory-based techniques such as Gestalt’s “empty chair” relate to the baby steps they are learning in class. They begin making fun of their own tendencies to say “Mm-hmm . . .” and “What I hear you saying is. . . .” They secretly yearn to do what famous therapists do in training films: have a tremendous impact on cli-ents. Just as in basketball or baseball, every helper needs to practice the fundamentals. In sports, when fundamentals are mastered, they are linked into more complex movements, or plays. Without solid fundamentals, the plays are less effective. An example of this prin-ciple is shown in the 2010 film, The Karate Kid. When the student begins to study karate, his teacher tells him over and over again to pick up his coat and hang it on the rack. At one point, he rebels and angrily confronts his teacher for having wasted his time. The stu-dent wants to be Bruce Lee. In a moving scene, the teacher shows him how each of the seemingly unrelated tasks is a fundamental move in the art of Kung Fu. Through repeti-tion, the movements become second nature; when combined in a combat situation, they form an impenetrable defense. Your training in the helping skills will be very similar. You will learn basic helping moves, many of which will seem awkward and repetitive. How-ever, when they are properly learned and put in the appropriate sequence, they form more elaborate and elegant techniques, and they will take on a naturalness that you can-not feel at first. The art of helping begins when the therapeutic building blocks have become second nature. Then the helper can learn and practice change techniques like those in Chapters 9 and 10.

THE STAGES OF THE HELPING PROCESS: A ROAD MAP

The advantage to mastering the building block skills is that they help in the development of a therapeutic relationship. A therapeutic relationship is one that allows the client to solve the problems for which he or she has sought help. Figure 1.2 presents the stages of the helping process over time. The diagram shows five helper tasks that occur more or less sequentially from the first session to the last. This five-part structure is based on the work of several different writers (Dimond & Havens, 1975; Dimond, Havens, & Jones, 1978; Ivey & Mathews, 1986). The road map of the helping process shows the typical progression of activities of helper and client through the process.

The road map proposes a two-lane road with helper and client side-by-side. At each stage of the road, something is required of each person if the process is to move forward.

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Chapter 1 • Helping as a Personal Journey 25

For example, at the first stage, relationship building, the helper uses invitational and reflecting skills to build a trusting relationship. If trust is established, the client recipro-cates: opening up and disclosing more fully.

Most helpers find that it takes a session or two in the beginning just for building the therapeutic relationship and allowing time for the client to open up. Establishing and maintaining the relationship is crucial to the other stages of the road. For example, a strong therapeutic relationship allows a client to disclose more easily in the assessment stage.

In the second stage, assessment, the helper collects information and the client pro-vides it through answers to questions or data from intake forms or tests. In this book, assess-ment skills are covered in Chapter 8, although we have not included them in the therapeutic building blocks. The reason for not saying more about assessment in this book is that these skills, although important, tend to sidetrack us from our central purpose, which is to learn the fundamentals of a helping relationship. Normally, your course of study will include an entire course on assessment. Many helpers might spend an entire session collecting back-ground data, and some might spend a session or two conducting more in-depth evaluations using tests. However, assessment actually occurs throughout the helping process when a new problem emerges, and the helper must take time to collect needed information.

The third stage in the helping process is goal setting. In goal setting, the client par-ticipates by thinking about and agreeing to the goals that are mutually determined. The helper must use his or her expertise to shape these goals into clear statements and accept only those goals that will lead to real improvement in the client’s life.

STARTHERE

STOP

Relationship Building

Assessment

GoalSetting

Interventionand

Action

Evaluationand

Reflection

FIGURE 1.2 Road Map of the Helping Process

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26

-treatment plans)

intervention and action

evaluation and reflection–

MyCounselingLab Video Exercise 1.1 After the Breakup

Summary

Helping, interviewing, counseling, coaching, psychotherapy

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Chapter 1 • Helping as a Personal Journey 27

identified characteristics of effective helpers, including self-acceptance, cooperation, and the ability to reach out to others, there is not just one kind of person who can practice the helping arts. As you begin, remember

the adage of the mountain climber: Don’t look at the summit; keep your attention on your next step. One day you’ll get to the top, but right now appreciate where you are.

Exercises

GROUP EXERCISES

Exercise 1: Dividing into Groups and Constructing Questions

Earlier, we made the statement that developing an atmosphere that allows the client to feel comfortable and relaxed enhances interviewing. In this exercise, students divide into groups of four or five. Each group develops a list of 20 questions it would like to ask someone about his or her life if the group members wanted to get important information or know the per-son better.

Structured Interview

When the list is compiled, one member of the group, an interviewer, asks these questions of another person in the group, the interviewee. The interviewee should answer honestly but may pass on any question if it is too personal.

Unstructured Interview

In the second part of the exercise, two new individuals from the group participate in an interview. This time, the interviewer does not use the list. Instead the inter-viewer should focus on making the interviewee feel comfortable and asking nonspecific questions, such as “Can you tell me a little bit about your family?” It should be more informal and the emphasis should be on helping the interviewee feel comfortable and re-laxed and on following up on the interviewee’s an-swers rather than opening up a new topic. Someone in the group will need to keep track of how many open questions are asked. This unstructured interview ends after the interviewer’s 20th question.

Discussion and Analysis

Finally, the group discusses the two contrasting inter-views. What was the effect of each interview style on the interviewees? What are the advantages and disad-vantages of each style? In the unstructured interview, did you obtain the answers to all the questions on the

list? What did you get that was new or unexpected in the unstructured situation?

Exercise 2: One-way versus Two-way Communication

The purpose of this exercise is to become aware of two basic communication forms. An example of one-way communication is when your boss sends you an e-mail or you get a letter from the credit card company. Two-way communication means both people are respond-ing to each other’s communication.

For example, you and your friend talk on the phone about a computer problem you are having, and at each step you tell her what you are doing and she helps you solve the problem. This exercise explores these two kinds of communication options. To begin, students find a partner and then sit back to back with one sitting facing the front of the classroom and the other facing toward the back of the room. Using a whiteboard or flip chart, the instructor draws a figure of four connected geometrical shapes, and in the first phase, each front-facing student explains the figure to his or her rear-facing partner. The rear-facing students draw what they hear their partner describing.

Of course, the rear-facing students cannot see the figure and are not allowed to speak until they have completed the drawing. When they have completed the drawing, they may stop and show it to their part-ner and look at the board. In the second part of the exercise, rear-facing students again look away from the board and the instructor draws a different figure of about the same complexity. The rear-facing students still may not look at the board, but this time they are encouraged to stop their partner and ask for specific information. For example, “Is the triangle twice as big as the square? Is the rectangle inside the circle?” When the drawing is complete, each set of partners compares their two drawings. Which took longer? Which one is more accurate? Conduct a class discussion on the ad-vantages and disadvantages of one-way communica-tion. Think about the noise that was going on in the classroom. Did this affect communication?

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28 Chapter 1 • Helping as a Personal Journey

It can be a small problem you are now facing or an issue from the past that you can pretend is an issue to-day. Jot down your answers to the following questions about each stage of the helping process and the helper who might be assisting you.

a. Relationship building:

How important would it be for a helper to be warm and inviting, or would you prefer a more businesslike atmosphere?

How much would you like the helper to say about himself or herself?

How long do you think it would take before you trusted a helper enough to disclose something extremely personal?

What sort of personal characteristics would you want in a helper?

b. Assessment:

What important issues would a helper have to find out about you, your family, your environ-ment, your goals, your cultural and religious background, and your history before he or she could help you?

How would you feel about spending the first ses-sion answering questions about your problem?

How might you respond to the helper’s request that you complete tests or inventories?

c. Goal setting:

Imagine yourself without the problem. What would you be doing, thinking, or feeling that you are not experiencing now?

Can you turn your problem into a goal? For ex-ample, rather than stating the problem, “I bite my fingernails,” transform it into a future sce-nario, such as “I would like to have attractive nails that I would not be ashamed of in public.”

d. Intervention and action:

What kind of approach by a helper would you object to? Is there anything that immediately comes to mind that you might want the helper to do? React to each of the interventions below as to whether you would want the helper to use this specific technique. If the problem you have selected does not really fit with a particular tech-nique, just leave it blank.

With my chosen problem, I would most like to:

Listen to advice about how to solve my problem

Write in a journal to express my feelings

GROUP DISCUSSIONS

Your instructor may pose these questions to the whole class or ask you to break into smaller groups to reflect.

Discussion 1: Interviewing

Sometimes job interviews are comfortable, and some-times they are stressful. Do you think there are ad-vantages to making someone uncomfortable in a job interview? Which jobs really require people to react quickly under stress? Discuss some job interviews that you have participated in. What conclusions can you draw about interviewing?

Discussion 2: Energizing

There are a number of high-energy spokespeople who run infomercials and talk about human motiva-tion. Frequently, they suggest that we all have greater potential than we are aware of. Do you think these energizers are helpful? Is this kind of encouragement enough to make people achieve lasting change?

Discussion 3: Your Present Strengths

In a small group, discuss the following: You probably were encouraged to study helping by friends or family members. What do you think are the natural helping qualities that you possess and that you do not want to lose during your training?

Discussion 4: Your Reaction to New Learning Experiences

Think of a time when you learned a new skill (for example, playing tennis, learning a new program on the computer, or learning to sew). What stages did you go through as you were gaining expertise? Was your improvement gradual or were there sudden growth spurts? Were you self-critical at first? If so, what ef-fect did your negative thinking have? Can you identify any particular thoughts that you had during that time? Discuss them with classmates and see whether you can relate your previous experience to what you might encounter as you learn helping skills.

WRITTEN EXERCISES

Exercise 1: Stages of the Road Map

To get a better idea of the sequence of the helping pro-cess, let us examine the five stages shown in Figure 1.2. Think about a problem that you are experiencing.

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Chapter 1 • Helping as a Personal Journey 29

4. Allow other people to cry or express negative emotions.

1 2 3 4 5 6 7 8 9 10

Not at all confident Very confident

5. Help people figure out answers to their problems.

1 2 3 4 5 6 7 8 9 10

Not at all confident Very confident

6. Make people think by posing challenging ques-tions.

1 2 3 4 5 6 7 8 9 10

Not at all confident Very confident

7. Talk about myself, my deeper feelings, and my ideas.

1 2 3 4 5 6 7 8 9 10

Not at all confident Very confident

8. Challenge people when they are not being honest with themselves.

1 2 3 4 5 6 7 8 9 10

Not at all confident Very confident

9. Describe any other skill that you have that you might be able to transfer to the helping relationship.

1 2 3 4 5 6 7 8 9 10

Not at all confident Very confident

HOMEWORK

Homework 1: Meet a Professional

Make an appointment with a professional who has been working for only a few years (say, 1–5). Ask him or her the following questions and react briefly in writ-ing to each answer. (Be sure to add a couple of ques-tions of particular interest to you.)

1. Does another helper supervise you? If so, what do you value about these sessions?

2. Thinking about the therapists you have known or observed, what qualities do they possess that you admire?

3. When do you feel least confident in your job?4. To what theoretical orientation do you subscribe?5. What kinds of professional reading do you do?6. Do you benefit from conferences?

Just have someone to listen (no advice)

Keep a record of specific behaviors

Role-play my problem

Enter group therapy and hear the reactions of others

Bring a family member with me to a session

Complete an assignment to say no to others more often

Hear a story by the helper about how he or she handled a similar problem

Other (anything here that you think would help)

e. Evaluation and reflection:

How would you know that you had definitely completed your goal?

How would you be thinking, feeling, and acting when you had accomplished it?

SELF-ASSESSMENT

Use the “Stop and Reflect: Helper Characteristics” sec-tion in this chapter as a self-assessment activity as de-scribed below. If you want to extend that activity, look at these qualities of effective helpers and ask someone who knows you to rate you on a 1–10 scale for each characteristic. Compare his or her answers with yours.

Efficacy and Self-Esteem If you are considering a career in a helping profession, you probably possess some important interpersonal skills already. Think about what you are good at when it comes to dealing with other people. While you are learning new skills, it is important to remember your old strengths and find a way to incorporate them with your new helping skills. How do you rate yourself on the following skills? I am confident that I can:

1. Talk to people about serious and painful subjects without being overwhelmed.

1 2 3 4 5 6 7 8 9 10

Not at all confident Very confident

2. Chat, make small talk, and keep a conversation going.

1 2 3 4 5 6 7 8 9 10

Not at all confident Very confident

3. Make people feel comfortable.

1 2 3 4 5 6 7 8 9 10

Not at all confident Very confident

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30 Chapter 1 • Helping as a Personal Journey

to class or share them privately with your instructor. Because this class invites so much personal growth, your instructor may ask you to complete journal entries several times during the semester. Try to be as honest as you can, not only in a journal but also with your classmates. Is it possible to share too much about a particular topic that might overwhelm others? Whether you are asked to share some of your journal or not, ap-proach it with complete honesty and edit it later. Some-times I suggest that students write everything down and then remove or black out those portions they want to keep private before they hand in their assignment.

The following are two stimulus sentences you can use to provide a warm-up for your journaling. Each chapter contains several of these starters. Be-cause these are warm-ups, continue writing, even if you feel that you have departed from the original stimulus sentences. After writing for a while, reflect on what you are learning in class and focus on the challenges you face. Feel free to modify these journal starters or create your own.

1. Reviewing times in my life when I have not been as successful as I wanted to be, how did I react? What helped me to overcome the problem? How can I best deal with setbacks in my basic skills training? What feelings do I have as I start this process?

2. Reflect on a time when you think that you really helped someone. What did you do and say that seemed to have been especially helpful? Contrast this, if you can, with another time when you tried to help but you were not as successful. What was different about the two situations?

7. Did you notice any big “jumps” or stages in your ability to help?

8. Other questions . . .

Homework 2: Review Your Work History

Review your résumé or your past work history, wheth-er paid or volunteer. Include jobs you held in organi-zations in high school or college if your work history is short. List your jobs and, under each, write significant learnings you gained about working with other peo-ple, both clients and co-workers. Even if your job was not in a helping capacity, did you find ways to help others? Has helping been a regular part of your work life, or is it a new development? Summarize your learn-ing in a page or two.

JOURNAL STARTERS

Consider creating a personal journal that chronicles your experiences on your journey. Through this book, your lectures, and other courses, you are definitely gaining knowledge and skills. The journal, on the oth-er hand, allows you to reflect on your own attitudes about helping and to react personally to the ideas. By looking back over your work later on, you will be able to see your own development and think about future goals. A journal is not just a record; it should be reread and thought about.

You can use a computer, purchase a blank book, or develop a three-ring binder to construct a journal that allows you to add other information such as arti-cles, poems, pictures, and so on. Bring your reflections

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31

The Importance of the Therapeutic Relationship in Creating Change• What Is a Helping Relationship? Is a

Professional Helping Relationship the Same as a Friendship?

• The Unique Characteristics of a Therapeutic Relationship

• What Clients Want in a Helping Relationship

How Can a Helper Create a Therapeutic Relationship?• Relationship Enhancers• Self-Disclosure and the Therapeutic

Relationship

Other Factors That Help or Strain the Therapeutic Relationship• Facilitative Office Environment• Distractions• Appearing Credible and Taking a

Nonhierarchical Stance• Therapeutic Faux Pas• Transference and Countertransference

Summary

Exercises• Group Exercises• Small Group Discussions• Homework• Journal StartersLEARNING OUTCOMES

By the end of this chapter, you will be able to:

2.1 Understand the unique characteristics of a therapeutic relationship.

2.2 Identify ways to create a working alliance with a client.2.3 Identify factors that help or strain the budding relationship.

This chapter digs a little bit deeper into the mystery of the interaction between client and helper, discussing briefly why helpers and researchers place so much emphasis on the therapeutic relationship. Here, you will learn how you can build such a relationship with another person. Finally, you will learn about

The Therapeutic Relationship

C H A P T E R 2

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32 Chapter 2 • The Therapeutic Relationship

mistakes that can be made that strain or weaken the helping relationship and the knotty problems of transference and countertransference. Before addressing these important issues, though, let us take a look at a real client’s recollection of her relationship with a counselor in her own words:

I came to counseling because my husband was having an affair, and I was devastated over the impending breakup of my marriage. I was anxious, depressed, and having trouble eating and sleeping. I was like a zombie at work. I don’t want to give the impression that I am a weak person. I had always been the kind of person others leaned on. This was the first time I had ever been so needy. I felt like the rug had been pulled out from under my life.

I heard that Jim was the best therapist in the area, so I called to make an appoint-ment. Jim was a minister who also had a degree in counseling. Although I am not a Christian, I am very spiritually oriented, and I wanted someone who could understand that side of me. In many ways, Jim fit perfectly my ideas of what a helper should be. He was older than me by 25 years and had gray hair, and I had heard that he had been happily married for many years to another therapist in the area. I had also heard that he studied with some famous teachers. My expectations were high, and I was desperate.

At our first meeting, Jim got up to greet me at the door, shook my hand warmly with both of his, ushering me into his crowded office. Then, I had one of the most powerful experiences of my life. He listened to me for the next half hour as though nothing else in the world was more important. I had talked to a few friends about the situation, but he seemed to make me feel that there was all the time in the world, and I sensed that all my problems were no burden to him. Although I cried through much of the first session, Jim remained calm and at the end offered some hope. First, he asked me the question, “What holds you together?” I then talked about my spiritual beliefs. It made me realize that I could rely on that to help me through this crisis. Later, he commented, “I don’t think it is time to give up on this yet.” Having that light at the end of the tunnel made a lot of difference. I was able to hold on for a few weeks while things sorted themselves out. I continued to see Jim over the next few months.

Once, I came to a session and found that there was a mix-up in communication and only a half hour of my session remained. I was upset because I really needed to talk to someone. I was bursting with sadness and anger. That night I dreamt that I was sitting in Jim’s waiting room and everybody else was allowed to go in except me. Even though it wasn’t his fault, I felt unimportant. When we talked about it in the session, Jim said, “I guess it was hard for you to face another rejection.” This really helped me become aware of how discarded and unwanted I felt in my relationship with my husband. I also felt sick to my stomach when I realized how dependent I had become on my therapist. As time went on, I became stronger and was able to handle my problems much better. Knowing Jim was there was a great comfort sometimes. At other times, I was frustrated that when I needed to talk to him, it was still 3 or 4 days until our session. For some irrational reason, it made me mad that he was not available when I called.

After 4 or 5 months, Jim told me one day that he thought I had become too dependent on the relationship and that we needed to reduce our sessions to once per month. I agreed that things were better and silently assented to this new arrange-ment. After that session, I met a friend for lunch, and as we went through the buffet line, I took three knives, three forks, three spoons, and four napkins. I was so diso-riented by powerful feelings that I could hardly concentrate. Part of me saw Jim’s reducing our sessions as a form of confidence in me. But I also felt suddenly adrift. It took 6 months or so before I was able to really get back on solid ground and feel a sense of confidence. I feel that I owe Jim a debt that I can never adequately repay.

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Chapter 2 • The Therapeutic Relationship 33

He helped me survive during the lowest period of my life. I don’t idealize him any longer, but I recognize his caring and his undivided attention as one of the things that pulled me through.

AliciA B.

Alicia’s story illustrates the power that a therapeutic relationship can have to sustain us in difficult times, and it also reveals that strong emotions can be evoked when the relationship is strained or terminated. In addition, that relationship sometimes is a mirror that reflects our ongoing relationships outside of therapy. Not all helping relationships are so intense, and sometimes the relationship does not even gel despite the best efforts of the helper. Still, there are a number of things you can do to make a helping relationship work. In the next section, we look at the reasons why we place so much emphasis on establishing and maintaining such a relationship.

THE IMPORTANCE OF THE THERAPEUTIC RELATIONSHIP IN CREATING CHANGE

There is strong research support for the contention that the relationship is a key factor in client success (Horvath & Bedi, 2002; Ilgen, Tiet, & Finney, 2006). Lambert (1986) indi-cates that utilizing effective techniques accounts for some of the success in helping but that the therapeutic relationship accounts for about twice as much as technique (Norcross, 2011). Therapists and researchers have long recognized the importance of a strong working alliance in potentiating change (Bachelor & Horvath, 1999; Belkin, 1980; Fiedler, 1950; Horvath & Greenberg, 1994). From behaviorists Kanfer and Goldstein (1986) to Carl Rogers (1957), helpers have indicated that achieving client goals is much more likely in a good relationship. In fact, the quality of the therapeutic relationship appears to be more predictive of success than the theoretical approach of the helper (Nuttall, 2002). On the flip side, a poor therapeutic relationship or a rupture can lead to dropout (de Haan, Boon, Jong, Geluk, & Vermeiren, 2014; Katzow & Safran, 2007). The quality of the relationship is truly a common therapeutic factor among all theoretical approaches (Duncan, Miller, Wampold, & Hubble, 2010). The therapeutic relationship is crucial in all modalities of helping including group work, working with children and ado-lescents, and working with couples and families (cf. Norcross, 2011).

The helper/client relationship is also an important factor in understanding why clients drop out in the first few sessions. Clients drop out because they feel uncomfortable with the helper, do not like the helper, or decide that the helper is not capable of helping. So the power of the therapeutic relationship not only is vital to creating improvement, but also must be created immediately to prevent attrition. Think about how you might feel if you were to go to a physician and, although he or she appeared to have a lot of technical skill, the physician showed no warmth or concern and did not seem to listen. You might com-plain, but more likely, you would “vote with your feet” by not returning. As in any profes-sional relationship, if the helper does not instill confidence and communicate warmth and acceptance in the first few sessions, the client’s fragile hopes may be dashed, and he or she will give up on the helper or even give up on seeking professional help altogether.

The central importance of the relationship in the helping process is portrayed in Figure 2.1, which shows the six therapeutic factors. These are the “mega-skills” (Young, 1998), or common factors that are thought to underlie more specific therapeutic techniques

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34 Chapter 2 • The Therapeutic Relationship

(see Laska, Gurman, & Wampold, 2014). The REPLAN system is a treatment planning method based on these six factors. It asks the helper to think about what the client needs in relationship to each of these factors. REPLAN is a mnemonic device that helps you to remember the therapeutic factors when you are setting goals for a client. “R” stands for the relationship located at the center of the diagram to emphasize that the other factors depend, to a large extent, on the power of the client/helper relationship for their effective-ness. The other factors are “E” for enhancing efficacy and self-esteem; “P” for practicing new behaviors; “L” for lowering and raising emotional arousal; “A” for activating client expectations, hope, and motivation; and “N” for providing new learning experiences. These factors are all things that helpers do regardless of their therapeutic allegiance. Later on in the text, we will look at specific techniques under each of these general headings. It is also true that each stage on the road map of the helping process—relationship building, assessment, goal setting, intervention and action, and evaluation and reflection, discussed in the preceding chapter—requires the presence of a strong, cooperative relationship between helper and client in order to accomplish the treatment goals (see Figure 2.1).

What Is a Helping Relationship? Is a Professional Helping Relationship the Same as a Friendship?

As you learn the art of helping, you will be able to provide friends with a listening ear, a caring attitude, and emotional support, enhancing your relationships and aiding those you care about. There is, however, a difference between a friendship and a professional helping relationship; each is built on a distinct contract.

PracticingNew

BehaviorsMaintaining aStrong

Helper/ClientRelationship

Loweringand RaisingEmotionalArousal

Activating ClientExpectations,

Hope, andMotivation

Enhancing Efficacyand

Self-Esteem

Providing NewLearning

Experiences

FIGURE 2.1 Six Common Therapeutic Factors

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Chapter 2 • The Therapeutic Relationship 35

For example, in a friendship, the assumption is that we are there for each other. When you are in trouble, you can talk to me and vice versa. However, in a professional helping relationship, it is the client’s issues that are discussed and the client’s welfare that is paramount. In exchange, the helper receives compensation for services rendered. Consider this analogy: You mention to your friend, who is a dentist, that you have a toothache. She may suggest that you take some aspirin and that you make an appoint-ment with a dentist as soon as possible. Despite her professional capabilities, she proba-bly won’t pull out her dental equipment and start drilling in the living room. Although the analogy does not hold completely, helping can sometimes be a painful process and it is best accomplished in a more professional environment where a particular block of time is set aside. In addition, a professional helper is required to identify and articulate issues not normally broached in a friendship, such as painful childhood memories and issues that evoke guilt and shame. Moreover, the professional helper is committed to hours of listening, confidentiality, responsibility for the outcome, and disregard for whether the client ultimately likes him or her. The helper’s concern, as a professional, is to do a good job, not to maintain the relationship over the long term.

One reason for drawing the distinction between a professional helping relation-ship and a friendship is that it is easy to make mistakes in both settings when you begin learning helping skills. You might be tempted to use elaborate techniques on your friends when all they are asking for is support. On the other hand, you might find your-self treating a client as a friend. When that happens, you might not be able to “hold his feet to the fire” when it is required. Remember that with friends you have no agreement or contract for change; instead you have an opportunity to care, to show concern, and to provide support. However, in the professional helping relationship, you have a con-tract to help the client make specific changes in his or her life, not to make a new friend, enjoy each other’s company, or discuss the weather, your family, or your favorite hobby. What makes this difficult is that we have learned our natural helping skills in the context of our friendships and family relationships. It is easy to find ourselves being sociable and sympathetic, rather than thinking about how to help the client. It is like-wise easy to act like a therapist with our friends, who may find this behavior intrusive and phony.

Before leaving this topic, let us take a moment to emphasize the importance of a contract in relationships. Eric Berne (1961), the founder of transactional analysis, felt that this is a vital aspect of the helping relationship yet it is often ignored. Clients must know what they are agreeing to and must participate in the changes that they are about to make. Berne believed that problems in relationships frequently occur because the parties have made assumptions but not outlined their expectations of each other. For example, clients may assume that everything that they say to their counselor is confidential, but it is not. There are several instances where counselors must release information—for exam-ple, to prevent harm to others. Thus, ethics trump the therapeutic relationship whereas in friendships, they may not. Some counselors outline the parameters of the helping rela-tionship in a handout that they discuss with their clients. As you become a professional helper, you will recognize how important it is to identify the contract early in the relation-ship so that people you meet on an airplane and clients you see in your office know whether you are acting as a friend or a professional helper. Although we have said that these two relationships are different, what are the specific qualities that the therapeutic relationship should have to maximize the client’s progress?

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36 Chapter 2 • The Therapeutic Relationship

The Unique Characteristics of a Therapeutic Relationship

Thus far, we have emphasized that professional helping relies on a contractual relation-ship involving a trained helper and a client wanting help. When the helper and the client have confidence in that relationship, they report greater progress on therapy goals (Clemence, Hilsenroth, Ackerman, Strassle, & Handler, 2005). More important, stronger therapeutic alliances are linked with better outcomes (symptom improvement) (Dinger, Strack, Sachsse, & Schauenberg, 2009; Falkenström, Granström, & Holmqvist, 2014; Horvath & Bedi, 2002; Horvath, Del Re, Flückiger, & Symonds, 2011). But what are the characteristics of this special relationship? How will you know whether you are providing these aspects to a client? Here are the elements of a therapeutic relationship:

There is a mutual liking—or at least respect: A therapeutic relationship has at its base respect. Does the therapeutic relationship have to be one where client and helper have mutual fondness and a kind of chemistry? Perhaps not, but at least the helper conveys respect for the client’s autonomy, and the client respects the help-er’s expertise. Without this, a real alliance may not be possible.

The purpose of the relationship is the resolution of the client’s issues: Com-pared with other relationships, the helper/client dyad is unbalanced in favor of the client. Even if the client invites it, the helper does not ask for or receive support from the client. It is a one-way street where the helper is the giver. The helper’s own issues are dealt with in his or her personal life outside the therapeutic hour. The helper discloses his or her life only if it is very likely to aid the client.

There is a sense of teamwork as both helper and client work toward a mutually agreed-upon goal: The client can draw strength from the fact that the helper is there to provide support for change in the mutually decided direction. Just as a friend might become your ally in quitting smoking or maintaining an exercise program, the client feels the helper’s presence as a constant nudge to grow.

Safety and trust are established, allowing honest disclosure by the client and feedback from the helper. There is a contract specifying what will be disclosed to others outside of the relationship: Unlike a friendship at work, confidences with a family member, or feelings shared with a neighbor, the client begins to realize that secrets will not circulate. As the client experiences this safety, he or she begins to discuss deeper and deeper issues.

The relationship not only is about support but also requires honest feed-back: At times, the helping relationship requires the helper to give the client feed-back or nonjudgmental information about the client’s behavior. This might strain the relationship but ultimately reassures the client that the helper is being honest.

There is an agreement about compensation for the helper: Although some help-ers may be volunteers or interns, most receive credit or money for each client hour. Even the volunteer may benefit by listing the work experience on his or her résumé. At the beginning of the relationship, helper and client discuss compensation. Help from a professional is usually not a gift but involves a fee-for-services relationship.

There is an understanding that the relationship is confined to the sessions and does not overlap into the participants’ personal lives: As a general rule, helpers try to devote regularly scheduled times to clients. Crises are exceptions to

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the rule, but nearly all helpers have a system for dealing with emergent problems. Most helpers give out a 24-hour crisis hotline number rather than their home phone number. They do not interact socially with clients when it can be avoided so that objectivity is not strained by other considerations.

As a contractual relationship, the relationship can be terminated at any time: A unique aspect of the helping relationship is that once the client has reached the identified goals, the helping relationship is put on hold until some future help is needed. The relationship can also be ended by either party at any time. Sometimes agencies specify how many sessions a client may be seen, and frequently insurance companies limit their payments to a certain time frame. Generally, the helper termi-nates the relationship when sufficient progress has been made or if the client is not making progress at all. Of course, it is unethical to abandon a client who needs help. In those cases, referral may be called for, especially if the therapeutic relationship is not developing. Sometimes the relationship is ended by referral to another helper when special expertise is required such as sex therapy or substance abuse treatment.

MyCounselingLab Video Exercise 2.1 Overscheduled

STOP AND REFLECT

Learning the art of helping is a personal journey that asks you to examine your own ideas and reflect about what you are reading. Try to use the “Stop and Reflect” sections, such as this one, to jot down your thoughts and reactions, and then share them with another classmate or small group. You will certainly find other points in the book where your own ideas are challenged. Learn to pause at those moments and contrast the two positions. If you can begin this habit now, you are well on your way to becoming a reflective practitioner. Start by considering the following questions about friendship and helping. Discuss your answers with a small group.

• Have you ever given a friend help that was not well received, not appreciated, or that some-how changed the friendship? What effect did this have on you?

• Some people think that our mobile, stressful society has led to a lack of community and has separated us from our extended family. If friendships and family relationships were closer, do you think that professional helping would be needed?

• What would you do if a friend told you that he or she were contemplating suicide? Think about your answer and then discuss it with the class. In what other situations do you think that a professional helper might have an advantage?

• Have you noticed that in group situations you become interested when someone mentions something you agree with or when you have similar backgrounds? This “similar-to-me effect” has a powerful influence on our connections with people. In a job interview, you may be more apt to hire someone who is a member of the same sorority, is from your home state, or reminds you of yourself at a younger age. When you look for friends, do you look for someone who is similar to you? Does this search for similarity mean that it is harder to make contact with someone who is quite different? How could one’s preference for similar people be a handicap in a helping profession?

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38 Chapter 2 • The Therapeutic Relationship

What Clients Want in a Helping Relationship

A client’s judgment about the strength of the therapeutic bond is a better predictor of cli-ent progress than the helper’s (Bedi, Davis, & Williams, 2005). Thus, it is critical to know what clients can tell us that weakens or strengthens the relationship. When clients were asked about incidents that helped establish a solid relationship with the helper, they men-tioned the following helper behaviors:

1. The helper taught me a technique, such as making a list of goals.2. The helper showed good nonverbals, such as eye contact and leaning forward.3. The helper showed good listening behaviors: remembering what was said and

paraphrasing.4. The helper self-disclosed that he or she had had a similar experience.5. The helper encouraged me by making comments, including pointing out strengths.6. The helper emphasized that it was my choice and that I knew myself best.7. The helper was open to my criticism about the structure of the sessions or what he

or she said.8. The helper validated my feelings and gave me support.9. The helper greeted me, introduced himself or herself, and said goodbye. I had a

positive first impression.10. The helper used humor.11. The helper’s office environment helped to enhance the relationship (including rel-

evant books).12. I liked some personal characteristics of the helper (well groomed, similar back-

ground).13. The helper normalized the feelings I was having.14. The helper came highly recommended.15. The helper was honest and frank.16. The helper explained how therapy would work.17. The helper went beyond a business relationship and made extra efforts to help.

Clients in two other studies (Ackerman & Hilsenroth, 2003; Lilliengren & Werbart, 2005) were asked to identify the most helpful things they experienced in the helping pro-cess. They mentioned:

1. Labeling and expressing feelings2. Using the relationship as a nonjudgmental space where they could open up to a

supportive person3. Becoming more aware of themselves through self-exploration4. Finding new ways of relating to people because of their experience in the therapeu-

tic relationship5. Having therapists ask questions and summarize to help them find patterns in their lives6. The helper facilitating new thoughts and actions

HOW CAN A HELPER CREATE A THERAPEUTIC RELATIONSHIP?

So far, we have examined the therapeutic relationship from the perspective of a client and identified its crucial role in creating change. But how can a helper create this special experience? Before looking at these suggestions, remember that you probably already

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know some of the ways to make a relationship work. You may have found that people naturally seek you out for help. It is important to recognize your own natural abilities and not discount them as you eliminate some behaviors and try out new ones. On the other hand, it is important to recognize that creating a therapeutic relationship consists of a set of skills that takes time to learn (Wachtel, 2011).

Relationship Enhancers

Frederick Kanfer and Arnold Goldstein (1986) identified key relationship enhancers, or helper behaviors that improve the quality of the therapeutic relationship. They include some nonverbal skills such as posture, as well as presence, empathy, and self-disclosure. These helper behaviors lead to the emotional qualities or relationship components of lik-ing, respect, and trust. In other words, the relationship enhancers create a favorable emo-tional climate for helping. Naturally, the presence of liking, respect, and trust has relationship consequences of communication, openness, and persuasibility. If we like, respect, and trust someone, there is a free flow of information—no holding back—and that person’s suggestions hold more weight. Furthermore, when there is communication, openness, and persuasibility, there is the possibility of change. Thus, the very small helper behaviors called relationship enhancers cannot be ignored because they lead ulti-mately to the kind of safe and open relationship that gives the client the courage to change. Because the focus in this part of the chapter is on creating and enhancing the therapeutic relationship, we look at three relationship enhancers (presence, empathy, and self-disclosure) in a little more detail. Nonverbal behaviors such as posture will be dis-cussed in a later, more in-depth discussion.

PRESENCE Do you recall what the client Alicia B. said about her therapist in the case that opened this chapter? She said, “Then, I had one of the most powerful experiences of my life. He listened to me for the next half hour as though nothing else in the world was more important.” Calling this listening is only part of what Alicia was trying to convey. She was describing a kind of intense, intentional listening with full attention. In most human interactions, this kind of presence is rare. More often, the people we are talking to are checking their phones, washing the dishes, or driving the car. Presence implies total absorption and is quite similar to the concept of flow (Csikszentmihalyi, 1990). Here is how Carl Rogers described it: “I think if the therapist feels ‘I want to be as present to this person as possible. I want to really listen to what is going on. I want to be real in this relationship’ then these are suitable goals for the therapist” (Baldwin, 1987, p. 47). As Alicia pointed out, being fully present is often a potent relationship enhancer. It says, more than anything else, “You are important and I want to help.”

EMPATHY The word empathy is related to the German word Einfühlung, which means “feeling oneself into” another person’s experience. Empathy means that you grasp the facts, the feelings, and the significance of another person’s story; more important, empa-thy involves the ability to convey your accurate perceptions to the other person.

There is a vast literature on the importance of empathy. Although much of it focuses on the helping relationship, empathy has proved to be a vital aspect of other interper-sonal situations. Empathy training has been found to be an essential in good leadership and parenting (Gordon, 1986). Stephen Covey, in The 7 Habits of Highly Effective People

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(1990), recommends seeking “first to understand then to be understood” as one of the ingredients of personal job success regardless of your profession.

Recent news events have focused on alienated adults and teenagers who seem to lack any recognition of the feelings and needs of others. One group of researchers has suggested that this is due to a trend in young people becoming more and more self- centered and narcissistic (Twenge, Konrath, Foster, Campbell, & Bushman, 2008). Face-book and reality television and talent shows are filled with examples of exaggerated self-perceptions. The problem is that being overly concerned with one’s own success and needs prevents us from focusing with empathy on the concerns of others. The book Emotional Intelligence, by Daniel Goleman (2006a), suggests training in emotional aware-ness as the long-term cure for this condition in our society. Goleman’s research shows that awareness of one’s own emotions and those of others is among the most important predic-tors of success, mental health, happy families, and solid friendships. In summary, beyond its uses in helping, empathy can have a positive spillover into other areas of a person’s life.

Neuroscience and Empathy. There is growing evidence that human beings are bio-logically attuned to others. There has been a lot of talk about the discovery of mirror neu-rons, which are brain cells that fire when we see another person performing an action (Decety & Ickes, 2009). We automatically put ourselves in the other person’s position if we pay attention. Note how your facial muscles cringe when you see someone about to fall.

In his book Social Intelligence, Daniel Goleman explains how developing our social IQ is vital to interpersonal functioning in our intimate relationships (Goleman, 2006b). Social intelligence means having empathy and understanding the intentions of others and also possessing the social skills to respond appropriately. Goleman also points out that one of the prime benefits of empathy—besides perspective taking—is that it soothes the other person’s emotional arousal. Empathy, all by itself, helps. A spate of other books, bolstered by these findings in neuroscience, have focused on the business (Patanaik, 2009) and relationship advantages of empathy (de Waal, 2009; Iacomboni, 2009).

Helper Empathy. The special thing about empathy in the helping relationship is that here the term encompasses the experiences of both client and helper. Empathy does not occur in this situation if the helper has not communicated understanding to the client. If the helper hears the story only superficially or appears judgmental, even if he or she is accurate about the facts, the client does not experience the helper’s empathy. Empathy occurs when the client feels and may even say, “That’s it! That’s how I feel!” If we further analyze this statement, it could be said that a client experiences empathy when the helper communicates that he or she understands the facts, the emotions, and the special mean-ings of the client’s story.

Empathy and Differences. Empathy is a crucial skill in overcoming cultural, gender, and other differences between client and helper. Empathy means taking a “tutorial stance” rather than an authoritarian position when we are confronted with a person’s life experi-ence that clashes with our own. A tutorial stance means that the helper becomes a learner, seeking to understand the client—recognizing that the helper must learn from the client what it is like to be that person.

Racism and prejudices about various cultural groups can be seen as a form of nar-cissism or self-absorption. We become so attached to our own perspective that we have no tolerance for those who do not share it. Of course, we all come to an interpersonal

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situation with cultural “baggage” and a worldview that contains prejudices of one kind or another. These will show up in our verbal and nonverbal messages. Clients recognize our attitudes not only from the things we say, but also by body language that may signal sub-tle disapproval. Later in this book, we take up the issue of how to deal with these kinds of differences.

Empathy is a first step in moving us away from our ethnocentric narcissism and signals to clients that we are trying to “feel ourselves into” their world, rather than attempt-ing to convert them to our perspective. Although empathy provides a doorway to the inner life of another person, is it really ever possible to enter that world completely, leav-ing behind the vestiges of our own beliefs? We may not be able to completely grasp another person’s reality; however, it is important that our clients recognize that we are struggling to understand and that we care enough to try.

What Empathy Isn’t.

Empathy Is Not Merely Supporting or Agreeing with the Client. Consider the follow-ing story related by a school counselor:

Last week, I saw 17-year-old Monique, a young woman who has been accepted to col-lege with a full scholarship. She has a keen intellect and is especially good in math. She has always preferred older men, and now she has become pregnant by David, who is 15 years older than she. Recently, she found out that he was lying to her about his relationships with other women and that he had even lied to her about his job, saying that he was an architect when, in fact, he is a paraprofessional in an architect’s office. Her parents have told her she cannot remain in their home because they do not wish to raise another child. Although David will support her, she is afraid of him because she has heard he can become violent. Monique is also afraid to stay with him and feels that if she has a child with him, they will be bonded forever. She is considering an abortion because she feels that she misjudged him and cannot see a good future for herself or the child.

This situation presented a dilemma for the helper because, although she could empathize with the client’s situation, she felt that by empathizing she was supporting the client’s decision to obtain an abortion. Many helpers are afraid to empathize with a client for fear of taking sides. In fact, though, empathy can help clients examine their feelings at a deeper level and make decisions that are more consistent with their own feelings and values. You can communicate understanding about the circumstances that spawned the problem without supporting or agreeing with the client’s subsequent action.

Empathy Is Not Pretending to Understand. In the next chapters, you will learn some techniques to help you communicate empathy to clients. You will discover, however, that empathy is not effective if it is not sincere. Clients pick up on the nonver-bals as well as on what you say. Merely responding according to the prescribed formula will not help the client if you truly do not understand the situation. The best advice for the beginning helper is to be patient. Spend as much time as you need to hear the story before you tell the client that you understand.

Empathy Is Not Taking on Your Client’s Problems. For the most part, helpers’ fears about being overwhelmed by the client’s problems are unfounded. Empathic people try to understand another person’s pain in order to relieve it (Johnson, 1990). Consequently, it may be natural to fear that problems are “catching” and that by entering another

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person’s world too deeply, we may become depressed ourselves. Although it is impossi-ble not to be affected in some way by great pain, you learn over time to deal with it within the session and not let it hamper your time with the next person or carry over into your personal life. The great therapist Frieda Fromm-Reichmann (1960) claimed that we must learn to be like skin divers—not only able to go to the depth of a client’s problems, but also able to surface when we need to.

Empathy Is Not Sympathy. Sympathy is a synonym for pity. No one likes to receive pity because it suggests that the sufferer is somehow less than the other person. Nietzsche (1920) contended that pity for someone creates a power imbalance that makes the pitied person resentful, because, in some sense, the person’s dignity is being attacked. Thus, sympathy is not compatible with a positive, nonhierarchical relationship.

Empathy Is Not a One-Time Behavior. Although empathy is especially important in the relationship-building stage of the helping process, empathy remains essential through-out. As the relationship develops, the client may disclose more and more deeply. For example, as marriage counseling progresses, instead of talking about the problems the kids are having at school, a couple might begin to examine their attitudes about child rearing and their disagreements about how to discipline. These very personal topics might require the helper to empathize at a deeper level, trying to understand their perspectives and how these were shaped by their own families. As Carl Rogers says, we talk about “the thing next to the thing” (Rogers, 1957). Empathy allows the client to eventually approach the thing we need to talk about.

Self-Disclosure and the Therapeutic Relationship

If we hold that the ideal therapeutic relationship is one of genuineness and authenticity, then shouldn’t the therapist be a real person in the

therapy process? As real in the therapy hour as outside of it?

(YAlom, 1999, p. 253)

How can we become real, as Yalom recommends, and be helpful at the same time? Should not our authenticity and self-disclosure be tempered with concern for the client? Indeed, Carl Rogers (1972) cautions that disclosure by the helper must be “appropriate” (p. 129). Self-disclosure is not initiated to develop a social relationship or to allow the helper to ventilate feelings (Weiner, 1979). It is a high-risk/high-gain strategy in helping (Farber, 2006). It has great potential, yet it must be used with care. For many reasons, some writers feel that beginning helpers should avoid self-disclosure altogether. The point of view of this text is that by discussing its ramifications now, you will be better prepared to disclose appropriately when the opportunity arises.

Helper self-disclosure has been shown to be associated with positive outcomes for clients (Barrett & Berman, 2001; Hill & Knox, 2002; Lilliengren & Werbart, 2005). It has also been shown to increase trust in the relationship (Johnson & Matross, 1977; Jourard, 1971), make the helper more attractive (Goodyear & Schumate, 1996), deepen client self-disclosure, and encourage expression of feelings (McCarthy, 2001; Nilsson, Strassberg, & Bannon, 1979; Sermat & Smythe, 1973). It appears that moderate levels of self-disclosure are better than highly personal or only mildly personal disclosures (Bannikotes, Kubinski, & Purcell, 1981; Edwards & Murdock, 1994).

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The research on self-disclosure has come to differentiate between self-disclosing and self-involving statements by the helper (Cashwell, Shcherbakova, & Cashwell, 2003; McCarthy, 1979, 1982). Helper self-disclosure occurs when the helper relates facts about himself or herself. Self-involving statements occur when the helper shares his or her thoughts and emotions about the client. To show this distinction, take a look at these two helper statements:

“You said you wanted to know a little bit about me. I have been practicing for the last 7 years in this area, but I grew up in New England where most of my family still lives. I’m married and have three children. My practice here centers on individuals going through divorce. I also run couples groups, which I really like.” (self- disclosing statement)

“I’ve noticed in the past few weeks that you seem to be irritated whenever I bring up the fact that you have not been looking for work. I am wondering if it is just too stressful a topic, and I find myself being reluctant to mention this even though it is one of the main problems we agreed to work on.” (self-involving statement)

In general, research has supported self-involving statements (Curtis, Field, Knaan-Kostman, & Mannix, 2004), but has not always endorsed self-disclosure (Cashwell et al., 2003; Knox, Hess, Petersen, & Hill, 1997; Watkins, 1990). One reason is that much seems to depend on the client’s preference for self-disclosure (Cashwell et al., 2003). In other words, clients vary in how much disclosure they can handle without feeling that the helper is too self-focused or unprofessional. Second, it appears that timing is important. Self-disclosing statements (facts about the helper) are more useful early in treatment, whereas self-involving statements may be more effective later on (McCarthy, 2001). Finally, there are all kinds of disclosures, ranging from the superficial “I have a master’s degree” to the very personal “I once had a drinking problem.”

Too much self-disclosure can be a serious mistake. One of the best discussions of this is contained in Kottler and Blau’s book, The Imperfect Therapist (1989). According to the authors, “Whether the therapist’s ignorance, insensitivity, or narcissism is at fault, more than a few clients have been chased out of treatment because they felt negated by the repeated focus on the therapist’s life” (p. 137). Kottler and Blau go on to say that cli-ents are “frightened away” because helpers who talk about themselves make the client feel less important. Clients with low self-esteem do not want to hear about the successes of others. Helpers may lose their authority as transference figures and might be less able to influence the client through modeling. Finally, the client becomes bored with the rep-etition of therapist stories and anecdotes. The common mistake here is that the helper simply spends too much time in self-disclosure, which may put more stress on a client who already feels overburdened. Kottler and Blau contend that the saddest aspect of this situation is that the helper is usually unaware of the problem. To give a concrete exam-ple, a couple recently came to me for premarital counseling. They had been dissatisfied with a previous therapist because “She didn’t seem interested in us. Instead, she spent the whole hour talking about her relationship with her husband and how they handled their differences. It seemed like they had the perfect marriage. It was a waste of time and money.” Later, I found out that this therapist and her husband were getting a divorce because of serious problems. Although one might be tempted to explain the lack of therapeutic connection as a feeling that the couple could not measure up, it is just as likely they felt ignored and bored.

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COMMON MISTAKES IN HELPER SELF-DISCLOSURE The purpose of self-disclosure is to enhance the relationship, help the client realize that he or she is not alone, help the client see another viewpoint, or convey that the client’s experience is normal. However, if the helper’s story clashes with the client’s, self-disclosure may have the opposite effect. Many of the mistakes are due to the helper failing to realize that the client needs to focus on his or her own issues. Obviously, self-disclosure shifts the focus onto the helper. Once dis-closure is made, it is imperative that the helper shift the focus back onto the client. The following are examples of common errors in self-disclosure:

Mistake 1: The helper’s self-disclosure is too deep. Thus, the client has to react to the helper, rather than focus on parallels between his or her own story and the helper’s.

Situation: The client expresses that she feels like a failure because he or she is going through a divorce.

Inappropriate Disclosure by the Helper: “When I was going through my third divorce, I thought that there was something wrong with me. After all, I am supposed to help other people with their problems. So I went into therapy for over a year.”

Appropriate Disclosure by the Helper: “I have been through divorce myself, and I can relate to those feelings. I guess they are pretty common.”

Mistake 2: Self-disclosure is poorly timed. When a person has gone through a trau-matic event, it is a poor time to get him or her to focus on the helper’s story. Rather, the client should be encouraged to disclose more.

Situation: The client’s mother died last week. (In this case, the client cannot really appreciate or focus on another person’s story.)

Inappropriate Disclosure by the Helper: “I know just how you feel because my mother died about 5 years ago after a long illness. It was a long time before I got over it.”

Appropriate Disclosure by the Helper: “I don’t know exactly what you are going through, but I know a little bit about what it means to lose someone that close. I can guess that this whole thing has been very painful for you.”

Mistake 3: The helper’s self-disclosure does not match the client’s experience.

Situation: The client has received a basketball scholarship to go to college. No one in her family has ever gone to a university. She is having trouble achieving satisfactory College Board scores for admission.

Inappropriate Disclosure by the Helper: “Once I wanted to go to a prep school that cost $40,000 per year. But I had to go to one that cost a lot less because my family couldn’t afford it.”

Appropriate Disclosure by the Helper: “I can relate to your story in that I have had some goals in my life that I wanted that badly. It must be frustrating to be almost there and run into this new hurdle.”

In summary, self-disclosure is a technique that must be used with caution and at the right time. We discuss it here because it can affect the therapeutic relationship, but we will also reintroduce it as you learn building blocks skills. Self-disclosure can be used to

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bond with the client. Self-disclosure at the beginning stages of the relationship can help the client feel less alone. Self-involving statements can be used later in the process to (1) inspire hope in the client and (2) provide feedback, confrontation, or an alternative viewpoint. We will learn more about self-disclosure later when we look at invitational skills and more about self-involving statements when we discuss challenging skills.

PHYSICAL CLOSENESS, POSTURE, AND WARMTH In the next chapter, you will learn the basic skills associated with physical distance, the creation of a warm atmosphere for help-ing, posture, and other body language skills. These nonverbals invite the client into a safe relationship and lead to greater openness. Although these may seem like small things, the ability to create an inviting relationship can have a powerful effect on others in all kinds of situations (Purkey, 1987). Let us assume that you are going for two different job inter-views. In the first case, the interviewer greets you by shaking your hand. Her voice is friendly and informal. When you arrive at her office, she smiles and welcomes you. Then she sits down in a chair next to you, turning it around so she can face you directly. Con-trast this scenario with another office in which a secretary ushers you into the interviewer. The interviewer greets you from behind her desk. She spends much of the session staring at a file and making notes as she asks direct questions about your history. Under which circumstances are you likely to feel more comfortable and to open up about your past? In which situation are you more able to convey information you would like the potential employer to know? If one of these interviewers were to ask you to say something very personal about yourself, to whom would you be most likely to disclose? Although inter-viewing is not necessarily a helping relationship, even in this circumstance it is easy to see how powerful the small nonverbal enhancers can be in eliciting greater communica-tion, openness, and persuasibility.

MyCounselingLab Application Exercise 2.1 Identifying Appropriate Helper Disclosure

OTHER FACTORS THAT HELP OR STRAIN THE THERAPEUTIC RELATIONSHIP

In the last section, we examined the effect of helper self-disclosure on the therapeutic relationship. Here, we will talk about some other commonly identified issues that may lead to a stronger or weaker therapeutic alliance. Among these are the environment where helping takes place, the therapeutic blunders that we can try to avoid, and the issues of transference and countertransference.

Facilitative Office Environment

The helper’s office should be quiet, comfortable, orderly, and well lit. Most profession-als and clients prefer soft lighting to bright fluorescence. Decorating that is comfortable rather than “clinical” is helpful, especially at the beginning of a therapeutic relationship. People prefer rooms that are decorated and “warm” (see Pressly & Heesacker, 2001). Sigmund Freud called his office a “consulting room.” In other words, it should not be the therapist’s living room, nor should it look like a laboratory (Bloom, Weigel, & Trautt, 1977). The office should not be merely an outgrowth of the helper’s personality

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but also a workplace. Generally, it is recommended that the helper face away from the desk so that there are no obstacles between client and helper (Gass, 1984; Pietrofesa, Hoffman, & Splete, 1984). Side tables are useful for a clock and the indispensable boxes of facial tissue.

Although it is easy to depict the ideal, not all helpers today have the model facilita-tive environment. Some helpers now work primarily on the telephone or conduct coun-seling online. Sometimes school counselors see students in the hallways and in the lunchroom in 5-minute snatches. Other helpers work in cubicles without soundproofing. Many work out of their cars, doing home visits and actually conducting sessions in their clients’ homes. For them, the issues of distractions and privacy must be dealt with crea-tively. Many have traveling kits that can be unpacked to create a “therapeutic space,” with clocks, tissues, and play equipment for working with children.

Distractions

Noise from outside can interfere with the session, disrupting a delicate moment or giving the client the feeling that he or she may be heard by persons outside. A “Quiet Please” sign or one that reads “Session in Progress” should be placed on the outside of the door. In some cases, it may be necessary to purchase a mechanical white-noise or ocean-sound device that can act as a “sound blanket.” Position office seating to provide the most free-dom from glaring lights, noise, and the possibility of being overheard.

Other disturbances to be avoided during the session include knocks on the door and phone calls (Benjamin, 1969). Beier and Young (1998), in their classic book on therapeutic communication, The Silent Language of Psychotherapy, make the point that a helper communicates the importance he or she places on the relationship by the way in which these distractions are handled. If you were a client, how would you feel if I answered the phone during our sessions or ate a bag of potato chips? What would you conclude about the importance I place on the session?

Appearing Credible and Taking a Nonhierarchical Stance

Certainly, the helper must be seen as credible (Ritter et al., 2002), but how do you, at this stage in your training, appear credible to the client? You may be still training and you may be inexperienced, but the following suggestions can help you feel self-assured:

1. Remember what you do know and use the skills that you have. Review your strengths that we discussed in Chapter 1. There is no need to exaggerate your expe-rience or downplay your ability. Don’t communicate your own lack of confidence to the client. Sometimes, under the guise of honesty, helpers level with their clients and reveal their feelings of inadequacy, youthfulness, or lack of experience. Clients have enough going on without having to deal with your issues.

2. Don’t use emotional distance as a way of being professional. Sometimes beginning helpers will be overly formal with clients in an attempt to hide their uneasiness. This is where the nonhierarchical therapeutic relationship comes in. Just forming a one-to-one working relationship is therapeutic.

3. Remember that credibility is enhanced by appearing confident, organized, and in-terested and exhibiting nonverbal behaviors associated with attentiveness. These are behaviors that you can develop.

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NONHIERARCHICAL STANCE Some approaches to helping such as narrative therapy emphasize the importance of an equal relationship between helper and client. After all, the client is the expert on his or her own life. Although the helper brings certain skills to the table, the relationship should reflect collaboration as equals, and so the helper takes a nonhierarchical stance. By the same token, the client is not allowed to retain his or her social rank, no matter how educated or important. This nonhierarchical relationship is well illustrated in the movie The King’s Speech, where King Albert George VI and his speech therapist, Lionel Logue, refer to each other as Lionel and Bertie.

Microaggressions in the Therapeutic Relationship

The term microaggression means verbal and behavioral insults and slights that minority group members experience from those of the dominant culture (Sue, 2010). Perhaps the term microag-gression is too strong because it tends to focus on blatant insults while deemphasizing “slights.” Slights are more veiled and may be unconscious. Either way, the result is a rupture in the relation-ship. Consider the following three real-life examples.

1. One of my colleagues took a job at a university as a professor. He and his family are from Puerto Rico and when he met his new neighbors, they assumed that his job was in the university maintenance department.

2. In an office workplace, a white colleague goes to the copy machine and finds a number of African American co-workers chatting. She says, “What is this? A protest?”

3. A therapist at a university counseling center responded to a Cherokee student, who was talking about her cultural background, that somewhere among his distant relatives he had a Cherokee ancestor.

When insults or slights occur in a therapeutic relationship, they threaten the very basis of the helping relationship, undermining trust and liking. They must be dealt with in an open discus-sion between helper and client. Consider the helper who dismissed the client’s Cherokee back-ground. He thought he was bonding with the client but completely missed the fact that the client was trying to tell him about the importance of her cultural background.

How can helpers avoid microaggressions? Avoiding subtle slights and insults may take more than a simple class in multiculturalism. Many of our attitudes are deeply embedded due to our upbringing. The culturally competent helper must recognize biases and prejudices by continu-ally checking his or her own thoughts, feelings, and behaviors. In addition, he or she constantly gauges the effects of his or her words on the client.

CULTURE CHECK

Therapeutic Faux Pas

Some of the factors that strain the therapeutic relationship are the responsibility of the helper. Faux pas is a French term meaning “false steps” or “wrong turns.” It is better to think of therapeutic faux pas not as mistakes, but as detours that can be corrected later. Thomas Gordon (1986) identified 12 such “wrong turns,” known as the “dirty dozen,” that have particular relevance in the initial stages of developing a helping relationship. They are roadblocks because they are obstructions the client must go around. These are listed—with examples—in Table 2.1.

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TABLE 2.1 Roadblocks to Communication

1. Ordering, Directing, CommandingGo home and relax.You cannot do this.I expect you to do this.Stop it.Go apologize to her.

2. Warning, Admonishing, ThreateningYou had better do this, or else . . .If you don’t do this, then . . .You’d better not try that.I warn you, if you do that . . .

3. Moralizing, Preaching, ImploringYou should do this.You ought to try it.It is your responsibility to do this.It is your duty to do this.I wish you would do this.I urge you to do this.

4. Giving Advice, Suggestions, or SolutionsWhat I think you should do is . . .Let me suggest . . .It would be best for you if . . .Why not take a different approach?The best solution is . . .

5. Persuading with Logic, Lecturing, ArguingDo you realize that . . .?The facts are in favor of . . .Let me give you the facts.Here is the right way.Experience tells us that . . .

6. Judging, Criticizing, Disagreeing, BlamingYou are acting foolishly.You are not thinking straight.You are out of line.You didn’t do it right.You are wrong.That is a stupid thing to say.

7. Praising, Agreeing, ApprovingYou usually have very good judgment.You are an intelligent person.You have so much potential.You’ve made quite a bit of progress.You have always made it in the past.

8. Name-Calling, Ridiculing, ShamingYou are a sloppy worker.You are a fuzzy thinker.You’re talking like an engineer.You really goofed on this one!

9. Interpreting, Analyzing, DiagnosingYou’re saying this because you’re angry.You are jealous.What you really need is . . .You have problems with authority.You want to look good.You are being a bit paranoid.

10. Reassuring, Sympathizing, Consoling, SupportingYou’ll feel different tomorrow.Things will get better.It is always darkest before the dawn.Behind every cloud there’s a silver lining.Don’t worry so much about it.It’s not that bad.

11. Probing, Questioning, InterrogatingWhy did you do that?How long have you felt this way?What have you done to try to solve it?Have you consulted with anyone?When did you become aware of this feeling?Who has influenced you?

12. Distracting, Diverting, KiddingThink about the positive side.Try not to think about it until you’re rested.Let’s have lunch and forget about it.That reminds me of the time when . . .You think you’ve got problems!

Source: “Skills That Help Subordinates Solve Their Problems,” from Leader Effectiveness Training L.E.T. by Thomas Gordon, copyright © 1977 by Thomas Gordon. Adapted by permission of G. P. Putnam’s Sons, a division of Penguin Putnam Inc.

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Thomas Gordon (1986), who identified the “dirty dozen,” feels that the 12 road-blocks communicate two general messages. First, they suggest that the client is incapa-ble of solving his or her own problems. Second, they indicate that the client needs another person to solve the problems for him or her. Both are disempowering messages that take the responsibility for change away from the client and place it in the hands of the helper. Besides these 12 common detours, Wolberg (1967) has identified some other helper responses that can weaken or disrupt the therapeutic relationship. These include the following:

EXCLAMATIONS OF SURPRISE

client: “I spanked the living daylights out of my kids last night.”

Not Helpful: “You what?!”

“That’s awful!”

Helpful: “Sounds like you’re feeling guilty about it now.”

BEING PUNITIVE

client: “I don’t think that you are giving me the help I need.”

Not Helpful: “Then I will just refer you to someone else.”

“You are not making progress because you are not working on the problem.”

Helpful: “You feel stuck and that you are not making any progress.”

“You’re wondering if I am the right person to help you.”

“What kind of help do you think would be useful to you at this time?”

GIVING FALSE REASSURANCE Sometimes clients want us to give them hope that the helping process will be successful. This can backfire if the helper makes promises that cannot be kept.

client: “Will I ever get over this completely and be normal?”

Not Helpful: “Of course you will.”

“I think that you are normal now!”

“You will be better in 6 weeks. I guarantee it.”

Helpful: “First, tell me how you would like your life to be. If you were normal, how would you be feeling and acting?”

“Right now, you are feeling unsure about whether you can conquer this problem. I am hopeful that we can make a significant change if we work together.”

PSYCHOBABBLE AND PREMATURE INTERPRETATIONS Psychobabble is a word describ-ing the overuse of psychological terminology. When the helper identifies a technical term

MyCounselingLab Application Exercise 2.2 Roadblocks

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for every issue, the client feels that his or her problems are trivialized or that they have become a clinical syndrome in the mind of the helper. Premature interpretations, on the other hand, suggest deep meanings before adequate data have been collected to sup-port these interpretations. Here is an example that incorporates both psychobabble and premature interpretation:

client: “My father was an alcoholic and my mother seemed to tolerate it. We lived in denial our whole lives.”

Not Helpful: “That’s because your mother was codependent and that makes you ACOA [adult child of an alcoholic].” (psychobabble)

“That is why you are a dependent personality.” (premature interpretation)

Helpful: “Tell me more about what you mean by denial.”

“Tell me something about your family relationships now.”

PROBING TRAUMATIC ISSUES WHEN THE CLIENT STRONGLY RESISTS Respecting the cli-ent’s wish to avoid a topic can be handled by noting it, reflecting, and suggesting that it can be put off until later. Damage to the relationship can take place when the helper mercilessly pursues a topic. It is often a question of timing. Sometimes it is best to nurture the relationship and address the topic later.

client: “I don’t want to talk about sex.”

Not Helpful: “We have to talk about it sometime.”

“Then, let’s talk about your past sex life.”

Helpful: “It is a painful subject for you.”

“All right, we can come back to that another time.”

Transference and Countertransference

As the relationship develops, a sort of intimacy grows. An atmosphere of openness, lik-ing, respect, and trust is hopefully developing. This kind of therapeutic intimacy is gen-erally seen as a positive state of agreement and mutual caring. It creates favorable conditions for change (Rogers, 1957) and increases client involvement and compliance with treatment. However, intimacy also tends to elicit strong feelings—feelings that may have had their genesis in previous relationships (Wachtel, 2011). Transference and countertransference are terms that originated among psychoanalysts to denote these powerful feelings that develop when client and helper bond. As client and helper grow closer, a client may experience the same emotions of self-doubt, fear of abandonment, and other residue from parental or love relationships. This is called transference. On the other hand, the helper may also see the client as a reflection of a past or present relationship or may experience strong emotions for the client. This is called countertransference. When the helper finds that the client’s progress is stymied by the relationship itself, the helper must be trained and willing to examine the therapeutic relationship as a living model of the client’s social world. When the helper finds per-sonal needs spilling over into the therapeutic setting, he or she needs to consult with a supervisor and deal with these issues privately.

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WHAT IS TRANSFERENCE? Transference is a client’s carryover of feelings from past rela-tionships into a new one—the client/helper relationship. Relationship-building activities, such as listening and providing conditions of safety, increase feelings of intimacy and enhance the possibility of transference. Clients’ feelings can be described as positive, ranging from liking to sexual attraction, or negative, ranging from suspiciousness to hatred (Watkins, 1986). Negative transference reactions are thought to be an important reason for treatment failures (Basch, 1980; Spinhoven, Giesen-Bloo, van Dyck, Kooiman, & Arntz, 2007), because clients often drop out of therapy rather than face them. Although it may be impossible to avoid transference altogether (Gelso & Carter, 1985), in many helping relationships, transference never endangers the relationship or the client’s pro-gress. For others, it is vital to examine the therapeutic relationship as a first step in setting other relationships straight. A client may experience such strong feelings toward the helper that they become a roadblock that must be overcome in order for treatment to continue. When issues of transference interfere with the attainment of goals, they must be dealt with, either in an isolated fashion or in conjunction with other relationship prob-lems the client may be experiencing.

Why are we looking at a complicated issue like transference so early in your skill training? Dealing with such matters is certainly an advanced skill. But this chapter is about all the things that can delay or prevent the formation of a therapeutic relationship, and it

STOP AND REFLECT

Transference is not confined to the helping relationship; it is a part of everyday life (Andersen & Berk, 1998). In the book Blink (Gladwell, 2005), the author tells us that we rely on snap judgments about people and the world every day. It is said that we can form our first impressions of someone’s person-ality in less than 4 seconds (Bar, Neta, & Linz, 2006). In other words, we are constantly experiencing transference reactions at our very first meetings with people. Most of us are familiar with automatic feelings of liking or disliking a person on sight. These emotional reactions are most likely due to expe-riences with a similar person in the past, and they may be vague and impressionistic or, in other words, unreasonable. One simple way to categorize such reactions is to label them positive, neutral, or negative.

As an experiment, take a look around at your classmates and mentally note your feelings for each one—especially for those you have never met before this class or know only slightly. List each person’s name or indicate some memorable feature such as “blue shirt.” Next to each person’s name, put a plus sign (+) next to those for whom you have a positive attraction and a minus sign (−) if you have a negative feeling. If there is neither attraction nor a negative feeling, write N for neutral. You may think that it is unfair to assign a value to your feelings without taking into account the fact that you do not really know all your classmates well. That is true, but these impressions, like all first impressions, can influence how you react. As mentioned earlier, we experience these first impres-sions within seconds and act on them whether or not they are valid. Are there any real reasons for the positives and negatives you recorded? Are they the result of experiences with similar people? Think about the names of your classmates. Do any evoke an emotional reaction? If you had to choose two people in the class to play your parents in a role play, whom would you choose? Are you transferring any of your experiences with your parents or significant others to these people?

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is crucial to address some of the initial challenges that you will face as you learn the art of helping. You may find that this chapter is most helpful when you start seeing clients in a school, agency, or clinical setting, although it is background for the basic skills you will learn and something to refer to when real relationship breakdowns occur.

TRANSFERENCE AS COGNITIVE DISTORTION Some believe that transference is caused by unfinished business from the past. This notion is central to psychoanalysis, which asserts that issues surface from the unconscious because they are unresolved (Corradi, 2006). Freud believed that resolution of transference was the most important aspect of therapy because it allowed the client to address emotional issues about parents and siblings. One alternative viewpoint that has emerged is to conceptualize transference as a set of cognitive distor-tions, rather than as unresolved conflicts or unfulfilled needs (Sullivan, 1954). These distor-tions are learned patterns of thinking, not unlike the irrational ideas that have been described by Albert Ellis (1985). Still, there is a common thread that binds the modern viewpoint to the psychoanalytic idea. In both conceptualizations, the client is seen as focused on the outside (external causes of behavior) versus the inside (self-direction). The client is thinking about the attributes of the helper, rather than focusing on self-awareness. Even if it is a positive distortion (the helper as ideal), it is not reality. Hero worship may damage self-esteem if one compares oneself in a negative way to the helper (Singer, 1970).

To summarize, on the one hand, the client may have distorted ideas about the helper and the helping relationship that should be addressed. These may appear as inflated expectations about the helper, believing that he or she will solve all the problems single-handedly. Alternatively, the client may have strong negative feelings for the helper, especially when overblown expectations are not met. Watkins (1986) has identified five major transference patterns that are based on the concept of transference as cognitive distortion. Table 2.2, adapted from Watkins, shows these patterns along with the client’s attitudes and the helper’s reaction to them.

COUNTERTRANSFERENCE: DEALING WITH THE HELPER’S FEELINGS Countertransference is defined as the helper’s strong emotional reactions to a client. To give an example of this, consider this true story that a practicum student tells about one of her first clients:

My client is a 35-year-old woman who owns her own business. She showed up for her first session 5 minutes late. When I came to the waiting room, she complained loudly that she had been waiting for 10 minutes and then followed me to my office in a huff. Although I was pretty sure that she had been late, not me, I was on the defensive from the beginning, and I felt very uncomfortable and intimidated by her. As I watched the video, I saw the many unreasonable demands she made. For example, she said that she needed to change seats with me because there was too much glare in her eyes. She criticized the decorating and quizzed me about whether or not I had read the notes of the previous counselor. I watched myself just back down and become silent. I talked this over with my supervisor, who also noticed my passive behavior. I think that I reacted this way partially because this was my typical behavior with my previous boy-friend. Although he was not violent, he was verbally explosive, and I learned to become quiet and back off during his rages. Now I am doing the same thing with this client.

Countertransference is an issue not fully appreciated by the beginning helper. When intellectualizing about the therapeutic relationship, one can hardly imagine the powerful feelings that some clients may elicit. In the preceding example, it would be easy to blame

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the client for her behavior and label her as uncooperative. Although the client’s interper-sonal behavior may have to be addressed later in the helping process, the helper’s reac-tion merits examination, too. In practice, helpers need ongoing supervision to monitor the tendency to be too helpful and to deal with feelings of sexual attraction, as well as fear and insecurity. Anger toward clients is one of the most common forms of counter-transference (Dalenberg, 2004; Fremont & Anderson, 1986). Normally such issues are dealt with between helper and supervisor and not in the presence of the client. However, countertransference can seriously disrupt the client/helper bond.

Table 2.3 describes common helper emotional reactions, based on Corey, Corey, and Callanan (2015). The essential point of the information in the table is that

TABLE 2.2 Major Transference Patterns

Client Behaviors/Attitudes Helper Experiences

Helper as Ideal

Compliments helper profuselyImitates helperWears similar clothingGeneral idealization

Feels pride, satisfaction, and all-competentFeels flatteredExperiences tension, anxiety, confusion, anger, and frustration

Helper as Seer

Ascribes omniscience and power to the helperViews helper as expert. Sees self as incompetentSeeks answers, solutions, and advice

Experiences “God complex” and self-doubtFeels incompetent and pressured to be right and live up to client’s expectations

Helper as Nurturer

Experiences profuse emotion and sense of fragilityCriesFeels dependent, helpless, and indecisiveDesires to be touched and held

Experiences feelings of sorrow, sympathy, depression, despair, and depletionHas urge to soothe, coddle, and touch

Helper as Frustrator

Feels defensive, cautious, guarded, suspicious, and distrustfulTests helper

Feels uneasy, on edge (walking on eggshells), tense, hostile, and hatefulWithdraws and becomes unavailableDislikes and blames client

Helper as Nonentity

Shifts topicsLacks focusIs voluble and desultoryMeanders aimlessly

Feels overwhelmed, subdued, taken aback, used, uselessFeels boredExperiences resentment, frustration, and lack of recognitionCharacterizes self as a nonperson

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countertransference issues are generally inappropriate emotional reactions to clients, which can then lead to certain unproductive behaviors by the helper. Instead of helping the client achieve mutually derived goals, the helper develops a second (you might say unconscious) agenda that changes the helper’s view of the client as a collaborator in the therapy process. The helper has come to see the client as a project, as something fragile, as a sexual object, as a friend, or even as a reflection of the self.

Much of the unethical behavior in which helpers indulge is probably due to the strong emotions elicited in the therapeutic relationship, which make us forget our con-tractual role. This is one reason why a supervisory relationship is so crucial for every helper. The supervisor’s role is to appeal to the helper’s professional and ethical sense, provide insight and support, and remind the helper to act in accordance with thera-peutic goals.

DEALING WITH TRANSFERENCE FROM A CLIENT A client’s strong emotional reactions to the helper may be either the result of transference or honest reactions to the helper’s behavior. In both cases, the task of the helper is the same: to help the client gain more awareness and to nondefensively explore the source of these feelings (see

TABLE 2.3 Common Patterns of Countertransference

Helper Emotional Response to Client Helper Behavior

How Helper Sees Client

Paternal/maternal nurturing OverprotectiveFailure to challenge

Fragile

Fear of client’s anger Reduction of conflictAttempts to please

Aggressor

Disgust, disapproval Rejection NeedyImmoral

Need for reassuranceNeed for likingAnxietyInsecurity

SocializingFailure to challengeAvoidance of emotionally charged topicsTentativeness

Friend

Feelings of identification Advice givingOverinvolvementFailure to recognize client’s uniqueness

Self

Sexual Seductive behavior Sexual object

Romantic Inappropriate self-disclosureReduced focus on presenting problemsInappropriate exploration of sexual topics

Romantic partner

Frustration Extreme confrontation Product

Anger ScoldingCriticizing

Success

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Dalenberg, 2004). Let us look briefly at how a helper can react therapeutically when a client expresses strong feelings of anger.

Step 1 Convey Acceptance of the Client’s Remarks but Don’t Retaliate. Dealing with an angry client is one of the most difficult and delicate issues in helping. One reason is that it tends to evoke anger or fear in the helper. Retaliation or a defensive response can be perceived by the client as a weakness, as an admis-sion of guilt, or as a punishment. The client’s anger may be triggered by frustra-tion over lack of progress or by the perception that the helper is unfriendly, inept, or destructive. After having expressed this hostility, the client may then be concerned about angering or hurting the helper or may fear abandonment.

Example (conveying respect): client: “I don’t think we’re getting anywhere. When are we going to deal with

the real issues? I’m sick of coming in here and paying all this money.”

Helper: “I can tell you’re angry. I’m glad you had the courage to be so honest. I can’t think of anything that will be of more help to you than dealing with this issue.”

Step 2 Explore the Client’s Feelings. Following an expression of hostility toward the helper, the client may retreat, fearing he or she will be punished, lose control, or hurt the helper. Exploration of a client’s hostile feelings involves continuing to encourage the expression and labeling of feelings while trying to clarify the source of the anger.

Example (exploring): client: “I don’t think this is working, and I am tired of coming in here and

being told that it is entirely my fault.”

Helper: “What makes you feel that it is all your fault?”

Or,

Helper: “Do you have the sense that I am blaming you for not changing?”

Or,

Helper: “You wish I would be more supportive.”

Step 3 Utilize Self-Involving Statements to Help the Client Become Aware of the Helper’s Genuine Thoughts and Emotions about the Client and the Cli-ent’s Behavior. Self-involving statements are the helper’s thoughts and feelings that are shared with the client as information about the relationship.

Example: client: “You are darn right you should be more supportive. Nobody supports

me, not my wife, not my boss. I have to blow my top before they will even listen.”

Helper: (Self-involving statement) “I can tell you’re angry with me because you think I am siding with these other people. I don’t see it that way. I feel very much on your side, but I also feel a duty to help you look at what you are doing. And I can see where your anger is hurting your relationships.”

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Here is another example of a self-involving statement given by a helper when his client expressed feelings of romantic attraction:

Example: Helper: “I must say I am flattered and a little uneasy when you say you feel this

way about me. I am uneasy because I don’t want this to interfere with the progress we’re making. At the same time, I need to tell you I don’t share your feelings. I don’t want to hurt your feelings, and I don’t want to make you feel embarrassed. I also don’t want to lose the closeness that we have felt going through all the crises over the past year.”

Step 4 Use the Experience to Help the Client to Find New and Better Ways of Expressing Feelings and Meeting His or Her Needs. If the helper can avoid blaming, embarrassing, or shaming the client, the client’s expressions of strong emotions such as anger or attraction can be used to examine the client’s interper-sonal life. Clients who exhibit excessive anger or who are indirect or revengeful may be alienating others. Clients who romanticize all close relationships may need to find ways of developing more intimate friendships that are not sexual in nature. Dealing with transference by listening, exploring, and using self-involving statements has the effect of making clients aware of these patterns.

Example (using the therapeutic relationship to consider alternative behaviors): client: “I don’t know why I blow up. But I don’t know what else to do.”

Helper: “In this session, you have mentioned a number of situations besides our relationship in which you feel that you have to explode in order to be heard. I am not at all sure that is your only alternative. I think it would be helpful to learn and try out some new ways of relating, and you can practice on me. How do you feel about that?”

SummaryThe therapeutic relationship is the keystone in the pro-cess of change. In the road map of the helping rela-tionship, it empowers all the other activities that a helper uses to aid a client, including assessment, goal setting, intervention, and evaluation. There are a num-ber of helper behaviors that can enhance the relation-ship, including nonverbals such as physical closeness, posture, and warmth. In addition, presence, empathy, and self-disclosure can make the helping relationship stronger. The attribute of empathy is discussed in some detail because it seems to be a foundational abil-ity, as well as an attitude that allows us to enter more deeply into relationships.

There are also issues and behaviors that can strain the budding alliance. Among these are Thomas Gordon’s 12 roadblocks, a number of therapeutic faux

pas, a poor office environment, and the challenges of transference and countertransference.

One of the subtle points of this chapter is that a helping relationship is not a social relationship. It is more important that there be a working alliance rather than a friendship, an egalitarian but not a social rela-tionship. The social skills of making clients feel com-fortable, talking about the weather, and being a friendly person can reduce anxiety in the beginning stages, but the helping relationship should not be inhibited by the constraints of politeness and cultural tendencies to avoid certain topics for fear of embarrassment or con-troversy. Entering a helping relationship requires you to boldly go where few have gone before, using the relationship as the fuel to explore more and more deeply into the mystery of another person.

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Exercises

GROUP EXERCISES

Exercise 1: Getting Feedback on Your Natural Helping Style

In groups of four or five, students take turns as the helper and client with the others acting as observers. The client talks about any minor problem he or she wishes to disclose. After about 5–8 minutes, the con-versation stops, and the helper receives feedback from the group, including the client, about the helper’s natu-ral style. Try to give the helper honest feedback about your reaction to his or her manner. What did the group see as strengths or things to work on? Was the helper warm or cold? Was the helper light or serious, friendly or professional, formal or informal? If you wish, you may use a metaphor to describe how the conversation felt. Following are some interpersonal style traits ex-pressed on a continuum. You might want to use these as a starting point for thinking about your feedback.

Leading–Submissive, Competitive–Non-competi-tive, Trusting–Mistrusting, Cold–Warm, Distant–Friendly, Inhibited–Uninhibited, Self-assured–Self-doubting

Exercise 2: Barriers to Communication

Divide into groups of three to five students. The in-structor will secretly assign each group one of Thomas Gordon’s roadblocks in Table 2.1. (Roadblocks 4, 7, 10, and 12 are especially effective.) Each group is to put together a presentation that demonstrates its roadblock to the class in a role play between a helper and a client and then show helper behaviors that could en-hance the relationship in that same situation. Following each demonstration, the rest of the class guesses which roadblock was demonstrated and then discusses the effects of the roadblock on the helping relationship. It is especially useful for the client to describe what it felt like when the helper used one of these roadblocks.

Exercise 3: Dealing with Strong Feelings from a Client

In groups of three, role-play a scenario in which the client expresses strong feelings toward the helper. As the client fumes, the helper is to try to use the four steps given in the section “Dealing with Transference from a Client”:

Step 1 Convey acceptance of the client’s remarks but don’t retaliate.

Step 2 Explore the client’s feelings.

Step 3 Utilize self-involving statements to help the client become aware of the helper’s genuine thoughts and emotions about the client and the client’s behavior.

Step 4 Use the experience to help the client to find new and better ways of expressing feelings and meeting his or her needs.

The observer in the group keeps track of any helper statements that seem to help the client explore this issue.

SMALL GROUP DISCUSSIONS

Discussion 1: Case Study

In a small group, read and discuss the following ex-ample: Marisol is a counselor in private practice. The following is her discussion of a client, Carrie, who was referred for help by her family physician when she came to the medical office crying and needing to talk.

The client began the therapeutic relationship with much enthusiasm and high expectations for achieving her goals. She was a 23-year-old only child who felt that she has never been able to maintain a serious relationship. After a few weeks of counseling on this issue, her enthusiasm waned, and she expressed disap-pointment in me as a helper. By this time, I knew enough about her past to identify her dis-satisfaction in counseling as being similar to her history of intimate relationships. She began relationships with an idealized picture of her boyfriends and then was quickly disappointed. She came to the session one day indicating that she was angry that I had not been able to give her an earlier appointment. During her phone call, she had said it was important but not urgent that she see me soon. She admitted that she expected me to know how upset she was and to set up an emergency appointment. When we examined our relationship, the client was able to pick out several times when she left hints and clues about her needs but failed to ask for things directly.

I shared my feelings of surprise, being unaware of her real feelings. Naturally, this led to a discussion of how her behavior might have affected other relationships. It was a very

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significant insight when she realized that she was undermining relationships by her failure to send clear messages about her needs and expecting others to fulfill them. In her case, this pattern of behavior could be traced back to her upbringing, which did not require that she state her needs and rewarded indirect sug-gestions. In therapy, she was able to learn some assertiveness skills and practice them in a group setting.

a. Do you think it was necessary to examine the client’s past to help her with the problem in the helping relationship?

b. Is it possible that the client has a legitimate gripe and that Marisol is just “saving face” by making it the client’s problem?

c. In a case such as this, how much responsibility should the helper take for the miscommunica-tion about the client’s needs? Would it have helped the client if the helper had apologized or assumed partial responsibility for the misunder-standing?

d. If you were Marisol, how would you have han-dled Carrie’s expression of anger?

Discussion 2: Transference

Part 1 Take a look at the common transference re-actions in Table 2.2. Now think back on the case of Alicia B. that introduced this chapter. Which of these reactions did she experience in her relation-ship with Jim?

Part 2 Have you ever experienced any of these feelings for someone in authority? Think for a moment about the concept of authority. You have probably heard it said that a person has “authority issues.” How is this similar to or different from the transference reaction discussed in this chapter? Discuss your findings with a small group.

Discussion 3: Self-disclosure

Pretend that you are a helper working in a public agency. Tell members of your small group a few things about yourself that you might disclose to a client. Get feedback from the group about the appropriateness of your disclosures. Recall that the appropriate uses of self-disclosure are to (1) enhance the relationship; (2) help the client realize that he or she is not alone;

(3) help the client see another viewpoint; or (4) convey that the client’s experience is normal.

HOMEWORK

Homework 1: Favorite Teachers

Make a list of your five favorite teachers from elemen-tary school to present. List the traits or qualities of these persons. Identify any similarities. Are there also glaring differences? Now contrast them with some teacher or learning situation that was either very un-pleasant or simply unhelpful. What do these experi-ences say about how you like to learn? Based on your experiences with teachers, what kind of helper do you think might be the best fit for you? What kind of helper is likely to “push your buttons” and elicit some of the feelings you have had in previous helping relation-ships? Summarize your reactions to this exercise in two or three paragraphs.

Homework 2: Your Reactions to Clients

One of the most common countertransference reac-tions is to feel sorry for a client and help the client too much. Another reaction is strong feelings of attraction for a client. Research the ethical codes of one of the helping professions. What guidelines can help you de-termine ethical action in such situations? In each case, what could be harmful about this particular counter-transference reaction? In two or three paragraphs, dis-cuss how you would handle each of the two situations, ethically and therapeutically.

Homework 3: Involvement with Clients

You will sometimes hear helpers talk about being “overinvolved” with clients, and they may sometimes suggest that you “keep a professional distance.” What kinds of behaviors do you think would indi-cate that a helper were too involved in a client’s life? What limits should the helper set in the relationship? Does this necessarily mean that the helper should not care about a client? What ethical guidelines do professional helpers rely on to determine whether the professional relationship has become too close? Write down your reaction to these questions in a page or two.

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JOURNAL STARTERS

Remember that these starters are designed to warm you up to the issues. You may take them in whatever direction you like.

1. Recall a relationship, past or present, where the other person was significantly different from you, either in age, culture, or ethnicity. Discuss the experience. Was the development of the relation-ship more challenging than with someone more

similar to you? In what ways? How did you your differences enhance or deter the relationship? How did you overcome any obstacles to communica-tion? What did you learn from the experience?

2. Reflect on a time when you think that you really helped someone. What did you do and say that seemed to have been especially helpful? Contrast this, if you can, with another time when you tried to help but you were not as successful. What was different about the two situations?

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LEARNING OUTCOMES

By the end of this chapter, you will be able to:

3.1 Identify and demonstrate nonverbal skills for inviting the client into the therapeutic relationship.

3.2 Identify and demonstrate the opening skills of encouragers and questions for inviting the client into the therapeutic relationship.

Humans have a great need to communicate and more importantly to be understood. This desire to explain oneself has been met in various ways through the ages, such as by keeping journals and diaries, by taking part in religious confession, by confiding in friends, and by praying. In the same way, the therapeutic

Listening to the Client’s Story

Nonverbal Communication between Helper and Client• Regulation• Intimacy• Persuasion

Nonverbal Skills in the Helping Relationship• Eye Contact• Body Position• Attentive Silence• Voice Tone• Facial Expressions and Gestures• Physical Distance• Touching and Warmth

Opening Skills: How to Invite• Saying Hello: How to Start the First

Session• How to Start the Next Session• Encouragers• Questions

Summary

Exercises• Group Exercises• Small Group Discussions• Written Exercises• Self-Assessment• Homework• Journal Starters

C H A P T E R 3 Invitational Skills

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Chapter 3 • Invitational Skills 61

relationship, described in the previous chapter, offers the client a way to disclose to another and hear himself or herself in a nonthreatening atmosphere with the safeguards of confidentiality. It is not enough to think about one’s life; it must be disclosed verbally or in writing. The act of disclosing can be a great relief and is the first step in the healing process.

James Pennebaker (1989, 1990, 2002) has conducted some of the most interesting research on the benefits of self-disclosure and confession. He became interested in the phenomenon while talking to polygraph operators who gave lie detector tests to people suspected of crimes. These technicians told him stories of suspects who admitted their guilt under questioning and who even thanked the operators. Some operators said they had even received Christmas cards from some of those they helped to convict! This sug-gested to him that there is a powerful need to confess. Pennebaker found in his own research that college students who regularly wrote about their most troubling experi-ences in diaries showed better immune system responses and significantly better health compared with those who did not. Pennebaker’s work stimulated research supporting the fact that “opening up” is good for the soul and the body (Carmack et al., 2011; Frattaroli, 2006).

Pennebaker’s work about disclosure also underlines the fact that when clients come for help, they are seeking to explain themselves to a nonjudgmental listener (Pennebaker, 1990). Clients want to untangle the knots of traumas, miscalculations, and resentments that are troubling them. However, they are not merely seeking absolution; they want to understand how things got so mixed up and how to deal with the unfinished business. The therapeutic relationship can provide the opportunity to heal the body and the mind if the helper can get out of the way and allow the client to open up and investigate all the nooks and crannies of the problem.

In this chapter, you will learn and practice the first set of getting-out-of-the-way techniques in the art of helping. They are called invitational skills. Invitational skills are broken into two general categories: nonverbal skills and opening skills (see Table 3.1). Nonverbal skills such as using eye contact and body position set the stage for an open and confiding relationship. Opening skills are verbal catalysts that consist of encourag-ing statements and questions. Together, these two categories of invitational skills will allow you to convey to clients that you are listening to them and that they are invited to open up. The invitational skills are especially useful early on in the helping session when they do not interfere with the client’s recitation of the story. However, these same skills are used throughout the entire helping process, session after session, as the helper listens to the client relate his or her progress, report setbacks, and describe new issues as they emerge.

LISTENING TO THE CLIENT’S STORY

My wife says I don’t listen to her . . . at least I think that’s what she said.

Lawrence Peter

The quote by Peter points out how often we fail to fully listen to those around us—even those closest to us. Most people do not expect others to solve their problems, but they do want someone to listen, and they want to have a chance to hear themselves as well.

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Can listening all by itself have a powerful effect on another person? Is it possible that merely giving someone your full attention is healing? Some writers have called this active listening, a way of attending and encouraging without intruding on the client’s telling of the story. It is called active because the listener is fully absorbed and commu-nicates this to the other. But listening is difficult. A number of competing thoughts and urges assail us.

One of the biggest distractions is the need to help. A client’s story can create tre-mendous pressure on the listener. We want to ease the client’s pain, help him or her decide upon a course of action, and create a change. It is this impulse that prompts friends to offer quick advice to difficult problems. Frequently, however, the best approach in the professional helping relationship is to allow clients to completely describe the situ-ation to you and to themselves rather than jumping in to offer an instant solution. If you think about it, the client has probably heard a lot of advice already. What makes you think that your ideas are likely to be any better than those of a close friend? It is through listening to the client’s story that client and helper are able to find the keys to change, not by attempting to solve the problem in the first few minutes. In fact, quick advice tends to disqualify the helper in the client’s eyes.

Sheldon Kopp (1978) emphasized the importance of clients needing to “tell their tales.” The tale is a full recitation of the problem from the client’s unique perspective. It is

TABLE 3.1 The Building Blocks for Invitational Skills

Nonverbal Skills

Nonverbal skills are the use of eye contact, body position, silence, voice tone, and nonverbal encouragers such as head nodding or hand gestures that invite the client to talk.

Nonverbal Skill Example

Eye contact Direct eye contact with occasional breaks for client comfort

Facilitative body position “Open” attentive body position, squarely facing the client

Appropriate use of silence Allowing the client to fill in the “voids” in the conversation

Voice tone Using a voice tone that reflects the client’s and is appropriate in volume and rate and shows warmth and support

Nonverbal encouragers Encouraging the client to open up with appropriate gestures and head nodding

Opening Skills

Opening skills are verbal encouragers or questions. They ask the client to explore a little deeper but are not very invasive. They also reassure the client that you are following the story.

Opening Skill Example

Encouragers

Door opener “Say some more about that.”

Minimal encourager “Uh-huh.” “Okay.”

Questions

Open question “Could you tell me what has been going on?”

Closed question “Is she your ex-wife?”

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the client’s story of his or her life. Michael White, the Australian therapist, calls these sto-ries “narratives” (White, 2000). Hidden in each story are the clues to understanding how that person views the world. Helpers who take the time to let the client’s story unfold will design helping interventions that fit the unique client and his or her special worldview (cf. Goldberg & Crespo, 2003). So besides the therapeutic effects of allowing the client to disclose, we also gain greater insight into the client’s world (cf. Goodman, Morgan, Juriga, & Brown, 2004).

STOP AND REFLECT

Many beginning helpers get stuck because they feel that they have heard the whole story in the first 5 minutes. They become nervous because they think that if they spend more time listening, they will end up covering old ground. They also anticipate the client’s unspoken question, “What should I do?”

Consider the first few minutes of this actual session between a 30-year-old woman, Tia, and her helper, Renee. Tia is living with her mother and her 4-year-old son.

My mother wants everything done her way. I can’t do anything right, even with my son. For exam-ple, I have to call her at the end of today’s session and let her know I came. She thinks I need counseling. But really I just need her to get off my back. I have a job possibility, and it’s walking distance from home. But my mother thinks that it doesn’t pay enough. But I have to start some-where, and I think I would like it. If it weren’t for her, I would probably be living on the street. But when I try to get more independent, it’s like she doesn’t want me to. There are so many things I want to do. I want to go to school, have my own place, but she just won’t let me.

After the session, Renee met with her supervisor, Marcy, to discuss the case:

Renee: “I had a hard time in the session because I just wanted to tell her to take the job and move out. I also wanted to agree with her that her mother is overbearing.”

MaRcy: “Do you know enough yet to make that kind of statement to her?” Renee: “I guess not, but I wanted to help her figure out what to do.” MaRcy: “Resist the temptation to intervene until you know more about the situation and

about her.” Renee: “So I just listen? For how long?”

• How would you answer Renee’s question? As you look back at Tia, what more would you like to know about her before you feel that you have enough information to help? As you look at Tia’s story, do you see any way in which the helper might actually be hurting the client by intervening?

• What cultural, family, and religious factors are in the background of this client’s story? How important are these things in understanding the client? What assumptions have you already made about Tia based on her background? How can you test them?

• In this situation, would you be tempted to find ways for the client to change her mother?• Why is Marcy cautioning Renee to listen longer? What other issues does Tia struggle with

besides her relationship with her mother?• What parts of Tia’s story would you like to hear more about? Why do you think that would be

helpful?• What specific issues does Tia need to address in herself? Would encouraging her to take a job

or move from her mother’s house solve her problems?

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Like Tia in the “Stop and Reflect” section of this chapter, some clients will open the floodgates of the story during the first session, pausing only to take a breath and perhaps ignoring most of the helper’s questions and comments. It often seems that a client wants to get the story told as completely as possible before he or she will allow the helper to make an intervention. For others, it is a grueling process as the client’s story is painstak-ingly extracted drop by drop. In either case, the role of the helper seems passive, waiting for the client to finish the tale. Actually, the helper is listening with full attention so as to understand the facts, the feelings, and the unique perspective of the client. At times the helper is stopping to clarify a very important point of fact. Many client stories are as ironic and full of twists and turns as a Shakespearean comedy or tragedy. You cannot make a comment that a client will respect until you know the names of all the players and their relationships. It is difficult for many beginning helpers to listen to all these details. They cannot see where the story is going, and their own personal anxiety and desire to help propel them to fall back on the skills they have used all their life: offering praise, giving advice, fixing it, or trying to track the client’s problems back to some original cause. The art of helping, however, requires the helper to initially place his or her own concerns, questions, and theories on the back burner and to focus on the client’s story, waiting until all the wrinkles have been explored.

NONVERBAL COMMUNICATION BETWEEN HELPER AND CLIENT

Nonverbal communication is also called body language. We generally talk about seven nonverbal ways that we speak to others without words: eye contact, body position, silence, voice tone, facial expressions and gestures, physical distance, and touching (Gladstein, 1974). Some writers have suggested that as much as 80% of communication takes place on the nonverbal level. It has been estimated that only 7% of emotions are conveyed by verbal means, whereas 38% are conveyed by the voice and 55% by the face (Mehrabian, 1972). Nonverbals can be compared to the musical score in a movie. They can affect us tremendously, but we may not notice their presence. For example, research-ers studying couples communication were at first confused when they examined written transcripts of troubled marriages. Everything appeared normal. It was not until they watched the videos that they were able to see the subtle nonverbal signals of contempt such as rolling of the eyes. Even very minor movements and expressions can set off an argument. For example, it has been found that a raised eyebrow takes only a sixth of a second, but it can be detected at distances of over 150 feet (Blum, 1998). When strong emotions are being expressed, nonverbals are even more significant than what the per-son is saying (Aviezer, Trope, & Todorov, 2012). Body cues, not just facial expressions, help us understand powerful feelings.

Besides conveying information, nonverbal behavior has three other functions in human interaction. Nonverbals regulate the interaction (indicating pauses and stopping points), they can enhance intimacy, and they can be persuasive (cf. Argyle, 1987). Let us look at each of these functions.

Regulation

Occasionally, we are required to interact with others without having access to all the non-verbal cues that the person is sending. Have you ever participated in a conference call on

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the telephone? In face-to-face conversations, cues about when to speak and when to lis-ten are communicated nonverbally. Without access to these regulators, everyone talks at once or there are long periods of silence.

Intimacy

For example, we might prefer e-mail from family members if we are merely exchanging information, but when we want to hear their voices to feel close to them we call or Skype to get access to their nonverbals. Think about the difference between sending a sympathy card and placing your arm around the shoulder of a grieving friend. To increase intimacy, we increase proximity and use touch.

Persuasion

Nonverbal communication is also a powerful component of persuasion. The gestures and voice tone of famous orators such as Martin Luther King Jr. are evidence of this. Certainly the most persuasive communication takes place when we can see another person’s face and when we are in the same room. It is much easier to say “no” to the salesperson on the phone than to the one who is standing right in front of you. The art of helping also relies on persuasive nonverbal messages to encourage the client to open up. Helpers use specific nonverbal behaviors to persuade their clients that they are listening nonjudgmen-tally and that the client is in a safe environment. Your willingness to take the time to provide the most inviting nonverbal atmosphere will ultimately affect your client’s per-ception of you and his or her willingness to open up.

NONVERBAL SKILLS IN THE HELPING RELATIONSHIP

One maxim says that you can’t not communicate. Our bodies are not very good liars (Archer & Akert, 1977; Ekman, 2009; Vrij, Akehurst, Soukara, & Bull, 2004). Folded arms and drooping facial muscles tend to give us away. Astute helpers learn to read the body language of their clients as clues to the depth and meaning of the client’s problems. How-ever, helpers must be aware of the signals that they are sending, too. The client is inter-preting and reacting to the nonverbal messages of the helper. Clients react to helper nonverbals from the very first contact by voice tone on the phone and even by the arrangement of the office where client and helper meet. This discussion brings up an important caution about nonverbal messages. They are ambiguous. A client whose voice seems monotonous and depressed may actually be suffering from a cold. Crossed arms may be a better signal that the air-conditioning is too high than that the client is “closed” to what you are saying. Although many emotions come through loud and clear regardless of culture, there is a wide variation in gestures and facial expressions because of one’s upbringing (Ekman, 2009; Kim, Liang, & Li, 2003). Because of the ambiguous nature of nonverbal communication, most helpers are cautious about interpreting a client’s posture, facial expressions, or voice tone, or about drawing serious conclusions about a client’s mental state from a single piece of data. On the other hand, we have no control over what conclusions clients may draw from inadvertent nonverbal signals that we as helpers send. For this reason, from the initial meeting, helpers try to present the most welcoming, nonthreatening, and facilitative nonverbals that encourage the client to talk and do not interfere with the client’s telling of the story. Recall that there are seven ways to

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communicate nonverbally: eye contact, body position, attentive silence, voice tone, facial expressions and gestures, physical distance, and touch. In the sections that follow, we will address each of these as they are best used in the helping relationship.

Eye Contact

Eye-to-eye contact is the first and most important indicator of listening. It conveys the helper’s confidence and involvement (Ridley & Asbury, 1988). In Western culture, we normally associate lack of eye contact with dishonesty, indifference, or shame (see Kleinke, 1986). By contrast, those who sustain eye contact are seen as more ambitious, confident, assertive, intelligent, independent, and decisive than those who do not (Brooks, Church, & Fraser, 1986; Droney & Brooks, 1993).

Further, speakers who maintain eye contact with their audience are considered to be more credible and create more interest than those who do not. One study showed that graduate students in a seminar class are more likely to participate when they receive more eye contact from the professor (Caproni, Levine, O’Neal, McDonald, & Garwood, 1977). This suggests that eye contact can have an important interpersonal effect. It can stimulate involvement.

Clearly, eye contact is a powerful communication tool, but one should also be cau-tious in making assumptions about eye contact made by clients, especially those from different cultural backgrounds (Timm & Schroeder, 2000). For example, some African American clients may have been trained to look away when listening (LaFrance & Mayo, 1976; Majors, 1991), and in many cultures, it is common to lower the eyes as a gesture of respect to superiors (Galanti, 2004). Care must be taken when interacting with people from cultures (such as some Asian cultures) in which direct eye contact may be consid-ered offensive. In some situations, such as in the military and with some cultural groups, direct eye contact can be considered an act of defiance, a rude gesture, a sexual invita-tion, or a sign that you consider yourself to be superior. If cultures seem to clash, it might be useful to discuss this with the client. Depending on the situation, it might be best merely to respect the client’s own way of using eye contact and try to mirror it. Discuss-ing it with the client might be distracting and make the client feel overly self-conscious.

There is also evidence to suggest that eye contact may be more effective in some situations than others. When people discuss difficult situations, are struggling for words, or do not trust the other person, they tend to look away (Brooks et al., 1986; Droney & Brooks, 1993). In addition, looking at the other person’s face takes a lot of mental energy, and when thinking deeply, a person breaks eye contact. Sometimes, the helper’s fixed stare may be disconcerting and should be broken naturally and intermittently if the client becomes uncomfortable. A rule of thumb is to maintain a moderate amount of eye con-tact while closely monitoring its effect on the client. Still, eye contact by the helper can be a powerful tool because it forces intimacy on the client and increases the helper’s ability to persuade (Goldman & Fordyce, 1983). During times when the helper wants to be heard, eye contact will make his or her message more potent.

Body Position

Actions speak louder than words. Posture may be the most often noticed aspect of body language, so it becomes important to have a “posture of involvement.” A relaxed alert-ness communicates, “I am comfortable with myself and I have time to listen to you.” A

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relaxed and attentive posture is one of the fundamental tools for putting the client at ease (Maurer & Tindall, 1983). Lounging or sprawling in the chair might add an air of informal-ity, but it may also communicate that the level of the helper’s involvement is minimal. It is suggested that the helper lean the torso slightly forward (not the limbs), because lean-ing forward conveys attentiveness. Helpers normally maintain an open posture—no crossed arms or legs. Open postures seem to relax the client and encourage less defen-siveness. In general, this kind of posture has been supported by research because it tends to increase rapport with the client (Sharpley, 2001).

Attentive Silence

Silence is a powerful tool in the helping session, whereas in social settings silence is deadly. When there is a gap in social conversations, people talk to fill the awkward void. If the helper is able to endure the discomfort caused by these silences, the social expecta-tion to keep the discussion going may prompt the client to open up (MacDonald, 2005). Words often seem somehow to deny the validity of a person’s grief or are perceived as attempts to sweep feelings under the rug. At these times, the helper falls back on atten-tive silence in order to be present without interfering. Allowing for small periods of silence gives the client moments for reflection and the helper time for processing. At times, silence is often the most appropriate response, such as when a client has experi-enced a great loss. If used too much or too early, it can make the client too uncomforta-ble and unsupported. Helpers tend to use silence more as they gain experience (Hill, Thompson, & Ladany, 2003). Thus, using silence is something of an art.

Experienced helpers use silence to allow the client to reflect, to communicate empa-thy, and to take time to think (Ladany, Hill, Thompson, & O’Brien, 2004). They do not use silence when a client is experiencing a great deal of anxiety or anger or if the client suffers from a psychotic disorder such as schizophrenia (Ladany et al., 2004). In addition, clients feel more rapport with the therapist when the therapist allows for intermittent silence (Sharpley, 2005). Clients also feel more positive about a session if the helper talks about one third of the time or less (Kleinke, 1986).

Voice Tone

A client’s voice can give clues to his or her emotional state. We can tell from the client’s tone which issues are the most painful and which are the sources of the greatest motiva-tion and excitement. Similarly, clients respond to the helper’s voice tone. Helpers attempt to show calm concern and empathy with their voices, and at times they try to mirror the client’s emotional tone. When clients come for help, whether they are adults or children, they may be in a state of emotional turmoil. The helper who conveys a sense of calm and empathy with the voice can help stabilize the situation and give the impression that the helper will not be overwhelmed by the problem (cf. Tepper & Haase, 1978).

Sometimes, helpers use the voice to communicate that they understand how intensely the client is experiencing the problem. When a helper uses his or her voice to mirror the client’s emotion, the helper does not try to match the intensity of the client’s feelings but, instead, raises the voice slightly or gives emphasis to words that convey that the client’s experience has been understood. Let us suppose, for example, that a client describes a situation in which he or she did not get an expected promotion at work. The helper may respond to the client’s situation by saying, “You were really angry,” or by

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saying, “You were really angry.” In the second sentence, the helper’s voice tone empha-sizes the word really to more closely reflect the intensity of the client’s feelings. This slight lifting of the voice can quickly let the client know you are listening very closely, not just to the facts but to the emotions as well.

Facial Expressions and Gestures

All human beings express the six primary emotions of sadness, joy, anger, surprise, dis-gust, and fear with the same basic facial expressions regardless of culture (Ekman, 1975), but interestingly, many of these expressions have cultural “accents.” In other words, although Americans can identify sadness in pictures of Japanese people, there is some-thing culturally distinct about their expression as well (Marsh, Elfenbein, & Ambady, 2003). Setting aside the basic emotions, human beings can also discern about 5,000 different facial expressions, many of which are culturally specific (Blum, 1998). Thus, helpers must pay close attention to facial expressions, especially when it is important to determine whether these signals match the clients’ words. Incongruities between facial expressions, gestures, and verbal messages are clues to deceit, lack of self-awareness, and conflict.

Besides carefully attending to a client’s expressions, the helper must consider what messages he or she is sending through facial gestures (Hackney, 1974). The first Freudian analysts were trained to avoid reacting to the client’s expressions of emotion, whereas those trained in the client-centered approach of Carl Rogers felt that facial expressions shown by the helper should be genuine responses to the client’s emotions. Regardless of one’s theoretical persuasion, it is clear that facial expressions that convey the helper’s reactions to the client’s joy or sadness, anger or fear, excitement or bore-dom can serve as invitations to greater disclosure or potentially close the door if the client detects pity, disdain, laughter, or boredom (Fretz, Corn, Tuemmler, & Bellet, 1979; Maurer & Tindall, 1983).

Gestures are physical motions we use to convey emotion or emphasize important points. At the two extremes, excessive movement may signal anxiety, whereas a motion-less statue-like pose communicates aloofness. Fidgeting, playing with a pencil, drumming one’s fingers, frequently shifting body position, checking a watch, and other such move-ments can be read by the client as nervousness, impatience, or disinterest. The listener who is moderately reactive to the client’s content and feelings is more likely to be viewed as friendly, warm, casual, and natural. Specifically, this includes occasional head nodding for encouragement, a facial expression that indicates concern and interest, and encourag-ing movements of the hands that are not distracting.

Physical Distance

One’s personal space, or “bubble,” varies considerably from culture to culture. You may have noticed that people from Northern Europe require more space during a conversation than do Southern Europeans or Middle Easterners. It has been said that some Italians, for example, are perfectly comfortable with a conversation that is almost nose to nose (4 inches or less). Most one-on-one dialogues among Americans take place at a distance of 1 to 4 feet. Normally, about 3 feet is a comfortable space for personal interaction. In general, the smaller the physical distance, the more personal the interaction. Although lit-tle research has been done on physical distance in helping settings, in general, we can say that a culturally appropriate distance enhances disclosure (Hazlewood & Schuldt, 1977).

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Physical barriers such as desks increase distance and add a feeling of formality to the relationship. On the other hand, extremely close quarters can also feel intimidating and create anxiety. Stone and Morden (1976) suggest 5 feet (knee-to-knee sitting down) as an optimal distance between client and helper in a Western setting; however, most social situations are closer, with people sitting about 18 inches apart. Many helpers like to set up office chairs at about this distance, allowing the client to rearrange the chair in a comfortable way if he or she feels it is too close or too distant.

Touching and Warmth

We usually greet our clients by shaking hands in Western society. It signals that we are harmless and friendly (just as dogs roll over on their backs and stick their tongues out to communicate the same thing). Shaking hands conveys our willingness to connect. Touch has a long history in the helping professions, dating back to Freud’s “pressure technique,” which involved placing a hand on the client’s forehead to encourage free association (Smith, Clance, & Imes, 1998). Touch can communicate caring and concern, especially during moments of grief and trauma (Driscoll, Newman, & Seals, 1988; Eyckmans, 2009; Justice, 2008). There are several writers who contend that helpers need to use appropriate touch (Swade, Bayne, & Horton, 2006; Willison & Masson, 1986) and, in fact, it might be anti-therapeutic to avoid it. Holroyd and Brodsky (1980) recommend touch with socially immature clients to foster communication and bonding and with clients who are grieving, depressed, or traumatized as a way of showing support. They also encourage the use of touch as a greeting or at termination. In addition, touch may be used to emphasize or underline important points (Older, 1982). Touching another person does increase one’s ability to influence that person (Goldman & Fordyce, 1983).

Although there is much to be said for the healing power of the human touch, cer-tain taboos must be observed (Bonitz, 2008; Goodman & Teicher, 1988; Hunter & Struve, 1997; Phelan, 2009). Touch can also engender powerful sexual and transference reactions in the client (Alyn, 1988). For a client who has been sexually abused, a good deal of anxiety may be aroused, and any kind of touch might be inappropriate (Hunter & Struve, 1997). Perhaps fears about physical contact are overblown in the literature, but many writers have cautioned that it is important to know the client well before initiating even the safest forms of touch, such as a pat on the shoulder or back (Eiden, 1998). One guide-line is to use touch only sparingly to communicate encouragement and concern, with the knowledge that even slight gestures may evoke sexual or fearful feelings in the client (Stenzel & Rupert, 2004). The helper must be prepared to recognize this reaction in the client and be willing to discuss it.

Fisher, Rytting, and Heslin (1976) established three useful guidelines for helper touch: (1) Touch should be appropriate to the situation; (2) touch should not impose a greater level of intimacy than the client can handle; and (3) touch should not communi-cate a negative message (such as a patronizing pat). It must be recognized here that there is a “pro-hug” school of thought among some helpers. A hug may be a special gesture at the end of the helping relationship, but it may be experienced as forced intimacy when used routinely. An embrace may be seen as phony, and then the helper may actually be seen as less trustworthy (Suiter & Goodyear, 1985).

Because touch has its dangers, most beginning helpers should probably avoid it at first except for a greeting or parting handshake. The helper can still convey caring

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nonverbally by communicating warmth. Warmth is not a skill but a synthesis of nonverbal communications that can have a powerful effect on a client’s willingness to open up. Warmth is difficult to define, but when it is present, we recognize it and respond by opening up. In Table 3.2, David Johnson (2000) shows how nonverbal messages can communicate either warmth or coldness.

TABLE 3.2 Nonverbals That Communicate Warmth or Coldness

Nonverbal Cue Warmth Coldness

Tone of voice Soft Hard

Facial expression Smiling, interested Poker-faced, frowning, uninterested

Posture Lean toward other; relaxed Lean away from other; tense

Eye contact Look into other’s eyes Avoid looking into other’s eyes

Touching Touch other softly Avoid touching other

Gestures Open, welcoming Closed, guarding oneself, and keeping other away

Spatial distance Close Distant

Source: David W. Johnson, Reaching Out: Interpersonal Effectiveness and Self-Actualization, 7/e, Copyright 2000. Reprinted with permission of Allyn and Bacon.

MyCounselingLab Video Exercise 3.1 Dancing or Helping

CuLTurE ChECk

Culture is the system of shared beliefs, values, taboos, customs, behaviors, and artistic products that a group of people transmits from one generation to the next and that members of the group use to understand their world and each other. Differences in nonverbal communication can be a stumbling block in forming a relationship with someone from a different cultural background. We make assumptions about people based on the way they talk, look, or dress. In this section, Dr. Andrew Daire, who worked in a university counseling center, describes how talking about these perceived differences can lead to a better helping relationship and turn a negative first impression into a source of growth for helper and client.

I was the only black counselor at a small, private, predominantly white institution in the South. Once I was called to the office to meet a new client named Ray. When I came downstairs, I saw a burly young man in Western wear and cowboy boots who possessed a strong Southern drawl. He seemed very guarded initially, which I attributed to his discomfort in talking about his relationship problems. Soon I realized that we were not talking about the obvious differences between us, so I made the decision to cautiously open a discussion about his upbringing and how it differed from my own.

During that first session, he talked about his father being a racist and then admitted that he had almost walked out the door when he saw that his counselor was black. Despite this first encounter, we were able to form a good counseling relationship, and over the next nine ses-sions, we talked about his relationship issues as well as stereotypes and prejudice. When I saw my client for the first time, based on his clothing and accent, I expected him to be racist, and I

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OPENING SKILLS: HOW TO INVITE

Beginnings are always messy.

John GaLsworthy

Beginnings in the helping relationship are messy because each person comes in with expectations. Perhaps the client has watched a television show about therapy and expects to lie on the couch. Meanwhile, the helper may be expecting the client to open up and the client remains silent and wooden. In the beginning, it is up to the helper to clear up the messiness of the first encounter by inviting the client into a helping relationship, clarifying conceptions about the process, and giving the client hope that problems can be resolved. Before we discuss the basic verbal skills that you will need, let us talk about beginnings.

was tempted to pull back and not even address our differences. I now believe that treating him in that way would probably have reinforced his stereotypes and prejudice, rather than provid-ing an opportunity for him to examine them. I also began to understand a little about the fears that drive the attitudes of people like Ray and his father. Most important, we were able to develop a relationship that helped him deal with the issues he had come to work on. Had I not brought up the impressions we shared of each other, he probably would not have come back after the first session.

• Have you ever thought about attitudes you might have about people from various parts of the country? Do certain accents lead you to make unfair assumptions about people? What does a Southern, New York, Appalachian, or British accent imply about someone?

• Have you ever thought of clothing, hairstyle, or jewelry as a form of communication? All of these can be culturally influenced. For example, many people wear religious jewelry, giving a glimpse of their background. What customs can you identify in your own culture that help you decide what clothes or jewelry to wear? Are certain colors best for certain occa-sions, such as black for funerals?

• What can you really tell about a person from his or her clothing? Is there a risk of “pigeon-holing” people based on their clothing choice or the kind of car they drive?

• Think for a moment about your experience with people from different cultural back-grounds. Which cultural groups do you have the most experience with through friends or family? Which groups do you know the least about? How important do you think it is for a helper to experience a variety of cultural groups during his or her training? Do you think it is always possible for a helper to cross over cultural lines, as Andrew did, and help someone who seems to be so different?

• In Andrew’s story, both helper and client reacted to the nonverbals of the other person—clothing, accent, skin color, and probably many other tiny cultural differences—but they were hesitant to mention them. When do you think it might be important in a helping relationship to notice these and talk about them? When do you think it is best to ignore them? Is part of your job as a counselor to open up areas of discussion that are tradi-tionally taboo? Is broaching difficult topics a separate skill? Discuss this with your classmates.

We have now seen that nonverbal communication can invite or discourage a client from self-disclosure. Next, we turn to opening skills, which are verbal prompts that encourage clients to disclose themselves even more deeply.

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Saying Hello: How to Start the First Session

Here are some examples of how to conduct the first session.

• Let the client know something about yourself and about the process. Some helpers have a printed professional disclosure statement concerning the helper’s schooling, training, as well as what to expect in a helping relationship. This can even be given to a client to read prior to the session. For children and adolescents, take the time to explain the process to them, helping them see that your role is an advocate, not a parent or a teacher.

• The session begins with a self-introduction. “Hi, I am Mark. I am a counselor here. Why don’t you come with me back to my office?”

• Don’t spend the whole session doing paperwork. At least one third of the ses-sion must be spent in building the relationship and understanding the client’s problem.

• Specifically describe the helping process. For example:

“Here is how I see us proceeding from this point. You and I would meet once per week at this time, evaluating how well you are solving problems and reaching your goals. It would be up to you to continue to work on your goals throughout the week and complete whatever homework assignments we decide upon. I will be here on time every week and I hope you will too. We will continue until we both feel that you no longer need help. I will try to be honest with you, and I hope you will be honest with me. That means if something is happening that you don’t like, you will bring it up during the session. I think your speaking up is very important because there might be similar issues in your other relationships that need to be clarified and because we need to correct the misunderstandings between us so that progress isn’t stalled. How does that sound?”

• When the time comes to discuss the client’s issues, the following are recommended beginnings:

“All right, let’s talk now about what brought you to counseling.”

“Did something happen in the last few days or weeks that made you feel you needed help?” (Suggests that a certain event may have triggered the appointment)

“How can I help you?” (Lets the client know that you are the helper and he or she is the helpee)

“I see from the notes that you went to counseling before to deal with an addictions problem. Is that what brings you here today?”

• At the end of the session, summarize and give hope. For example:

“Well, we have talked about a number of different issues you are facing right now, and I hope that at the next session we can focus in on one or two of the most important ones. I am confident that we can successfully deal with the problems that you are confronting.” (It is important not to give false reassurance but if you feel hopeful, let the client know.)

How to Start the Next Session

Student helpers frequently begin subsequent sessions with:

“How was your week?”

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Unfortunately, this conveys that the client should recount the recent past and to some extent evokes a social atmosphere. Typically, clients begin to ramble and tell sto-ries. Instead, consider the following possibilities to get the client on track immediately:

“Last week we left off talking about how you want to be more assertive in your relationships. Let’s continue to explore how we can deal with this issue.”

“At the end of last session, I gave you a homework assignment about irrational thoughts. Let’s have a look at your diary and talk about how you are doing with that.”

“Last week we uncovered a number of issues that you are facing in your life. Let’s track one or two of these down and see if we can find the ones that are causing you the most difficulty right now.”

The preceding examples demonstrate how the beginning helper can effectively conduct the first two sessions with a client. After you say, “Hello,” the helper uses open-ing skills to prompt the client to talk more deeply about his or her troubles. The nonver-bal skills say to the client, “I am ready to listen,” but the opening skills say, “Tell me more,” and ask, “What did you want to talk about?” You can see that opening skills are actually demands, and so they must be presented in a way that the client feels that he or she has the opportunity to refuse. They are soft commands, and they fall into two catego-ries: encouragers and questions.

Encouragers

Encouragement means “to cause to have heart.” Encouragers are words the helper uses to bolster the client’s courage to confide. We have divided these encouragers into two categories, but both types—door openers and minimal encouragers—are brief interven-tions to kindle the fire of self-expression. We will discuss them separately here, but later in the book, we will simply refer to them both as encouragers because both serve the same basic function: to spark disclosure without taking over the conversation.

DOOR OPENERS The first kind of encourager is called a door opener, which is “a non-coercive invitation to talk” (Bolton, 1979, p. 50). The door opener is initiated by the helper, but the client determines the depth of the response. More than a passing social response or greeting, the door opener signals availability on the part of the listener and encourages exploration and discussion. By contrast, evaluative or judgmental responses are “door closers.” Some parents and teachers use door closers and wonder why their children or students clam up. Here are some examples of door closers:

“I suppose you are going to sulk again this morning, aren’t you?”

“When will you ever learn?”

By contrast, a door opener is generally a positive, nonjudgmental response made during the initial phase of a contact. It may include observations by the helper such as the following:

“I see you are reading a book about Sylvia Plath (observation). How do you like it?”

“You look down this morning (observation). Do you want to talk about it?”

“What’s on your mind?”

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“Tell me about it.”

“Can you say more about that?”

“What would you like to talk about today?”

Door openers are invaluable to helpers because they can be used to get clients to expand on what they have been saying, to begin conversations in the first place, and to allow helpers additional time to formulate a response.

MINIMAL ENCOURAGERS Minimal encouragers are brief supportive statements that convey attention and understanding. Most of us are familiar with minimal encouragers from the media’s image of the Freudian analyst behind the couch, stroking his beard and saying, “Mm-hmm.” Minimal encouragers are verbal responses that show interest and involvement but allow the client to determine the primary direction of the conversation. They are different from door openers in that they communicate only that the listener is on track (Hill, 2004). Such phrases reinforce talking on the part of the client and are often accompanied by an approving nod of the head. Examples of minimal encouragers include:

“I see.”

“Yes.”

“Right.”

“Okay.”

“Hmm.”

“I’ve got you.”

“I hear you.”

“I’m with you.”

Of course, these responses are not sufficient to help a client achieve the goals of therapy, but if they are not used frequently enough (especially in the beginning of the session), the client feels stranded and uncertain. Minimal encouragers tell the client, “I am present,” but they do not interrupt the story’s flow.

Questions

Most of us think that questions provide the ultimate road to understanding. But question-ing is not listening. It is directing the conversation away from what is powerful for the client and fills the need of the helper. Frequently, we can learn the most by patiently liv-ing with our questions until the answers come of themselves. We fall back on questioning when silence fails or when we feel uncertain about the direction of the conversation with someone we are trying to help. Sometimes questions get in the way of understanding for both helper and client.

Of all the opening skills, questions are the most easily abused. Excessive questions distract us from listening, and on the other side, the client may feel interrogated and evaluated (Brodsky & Lichtenstein, 1999). Questions can sidetrack the client from the story that is emerging because a question is a demand. In the beginning, questions inter-fere with the need the client has to tell the tale. Even more important is the fact that we are training our clients to answer questions rather than express themselves. Clients learn

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what helping is from the helper. Therefore, we want to be very careful, especially in the beginning, not to convey the impression that helping is an inquisition into what is wrong. Some of the most useless questions helpers ask are:

“How are you doing?”

“How have things been this week?”

“Why do you feel that way?”

“How does that make you feel?”

Research suggests that helpers ask fewer questions as they gain experience (Ornston, Cichetti, Levine, & Freeman, 1968). Still, the helper must ask some questions in order to gain key information. So the problem is to know when to ask questions and which ques-tions to ask. Certainly questions are called for when key elements of the story are confus-ing, but beginners frequently ask the wrong kinds of questions too early in the session when they should be finding other ways to get client to open up. The next section takes aim at two common kinds of questions that are fraught with difficulty: “why?” questions and leading questions. After that, we will talk about the appropriate use of questions in the beginning stages of helping.

“WHY?” QUESTIONS Asking the client why he or she behaves or feels a particular way is very enticing because this inquiry seems very psychological and appears to be getting to the root of a problem. The assumptions here are (1) that the client knows why and (2) that knowing why will be helpful. In fact, asking a client, “Why did you get a divorce?” may put him or her on the defensive rather than stimulating deeper thought (Brodsky & Lichtenstein, 1999). Adults tend to respond to “why?” questions with intellectualizations and rationalizations. On the other hand, if you ask a 5-year-old why he or she stepped in the mud, the inevitable and truthful answer is “I don’t know.” In reality, a few decisions people make, such as buying a car or a house, may have been the result of a lengthy, rational process, but the best answer to most “why?” questions is usually “It seemed like a good idea at the time.” This may be true even for important life decisions such as get-ting married or changing jobs. Over time, helpers learn to ask fewer “why?” questions and learn to extract the motivations, or “why,” of the client’s behavior from the whole of the story. When you understand why and share that with a client, it can convey a very deep level of understanding.

Frequently the reason for asking questions is that the helper feels stuck. When you encounter a sullen, reluctant, silent, or angry client, you may find the almost irresistible urge to revert to questioning because listening and waiting do not seem to be working. This feeling generally leads to desperate measures that do more harm than good. At such times, the helper should fall back on attentive silence and encouragers to keep the door open. Later in the process you will see times when more complex questions can be help-ful, but this chapter is about inviting the client into the relationship. At this point, exces-sive questioning puts the client on the defensive.

LEADING QUESTIONS Leading questions have an embedded message. The message usually is “If you follow my logic, you will soon see the answer to your problem.” Lead-ing questions are usually grouped together as a subtle argument or a covert way of giving the client advice (Hargie & Dickson, 2004). Clients may feel belittled by leading questions

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because their use implies that the client should have been able to figure out the cause of the problem. Consider this example:

raymond (cLient): “Since I was diagnosed with cancer, my entire life has changed. People have started looking at me differently. They look down on me like I can’t do the job anymore. I am sick of being pitied.”

LeiLa (heLPer): “Are you letting other people affect your mood?” (leading)

raymond: “I guess so.”

LeiLa: “Would you let other people affect you so much if you had more faith in yourself?” (leading)

raymond: “No, probably not.”

LeiLa: “Do you think that if your self-esteem were higher, you would feel better?” (leading)

raymond: “Yeah.”

These questions are leading because they are really disguised attempts to push through the client’s acceptance of the helper’s agenda. Can you see that in this example the helper is trying to get the client to acknowledge that his lack of self-esteem is the cause of his problem? Notice that the client tacitly agrees, but does not respond with more information or real enthusiasm. Unfortunately, this type of questioning is very com-mon among those who are trying to work with children and adolescents, but the evi-dence suggests that this approach shuts down the conversation (Sternberg et al., 1997). Beginning helpers should not immediately try to fix the problem but should invite the client to explain and then strive to understand what the client shares.

OPEN AND CLOSED QUESTIONS Although “why?” questions and leading questions are to be avoided, there are two other categories of questions that you will need to use regularly but at different times. They are open questions and closed questions.

Closed Questions. Closed questions ask for specific information and usually require a short factual response. Some closed questions can be answered with a “yes” or “no”; others demand information such as when you ask someone’s age. Closed ques-tions are important when you need to get the facts straight—especially when there is an emergency situation or when an understanding of the complicated facts is crucial to your getting the full picture of the client’s story. This became apparent in a recent dem-onstration session during which a client discussed the trauma and aftereffects of a seri-ous two-car accident. The helper, using door openers, minimal encouragers, and appropriate nonverbals, was able to get the client to talk about many of the important issues. However, the student helper failed to ask whether the other victim of the acci-dent had been killed or injured, an event that was the key to the client’s shame and remorse about the incident. The student helper felt that the client should have volun-teered this vital piece of information, but clients often talk about a problem on a super-ficial level at first. Sometimes, the helper must delve and pry to get the important facts. The difficulty is in knowing which aspects of the story are likely to be important. In this incident, for example, it was the seriousness of the accident that needed to be explored. Many beginning helpers might ask about less relevant details such as when and where the accident occurred, how bad the damage was to the cars involved, and so forth. These are the sorts of questions that sidetrack the client from the important issues.

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Although there are times when closed questions are called for, they can have a dampening effect on the relationship and on the conversation. If a helper begins with a series of questions such as name, address, and phone number, the client may begin to believe that his or her job is to respond to the helper’s questions rather than to tell the story. The client can become passive, waiting for the right line of questioning before speaking. Sometimes the deadly silence in the session is due to the fact that you have trained the client to wait for questions rather than initiate conversation. It may also be true that, depending on a client’s cultural background, the helper is viewed as an author-ity. The client might feel that it is only respectful to wait for a question. At such times, the helper should not let the client suffer in silence, but instead let the client know that help-ing means a partnership in which both people have the opportunity to contribute. The use of open questions will help these clients make a transition to greater involvement.

Open Questions. Compared to closed questions, open questions allow more free-dom of expression and are perceived as more helpful (Elliott, 1985). Open questions do not request specific information but encourage one to speak about the general topic. Because open questions are less coercive than closed questions, clients who are reluctant to seek help may respond better to open questions (Brodsky & Lichtenstein, 1999). Here are some examples. Consider how you might respond to them.

“Could you tell me about the kinds of problems you have been having?”

“Last week, we discussed your relationships with men. Would you mind going into that again?”

“What makes you think that it is time to make a change in your life?”

“Can you tell me about your problems with math?”

“You say you have self-esteem problems. What do you mean by that?”

Now consider the following closed questions:

“How old are you?”

“What school do you go to?”

“Are you planning to go to college?”

“Would you describe your marriage as happy?”

The difference between the two question types is something like the comparison between multiple-choice and essay exams. Multiple-choice tests check your knowledge of the facts, but essays ask you to show a deeper level of understanding. Here are some pairs of open and closed questions that each explore a similar topic. Note the differences in the client’s typical response to open versus closed questions.

Closed

heLPer: “Are you getting along with your parents these days?”

cLient: “Yeah. Pretty good.”

Open

heLPer: “Can you tell me how you and your parents have been dealing with your differences recently?”

cLient: “Well, we haven’t been, really. We’re not fighting, but we’re not talking, either. Just existing.”

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Closed

Helper: “Are you married now?”

Client: “No, divorced.”

Open

Helper: “Can you tell me a little about your personal relationships during the past few years?”

Client: “Well, I’ve been divorced for 6 months from my second wife. We were married for over 7 years, and one day she left me for this guy at work. Since then, I haven’t really been up to seeing anyone.”

As these examples suggest, open questions eventually elicit more information than closed questions, even though they may not seem as direct (Johns Hopkins University, 1998). Open questions enhance the therapeutic relationship (Boyd, 2003). Open ques-tions also persuade the client to answer by giving the client the opportunity to refuse. They do not box the client in by forcing him or her to answer directly. When you feel the need to ask a closed question, try to transform it into an open one first.

In summary, there is a tendency for beginners to ask too many questions including “why?” questions, leading questions, and unnecessary closed questions. Yet it is also important to get crucial information. Good questioning is an art (Goldberg, 1998), and we will consider it in greater detail when we discuss its use in the assessment stage of the helping process. Other uses of questions are not discussed here because this chapter cov-ers the beginning of the helping process, and questions at this point are less useful than they may be later on in the process. For the time being, keep a close watch on the over-use of questions in the exercises and practice sessions. See whether you can listen with-out closed questions, and let your nonverbal skills and other encouragers be the workhorses of your helping conversation.

MyCounselingLab Video Exercise 3.2 Can’t Delegate

MyCounselingLab Application Exercise 3.1 Labeling Opening Skills

MyCounselingLab Application Exercise 3.2 Responding Using Opening Skills

STOP AND REFLECT

Are You a Natural Helper?

In this chapter, we talked about opening skills, the ability to be attentive and available to another person, signaling that you are ready to listen. Some people seem to have the inherent ability to get

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Chapter 3 • Invitational Skills 79

other people to talk. Does it seem sometimes that you are carrying a sign that says, “Tell me your story?” You may be a natural helper.

Within every organization, school, or workplace, some individuals are identified by their peers as “someone you can talk to.” Recognizing this, the Annie E. Casey Foundation developed a project to identify good neighbors who are natural helpers in communities, and connected them with pro-fessional helpers (The Annie E. Casey Foundation, n.d.). There are also public and private k-12 schools that identify, provide training to, and utilize natural helpers to deal with problems in the school. They define natural helpers as individuals who are already sources of listening and support, and may include staff, faculty, and students.

Here are some questions that might help you determine if you are a natural helper:

• Do people you don’t know often strike up conversations with you?• Do people tell you that you are easy to talk to?• Do you enjoy finding out about people and know how to get them talking about

themselves?• Do your friends say that you should be in a helping profession?• Are you basically a nonjudgmental person?

Consider the qualities above. Do they apply to you? We have found that many beginning helpers take these skills and abilities for granted, thinking that everyone possesses them. In fact, while your fellow learners probably possess these abilities, most people don’t.

If you are a natural helper, does this mean that you don’t need additional training? Con-sider the fact that possessing these opening skills is only the beginning of helping. Beyond get-ting people to talk, we must know how to listen, how to help them set goals, behave ethically in a helping relationship, and develop advanced skills. These are all part of being a professional helper. Thus being a natural helper is a good foundation and makes the going easier—especially in the beginning—but professional training can allow you to help even more effectively and ethically.

Summary

Every client has a story to tell, and invitational skills let the client know that you are interested in that story. Invitational skills have two basic components: nonverbal skills and opening skills. Nonverbal skills are messages used by helpers to provide the right conditions for the client to open up. The skills are eye contact, body position, attentive silence, voice tone, facial expressions and gestures, physical distance, and touching. Opening skills are the verbal messages the helper sends to facilitate the client’s disclosure. Opening skills include encouragers and open and closed questions. Invitational skills are relatively sim-ple to learn, but they count for so much in the

relationship between client and helper. A summary of suggestions about how to use invitational skills effec-tively is presented in the following “Quick Tips: Invitational Skills” section.

QUICK TIPS: INVITATIONAL SKILLS• Once you have adopted a facilitative body

position, take a deep breath and relax.• Remember that the ball is in the client’s court:

Invite the client to talk and to tell the story.

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• After an open question or two, use the first few minutes to listen to the client, using minimal encouragers and head nodding.

• When a silence occurs, don’t rush to fill the void. Wait for the client to do it first.

• Rely on door openers such as “Go on” and “Say some more about that,” rather than asking too many questions at first.

• Use closed questions sparingly, but ask yourself whether you have understood the most important facts. If you are unsure, stop the client and ask a closed question or two.

Getting the relationship off on the right foot means establishing the norm that the client has free rein to explore his or her deepest issues in a non-judgmental atmosphere. Besides their importance in the beginning, invitational skills are needed at all stages of the helping process. As each new issue comes to the surface, the helper relies on invitational skills and a nonjudgmental attitude to provide the atmosphere of warmth and safety that allows for the deepest exploration of the client’s needs, fears, and dreams.

Exercises GROUP EXERCISES

Exercise 1: First EncountersIn this activity, the instructor selects two or three people to demonstrate a first encounter with a cli-ent. These may be students who have had some experience in the helping field or even individuals who have worked in the professional or retail world. These “helpers” each select a student to play their clients and one by one demonstrate, in a role play, how they establish conditions in which the client feels comfortable talking. For example, one student might role-play a school counselor bringing an el-ementary student from the playground to his or her office. The helpers should demonstrate in the role play how they greet the person and how they begin the helping conversation. After each role play, stu-dents in the class discuss what they liked about each helper’s approach. Does the class think that this first impression is crucial? What skills did you observe in each helper’s vignette?

Exercise 2: Practice and Feedback Session Using Invitational Skills

Some Notes on the Helper/Client/Observer Training Group

For many of the practice sessions in this book, we will be asking you to break into groups of three or four. This works in a circular fashion, with person A coun-seling person B, then person B counseling person C, and finally person C counseling person A. You can learn something in each role. Depending on how your instructor likes to work, you may be assigned to the

same groups for all practice sessions, or you may fre-quently change groups.

Practicing on fellow students is a method used in medical and dental schools as well as in the training of mental health professionals. Recently, I met a dental student who told me that he and his fellow students practice giving each other numbing shots. Just as in giving an injection, there is some risk involved in role-playing, but one of the prime benefits is that you learn something about being in the client role. You learn how it feels to be challenged or supported. You also get a feeling about what is too invasive or too super-ficial. Pay attention to these feelings and share them with your colleagues during the feedback portion of the exercise. Doing so will be extremely valuable to them even if it feels uncomfortable at first.

Although you may be role-playing part of the time, some of the situations may be real and so you should have an agreement for confidentiality in your practice group. It has been our experience that stu-dents respect this confidentiality and take it very se-riously. Still, confidentiality and its limits need to be explicitly discussed in each group.

Instructions for Group Exercise 2

Break up into groups of four. One person is the helper, another the client, and two act as observers. Before the “session” begins, the helper should take time to re-view the “Quick Tips: Invitational Skills” section. Mean-while, the client decides on the topic he or she wants to discuss, and the observers look over their checklists. Observer 1 will use Feedback Checklist 1 to give the helper data on his or her nonverbal skills. Observer 2 will use Feedback Checklist 2 to rate the helper on

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opening skills. If there are only three in your group, the observer should try to give feedback on checklist 2 and the client can comment on the helper’s nonver-bals. For 5–8 minutes, the helper invites the client to discuss one of the following topics:

• How I chose my present job• A trip I took that was very important to me• My relationship with a close friend• A topic of the client’s choice• The problem of a friend or acquaintance whose

role the client assumes

Feedback

At the end of the time period, the observers and client give feedback to the helper. The client is encouraged to give qualitative feedback that may include general impressions of the helper’s manner. The client should indicate whether or not he or she felt genuineness, empathy, and respect from the helper. The observers then give feedback based on their checklists. The par-ticipants switch roles, giving each person a chance to experience helper, client, and observer roles. The en-tire process will take about 45 minutes.

Feedback Checklist 1 (to be completed by Observer 1)

During the practice session, try to work through the checklist systematically, recording your comments for each skill on a separate sheet as you observe it. If you have time, start at the beginning and review each skill, at the end of the conversation, to check your observa-tions. When you are finished, write down any sugges-tions for improvement. Be as honest as possible so that the helper can benefit from feedback.

1. Draw a stick figure sketch of the helper’s body position.What does the body position convey? (Circle all that apply.)

Openness Relaxation Tension

Stiffness Interest Aloofness

Suggestions for improvement:

2. Evaluate the helper’s ability to maintain appropri-ate eye contact. (Circle one.)

AvoidsOccasionalIs constant with breaks

StaresSuggestions for improvement:

3. Evaluate the helper’s voice tone. (Circle all that apply.)

Too loud Cold

Too soft Soothing

Confident Clipped

Hesitant Interested

Moralistic or smug Bored

Warm Other

Suggestions for improvement:

4. Evaluate the helper’s gestures and facial expres-sions. (Circle all that apply.)

Gestures:Nervous movement or distracting movementOccasional gesturesInviting gesturesRigid gestures

Nodding:Head nodding appropriateHead nodding too frequentHead nodding too infrequent

Expression:Helper’s face shows concern and interestFace shows disinterestFace reflects client’s feelingsFace is unchanging/masklikeOther (e.g., warmth or use of touch)Suggestions for improvement:

Feedback Checklist 2 (to be completed by Observer 2)

You are to give feedback on the helper’s use of en-couragers (door openers and minimal encouragers) and questions (open and closed). Your task is to write down everything the helper says during the interview. At the end, categorize each response and give the helper feedback.

Categories

Encourager (E)—include door openers and min-imal encouragers under this same category

Open question (OQ)

Closed question (CQ)

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82 Chapter 3 • Invitational Skills

Helper Question or Statement Category

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Feedback on the Use of Encouragers

1. Did the helper supply enough encouragers during the initial 2 minutes of the interview to let the cli-ent know he or she was listening?

2. Were minimal encouragers used too often, instead of open questions that might have given more depth to the discussion?

Feedback on the Use of Questions

1. Look at the list of closed questions used by the helper. Based on the client’s responses, were they vitally important or merely asked out of curiosity? How many “why?” questions did you detect?

2. Were there more open or closed questions? Does the helper need to increase the use of open ques-tions or decrease the use of closed questions?

SMALL GROUP DISCUSSIONS

The following activities can be done in a small group or as a whole class.

Discussion 1: Open versus Closed Questions

Each member of a small group (two or three students) should individually turn the following closed questions into open questions. Write your answers on a separate

sheet. Remember, an open question can expand a topic beyond the original closed question. For example, the closed question “Are your parents still married?” can be “opened” by changing it to “Can you tell me something about your family?” Share your open questions with others in a small group. Think how you might answer your own open questions. Do they give you room to expand and disclose?

• Where are you from?• What is your problem?• Why do you need help?• When did all of your problems begin?• Do your mom and dad fight?• Did you have fun on the class trip?• How old is your daughter?

Discussion 2: Watch a Video of a Practice Session between Another Helper and a Client

View 10–15 minutes of a video that shows a client/helper interaction. While watching, write down any observations you may have concerning the client’s body posture, gestures, and movements. Afterward, discuss the relationship of these nonverbal messages to the client’s concerns. Alternatively, half of the class can observe the client and the other half can focus on the helper. Check the helper’s invitational skills against the list in Table 3.1.

Discussion 3: Eyes Closed

Form dyads (groups of two) and sit facing each other with your eyes closed. Discuss your activities over the past week for about 4–5 minutes. In the class discus-sion that follows, take turns giving your reactions to the experience. What nonverbal behaviors did you and your classmates find it most difficult to do without?

Discussion 4: The Effect of Distance

Set up a simulated office for a role-playing situation. Provide one chair for the client and another for the helper. Use a third chair to represent a desk if one is not available. Place the chairs about 10 feet apart, and ask two participants to hold a conversation at that dis-tance concerning a minor problem one of them is hav-ing. Ask the group to comment on how the distance has affected the conversation. Next, allow the partici-pants to move the chairs to a comfortable distance. Once the chairs have been moved and the participants are seated, measure the distance from knee to knee with a yardstick or tape measure and see whether it

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Chapter 3 • Invitational Skills 83

is approximately 18 inches, an average social distance. Does it seem too close or too far away? Next, move the chairs so close that the participants feel uncomfortable. Measure that distance. If participants from diverse eth-nic backgrounds are members of the group, interesting variations can occur. Try the exercise with participants standing instead of seated. You will find that some people will feel comfortable with an interpersonal dis-tance of 6 inches or less.

Discussion 5: Touch with Caution

Conduct a group discussion on the implications of touching clients. What constitutes sexual touching? Whose needs are being fulfilled by touching? Is it all right for the helper’s emotional needs to be met by hug-ging a client? Under what circumstances would a hug be beneficial or harmful? What about hugging in group therapy?

Discussion 6: Try a 10-Minute Video Session

Make a 10-minute video of two trainees, one of whom acts as the client and the other as the helper. The cli-ent discusses a minor problem he or she is having at work or at school. Focus the camera for half of the session on the helper’s face and the other half of the session on the helper’s whole body. Replay the tape and ask the helper to evaluate his or her own facial expressions, body position, and gestures. Although this is a very simple exercise, it may help students who are

feeling camera shy. Our experience is that the more opportunities students have to be recorded, the better their final sessions will be. As the normal fear of being observed lessens, the helper’s responses become more natural, and more attention is focused on the client.

Discussion 7: Sustained Eye Contact

In this exercise, students form dyads. The leader or instructor will keep time and signal the completion of the activity at the end of 2 minutes. Maintain eye contact with your partner and assume the appropri-ate helper’s posture while remaining completely silent. Afterward, discuss your personal reactions to this exer-cise with your partner and then with the larger group.

WRITTEN EXERCISES

Exercise 1: Practice in Classifying Opening SkillsLearning to identify skills is the first step. The second step is performing the skills aloud. We have found that the more practice you have in identifying skills, the more rapidly you will be able to produce the skills yourself. Read the following excerpt from a session between a helper, Mrs. Henderson, and her new stu-dent, Maryann, and then classify each of the eight helper responses as an Encourager (E) (door open-er or minimal encourager), open question (OQ), or closed question (CQ).

Skill Used

Mrs. Henderson: It looks like you’ve been crying, Maryann. 1. ___________

Maryann: Yes, that is why I came to see you.

Mrs. Henderson: Can you tell me what’s upsetting you? 2. ___________

Maryann: Everything! I hate this school!

Mrs. Henderson: Go on. 3. ___________

Maryann: I hate the other kids, and I hate my teacher.

Mrs. Henderson: Tell me some more about what has been happening. 4. ___________

Maryann: Well, ever since I moved here, Joe and Maggie have been calling me names.

Mrs. Henderson: And how long ago was that? 5. ___________

Maryann: About half a year now.

Mrs. Henderson: What are they saying? 6. ___________

Maryann: That I’m stupid and ugly. Someone called me dummy today.

Mrs. Henderson: I see. 7. ___________

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84 Chapter 3 • Invitational Skills

SELF-ASSESSMENT

One simple way of evaluating yourself is “Did Well” and “Do Better.” This consists of recognizing what you liked about your performance and what you want to improve. Based on your feedback and experience in the group exercise or other exercises so far, write down one or two things that you did well in your first practice sessions:

1. ___________________________________________

2. ___________________________________________

Now, based on your feedback, write down one or two things you could do to improve your skills:

1. ___________________________________________

2. ___________________________________________

HOMEWORK

Homework 1: Sound Off

Record a television show or movie and replay it with the sound turned off. Try to see whether you can guess emotional content by examining the characters’ body language. Write a half-page reaction to this assignment. If you want to have the voice tone added, try watching a program in another language and see whether you can still get the gist of the story without understanding the words.

Homework 2: Hug Survey

Conduct a survey among a few friends or family mem-bers. How would they feel about being hugged or

touched by a professional helper? Try to be objective and prepare a one-page summary of their answers and your conclusions.

Homework 3: Experiment with Silence

In conversations with co-workers, family, and friends, instead of immediately responding to what they say, build in attentive silence and notice the effect. The pur-pose of the assignment is to observe the effect of si-lence on the communication of others. Make notes and report findings to the group. Write a one-paragraph reaction to this exercise. If your silence is too long, your friends and family will complain or look at you strangely. If it is just right, it should have the effect of encouraging them to talk.

JOURNAL STARTERS

Think about a secret that you have not shared with anyone. How do you think you would feel if a helper urged you to share this private information? Would it be easier to share it with a close friend? What kind of response would you expect if you told a close friend about this issue? How do you think you would feel after sharing this information? What are your fantasies about what might happen if you were to disclose this secret to a helper? Do you imagine the helper telling others, or is it simply disquieting to think about the se-cret? Would any of these expectations affect your will-ingness to share the information with a professional helper?

Maryann: It happens a lot. It’s not fair.

Mrs. Henderson: What has it been like—having to deal with this? 8. ___________

Maryann: Horrible! I feel like I want to go back to my old school. I had lots of friends there.

Feedback for Written Exercise 1: (1) E, (2) OQ, (3) E, (4) OQ, (5) CQ, (6) CQ, (7) E, (8) OQ

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85

Reasons for Reflecting

Reflecting Content and Thoughts, Reflecting Feelings, and Reflecting Meaning

The Skill of Paraphrasing: Reflecting Content and Thoughts• How to Paraphrase• Paraphrasing: What It Is, and What

It Isn’t• When to Paraphrase and the

Nonjudgmental Listening Cycle

Common Problems in Paraphrasing• Simply Reciting the Facts• Difficulty Listening to the Story Because

of “Noise”• Worrying about What to Say Next• Being Judgmental and Taking the

Client’s Side• Being Judgmental of the Client• Turning a Paraphrase into a Question

Summary

Exercises• Group Exercises• Small Group Discussions• Written Exercises• Self-Assessment• Homework• Journal StartersLEARNING OUTCOMES

By the end of this chapter, you will be able to:

4.1 Differentiate between different kinds of reflections including paraphrases, reflections of feeling, and reflections of meaning.

4.2 Construct paraphrases of client statements.4.3 Be aware of common problems in paraphrasing and

understand strategies to overcome them.

The unexamined life is not worth living.

Plato

The invitational skills you learned in the last chapter send this message to the client: “I am ready and willing to listen.” Although invitational skills, such as eye contact, convey that you are present and available,

Reflecting Skills: Paraphrasing

C H A P T E R 4

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86 Chapter 4 • Reflecting Skills: Paraphrasing

they do not indicate that you understand. In contrast, reflecting skills are specialized interventions used by professionals to stimulate deeper exploration of the facts, feelings, and meanings by supplying the client with a condensed version of the story: a mirror that you hold up to him or her that represents the story as you hear it.

REASONS FOR REFLECTING

In general, reflecting entails repeating back to the client his or her own thoughts and feel-ings and implied meanings in a condensed way, using different words and in a manner that communicates nonevaluative, nonjudgmental understanding.

Four functions are served by reflecting skills in helping:

1. Reflecting is a verbal way of communicating empathy: In Chapter 2, we dis-cussed the concept of empathy, or trying to “feel oneself into” another’s experience. Reflecting shows the client that the helper understands what the client is going through.

2. Reflecting is a form of feedback or a mirror that enables the person to con-firm or correct the impression he or she is giving: Frequently, the client does not agree with the helper’s reflections, but a reflecting statement, even if it is inac-curate, can give the client an opportunity to clarify the experience to others and to himself or herself (Hill, 2004). In other words, beginning helpers should try to reflect without being concerned that every reflection is perfect or that the client endorses it. If the helper does not hit the bull’s-eye, in many cases the client will expand on the situation and explain it more clearly.

3. Reflecting stimulates further exploration of what the client is experienc-ing: Accurate reflection has an “opening effect,” bringing out more facts and deeper feelings. Reflecting can be compared to the soliloquy in a Shakespearean play where the main character turns to the audience and expresses what is going on inside of him or her. Because clients do not always express or even recognize these deeper thoughts and feelings, the helper primes the pump with reflections.

4. Reflecting captures important aspects of the client’s message that other-wise might remain camouflaged: Many people have difficulty admitting to neg-ative feelings such as fear and anger or ungenerous thoughts about others. When the helper reflects these in a nonjudgmental way, the client may suddenly recognize that the helper is correct. The helper’s words resonate with the client’s unspoken and perhaps unrecognized experience.

REFLECTING CONTENT AND THOUGHTS, REFLECTING FEELINGS, AND REFLECTING MEANING

Every client’s message has three basic components: (1) the client’s understanding of the facts and his or her thoughts (a cognitive level), (2) the client’s underlying feelings (an emotional level), and (3) hidden meanings (an existential level; see Figure 4.1). Each of these three dimensions of experience can be stimulated or evoked by a helper using spe-cific skills. As Figure 4.1 suggests, you might want to think of them as three separate boxes that have to be unpacked if you are to accurately grasp the whole story. Fre-quently, students feel that they have reached a point with a client where there seems to

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Chapter 4 • Reflecting Skills: Paraphrasing 87

be “nowhere to go.” In most of these cases, it is because he or she has not examined all of the boxes.

In this chapter, you will learn about the first box, reflecting story content and client thoughts, a skill that is called paraphrasing. The next chapter focuses on learning the skill of reflecting feelings, and the following chapter addresses the skill of reflecting meaning. You will learn these skills separately and then practice putting them together in a com-plete helping session. Table 4.1 gives examples of these three types of reflecting skills.

To gain a clearer idea of the distinction between the parts of the client’s message, consider the following story in which a helper describes how he began to recognize that parts of a story are suppressed and must be reflected.

Once I ran a private practice in a small town. The house next door to my office was guarded by a huge German shepherd dog that frequently growled at my clients when they approached the front door. When I greeted my clients, I was always interested in how they framed their reaction. They often said, “That is the biggest dog I’ve ever seen.” If I had responded to the content of the message, I might have said, “Yes, that is exceptionally large for a German shepherd,” or, “Actually, I’ve seen bigger,” or even, “Yes, he weighs over 100 pounds and has excellent teeth!”

Facts &Thoughts

Feelings

HiddenMeanings

FIGURE 4.1 Components of the Client’s Message

TABLE 4.1 Three Types of Reflecting Skills

Skill Examples

Paraphrase Topic A: “So this week has been very difficult, at work and at home.”

Topic B: “If I understand, an old friend contacted you about getting together (content), and you are not looking forward to it (thoughts).”

Reflection of feeling

Topic A: “You felt discouraged (feeling) about your job and sad (feeling) about the problems at home.”

Topic B: “After all that had happened, you were wary (feeling) about continuing your friendship and perhaps you are still angry (feeling).”

Reflection of meaning

Topic A: “You began looking at yourself as a failure (meaning) because neither of these two important areas of your life are fulfilling at the moment.”

Topic B: “You want to see yourself as a forgiving person (meaning), but the fact that you harbor some resentment after all this time makes you doubt this view of yourself.”

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This example illustrates that every communication has at least two dimensions: the explicit and the implicit. In this case, the hidden message is an emotional one concerning the fear that the dog evoked but that very few people felt comfortable in expressing. From culture to culture, people vary in their willingness to reveal their feelings. Gender also affects what a person feels is permissible to share. For example, many men will not acknowledge feeling fearful or weak. In general, we are all much more comfortable talk-ing about content or facts. That is why weather but not politics or religion is most likely to be an early conversation starter.

In helping conversations, the content and the emotional side are equally important if we are to really know someone. A response that recognizes both will lead to deeper communication of understanding. At the beginning of the helping relationship, clients usually find it more comfortable if the helper is able to reflect the content of their stories. Later, a helper can show that he or she also grasps the other layers of the story.

MyCounselingLab Application Exercise 4.1 Differentiating between Paraphrases and Reflections of Feelings

It is not usually possible to understand the deeper layers of the story right away. Dur-ing a session, the helper makes a series of reflections. As the client responds to the reflec-tions, the helper gets more information about what has happened and the client’s emotional response to the events. Eventually, the helper begins to grasp the meaning, which involves the client’s values and beliefs about the self, others, and the world in general.

To demonstrate how a helper can lead a client to fully explore a story, let us look at the case of Philippe, a single father who has come for help with his adolescent daughter.

PhiliPPe (Client): “I am having trouble with my daughter. She has just started driving. I think she is a good driver, but I am not so sure about the kids she hangs around with. My wife says I am overreacting, that I don’t want her to grow up.”

traCy (helPer): “So the main reason you’re here is to think about how you are handling the conflict you are having with your daughter, and it sounds like driving is an important part of that.” (paraphrase)

PhiliPPe: “Yes, I guess it is. When I was 16, I stole a car with some other kids. We went joyriding and had an accident. The driver was drunk, and one of the kids in the car was killed. Every time my own kid goes out on Saturday night, I think of that. I yell and scream, and maybe I am too strict with her.”

traCy: “You remember that incident and worry that the same kind of thing might happen to her.” (reflecting feeling—worry)

PhiliPPe: “Yes, sometimes I get really scared. My own parents didn’t care what I did. I don’t want to keep her at home all the time, but I don’t want her doing something stupid.”

traCy: “It seems that you’re wondering, ‘Am I being a good parent.’” (reflection of meaning—being a good parent and not repeat-ing his parents’ mistakes is a deeper level of meaning)

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The reflecting skills in this example go beyond invitational skills by bringing out a deeper level of the story—the emotional reactions of the client and the potential meaning behind the story. To use a metaphor, recognizing these deeper levels adds color to the black-and-white facts. With the example of Philippe and Tracy in mind, we are ready to explore how to paraphrase, the characteristics of paraphrase, and when to paraphrase.

THE SKILL OF PARAPHRASING: REFLECTING CONTENT AND THOUGHTS

How to Paraphrase

The reflecting skill of paraphrasing involves two steps: (1) listening carefully to the client’s story and then (2) feeding back to the client a condensed, nonjudgmental version of the facts and thoughts. The second step in paraphrasing involves finding the important infor-mation in a large volume of client material and repeating it in a succinct summary. If the paraphrase goes on too long, it can fatally disrupt the client’s story, and he or she will not stay on track. Using a boxing analogy, the paraphrase is more like a jab. The helper gets in and out quickly. The paraphrase is actually a miniature version of the client’s story. A good paraphrase keeps the client’s story on course by mentioning only the important aspects, not issues that sidetrack the client. Here is an example of a paraphrasing between a helper, Paulina, and her client, Zach. Notice how paraphrase assists the helper in understanding the facts of the story and also allows the client to feel the helper is following the story:

Paulina (helPer): “Can you tell me about what brought you in today?” (open question)

ZaCh (Client): “Well, I am a teacher, and I have been having some problems at school recently.”

Paulina: “Okay, can you tell me about that?” (door opener)

ZaCh: “I have a group of sixth graders this year that are just wild. They won’t listen, and they constantly challenge me. I’ve sent more kids to the office this year than I can ever remember. I’ve sent notes home and scheduled a lot of parent conferences.”

Paulina: “Uh-huh. Okay.” (encouragers)

ZaCh: “I guess you get a bad group sometimes. I’ve been teaching for 13 years, and I am used to working with rowdy kids. But this year it seems like it’s getting on my nerves even more.”

Paulina: “So you are not sure if it’s just a wild class or if you are over-reacting.” (paraphrase)

ZaCh: “For some reason, I am really feeling the stress. This year, one of the teachers was fired during the first week for some unknown reason.”

Paulina: “I see.” (encourager)

ZaCh: “That has left a lot of people upset. With that kind of support from the principal, I just don’t know what this year is going to be like.”

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Paulina: “So on top of the new students, you’re dealing with a new atmosphere at work.” (paraphrase)

ZaCh: “I guess this atmosphere isn’t new. But it never really affected me before. I tried to stay out of all the politics and the com-plaining in the teachers’ lounge. This year, all the teachers do is gripe. At meetings and after school, somebody is always talking about it.”

Paulina: “So for the first time, it’s getting to you and it’s hard to escape the gossiping.” (paraphrase)

ZaCh: “Yeah. And I am wondering if the gossiping is worse or if it is me. There are a lot of other things happening in my life.”

Paulina: “You are wondering if the things going on in your life are col-oring your whole viewpoint about work.” (paraphrase)

ZaCh: “That’s it. That’s what is so confusing.”

Paraphrasing: What It Is and What It Isn’t

Now that you have read the dialogue between Paulina and Zach, consider the following characteristics of a paraphrase that distinguish it from other helping skills.

A PARAPHRASE IS THE ESSENCE OF WHAT THE CLIENT SAYS, NOT PARROTING Do you notice how Paulina does not repeat Zach’s statements exactly? Paulina rewords Zach’s statements to show that she grasps the essence. The paraphrase is not a word-for-word reiteration (parroting). Instead, it is a distilled version of the content of the client’s mes-sage that restates the facts and thoughts in different words and in a nonjudgmental way. It is short and sweet and therefore does not slow the client down while he or she is disclosing.

A PARAPHRASE HIGHLIGHTS WHAT IS IMPORTANT You might think that the helper’s paraphrasing is just mimicking the client. However, as you can see in Paulina’s para-phrase, “You are wondering if the things going on in your life are coloring your whole viewpoint about work,” she is picking out something said and very softly guiding and underlining a key issue. Now Zach is being asked to talk about what is going on in his life outside of school that may be contributing to his feelings.

A PARAPHRASE IS NOT A QUESTION As a client tells his or her story, the paraphrase is used as a mirror to let the client know that the helper is following but does not pressure the client by asking a question. Questions, especially closed questions, can interrupt the flow of the client’s story and make the client feel as though he or she is under a microscope.

A PARAPHRASE DOES NOT TAKE SIDES The helper’s paraphrase does not take sides with the client by supporting his or her version of the story but, rather, points out that this is the client’s perspective. Paraphrasing means reflecting what the client knows to be fac-tual, but these facts are those that are uniquely perceived by the client. Facts and the cli-ent’s thoughts and perceptions are intertwined. To accurately reflect them and at the same time remain nonjudgmental, the helper must take a neutral stance.

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Here is an example of a helper/client exchange where it is tempting to support the client’s view. In the first helper response, the helper unfortunately takes sides, and in the second, the helper remains neutral yet correctly identifies the essential message.

Client: “Okay, I came in 2 hours late. And then my mom sent me to my room for the rest of the day. I am 17 years old. She treats me like a baby just because she likes to be in control all the time.”

helPer: (Paraphrasing and taking sides) “Your mom treats you like an infant even though you’re nearly an adult because she needs to be in charge.”

helPer: (Paraphrasing and remaining neutral) “So you were punished again for breaking curfew. You think it is unfair and that she is doing it to control you.”

When to Paraphrase and the Nonjudgmental Listening Cycle

Of course, each client tells his or her story in a particular way and at a particular pace, depending on personal history, previous experiences with helpers, and present emo-tional condition. So it is not possible to predict the exact order in which you will use the skills you are learning. However, we can assume that, in general, helping sessions will follow a fairly similar path. We call this the nonjudgmental listening cycle (NLC) to emphasize that it is a repeating series of basic helping skills. The nonjudgmental listening cycle is a way of conceptualizing a normal or average helping session during which you use the most common building blocks. It is shown here so that you can see where the skill of paraphrasing fits into the larger picture of exploring a topic. The listening cycle is repeated with each major topic the client presents.

Following is an example of helper responses to client statements that represents each major skill in the listening cycle. The session is condensed here to illustrate the major components in sequence.

1. Open question: “Can you tell me about your relationship with your family?”2. Minimal encouragers: “Okay,” “Uh-huh,” “Yes,” “Can you tell me more about

that?”3. Closed question (important facts): “So, Ron is your stepfather?”4. Paraphrase: “In a lot of ways Ron has acted as more of a father to you than your

biological dad.”5. Reflection of feeling: “You feel a bit guilty about including your stepfather.”6. Reflection of meaning: “Still, it is important for you to acknowledge someone

who has been so supportive in your life.”7. Summary: “You are a torn between feeling disloyal to your biological father and

yet you think it would not be fair to leave out someone who has been there for you in a fatherly role.”

WHY IS THE CYCLE DESCRIBED AS NONJUDGMENTAL? The listening cycle is called non-judgmental because the helper must demonstrate the attitude of positive regard—the ability to suspend judgment and accept a person regardless of his or her actions. Without such an underpinning, the client may perceive the helper’s skills as cold and robotic and feel dissected rather than understood. How can a helper develop such a nonjudgmental attitude? One way is through vicarious learning. By watching videos or live demonstrations

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by helpers who demonstrate this nonjudgmental attitude, you may be able to acquire it. If you are a very judgmental person, you will have trouble learning reflecting skills. Judg-ments come from your own perspective and what you believe to be true. The ability to be nonjudgmental can be developed by putting yourself in situations where you can see another person’s perspective.

CULTURE CHECK

Self-Disclosure, “Face,” and Culture

Helping can only be successful if the client discloses personal information about his or her rela-tionships and problems. Because of cultural differences, some ethnic minority clients may be unwilling to disclose intimate details of their lives because they find it hard to trust the helper right away. Yang and Kleinman (2008) suggest that this cultural mismatch may be responsible for the fact that Asian American clients are underserved and have high attrition rates in therapy. One of the possible reasons that Asian Americans are slow to disclose is related to “face.” Saving face means monitoring one’s words so as not to put oneself or one’s family in a bad light. If an Asian American is afraid of losing face by disclosing family secrets and would feel a sense of shame and betrayal in doing so, the helping process is stymied until trust is developed (Zane & Ku, 2014). Zane and Ku first suggest directly addressing the issue of losing face with the client as well as discussing the associated sense of shame. Second, they recommend using “face saving” strate-gies to win over the client. These may include affirming that self-disclosure is a natural part of the helping process and reframing the client/helper relationship as the exploration of problem solving rather than personal therapy. In any case, trust may develop much more slowly when a client is concerned with face. Zane and Ku say that concern for face is found not only in Asian Americans but also in other groups, including Midwestern farmers.

FOLLOWING THE NONJUDGMENTAL LISTENING CYCLE THROUGH THE SKILL OF PARA-PHRASING Figure 4.2 shows the nonjudgmental listening cycle on a single topic in the first few minutes of a session. Later in the book, you will see the next steps, which include reflecting feelings, advanced reflecting, challenging, and summarizing. A general guideline for the beginning of the session is to use a sequence of invitational and reflect-ing skills from an initial open question to encouragers to paraphrasing. This slowly allows the client to open up and discuss more difficult issues. In this book, I use the term topic to refer to a specific subject that the client is discussing. Each topic is represented by a single circle, as shown in Figure 4.2. It is quite possible to discuss more than one topic in a given session. For example, a client might, in the same hour, discuss the topic of her relationships, the topic of her problems at work, and the topic of her family. These would be represented by a sequence of circles, each on a different topic.

As a beginner, you might have the tendency to rush a client through a topic without discussing all the facts, feelings, and meanings, going on to the next issue and then the next. Beginning helpers generally have more and smaller circles because they cover a greater number of topics in less depth. More experienced helpers instead take time to ask open questions, check out key facts with closed questions, and paraphrase to make sure they understand the story. They explore every nook and cranny. Experienced helpers generally have fewer and bigger circles because they explore a smaller number of topics

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in more depth. They are more patient, allowing the client to go down every alleyway. Beginning helpers become impatient at this point. They would like to do something to alleviate the client’s discomfort and to solve the problem, and they quickly find them-selves at the end of a topic. As you practice, see for yourself how a gradual warm-up and staying with a topic can lead to deeper sessions.

The first steps in the nonjudgmental listening cycle are shown in Figure 4.2. In the following conversation between a child and a school counselor, we will follow that sequence so you can see how a paraphrase fits into the exploration of a topic. Later, you will have a chance to identify these elements and to practice paraphrasing along with the invitational skills you have learned thus far.

Chris: “The teacher said I have to tell you what happened yesterday.”

sChool Counselor: “Do you want to give me an idea about what went on?” (encourager)

Chris: “Well, I was walking around the playground, not really look-ing at anything, you know? I was bored.”

sChool Counselor: “Yes; um-hmm.” (encouragers)

Chris: “And then these three second graders came around the corner and started calling me names. I said, ‘Shut up.’ And later I punched William in the nose. It was bleeding, and he was cry-ing, but I didn’t care because he’s mean.”

sChool Counselor: “Can you tell me more about what you mean when you said, you didn’t care that William was hurt?” (open question)

Chris: “Well, I didn’t mean to hurt him, but I am not saying ‘Sorry’ because he started it.”

sChool Counselor: “So, you got into a fight with William. He got hurt but you don’t think it was your fault.” (paraphrase)

Can you see how the counselor used encouragers and an open question before paraphrasing? These invitational and opening skills allow more of the story to come out.

Door Opener(start)

Paraphrase

Paraphrase

Closed Question

Minimal Encourager

Minimal Encourager

Open Question

One Topic inthe Story

FIGURE 4.2 A Typical Sequence of Helper Responses in the First Few Minutes of a Session

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Notice that the counselor’s paraphrase is not just a restatement of what Chris said. It is a summary of the child’s story, giving its essence in a nonjudgmental way. The paraphrase is brief and therefore does not interrupt the child unduly as he talks. It does not take sides by supporting one version of the story, but recognizes instead the child’s perspective. It also identifies the child’s thoughts, “You don’t think it was your fault.” Let us now look at some of the challenges in using paraphrases.

MyCounselingLab Video Exercise 4.1 Paraphrasing

COMMON PROBLEMS IN PARAPHRASING

Simply Reciting the Facts

A common mistake (Corey & Corey, 20106; Corey, Corey, & Corey, 2010) is to simply list the major points the client has made in exactly the same way that the client said them. This is sometimes called parroting. The best way to illustrate this mistake is to take an example from Paulina and Zach’s dialogue in the earlier section “How to Paraphrase.” Here is a statement by Zach (the client) followed by two alternative paraphrases by Paulina (the helper). The first one is copied from the actual dialogue, and the second is a less effective paraphrase that merely recites the facts.

ZaCh: “I guess this atmosphere isn’t new. But it never really affected me before. I tried to stay out of all the politics and the complaining in the teachers’ lounge. This year, all the teachers do is gripe. At meetings and after school, somebody is always talking about it.”

Paulina 1: “So for the first time, it’s getting to you and it’s hard to escape the gos-siping.” (paraphrase)

Paulina 2: “So the atmosphere isn’t new. You tried to stay out of the politics and the complaining that all the teachers are doing. Everywhere you go, somebody is talking about it.”

Besides the fact that this last reflection is longer and tends to parrot the client’s exact words, the helper would be merely reflecting the content without getting to the important point that now, for the first time, the situation is bothering Zach and he can’t seem to get away from it.

Difficulty Listening to the Story Because of “Noise”

Another problem is caused by distractions. Of course, helpers must select quiet environ-ments so that listening is not impaired by external noises. However, the biggest distrac-tions come from “mental noise.” You cannot grasp the client’s message when you are listening to your own thoughts. Helpers sometimes experience mental noise when the client’s story evokes a personal memory of a similar situation. Internal noise may interrupt because the client is expressing something that you find distasteful or that evokes moral outrage. When you realize that you have lost track of the client’s story because of mental noise, stop and request that the client repeat the last part of the story again. Then respond with an appropriate paraphrase. Even though it is a distraction, it is better to stay on track than to miss the key elements of the story. If you find a client boring, morally repugnant,

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sexually attractive, or pitiful, you are probably going to have difficulty really listening. You can start now to identify those issues that trigger mental noise and discuss them or write about them in your journal.

Worrying about What to Say Next

Worrying about what to say next is perhaps the biggest source of mental noise. Rather than responding to the client’s statement, the helper is sidetracked into thinking about what his or her response ought to be. This is especially true when you are being observed by others, such as your instructor. One thing to remember is that almost everyone becomes less anxious as time goes on. Practicing in front of others may expose your weaknesses, but it is also the best way to get feedback and to learn. Still, there are a few things you can do to cope with this kind of worry.

The first antidote is to shift your attention to the client. Because it is difficult to do two things simultaneously, when you become focused on your own thoughts, you lose track of the client’s story. This happens to everyone at some time. Your mind will go blank! The remedy is to refocus your attention keenly on the client’s story. A second helpful hint is to remember that your job is to respond to the last thing the client said, rather than stimulate a new topic or ask a question. This will lead to greater exploration of the topic rather than shifting topics. If you cannot remember the client’s last statement, ask him or her to repeat it.

Both of these suggestions share a common idea. As the helper, you must be present; when you are thinking about yourself and what you are going to do, your focus shifts away from what the client is saying. In Chapter 2, we identified presence as a relationship enhancer. Carl Rogers (see Brodley, 2000) used the term and defined it as being com-pletely absorbed in the relationship in the present moment. Rogers felt that presence itself is healing (Baldwin, 1987). Certainly being looked at and listened to tells the client that he or she is important in your eyes and conveys an acceptance that transcends words.

Being Judgmental and Taking the Client’s Side

Earlier, we tried to distinguish paraphrasing from other behaviors and we noted that it is not support but a nonjudgmental reflection of the facts. Still, beginners are often too quick to take the client’s side and to agree with the client’s judgment that the problem is caused by other people. You may think you are being supportive, but you may be accepting the client’s version of the story prematurely. For example:

raChel (Client): “At work, the other women ignore me because I don’t go drinking with them on Friday nights, and they think I am the boss’s favorite. The boss always compliments me on my work. I can’t help it if they don’t work as hard as I do.”

santiago (helPer): “Things aren’t going very well at the job because your co- workers mistreat you.” (judgmental paraphrase)

With a judgmental paraphrase, the helper has essentially agreed that the co-workers are at fault. Shifting the blame to other people will not widen the client’s perspective or help the client change his or her behavior. The following is a nonjudgmental response to Rachel’s problem:

santiago: “So you see yourself as a hard worker, but you think your co-workers may be critical of you because of your dedication.”

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Here Santiago is subtly telling Rachel that his mind is open about who is causing the problem and that he hears Rachel’s perception. It is possible that her co-workers have no such thoughts.

Being Judgmental of the Client

This error is the flip side of taking the client’s side. It often occurs when the helper feels strongly that the client should correct his or her behavior. This is an error, especially in the early sessions, because it will undermine the trust that has been building.

raChel: “At work, the other women ignore me because I don’t go drinking with them on Friday nights, and they think I am the boss’s favorite. The boss always compliments me on my work. I can’t help it if they don’t work as hard as I do.”

santiago: “You’re having trouble at work because you haven’t been a team player.” (judgmental paraphrase)

Sometimes helpers show a judgmental attitude when they try to sneak in a little advice. In the previous example, there is a hidden message, “If you want to be liked, be more a part of the team.” A nonjudgmental response would be:

santiago: “So you’re saying that your boss appreciates you, but in your mind, your co-workers don’t accept you.” (nonjudgmental paraphrase)

In summary, the purpose of a paraphrase is to make sure that you understand the facts and the client’s thoughts rather than to supply a solution, support the client’s version of the situation, or place blame.

MyCounselingLab Application Exercise 4.2 The Skill of Paraphrasing

MyCounselingLab Application Exercise 4.3 Making Your Paraphrases Nonjudgmental

Turning a Paraphrase into a Question

As we mentioned earlier questioning makes a demand on the client that he or she must address, and although a paraphrase slows the client down, it does not stop the flow of conversations. Here are two examples, one of a paraphrase and the other of a paraphrase and a question:

helPer a: (Paraphrasing) “So, your stepmother and your dad divorced when you were 6 and then remarried when you were 12.”

Client: “And it’s been up and down ever since.”

helPer B: (Paraphrasing then questioning) “So your stepmother and your dad divorced when you were 6 and then remarried when you were 12. What happened then?”

If you were the client in the second example, would you react to the paraphrase or respond to the question? Generally, when the helper tacks on a question, the client feels obligated to follow it. It is better to let the client respond to the paraphrase. A subtle point

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QUICK TIPS: PARAPHRASING• Don’t paraphrase too early. Wait until you have a firm grasp of the important details

and thoughts, and then compress them into a short paraphrase.• Early on in the conversation, use encouragers liberally to invite the client to supply

essential information.• Don’t repeat the client’s exact words. Give a condensed version in slightly different

words.• When you can, paraphrase the client’s thoughts and intentions as well as the basic

facts.• If you get lost, ask the client to repeat his or her last statement and try another

paraphrase.• Remain present by responding to the last thing the client said.

SummaryParaphrasing is the first of three reflecting skills, all of which involve feeding back to the client a distilled ver-sion of the story. The challenge is to construct the paraphrase so that it does not mimic the client’s words but encapsulates the essence in a slightly different way. At the same time, the paraphrase should be non-judgmental, not implying any advice or taking sides. Good paraphrases let a client know that you really un-derstand the facts and the client’s thoughts, but they do not stifle the client’s attempts to get the story out. Paraphrasing may seem like a very minor skill, but it is deceptively simple. A good paraphrase can convey un-derstanding and even push the client to examine his or her version of the story more objectively.

The nonjudgmental listening cycle is a way of understanding how to sequence the skills you are learning. The first part of the sequence begins with an open question, encouragers, and then building up to a paraphrase when the helper has enough data to reflect. In the following chapters, we will build on this founda-tion by adding more advanced skills to the nonjudg-mental listening cycle. At each stage, it is important to practice the skills separately until you have mastered them. Just like learning keyboarding skills, you learn how to type each letter separately before putting them into words.

Exercises GROUP EXERCISES

Exercise 1: Practice Using Invitational Skills, Opening Skills, and Paraphrasing

In groups of three, divide into helper, client, and ob-server. The helper should review the “Quick Tips: Paraphrasing” section while the client takes a moment to think about a story that is often told in his or her family. Alternatively, the client can talk about career goals from childhood to the present. The exercise

begins with the client relating his or her story. As the client talks, the helper will try to demonstrate all of the opening and invitational skills first and then try to paraphrase once or twice during the practice session. The observer may use the Feedback Checklist: Par-aphrasing to record the helper’s responses or may simply write the responses on lined paper. Following the session, all three participants join in labeling the helper responses as indicated in the Category column of the checklist.

here is that the paraphrase should be made as a statement rather than allowing your voice to rise at the end of the sentence. Doing that can turn a paraphrase into a question, telling the client that you really don’t understand what has been said and you want clarification.

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The group then considers the questions, “Were the helper’s interventions in line with the expected se-quence in the nonjudgmental listening cycle?” “Were paraphrases and encouragers the most common or were questions the primary tools of the helper?”

Exercise 2: Replacing Questions with Encouragers and Paraphrases

Earlier, we talked about reducing the use of questions and trying instead to use encouragers and paraphrases. This exercise asks students to replace questions with en-couragers and paraphrases and to take turns as helper, client, and observer. The client’s topic is “a brief history of my life,” and the helper’s job is to use encouragers and paraphrases but not questions of any type. The observer notes any questions that the helper asks and also identi-fies how many times the helper’s voice rises at the end of a sentence (which is a nonverbal cue that a question is being asked). After everyone has had a chance to be the helper and receive feedback, the class discusses the activity. Was it difficult to withhold questioning? What is the difference between “Are you and your mother not getting along?” and “I’m picking up that things between you and your mother are rather strained”?

Exercise 3: Give Me the Floor

The PREP program is a well-known psychoeduca-tional approach to improving couples’ communication.

Couples often have trouble hearing a paraphrasing of their partner’s statements because of noise such as defensiveness. One of the techniques used in the pro-gram, called the Speaker/Listener technique (Markman, Stanley, & Blumberg, 2010), allows the speaker to contin-ue talking until the listener gives an accurate paraphrase.

In this version of the program, students form groups of three. One member writes “The Floor” on a piece of paper. Whoever is holding the floor is the only one in the group who is speaking. Person A holds the floor first and describes a problem to person B, who then paraphrases what person A has said. If person A feels that the paraphrase by person B is completely accurate (distilled version with correct and important information), then person A passes the floor to person B. If the paraphrase is not 100% accurate, person A contin-ues to talk until person B gives an accurate paraphrase. When person B holds the floor, person C listens and paraphrases, and the cycle continues until time is called.

SMALL GROUP DISCUSSIONS

Discussion 1: Constructing Paraphrases

Following are parts of three clients’ stories. Try to par-aphrase the facts of the stories as well as unspoken thoughts. See whether you can use slightly different words than the client did. In your responses, leave out the client’s feelings for now. Compare your paraphrases

Feedback Checklist: ParaphrasingObserver Name: _______ Helper Name: _______

During the session, the observer records the helper’s responses verbatim on a sheet of paper. After each helper/client conversation, the observer reads the helper’s statements aloud and the group categorizes the responses with the following symbols: E for an encourager (either door opener or minimal encourager), CQ for closed question, OQ for open question, or P for paraphrase.

Category Helper Response Client Feedback

___________________________ 1. _________________________________ _____________________________

___________________________ 2. _________________________________ _____________________________

___________________________ 3. _________________________________ _____________________________

___________________________ 4. _________________________________ _____________________________

___________________________ 5. _________________________________ _____________________________

___________________________ 6. _________________________________ _____________________________

___________________________ 7. _________________________________ _____________________________

___________________________ 8. _________________________________ _____________________________

___________________________ 9. _________________________________ _____________________________

___________________________ 10. _________________________________ _____________________________

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Chapter 4 • Reflecting Skills: Paraphrasing 99

with those of others in your small group, and discuss any differences in your approaches. Did you get the crucial information in your paraphrase?

1. “I had to tell one of my co-workers he couldn’t go on the trip. He had not put in enough time with the company. I was forced to follow the rules. It wasn’t really my fault, and I couldn’t do anything about it. When I told him, he didn’t say much. He just walked away.”

2. “I met this woman. She seems too good to be true. I don’t know too much about her. We only met last week. But since then, everything I find out about her makes me feel more like she is ‘the one.’ I believe there is only one person out there for everyone, you know. But how can I be sure?”

3. “I was recently laid off from my job as vice presi-dent in charge of purchasing. They said it was a layoff, but it feels like being fired. They have farmed out my work to my subordinates, many of whom were not let go. My friend wants me to go into business with him, but there is a big part of me that feels that I gave my heart and soul to that company, and I don’t feel ready to move on.”

After you have read and responded to these short stories, answer the following questions for yourself:

• Did any of these stories challenge your ability to be nonjudgmental?

• What feelings were aroused in you?• Which one was the most challenging to remain-

ing nonjudgmental? Why?• What might you be tempted to say that would

indicate that you were taking sides?• How well were you able to distill the story,

including the client’s thoughts, rather than just reiterating the facts?

• Did you find it hard to leave out the feelings? Is there a time for listening to the facts of a story without reflecting the feelings?

WRITTEN EXERCISES

Exercise 1: Making Your Paraphrases Nonjudgmental

The following client statements test your ability to be nonjudgmental—neither agreeing nor criticizing. On a separate sheet, paraphrase the content of the following

client statements without taking sides.

1. “I’ve just started a relationship with a co-worker. It’s the best thing that’s ever happened to me. But here’s the thing: She’s married and has a kid. I don’t want to be the kind of person who breaks up a relation-ship, but I guess she wouldn’t be seeing me if every-thing were fine between her and her husband.”

2. “My best friend and I are both seniors and head-ing off to college next year. SATs are over and I am partying a lot. She looks down on me because I started drinking. She says I’m an alcoholic. We can’t even talk anymore because she’s so down on me.”

Feedback

Below are two suggested paraphrases for the client statements above. Yours might be slightly different. Do your paraphrases get the main points without judging the clients?

1. “So, part of you thinks this is a great thing and at the same time you are thinking about the fact that you are potentially breaking up her family.”

2. “There seems to suddenly be distance between you and your friend and the fact that you are drinking is part of that.”

SELF-ASSESSMENT

Now that you have had the opportunity to practice paraphrasing, look at the aspects of paraphrasing be-low and indicate with a check mark whether you have been able to:1. Listen carefully using invitational and opening

skills before paraphrasing. _____2. Supply a distilled version of the facts and the cli-

ent’s thoughts. _____3. Make the paraphrase in slightly different words.

_____4. Make paraphrases that are nonjudgmental. _____5. Respond to the last thing the client said. _____

What part of the skill do you need to work on? _________________________________

HOMEWORK

Homework 1: Stop the Show and Paraphrase

In the last chapter, it was suggested that you watch a television program with the sound off to see whether

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100 Chapter 4 • Reflecting Skills: Paraphrasing

you could guess the emotional content based on body language alone. For this assignment, watch a television program where one individual is speaking. An interview on a news program works well for this activity. Using a remote control, listen to a couple of minutes of the dialogue, and then press the mute button. See whether you can paraphrase the content of the preceding 2–3 minutes in a couple of brief sen-tences. This activity can provide anxiety-free practice because you can turn the “client” off while you are paraphrasing.

JOURNAL STARTERS

Think about a strong personal value you hold, and think about how you might react to a client who holds the opposite value. For example, let us say you value health and you encounter a client who smokes, drinks excessively, and takes other substantial health risks. Or perhaps the client has a different sexual orientation. Do you think you would have trouble listening to the client’s story? Do you think that clients pick up on non-verbal indicators of disapproval?

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101

The Importance of Understanding Emotions

The Skill of Reflecting Feelings• The Benefits of Reflecting Feelings• Why It Is Difficult to Reflect Feelings

How to Reflect Feelings• Step 1: Identifying the Feeling or

Feelings• Step 2: Putting the Emotion into Words

Common Problems in Reflecting Feelings and Their Antidotes• Asking the Client, “How Did You Feel?”

or “How Did That Make You Feel?”• Waiting Too Long to Reflect• Making Your Reflection a Question• Combining a Reflection and a Question:

The Error of the Compound Response• Focusing on Other People• Interrupting Too Soon and Letting the

Client Talk Too Long• Confusing the Words Feel and Think• Missing the Mark: Overshooting and

Undershooting• Letting Your Reflecting Statements Go

On Too Long

Summary

Exercises• Group Exercises• Written Exercises• Self-Assessment• Homework• Journal Starters

LEARNING OUTCOMES

By the end of this chapter, you will be able to:

5.1 Identify feelings in a client’s story.5.2 Reflect feelings using the algorithm “You feel ____.”5.3 Identify and avoid major problems in reflecting feelings.

THE IMPORTANCE OF UNDERSTANDING EMOTIONS

Understanding another person’s emotions helps us better understand the whole person because emotions give a window into motivation, current mental state, behavior, and how he or she views the world (Izard, 2009). It might even save your life. As an example, Daniel Goleman, the author of Emotional Intelligence (2006a), describes an incident in Iraq where a group of soldiers

Reflecting Skills: Reflecting Feelings

C H A P T E R 5

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102 Chapter 5 • Reflecting Skills: Reflecting Feelings

who were distributing relief supplies were surrounded by an angry mob of people who thought the soldiers were there to arrest one of the villagers. Using emotional intelligence, the officer in charge ordered his men to kneel, point their guns at the ground, and smile, all of which defused the situation without anyone being hurt. The officer, Lieutenant Colonel Christopher Hughes, was able to transmit the message through nonverbal means that the soldiers were nonthreatening and friendly.

Goleman’s story is in support of his thesis that there is a kind of intelligence that is quite different from what IQ tests capture (Goleman, 2003). If the soldiers had attempted to explain their mission to the villagers, it might have been a logical move, but not emo-tionally smart. Emotional intelligence has been described as the “ability to monitor one’s own and others’ feelings and emotions, to discriminate among them, and to use this information to guide one’s thinking and actions” (Salovey & Mayer, 1990, p. 189).

There is little doubt that helpers must possess this emotional intelligence in the same way that an engineer must have the intellectual ability to understand higher mathematics. Yet emotional intelligence can be developed just as mathematical skills can be enhanced (Goleman, 2003). The ability to recognize and express another person’s feelings can be learned, and it has power to deepen the relationship and allow the client to release his or her emotional burdens.

THE SKILL OF REFLECTING FEELINGS

Being able to recognize emotions in others and convey that you understand their feelings is a special ability. This skill of reflecting feelings tells your client that you recognize the emotional background of the story. The building block of reflecting feelings involves essentially the same technique as paraphrasing. This time, however, the focus is on emo-tions rather than on content and thoughts. Reflecting feelings involves listening and then expressing in one’s own words the emotions stated or implied by the client. These emo-tions may be hidden in the content of the story or in the nonverbal responses of the cli-ent. The emoticon is an unfortunate attempt to communicate the emotions behind a text-based message or e-mail that cannot be communicated by the words alone.

Here is an example of how clients may not openly express a feeling but it is implicit in the message. The client says, “I just lost my job,” and looks down. The client’s feelings (shock, hurt, embarrassment) are beneath the surface of the nonverbals and the description of the event. Reflecting feelings shows the client that you understand the deeper message.

The Benefits of Reflecting Feelings

A number of therapeutic events occur when feelings are reflected. For one thing, the cli-ent becomes more keenly aware of the emotions surrounding a topic. Many clients under-disclose, and any method or technique that allows them to more fully experience and express their feelings is thought to be therapeutic (Young & Bemak, 1996). Let us sup-pose that the helper makes a reflection such as, “I can tell that you are terribly angry about that.” The client’s response may be one of surprise, “Yes, I guess I am.” Because a reflection is done in a nonevaluative manner, it communicates understanding of feelings that the client may not be conscious of and that the client may even think he or she has no right to feel.

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Chapter 5 • Reflecting Skills: Reflecting Feelings 103

Reflecting feelings also brings the client to deeper and deeper levels of self-disclosure. An accurate reflection focuses the client on emotions and teaches him or her to become aware of and to report feelings. It stimulates the client to express other, perhaps more deeply felt, emotions. Even if the reflection is not quite accurate, the client will provide a correction that is more on target.

In addition, an accurate reflection of feelings has the almost magical power to deepen the relationship between client and helper. Nothing transmits nonjudgmental understanding more completely. This is why this technique, which originated in the client-centered tradition of Carl Rogers (1961), has gained such wide usage. It taps the enormous healing properties of the therapeutic relationship. A beginning helper who is able to accurately reflect feelings can provide support and understanding without any other tools.

Finally, reflecting feelings brings genuine relief from emotional pressure. Take, for example, the client whose wife had left him but she would not say why. He came for help, crying about the lost relationship. He ran the gamut, on an emotional roller coaster, from confusion to shock to disgust to affection to rage. Experiencing all these conflicting emotions in one session can make anyone feel “crazy.” Even though there were still con-flicting feelings, by the end of the first session, the client felt more in control simply because he had sorted out his feelings and labeled them. Untangling the emotional knots seems to be healing even if no real action is taken. Somehow we can accept our feelings as normal reactions when we bring them to the surface and sort them out. Reflecting feel-ings by saying, for example, “You feel so betrayed, and yet you still feel a bond of affec-tion,” can help to normalize what the client perceives as a deeply conflicting emotional experience.

Why It Is Difficult to Reflect Feelings

Reflecting feelings is one of the most valuable tools of the helper, but it is not an easy one to learn. Theodore Reik, the famous analyst, claimed that in order to hear deeply, one must learn to become sensitive to the unexpressed and listen with the “third ear.” Refer-ring to the fact that the client may not even be aware of these feelings, Reik said, “The voice that speaks in him speaks low but he who listens with a third ear, hears also what is expressed almost noiselessly, what is said pianissimo” (Reik, 1968, p. 165).

One reason that feelings may be hard to hear is that our upbringing, family back-ground, and culture affect the way we express them (Matsumoto, 2009; Tsai, Levenson, & McCoy, 2006). For example, many individuals with Appalachian and English roots may tend to express emotions in very subtle ways. Some Native Americans, East Indi-ans, and Europeans may come from cultures where open expression of feelings is rude or is a sign of weakness. For instance, a conference was held in Amsterdam on the “underexpression” of emotions as a mental health issue in Europe. When a client’s fam-ily background or culture is constantly sending the message “Don’t let anyone see your feelings,” the job of helping is more difficult because the helper can only guess what the client is experiencing. Getting to feelings may require more time and effort, and even then expression may seem faint by comparison. This can be frustrating when the client does not seem to respond to your reflections. For some clients, though, even a small crack in the voice may be quite a strong emotional sign and should be valued as a deep disclosure.

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HOW TO REFLECT FEELINGS

Step 1: Identifying the Feeling or Feelings

Like paraphrasing, reflecting feelings involves two steps. The first step is identifying the client’s feelings; the second step is articulating the underlying emotions that you detect in his or her statements. You can learn the first step in your practice sessions as you listen intently to the client. Imagine how he or she feels in this situation, and then first try to label the feeling. The best way to do this is to think of yourself as the client, taking into account all the facts and also thinking about what you know about the client’s personality and history. In other words, do not try to think about how you would feel in this situa-tion; instead, become the client and think about how he or she might feel. Take a look at the feeling words in Table 5.1 to see whether another word is closer to what the client seems to be expressing. Do not forget that nonverbals are major clues to the client’s feel-ing state. Although reading and responding to vignettes in this book will be a good train-ing exercise, practicing with classmates will be more realistic as you must pay attention to the nonverbal expressions as well as the words.

Step 2: Putting the Emotion into Words

Once you have identified the emotion the client is feeling, the next step is to put your understanding of the emotion into words. Although this sounds easier than the first step, it is actually more difficult because you must accurately express emotions in words. The next section provides a formulaic way of reflecting the feelings you have recognized. In my experience, the two steps to reflecting feelings (identifying and expressing in words) are often learned independently. Identifying feelings seems to be a precursor to actually reflecting them. Take some time to practice identifying feelings, and then it will be easier to put them into words. Later in this chapter you will find more opportunities to identify feelings in writing before you try to actually reflect them to a person.

Gender

Gender also has a bearing on emotional expression. Men, more than women, have been trained to “never let them see you sweat” and to believe that “big boys don’t cry” (Kottler, 1997; Wong, Steinfeldt, LaFollette, & Tsao, 2010). Consequently, it may be difficult for some men to openly display feelings in the helping relationship and in their other relationships, too. When feelings leak out, a man may feel weak or out of control. Feminine socialization, on the other hand, is more relationship-oriented and is more likely to encourage telling another person how you feel (Kring & Gordon, 1998; Madrid & Kantor, 2009), even on Facebook and Twitter (Parkins, 2012). However, women, too, are asked to repress certain emotions, such as anger or even confidence, that are not considered feminine. Emotional health means recognizing one’s own feelings and appropriately expressing them. When a helper sees a cultural handicap to emotional expression and helps the client recognize what is being suppressed, the client may be better able to own and accept those emotions.

CULTURE CHECK

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Chapter 5 • Reflecting Skills: Reflecting Feelings 105

TABLE 5.1 Feeling Words

Feeling Mild Moderate Strong

Joy at easepleasedsatisfiedcontent

gladenjoyinghappypeaceful delighted

overjoyedjubilantelatedthrilled

Sadness downsad, saddenedlow

glumdownheartedmelancholyblue gloomy

depresseddejecteddespondentmiserable dismayed grieved sorrowful

Anger annoyed irritated miffed ticked antagonistic exasperated

angry mad resentful indignant incensed

furious outraged enraged bitter fuming

Guilt and self-hostility responsible at fault culpable

mad at yourself self-reproachful contrite

guilty remorseful blameworthy

Shame chagrined embarrassed disgraced

mortified ashamed humiliated

Fear apprehensiveuneasywary restless concernedinsecure on edge

anxiousscaredworried afraid nervous unnerved

alarmed frightened terrified dreading panicked

Disgust offended put off

turned off disgusted averse repelled

repulsed repugnant abhorring appalled sickened revolted nauseated loathing revulsive

(continued)

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106 Chapter 5 • Reflecting Skills: Reflecting Feelings

A FORMULA FOR REFLECTING FEELINGS Statements that reflect feelings take two forms. The simple version of reflecting feelings is a helper statement with the structure “You feel ____.” As you look at the following interactions between helper and client, think about what the reflection of feelings brings to the client’s story and to the relationship.

Joseph (Client): “You can imagine how everyone in the family reacted when Grandpa got married 6 months after Grandma’s death.”

Abdi (helper): “It must have been quite a shock.” (simple reflection of feelings) Or, “You felt shocked.”

Feeling Mild Moderate Strong

Contempt disliking disapproving disrespect

disdainful scornful hateful

Surprise perplexed puzzled stumped startled

amazed bewildered baffled surprised

awedshocked in wonder stunned astounded astonished

Interest/excitement bored interested

amused curious inspired engaged

excited marvel in wonder stimulated fascinated intrigued

Feelings Associated with Thoughts about Power and ConfidenceFeelings of Weakness unimportant

awkwardunsureconfused

inadequateincompetentineptpowerless weak

worthlesshelplessdependentimpotent discouraged

Feelings of Strength ablecapable

confidentstrongauthoritativesecure competent

self-assuredpotentpowerfuloptimistic

Feelings of General or Nonspecific Distress

upsetconcernedtroubledbothereduneasy

frustrateddisturbedperturbeddistressedrestless

painedmiserableanguishedagitatedoverwhelmed

TABLE 5.1 (continued)

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Chapter 5 • Reflecting Skills: Reflecting Feelings 107

CONNECTING FEELINGS AND CONTENT After one or two reflections of feeling, a helper may then use a reflection of feelings that connects emotions and content. In other words, you add a paraphrase to the reflection of feeling. The format of this combination response is “You feel _____ when _____.” The first blank is a reflection of the client’s feeling. The second blank explains the feeling by paraphrasing the content while, at the same time, showing the connection between the feeling and the content (Carkhuff, 1987).

As the conversation between Joseph and Abdi continues, Abdi begins to understand and articulate the reason for Joseph’s resentment and anger:

Joseph: “I was floored. I had always thought that they had the perfect marriage.”

Abdi: “You felt really disappointed when you found out he had apparently gotten over her death so quickly.”

The reflection of feeling “You felt really disappointed” is connected to the para-phrase “when you found out he had apparently gotten over her death so quickly.” Can you see that Abdi’s statement is essentially a mirror image of Joseph’s, containing both a paraphrase and a feeling?

MyCounselingLab Application Exercise 5.1 Practice in Identifying Specific Feelings

Not every reflection has to be connected to a paraphrase. Sometimes it is sufficient to reflect the feeling using the simple “You feel _____.” There is nothing wrong with a simple paraphrase or a simple reflection of feeling. But, when you understand the connection between feeling and content, you can then utilize the combined form because it shows the client you recognize the connection between the feeling and what happened. In Table 5.2, the skills we have presented in this chapter are illustrated, including examples of simple reflection, paraphrase, and a combined form. The third column shows a way of coding the response when you practice in class or in your transcripts. Counting reflections of feeling and paraphrases will give you a rough idea about how deeply the session is reaching.

TABLE 5.2 Skills in This Chapter and How to Code Them

Skill Example

How to Code Your Classroom Practice or Transcripts

Reflecting a Single Feeling You felt angryYou felt foolishYou were shocked

ROF

Paraphrase (facts/thoughts/events)

Someone stole your walletThe car hit the mailbox It was not what you had expected

P

Reflecting a Feeling and Content

You felt angry when you found out who stole your walletYou felt foolish when you hit the mailbox with your carYou were shocked when your expectations were not met

ROF + P

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108 Chapter 5 • Reflecting Skills: Reflecting Feelings

STOP AND REFLECT

Let us take another look at the distinction between content and feelings. Read the following excerpt from a client’s story and see whether you can respond as a professional helper would, answering the related questions and comparing your responses with those of your classmates. At the end, I give some possible paraphrases and reflections of feelings.

Teresa: “First, we went to the drugstore; then we went to the grocery. We went to two or three other places and ended up in a bad part of town. All because he wanted this particular kind of candy. I had a lot to do that day. And this wasn’t the first time this kind of thing had happened. He’s a lot of fun most of the time; other times, he is a pain! What can you do?”

• What might Teresa be feeling? Identify as many emotions as possible. Try to pinpoint her feel-ings using the words in Table 5.1. Use qualifiers like a little or very as needed to try to get the right shade of emotion. My answers, your answers, and those of your classmates may vary because in a written example we cannot hear the client’s voice tone or see body language to clue us in on how strong her emotions are.

• Why do you think Teresa does not express her feelings about the situation in this opening statement?

• Try to summarize the content of Teresa’s message (not the feelings) in a single sentence. Remember that the content includes thoughts, intentions, and facts that she relates.

• Try to make a connection between what Teresa is feeling and the content of her story: Teresa feels _____ (emotion) when _____ (reason you identify from content).

My Answers: Some of the things Teresa might be feeling and a brief paraphrase:

1. Annoyed or irritated when she had to spend so much time on a minor errand2. A little angry and rather scared when she ended up in a bad part of town3. Somewhat troubled about the relationship when there are both highs and lows, and perhaps

hopeless when she says, “What can you do?”

IMPROVING YOUR FEELING VOCABULARY To learn the first step in reflecting feelings—identifying feelings—it is important to recognize that emotions have many shades and variations. In English, we have at least 3,000 words that describe feelings (Elert, 2013). Table 5.1 categorizes feelings in a way that will help you recognize the fundamental emo-tions. They could be compared to the primary colors in the light spectrum: red, orange, yellow, green, blue, indigo, and violet. The color analogy is used here because the emo-tions of clients are often mixed together, producing a completely unique hue, and your job is to identify the particular shade. The primary emotions are listed top to bottom on the left-hand side of Table 5.1. They are joy, sadness, anger, guilt and self-hostility, shame, fear, disgust, contempt, surprise, and interest/excitement. People around the world can recognize facial expressions of these primary emotional states whether the people are from remote parts of New Guinea or New York City (Izard, 1977; Youngstrom & Green, 2003). These facial expressions appear to have deep biological roots (see Darwin, 1889).

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Chapter 5 • Reflecting Skills: Reflecting Feelings 109

Despite this, individuals have also learned through their culture to disguise their emotions by turning away, looking down, and avoiding eye contact when they don’t wish to dis-close their feelings.

In addition to the primary emotions, three other categories of emotions are indi-cated in the table: feelings of weakness, feelings of strength, and feelings of general or nonspecific distress. Normally, the helper should be trying to identify the specific feeling that a client is experiencing. Sometimes though, especially at the beginning of a client’s story, you may only be able to reflect these nonspecific emotional states before honing in on the target feelings.

Across the top of Table 5.1, the emotions are categorized by intensity (mild, moder-ate, and strong), much as colors can be described in terms of brightness. Take a look at the emotion of fear in the table. Suppose you had a client who was a little nervous about an upcoming exam, and you reflected “terrified” in the Strong category. Can you see that the client would feel misunderstood? Besides finding precise words that suggest different intensities, you can qualify your reflections by adding terms like a little, somewhat, and very to zero in on the client’s exact feeling. In fact, some clients do not have large feeling vocabularies or do not understand the culture-bound language of the helper. It is better to say, “You were very angry,” rather than, “You were filled with consternation.” Use Table 5.1 to familiarize yourself with a wider variety of feeling words. The more closely you express the exact shade of feeling, the more the client will sense that you understand his or her emotional experience. Figure 5.1 shows a helper’s attempts to target a client’s exact feeling of disappointment. The outer ring shows the feeling words that the helper attempted to use but that did not hit the target. The helper is like an artist who holds up the client’s feelings as a portrait and says, “Is this right?” The client then gives feedback that allows the helper to hone in on what the client is trying to say.

REFLECTING MULTIPLE FEELINGS INSTEAD OF STRUGGLING TO FIND THE RIGHT WORD When you cannot find the exact feeling the client is expressing, try reflecting more than one feeling such as, “You are both excited and scared.” For example, a client might say he or

Sad

Annoyed

Ashamed

DisappointedHurt

FIGURE 5.1 Hitting the Emotional Target

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110 Chapter 5 • Reflecting Skills: Reflecting Feelings

she is disappointed but you sense there might be more than just the feeling of sadness. In this case, the helper might say, “I can tell you were both embarrassed and angry.” Clients frequently tell stories that contain multiple feelings. One way to format your response is as follows: “You feel ______ and ________ when ______.” For example,

“You feel close to your family and a sense of happiness when you are at home.”

In summary, when you find yourself confused about what the client is feeling, go ahead and reflect the two or three major feelings you suspect, and let the client’s response guide you to the exact feeling.

MyCounselingLab Video Exercise 5.1 Reflecting Feelings Accurately

CULTURE CHECK

Language

Helping someone in his or her own language is ideal because language is a basic element of one’s culture and allows the helper to quickly connect. I believe that every helper should speak more than one language (consider Spanish). Once I worked at a rural mental health clinic, and we received a call from “Meals on Wheels.” One of the clients being serviced, an elderly French woman, was yelling and screaming at the one who had delivered her meal, and I was the only person in the social services (maybe in the whole county) who spoke French. When I went to her home, I met a pleasant older woman who was very relieved to meet someone who spoke her language. After a few minutes, she indicated that there was a problem with communication—she just could not get her point across to the person who had delivered the food. This was the reason for her angry outburst. “What would you like me to say to him?” I asked. She replied, “Tell him that is not the way you cook liver!” There was both a language problem and a cultural disconnect over cuisine. Although this might seem like an isolated situation, in reality many sim-ple communication problems could be alleviated if someone spoke the language of the client.

So how can you help someone if you do not speak his or her language? Our first thought is, why not use a translator? Many of us have tried to help clients using translation. Translation is sometimes unreliable because certain words just cannot be expressed in another language. For example, translators say that it is difficult to accurately translate the English words nice, stuff, and insight. Table 5.3 shows some emotion words from other languages that we do not have in English. Instead of translation, try to refer the person to a helper who does speak the language. If this is not possible and the client has some English fluency, it is important for the helper to be patient and take the process very slowly, rather than jumping to conclusions about the meaning of the client’s words. Next, when reflecting use multiple basic emotions rather than trying to find the exact English word. Finally, recognize that not being able to express your feelings in another language is frustrating and isolating. Emotions connect us with others, and when our language ability only allows us to conduct business it can be lonely.

COMMON PROBLEMS IN REFLECTING FEELINGS AND THEIR ANTIDOTES

In your practice sessions, you may find it easy to use opening and invitational skills and even paraphrase; however, you may find that some practice sessions seem to have gone by without a single reflection of feeling. At these times, you may wish to review the

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TABLE 5.3 Emotion Words without English Translation (Adapted from Elert, 2013; Ishwar, 2013)

Emotion WordLanguage Source English Concept

Some Typical Events Associated with the Feeling

Toska Russian Spiritual anguish, a cry of the soul, a pining without a source

Ennui, boredom, desperation to make sense out of life

Hiraeth Welsh Homesickness and sadness for those who are lost or dead

Reminiscing when parted

Saudade Portugese A feeling of sadness and incompleteness, a yearning for something that may not return

A history of loss (also in fado music)

Ti vogleo bene Italian Sense of attachment to friends and family

A moment of closeness

Gezelligheid Dutch Coziness and togetherness of being at home with loved ones

Coming home and “cocooning”

Ei viitsi Estonian Feeling of mild laziness, unwillingness to work or go out

Rest after working hard

Litost Czech Anguish caused by seeing one’s own misery

Realizing one’s suffering makes it worse

Pena ajena Mexican Spanish

Embarrassed by witnessing someone else’s humiliation

Seeing another person put down

Schadenfreude German Pleasure from someone else’s pain Someone else, perhaps a competitor, fails

Lykke Danish Feeling that everything in life is going perfectly

Suddenly, several things work out at once

Cafune Brazilian Portugese

Running your fingers fondly through someone’s hair

Spending time with someone

Forelsket Norwegian The euphoria of falling in love Falling in love

Gigil Filipino The feeling that something is so cute you want to squeeze or pinch it; also when you get frustrated and want to “shake” the person

Seeing a dog, a baby, or a small animal; or being frustrated with someone

Zhalost Russian The positive feeling when someone takes pity on you

When you feel hopeless and someone understands your situation

following common problems. These problems and their solutions have been gathered from students and teachers who have experienced them. Under each problem are some suggested ways of dealing with that issue (antidotes). If you find that you are having dif-ficulty with one of these typical hurdles, let your instructor and fellow students know so that you can receive specific feedback during practice sessions.

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Asking the Client, “How Did You Feel?” or “How Did That Make You Feel?”

When you are not able to reflect the client’s feeling, you may be tempted to ask the ques-tion, “How did you feel?” When you ask a closed question like this, the client does not feel that you understand—empathy is lost. To make matters worse, the client can rarely pinpoint the feeling when asked, and the conversation stalls.

Antidote: At such times, the best advice is to use your opening skills, asking open questions and door openers to keep the client talking. Eventually you will realize what the client is feeling and be able to reflect. Give yourself a break from closed questioning for a while. That will force you to wait for feelings.

Waiting Too Long to Reflect

In the opening minutes of the helping session, utilize invitational skills to help elicit the client’s story, but don’t wait too long. A common mistake is to wait 10–15 minutes before going on to reflect the client’s feelings. You may want to reflect a feeling after 2–3 min-utes of listening if possible. It is better to reflect inaccurately than never to reflect at all—be courageous.

Antidote: To avoid the mistake of waiting too long, work first on becoming profi-cient at identifying feelings. Go ahead and reflect even if you are not entirely cer-tain. Make full use of the written exercises in this chapter. Look at exercises in pre-vious chapters, read the client statements, and see whether you can pick out the feelings. Also, watch television shows, particularly daytime dramas, to see whether you can listen to people’s statements and then reflect their feelings immediately after they speak, picking up on nonverbal as well as spoken cues.

Making Your Reflection a Question

As we noted before, clients respond better to statements because the helper’s making a statement does not interrupt the story as much as questioning does and it conveys under-standing. A question demands that the client answer and it is rude not to respond to a direct question. Sometimes just lifting the voice at the end of the sentence is enough to turn a reflection into a question.

Another error is when we are able to reflect the client’s feeling but state it as a ques-tion. This is usually because we lack confidence in our reflection. When we ask a ques-tion, we are giving the client the option of saying either “yes” or “no” instead of agreeing with our reflection or correcting it. In the conversation that follows, the helper’s grasp of the client’s feeling is correct but she waters down her reflection by making it a question. The result is that the client does not have to expand her answer, but merely has to answer the question.

XiomArA (Client): “I’ve had a very difficult time. My mother died about 1 month ago, and now my dad is in the hospital with pneumonia. I’m here 2,000 miles away, and I am running out of sick leave at my work.”

tori (Celper): “Are you feeling sad over the death of your mom and a sense of helplessness as you worry about your dad?”

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Can you see how a client might respond with a simple “yes” or “no”? The question suggests that the helper is confused, and it does not provide as many options to explore.

Antidote: Practice boldly stating your reflections and then let the client react. In this example, had the helper reflected the client’s feelings with a statement, she could have said, “It must be a very helpless feeling for you to be so far away when you are worried about your dad and still trying to deal with the sadness of your mom’s death.” Such a statement more effectively communicates understanding of the client’s situation and is more compassionate. Rather than responding to a ques-tion, the client can then go on to explore whatever issues seem important to him or her. If you have the tendency to turn statements into questions by raising your voice at the end of a sentence, tell your fellow students and ask them to alert you when you do it.

Combining a Reflection and a Question: The Error of the Compound Response

In the early stages, it is tempting to add a question after the reflecting statement. We might call this a compound response. However, a compound response confuses the client because he or she has been asked to do two things: respond to the reflection of feeling and answer the question. For example,

helper: “You feel really alone since your best friend moved away. Do you have any other close friends?”

Client: “Yes, I have one other friend, but we are not that close.”

In this example, the client goes on to tell you about another friend but fails to return to “feeling alone” that the helper reflected.

Antidote: If you have the tendency to add a question to your reflections, try elimi-nating questions altogether for a while in your practice sessions and try to keep your reflections simple. Get in and get out. Tell your practice partners to alert you when you use compound responses.

Focusing on Other People

In a therapeutic conversation, there are four domains that can be a topic of discussion between helper and client: (1) talking about what is going on inside the client, (2) talking about the helper, (3) talking about the relationship between helper and client, and (4) talking about external factors such as the environment and other people. The first domain, the client, is where you, as a beginning helper, should focus most of your conversation. This is called focusing on the client. It is the domain of the client’s story including his or her thoughts, feelings, and meanings. This is based on the assumption that the client cannot change others, and it is best to keep bringing the conversation back to the client’s viewpoint and reaction to events even when he or she complains about others. Consider the following interchange between client and helper:

Client: “I am sick and tired of my sister butting into my life when she knows I need to make my own decisions.”

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helper: (Focusing on client through reflection of feeling and content) “So, you are frustrated by her advice and look forward to being able to run your own life.”

In the next example, the helper is tempted to focus on the client’s friend:

Client: “My best friend, Hope, and I are not as close as we used to be. Some-times I think she just wants to neutralize our relationship. It seems like she has no time for me, like she doesn’t care.”

One way to get off track is by paraphrasing in a judgmental way by focusing on the client’s friend: “She neglects you,” or “She must not be a really good friend.” If the helper wants the client to go deeper, he or she needs to keep attention centered on the client: “You miss the relationship you used to enjoy so much.” Can you see how focus-ing on the other person can send a judgmental message about the friend? Because you do not know anything directly about the other person, such a statement is unfair and perhaps inaccurate.

Antidote: To eliminate this problem, record your practice sessions, and go over your responses and write Wrong Focus or WF next to such a response when you see it. When the client makes statements about other people, check to see what you are reflecting: the client’s thoughts and feelings, or the issues of the third party.

MyCounselingLab Application Exercise 5.2 Keeping the Focus on the Client While Reflecting Feelings

Interrupting Too Soon and Letting the Client Talk Too Long

INTERRUPTING WITH QUESTIONS Interrupting too soon is a mistake and so is its opposite—letting the client talk too long without responding. Interrupting really means asking questions too early in the session. Questions interfere with the flow of the cli-ent’s story.

Antidote: Eliminate questions for the time being and focus on understanding the client’s story by encouraging the client to talk.

LETTING THE CLIENT TALK TOO LONG Now let us look at the error of letting the client talk too long. In social situations, it is not polite to interrupt. However, clients need para-phrases and reflections in order to know that their story is making sense to the helper. Because some clients are talkative or anxious, they leave little room for the helper to reflect and the important issues just fly past. Beginning helpers hesitate to interrupt, espe-cially when the client is very talkative. Thus, the main reason to stop the client is so that the helper does not miss crucial information.

Antidote: The main cure for this error is to give yourself permission to stop clients and make reflections. You may have to do this several times during a session.

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Surprisingly, stopping and reflecting often serves to reassure clients that each aspect of their story is being heard in a systematic way. Here are two examples of ways that a helper politely requests a pause to verify that the right message is being received:

helper: “Let me stop you here for a second and see if I understand correctly. You feel both angry and hurt that your friend is not spending time with you, but you are afraid to mention it because you are afraid that she may sim-ply terminate the friendship.”

Or,

helper: “I’m sorry to interrupt, but let me tell you what I know so far. You resent the fact that you and your friend don’t get together much anymore, but it is too scary to think about bringing it up.”

A footnote to this discussion is that a helping relationship needs to have both peo-ple actively participating. By stopping the flow of the client’s story to catch up, the helper is becoming involved with the client, creating a connection and actively listening, rather than becoming a “listening post.”

Confusing the Words Feel and Think

When you watch a recording or view a transcript, you may believe you are reflecting feel-ings when you are actually paraphrasing because you are confusing the words feel and think. For example, when the client says, “I feel that I am making progress,” and you reflect, “You feel you are getting somewhere now,” you have made an accurate para-phrase but it is not a reflection of the feeling. Can you see that in this client’s statement, he or she might be feeling optimistic or confident but that “getting somewhere” is not a feeling? In this case, you might say to the client; “You think you are getting somewhere now and you feel more confident.” Thus, you have a paraphrase, “think you are getting somewhere,” and the reflection of feeling, “confident.”

Antidote: This is where practice in identifying feelings can help. The alter-ego technique is one of the best methods for practicing this skill (see Group Exercise 1). Some people use feel instead of think a great deal in their daily conversations. If you have this tendency, try to become aware of it and change your feel to think whenever you can. By being specific about these two words, you are subtly teach-ing clients to recognize the differences between thoughts and feelings.

Missing the Mark: Overshooting and Undershooting

Has anyone ever said to you, “I know exactly how you feel”? Frequently, the person goes on to tell a story that really doesn’t match what you are saying at all. The feelings he or she experienced are not identical to yours. Helpers reflect the client’s feelings and thus avoid the error of comparing the helper’s situation to the client’s. Sometimes, though, when you reflect a client’s feeling you do not quite hit the bull’s-eye, and accurate reflect-ing is essential in developing rapport. Take a look at Table 5.4. The situation is that a client feels anxious (general emotion), and you are trying to reflect just the right amount

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to accurately convey what he or she is feeling. In this case the client feels a little nervous about an upcoming job interview.

Overshooting and undershooting are two common mistakes in reflecting feelings (Gordon, 1975). Overshooting means that the helper has reflected a feeling that is more intense than the one expressed by the client. Undershooting is reflecting a feeling that is too weak to adequately mirror the client’s emotion. Consider this client statement and three possible responses:

Client: “Becky told Mrs. Gordon that I was not a fast worker, so she started giv-ing the most interesting work to Rolando instead of me.”

helper: “You must have been mad enough to kill!” (overshooting)

helper: “You were mildly annoyed.” (undershooting)

helper: “You were mad.” (accurate intensity)

Antidote: Overshooting and undershooting are beginners’ mistakes; this ten-dency normally corrects itself as you gain a larger feeling vocabulary. Like play-ing darts, you learn to hit the bull’s-eye more often when the client corrects you. In your practice sessions, note the difference between a polite “Yes, that’s right” and “Yes!” from the client when you hit the mark. If you undershoot, in your next statement, you can raise the intensity a notch, or you can lower it if you over-shoot. If your feeling vocabulary seems limited at present, study lists of feeling words like those in Table 5.1. You may also try using qualifiers such as a little angry, somewhat angry, or very angry to convey various shades of emotional intensity.

Letting Your Reflecting Statements Go On Too Long

Sometimes helpers tend to continue to reflect and paraphrase, not in sentences, but in chapters. When this happens, the important aspects of your response are lost in the verbi-age. The student thinks, “If I reflect several different things, one of them is bound to be right.”

Antidote: Try thinking of reflecting as a form of gambling, like playing poker. You must wait until you think you understand and then you place your bet on a single brief reflection, paraphrase, or combination. If you are wrong, the client will correct you and proceed to describe the accurate feeling, helping you to find the bull’s-eye. You will become more aware of your tendency to make lengthy reflections when you record your sessions and transcribe them. You may notice that you are saying more than the client. That is a good indication that you are saying too much. Try sticking to the formula “You feel _____ when _____,” which will help you limit the length of your interventions.

TABLE 5.4 Undershooting, Accurate Reflection, and Overshooting

Accuracy of the Reflection Undershooting Accurate Reflection Overshooting

Feeling Helper Reflected Concerned A little nervous Paralyzed with fear

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Summary

The reflecting skills are a quantum leap from the invi-tational skills because they do much more than en-courage clients to tell their stories. The reflecting skills move clients to greater self-awareness and encourage them to address deeper issues beneath the surface. They forge an empathic bond between client and helper as the client senses that someone has taken the time to try and understand.

Reflecting feelings involves identifying and labe-ling the client’s feeling and then reflecting the feeling back to the client, whether or not such feelings have been openly expressed. The feeling component of the

message is often hidden because disclosure of feelings is bound by culture, gender training, and family rules. Labeling and reflecting feelings can be one of the most difficult processes to learn. There is a great variability in how quickly students learn to reflect feelings. Some come to it very naturally and quickly. Others take longer but can learn the skill eventually through per-sistence and practice. There are a number of common stumbling blocks or problems you will encounter as you develop this skill. Return to this chapter later as you identify the specific difficulties you are having and review the antidotes.

Exercises

GROUP EXERCISES

Exercise 1: The Alter-Ego Technique for Identifying Feelings

Identifying feelings precedes reflecting them. One of the best action methods for learning to identify feel-ings is the alter-ego technique, which comes to us from psychodrama (Moreno, 1958). The alter-ego technique asks the student to pretend that he or she is the client in order to imagine the client’s feelings. This group exercise requires four members: the client, the helper, the alter ego, and the observer. It is in the role of alter ego that the student learns most about how to identify feelings.

The Client

The client discusses an experience with either posi-tive or negative ramifications, such as a good or bad vacation, a relationship that ended abruptly, a missed opportunity, or another minor problem. If the alter ego correctly identifies an emotion, the client repeats it, such as “Yes, I do resent that.”

The Helper or Listener

The trainee who plays the part of the helper has little to do in this exercise. The job of the helper is to listen with appropriate body position, using only open ques-tions and minimal encouragers, providing a focus for the client but rarely intervening.

The Alter Ego

The third student, the alter ego, stands beside the client and speaks for the client, identifying anything the cli-ent might be feeling but has left out. Standing beside the client gives clues to the client’s facial expressions and body language. It is very important that the alter ego speak using the word I as if he or she were speak-ing for the client: “I am angry,” “I am embarrassed,” and so on.

The Observer

The fourth member of the group is an observer who re-cords the alter ego’s remarks on a blank sheet of paper. In the discussion phase, the client gives the alter ego feedback on the most accurate and the least accurate reflections and paraphrases. The observer should gen-tly correct the alter ego if he or she forgets to speak as the client and lapses into “you feel” rather than “I feel.”

Action Phase

Once roles have been assigned, the client tells his or her story to the helper/listener. The alter ego, standing beside the client, expresses underlying feelings in the client’s story. The client should be directed to ignore the alter ego, except when the alter ego really hits the mark. At that point, the client should incorporate the alter ego’s comment into his or her statements. For example, if the alter ego says, “I am angry and embarrassed,” the client

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may then respond, saying, “I am embarrassed.” The cli-ent always directs his or her response to the helper/listener, even when reacting to the alter ego. Although client and helper/listener may find this exercise frustrat-ing, it allows the alter ego to stand outside the relation-ship and he or she can learn to hear feelings, imagining himself or herself as another person.

Discussion Phase

After 5–8 minutes, the group members discuss their experiences, and the observer gives the alter ego feed-back. Members then exchange positions until everyone has had a chance to experience the role of alter ego.

QUICK TIPS: REFLECTING FEELINGS• You will probably need to use invitational

skills and paraphrasing before you have enough information to reflect feelings. Don’t expect to hear feelings immediately. When you have heard enough of the client’s story to grasp the emotional content, stop the client and make a reflection.

• If you don’t know how the client is feeling, imagine yourself in the client’s shoes. What would you be feeling if you were the client? If you can identify what the client is thinking or you understand the client’s problem, ask yourself the following: “What would I be feeling if I were thinking that?” or “What would I be feeling if I were in that situation?” For example, the client says he is being treated unfairly. The trick is to ask oneself, “If I were being treated unfairly, how would I be feeling (hurt, angry, ignored, devalued)?”

• If you can’t home in on a particular feeling, reflect two feelings to get at what the client is experiencing.

• Keep your focus on the client’s viewpoint and reflect that. Convey that you understand the client’s perspective without agreeing that other people are at fault.

Exercise 2: Using the Feedback Checklist in a Practice Session

The alter-ego technique is a good way to develop the initial skill of imagining oneself as the client and

Feedback Checklist: Reflecting Feelings

Observer Name: ______ Helper Name: _______

During the session, the observer records the helper’s responses verbatim. After the session, the group decides on a category for each response: E for an encourager (either door opener or minimal encourager), CQ for closed question, OQ for open question, P for paraphrase, ROF for reflecting feelings, and ROF + P for a response that paraphrases and hits the feeling. Were any of the helper’s responses focused on the wrong person? If so, note WF for wrong focus.

Category Helper Response Client Feedback

_________ 1. _______________ _______________

_________ 2. _______________ _______________

_________ 3. _______________ _______________

_________ 4. _______________ _______________

_________ 5. _______________ _______________

_________ 6. _______________ _______________

_________ 7. _______________ _______________

_________ 8. _______________ _______________

_________ 9. _______________ _______________

_________ 10. _______________ _______________

identifying thoughts and feelings. The next step is to incorporate the skill within the helping interview. Break into groups of three with a helper, client, and observer. During a 5–8 minute session, the client de-scribes a small problem he or she has been having with a friend, a family member, or someone at work. The helper uses invitational skills, paraphrases, and, whenever possible, reflects feelings. The helper’s goal is to reflect at least three feelings during the practice session.

The observer makes certain that the time lim-its are observed and, during the period, records every helper statement on the Feedback Checklist: Reflect-ing Feelings. At the end of the time, he or she shares feedback with the helper. The client gives the helper feedback on which responses on the checklist were most accurate and which were least accurate. The cli-ent makes a check mark next to those that seem to hit the mark. The group members exchange roles un-til everyone has had a chance to practice the role of helper and receive feedback.

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Exercise 3: Reflecting More than One Feeling

Clients are usually not experiencing a single emotion associated with their problem. Emotions are often tan-gled like spaghetti. When you are trying to reflect all of the feelings a client is experiencing, it helps to untangle the problem so that it begins to feel more manageable. In this exercise, you will try to identify more than one emotion in a client statement from Written Exercise 1.

First, form circles of four students. Each student reads one of the eight client statements in turn as if he or she were the client, using voice tone that expresses the client’s feelings. The student across from the client reflects the feeling the client seems to be experiencing using the “You feel ___ when ___” format. But this time, the student attempts to identify two or more feelings that might be associated with the statement. For example, “You felt angry and hurt when you thought manage-ment didn’t care about the workers.” In groups of four, each student will have two chances to reflect more than one emotion. Following each round, the group should discuss the accuracy of each student’s reflections. You may want to consult the list of feeling words in Table 5.1.

WRITTEN EXERCISES

Exercise 1: Practice in Identifying Feelings and Reflecting Feelings in Writing

Listed below are eight client statements. First go through and identify the major feeling or feelings in each client statement. Then write down, “You feel ________.” If more than one feeling exists, reflect all that you can. If you have identified the right primary emotion but differ on the exact shade of emotion, you could be right depending on the context and nonver-bals of the client.

1. “There I was, standing in front of the entire assem-bly, and I froze. Everyone was staring at me. My heart was pounding and I started to shake. I thought I was going to die right there on the spot. I can never show my face again after that.”

2. “And for the third time in a row, he failed to show. What a jerk! My daughter looks forward to these times with her father, and I hate to see him treat her this way. But I can’t seem to do anything to make him listen.”

3. “The more I do, the more the boss seems to expect. He’s never satisfied and is always finding fault. I think I should start looking for another job because I can’t take it anymore.”

4. “I can’t believe I trusted my sister-in-law. She is such a backstabbing witch. I hate her. She’d start bad-mouthing my mother-in-law and get me going. Then after she got me saying negative things, I found out she was going back and repeat-ing everything I said to my mother-in-law! Now my mother-in-law hates me.”

5. “We just moved here, and I’m working two jobs. But somehow I’ve got to find time to take my kids to their schoolmates’ houses so they can get to know people and have some friends. I just don’t seem to have time.”

6. “My son keeps staying out late at night with his friends. He won’t tell me where he goes. I’m afraid he’ll get hurt. He’s probably able to take care of himself. I don’t know what to do.”

7. “My best friend was hoping that Glenn would invite her to the formal, but he invited me. She’s not talking to me now and I don’t know what to say. It’s not my fault.”

8. “My dog is really sick and he’s suffering. I know you probably think it’s silly but I am paralyzed. I don’t know whether I believe in putting him out of his misery, and I don’t know how I would cope with that loss on top of everything. But am I being selfish?”

Exercise 2: Connecting Feelings and a Paraphrase

Using the stem “You feel ________ when _______,” create statements that reflect feeling and the related events, which come out of the content of the story. Write your reflection + paraphrase down on a sheet of paper and compare your answers with mine. Make your paraphrase brief.

1. “My husband and I keep fighting. We argue over very minor things. I didn’t really mind before, but I think it’s having a big impact on the kids.”

2. “I think my girlfriend likes someone else. When-ever I turn around, I see her talking to Kent. She seems to laugh a lot when I see them together.”

3. “I’ve always wanted to be an actor. But my mom and my teacher have told me it’s a crazy idea and I need to get a proper job. It makes me wonder.”

4. “I told my best friend something that was top secret. I found out yesterday that she has told my worst enemy in the whole school.”

5. “My sister’s boyfriend is just terrible. He drinks too much and never works. I have heard things about him that she doesn’t even know.”

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My answers: (1) “You feel more concerned about the fighting when you thought about the effect on the kids.” (2) “You feel jealous and concerned about the relationship when you see her enjoying other people.” (3) “So you begin to feel uncertain when other people bring doubts about your career choice.” (4) “You feel angry with your friend and a bit worried when you discover that someone who dislikes you knows that secret.” (5) “You feel afraid for your sister when you think about her boyfriend’s drinking, his lack of a job, and rumors you’ve heard about him.”

SELF-ASSESSMENT

Practice reflecting feelings with a fellow class member who plays the role of the client. This practice can be as short as 10 minutes. Following the practice session, ask your client to fill out the following feedback.

To the Client:Please respond as honestly as possible to the

following statements, using the 5-point scale below:

1 2 3 4 5

Strongly Disagree Disagree Neutral Agree Strongly Agree

1. ____ The helper’s nonverbal and opening skills seemed appropriate.

2. ____ The helper interrupted me with questions.3. ____ The helper showed warmth.4. ____ The helper’s responses seemed concise.5. ____ The helper seemed to understand the facts.6. ____ The helper identified one or two primary

feelings accurately.7. ____ The helper reflected a feeling of which I was

unaware.8. ____ Overall, the session helped me think a little

more deeply about the situation.

Please identify one or two things the helper did well in the session.

1. ___________________________________________2. ___________________________________________

Please identify one or two things the helper can do to further improve his or her skills.

1. ___________________________________________2. ___________________________________________

To the Helper:

Based on the feedback you received, identify one or two things you hope to work on in upcoming practice sessions.

1. ___________________________________________2. ___________________________________________

HOMEWORK

Homework 1: Keeping an Emotions Diary

Make a copy of Table 5.1 and keep it with some blank paper on a clipboard near your bed. Think about an emotion you experienced today. For ex-ample, if you felt angry at work, at school, or with family, record that feeling as the answer to the first question below. Fill out this diary for 2 successive days and then write a one-paragraph reaction re-cording your discoveries.

• What was the emotion?• Think of a synonym for the emotion as you expe-

rienced it today.• Describe the situation in which you experienced

the emotion.• Who was present when you experienced the

emotion?• What do you think caused your emotion? Do you

blame other people for your emotion? Which of your personal values and beliefs might have given rise to this emotion? In other words, what did you say to yourself about this emotional response?

• How did you express the emotion?• What societal rules come to mind when you think

about expressing this emotion?• Record any other thoughts you have about your

experience today.

JOURNAL STARTERS

Think about the ways emotions are commonly ex-pressed in your own family. Do you think that, in your family, some emotions are more acceptable than others? How do you think your family or ethnic back-ground might affect your willingness to listen to a cli-ent’s feelings?

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121

Meaning, Uncovering the Next Layer• Why Reflect Meaning?• Challenging the Client to Go Deeper: The

Inner Circle Strategy• Worldview: Meanings Are Personal

How to Uncover Meaning in the Story• Reflecting Meaning• Using Open Questions to Uncover

Meaning

Summarizing• Focusing Summaries• Signal Summaries• Thematic Summaries• Planning Summaries

The Nonjudgmental Listening Cycle Ends with Summarizing• What Happens after the Nonjudgmental

Listening Cycle?• A Questioning Cycle Typically Found

Early in Training

Summary

Exercises• Group Exercises• Small Group Discussions• Written Exercises• Self-Assessment• Homework• Journal Starters

LEARNING OUTCOMES

By the end of this chapter, you will be able to:

6.1 Recognize reflections of meaning and helper statements that move clients deeper.

6.2 Reflect meaning in client statements.6.3 Make summaries to signal transitions, begin and end sessions,

and identify themes.6.4 Identify the various parts of the nonjudgmental listening cycle

(NLC).

It is not what happens to us but what we make of it.

EpictEtus

The quote that starts this chapter is from the Greek stoic philosopher Epictetus, who reminds us that how we look at things determines our

Advanced Reflecting Skills: Reflecting Meaning and Summarizing

C H A P T E R 6

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122 Chapter 6 • Advanced Reflecting Skills: Reflecting Meaning and Summarizing

reaction to them. For some, a death in the family can be a tragedy that ruins their lives. For others, the person who has passed on becomes an inspiration. Our emotional reaction is largely determined by the unique meanings we assign to the events of our lives. For example, a client once told me her 90-year-old mother failed to recognize her at the grocery store. Here was the client’s statement: “I saw my mother and she didn’t even acknowledge or recognize me. That’s typical.” Can you see that reflecting the content (she didn’t recognize you) and the feeling (sad, angry) does not capture the client’s whole message? Underneath the story is the meaning that is something personally constructed by the client: “I am nothing in her life,” or “I am invisible and irrelevant to her.”

This example illustrates how each person’s interpretations, values, and perceptions are formed by his or her particular history, needs, values, and beliefs. Two people expe-riencing the same event will have different views of its significance. Notice that the client did not say, “My mother is elderly and perhaps her eyesight is failing.” Instead the client assigned a very personal meaning to the fact that her mother did not greet her. If you, as the helper, do not understand the meaning of the event to the client and reflect it, then you will not truly comprehend the story.

Understanding and then reflecting meaning to the client is perhaps the most difficult skill you will learn. In this chapter, we will present several different ways for you to get a feel for this advanced skill. Later in the book, we will identify some change techniques aimed at helping a person change unhelpful or unproductive perspectives, including reframing, but in this chapter, we will look at how a helper can identify and respond to the meanings behind a client’s story. In other words, our focus here is to understand and reflect rather than intervene. Still, the helper must recognize the therapeutic value of mak-ing clients aware of the meanings in their narratives (Adler, Harmerling, & Walder- Biesanz, 2013). Viktor Frankl’s Logotherapy (2006) emphasized that human beings are meaning-makers. We want to make sense of our experience and this meaning-making process can help us endure the crises of life (Wong, 2012).

In this chapter, we will also look at summarizing, a method of binding together the parts of the client’s story into a capsule account. Summaries are ways of pulling together the loose ends and communicating that the helper has grasped the totality of content, feelings, and meanings. Both summarizing and reflecting meaning are advanced reflect-ing skills that strengthen the client/helper relationship because the client feels understood at a very deep level. If the client does not feel completely understood, the next phases of helping falter. Let me relate a brief story to illustrate this point. I called my telephone service provider to report problems I was having with my phone. Before I could describe the problem, the person began describing solutions. Through her experience, she knew a few quick fixes but I was not ready to try them until I knew that she fully understood the problem. Similarly, a client may not let you help until you have qualified to do so. The way to qualify is to show the client that you fully grasp the issues. You can commu-nicate this by showing a complete understanding of the facts, feelings, and meanings.

MEANING, UNCOVERING THE NEXT LAYER

We don’t see things as they are; we see things as we are.

AnAïs nin

Understanding the content of the client’s story gives us an outline or picture in our minds about what has happened. The emotions add color to the story and help us imagine the

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Chapter 6 • Advanced Reflecting Skills: Reflecting Meaning and Summarizing 123

sometimes overwhelming feelings that he or she is experiencing. On the other hand, when we understand a person’s meaning system, we begin to grasp how the person views the world. Meanings are built from a person’s past experiences, which are “alloyed with firm beliefs, fuzzy ideas, and unconscious schemes and prejudices” (Leontiev, 2007, p. 244). Thus, reflection of meaning is a significant step beyond reflection of content and emotion, because it helps us understand the client’s unique background and perspective. It also allows clients to become aware of the lens through which they are seeing them-selves and others.

Consider the case of Joan, who had been having problems at work for 2 years. Her co-workers had split into two factions that everyone on the job called “the red-birds” and “the bluebirds.” There was considerable animosity because of a power struggle between the leaders of the two groups. Joan found herself allied with the bluebirds. During one of their after-work gripe sessions, she revealed that she knew one of the redbirds, Bob, had sought treatment for alcoholism. Bob had told her this several years ago when they were on good terms. Somehow this information leaked to the administration; Bob’s boss called him “on the carpet” because the company was working on several government contracts, and Bob was investigated as a security risk. A couple of weeks later, Joan went to the company’s employee assistance program and asked for counseling. During the interview, she and the helper (Lynn) had the fol-lowing exchange.

JoAn: “There is just so much turmoil. It used to be a good place to work. Now it’s ‘dog eat dog.’”

Lynn: “You are sad because things have changed and now there is so much com-petition.” (reflection of feeling and paraphrase)

JoAn: “Yes, that among other things.”

Lynn: “Okay, say more.” (door opener)

JoAn: “Well, Bob told me about his treatment for alcoholism one night when we were working late, sort of offhandedly. I even thought of him as a friend.”

Lynn: “You’re afraid of his reaction when he finds out that you leaked the infor-mation.” (reflection of feeling and paraphrase)

JoAn: “Not really. It just seems a nasty thing to do to someone who was trying to be friendly.”

Lynn: “In other words, you are disappointed in yourself for having betrayed a confidence.” (reflection of feeling and meaning)

JoAn: “Yeah, that’s the thing. I think I did it just to be part of the club. I don’t like that about myself. I wish I were secure enough to have my own opinions about people.”

Lynn: “It sounds like it has always been very important for you to be approved of, and sometimes, to be part of the group, you find yourself doing some-thing you don’t even agree with.” (reflection of meaning)

If Lynn had merely paraphrased the story of Joan’s problems at work, her thoughts, and her underlying feelings, it would have been a productive session. However, Lynn chose to dig more deeply, not only paraphrasing Joan’s feelings about recent events but also looking at the underlying meaning—the perceptions and values her client attributed

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to the self, the office situation, and the other workers involved. Notice how Lynn under-stands Joan’s disappointment in herself and how this leads to a deeper response by Joan. Previous paraphrases and reflections of feeling were not nearly as effective as when the helper keyed in on what was really bothering Joan.

Figure 6.1 shows that every client’s story, like Joan’s, has several layers. As if peeling an onion, a client is likely to give us first the content of the story, then the feelings it evokes, and finally, its personal meaning. The figure also illustrates the fact that as the client’s story becomes deeper over time, there are occasional returns to more superficial material. Increasing depth is due to the development of trust, but at the same time, more threatening material emerges, such as feelings and meanings that evoke embarrassment and shame. Therefore, depth varies as the client discloses. If the helper can keep the cli-ent focused on deeper issues and provide a safe environment, the full meaning of the story starts to emerge and the session trends deeper.

Why Reflect Meaning?

The story of Joan and Lynn demonstrates that unless we understand meaning, we are missing a crucial aspect of the message. In the section that follows, some of the rea-sons for reflecting feelings are described using Joan and Lynn’s conversation as an example.

TO UNDERSTAND THE CLIENT AT A DEEPER LEVEL Some investigations into the transcripts of Carl Rogers have found that 70% of his responses were reflections of meaning, not feelings (Elliott, Bohart, Watson, & Greenberg, 2011). You might notice that he some-times speaks for the client, starting his sentences with “I,” such as “I just don’t trust myself

Reflect Meanings

Paraphrase

Depth

Depth of client responsesvaries through the session,based on the helper’s statements.

Reflect Feelings

Level 1—Content”What happened?”

Level 2—Feelings”How did you feel?”

Level 3—Meaning”What did it mean?”

Time

FIGURE 6.1 Levels of Disclosure

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Chapter 6 • Advanced Reflecting Skills: Reflecting Meaning and Summarizing 125

to be a good partner.” Rogers used this method of pretending to be the client as a way of getting in touch with the meaning the client assigns to events, thereby understanding him or her at a deeper level. Thus, one of the benefits is that the helper gets a feel for the cli-ent’s worldview.

TO LEAD TO DEEPER SELF-UNDERSTANDING IN THE CLIENT Thinking back about the con-versation between Joan and Lynn, recall that the events in Joan’s story clearly have a deeper significance than Joan herself is able to identify at first. Why is it important for the helper to bring this deeper level of meaning to the surface? One reason is that the client takes these backdrop issues for granted. When the helper highlights them, the client begins to realize their significance and begins to understand that these meanings are part of the unique way he or she constructs the world.

TO EMPHASIZE THAT THE STORY IS THE CLIENT’S VERSION Besides increasing the cli-ent’s insight and the helper’s understanding of the client, reflection of meaning allows the client to recognize that the story he or she is telling is not the facts but is, instead, a perspective. The helper holds up a mirror to the client, “reflecting” rather than agree-ing with what the client says. The helper lets the client get a good look at his or her own values and viewpoint about the self, others, and the world. When a client sees himself or herself through the eyes of another, he or she begins to envision how to make constructive changes. In Joan’s case, by opening up to the meaning of the story, she begins to see that her actions were due, in part, to her long-felt need for approval. When she makes this connection, it paves the way to set a goal for becoming more self-directing. Here are some leads a helper might use to emphasize the point that this is the client’s distinctive story and to avoid agreeing with the client that his or her perception is reality:

“In your mind, you were snubbed.”

“For you, this was another piece of evidence that trusting people is dangerous.”

“From your perspective, if only you had had better parenting, you wouldn’t be so down on yourself.”

TO PUSH THE CLIENT TO GO DEEPER Reflecting meaning inevitably has the effect of get-ting the client to discuss even deeper issues than those brought out in the first version of the story. Take a look at the end of the dialogue between Joan and Lynn. Can you see how Joan’s next statements in her dialogue with Lynn might progress? Perhaps she will discuss how she was raised, where her values came from, and how she is going to inter-act with her colleagues in the future. Whereas reflecting meaning leads to more disclo-sure and exploration of a topic, a helper’s inability to tap meaning results in more superficial conversations.

TO EXAMINE THE CONCEPT OF DEPTH Beginning helpers are often confused when the client’s story seems to have run its course. They feel that once the basic facts are known, where else can the conversation go? This is because the helper has not gone deeper into the meaning of the story. Figure 6.1 shows the concept of depth in a client’s story over time. According to this model, superficiality is the result of traveling too rapidly through

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the story in a horizontal direction, rather than going deeper, or vertically. The depth that a client is willing to reveal depends on a number of factors. Among these are helper responses, client readiness and willingness, and whether or not the client feels safe in the therapeutic relationship.

Encouragers like “Uh-huh” and “Go on” do not necessarily nudge the client to go deeper. They tend to keep the client at whatever level the discussion has reached. If the helper does not invite the client to reach deeper levels by reflecting feelings and mean-ings, the client will normally remain at level 1 (Figure 6.1). Of course, some clients are very psychologically minded and will quickly discuss the deeper aspects of a problem with little prompting, but even insightful clients frequently miss the importance of mean-ing because they take their meanings for granted.

On the other hand, some clients are not very talkative and are uncomfortable with expressing feelings and uncovering personal issues. In that case, going deeper takes a much longer time, even if the helper is very inviting and uses reflecting skills. Such clients may have trouble getting to the feelings and meaning levels, and when they do, they only visit briefly. Clients are more likely to disclose deeply if the helper is perceived as com-petent, trustworthy, and nurturing.

Obviously, the only factors that the helper can control are his or her own actions. The helper cannot always break through a client’s reluctance to open up. To increase the likelihood of greater depth in the client’s explorations, the helper must not only avoid the overuse of closed questions and an interrogating attitude but also rely on reflecting skills to enhance empathy in order to deepen the client’s story whenever possible.

Challenging the Client to Go Deeper: The Inner Circle Strategy

In Joan’s case, the helper used questions and reflections of meaning to get at the deeper levels of the story. Sometimes clients have difficulty recognizing that their sto-ries have these deeper layers, and it is useful to challenge them to move from a super-ficial recounting to the area of personal meanings, secrets, and core beliefs (see Shaughnessy, 1987). Arnold Lazarus, the founder of multimodal therapy, used what he called an “inner circle strategy” for getting clients to identify deeper, more per-sonal issues (1981, p. 55). Using the inner circle strategy, the helper draws a series of concentric circles labeled A, B, C, D, and E (see Figure 6.2). At ring E are issues that are essentially public and might be discussed with almost anyone on first meet-ing, including one’s appearance and occupation. Issues at ring A are very personal such as sexual problems, anger and resentment toward people, negative views of the self, and secrets that the client feels are immoral or dishonest. Most relationships start at D and move toward A as the relationship grows. However, some relationships remain very close to D, and deeper topics are never broached. To understand a cli-ent’s willingness to disclose, the helper may ask the client to write in the names of individuals, including the helper, who have access to the various rings from A to D. Lazarus advocated using the diagram to confront the client when therapy has become too superficial. For example, the helper might say, “It seems to me that we are dis-cussing issues that fall in the D or C category. The most effective work occurs at level A or B. I am wondering whether you do not feel comfortable talking about these deeper levels yet.”

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STOP AND REFLECT

Secrets

“You are only as sick as your darkest secret.” In Alcoholics Anonymous, this aphorism is used to remind those in recovery that being truthful and open about themselves is much healthier than put-ting on a false front. The positive consequences of disclosing to others include the following:

1. We may see a reduction in psychological and physical problems.2. We may be better able to quit smoking or other addictions because we are affected by the

opinions of others.3. The secret does not have to be suppressed and therefore it loses its power to dominate one’s life.4. When we reveal secrets, we may gain insight and see the issue in a different light. (Kelly &

McKillop, 1996)

Although being honest within a professional relationship has these benefits, more than 50% of therapy clients report that they have kept secrets from their helpers (Hill, Thompson, Cogar, & Denman, 1993; Kelly & Yuan, 2009; Robey, 2011). When a client comes to a helper for help, how important is it that he or she be completely honest? Is it permissible for a client to retain some privacy and under what circumstances? How can we invite clients to share but show respect for their refusal to examine every nook and cranny of their private lives (Kottler & Carlson, 2011)? Many ethical guide-lines of professional organizations deal with the issue of secrets because their members are expected to maintain their clients’ confidences. It is a paradox that we are to keep our client’s secrets, yet we

A

B

C

D

E

FIGURE 6.2 The Inner Circle Strategy

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cannot force them to be completely honest with us. Consider the following scenarios and think about how you might handle them. If possible, discuss them with a small group of fellow learners.

• Your client is a 43-year-old married man who has just returned from an alcohol treatment center. He does not want to attend Alcoholics Anonymous (AA) for aftercare but comes weekly for counseling. During his sessions, he is open about his substance abuse issues but is very quiet about his family relationships and his sources of social support. You feel that going to AA would be helpful in maintaining his sobriety and in providing a social outlet. Apparently he has no friends and confides in no one. How would you deal with this situation? How far would you go in insisting that he learn to open up?

• You are conducting outpatient group therapy for 12 women. One of the rules of the group is that there will be no socializing outside of the group. One evening while shopping, you hap-pen to see two of the women from the group sitting together at a restaurant in the mall. They are deep in conversation, and they do not notice you. How do you think their secret relation-ship might affect their interactions with each other and with the group? As the group leader, what should you do? Should group leaders have rules about keeping secrets?

• You have been seeing a client, Isabel, for 4 weeks. At first, she discussed her dissatisfaction with her job and her concerns about parenting her teenage son. On the fifth week, Isabel admits she is having an affair with a co-worker, unbeknownst to her husband. Isabel says that her husband senses something is wrong in the relationship and wants marriage counseling. Isabel believes they could benefit by being seen as a couple and asks you to do the counseling, but not to reveal the ongoing affair. What would be the best response to Isabel? Can you agree to keep this secret if you see them as a couple?

STOP AND REFLECT

We have been talking about the fact that the most productive therapeutic relationships are devel-oped when clients feel free to reveal their deepest thoughts, feelings, and perceptions. Clients who venture to this level of disclosure are, however, risking a great deal. What would a person need to know about you before you would feel that he or she were sufficiently informed to help you? How long would you have to know someone before discussing your deepest secrets? Read each topic in the following list, and identify something relevant about yourself that you would be willing to discuss with a helper during the first session and something else that you probably would not discuss. Write down brief notes under each heading. What do you fear might happen if you were to disclose the thoughts, feelings, and perceptions that you would prefer not to discuss?

Topic I Would Disclose I Would Not Disclose

• Your family values and family history

• Your religion or spiritual beliefs

• Your sexual history

• Your personal dreams and ambitions

• Happy and unhappy childhood memories

• Physical limitations, disabilities, and illnesses

• Times when you were dishonest or unethical

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Draw an inner circle for yourself like the one in Figure 6.2 and write down the names of people who have access to the deeper issues in your life. Now think of one or two issues that you would not discuss with anyone, even a professional helper. What would stop you? Are there also issues at rings B and C that would be difficult but not impossible to discuss with a helper? What issues would you discuss only if there were safeguards of confidentiality? Share your inner circle with a small group of classmates if you feel comfortable in doing so. There is no need to discuss the issues at each of the levels. However, it might be interesting to compare the numbers of people who have access to the various levels of your life. Who are these people, and how did they gain this kind of trust?

Worldview: Meanings Are Personal

For the meaning of life differs from person to person, from day to day and from hour to hour. What matters, therefore, is not the meaning of life in

general but rather the specific meaning of a person’s life at a given moment.

Viktor FrAnkL

One way to think about meaning is that it is a product of a person’s worldview. Worldview is a term that refers to a person’s view of self, others, and the world (Koltko-Rivera, 2004). Language, gender, ethnicity/race, religion/spirituality, age, physical abilities, socioeconomic status, and trauma all influence the development of one’s worldview. In addition to world-view, a client’s personal values (what is important in life) are sources of meaning that can be brought to the surface. Recall the discussion between Lynn and Joan. The issue boiled down to Joan’s feeling that she had betrayed herself as well as a friend’s confidence. Viola-tions of one’s personal values are frequently background issues in client’s messages. The helper’s job is to understand both the client’s worldview and his or her values so that the client’s viewpoint—and the meaning of his or her story—can be appreciated and an appro-priate solution to the client’s problems found. Without understanding Joan’s moral dilemma and disappointment in herself, do you think it would be possible to help her deal with her situation at work? The appropriate solution must be consistent with her ideas of what is right and healthy. In other words, it must take into account her worldview and values. One of the ways that helpers can understand a client’s worldview and access the meaning a cli-ent ascribes to his or her situation is to be sensitive to client disclosures.

Following are some other examples of client statements that give a window into worldview or values.

View of Self

“I am essentially . . . (a good person) (evil) (selfish) (okay/not okay) (smart/dull) (damaged) (unlovable).”

“Nothing I do seems to work out.”

“I always land on my feet.”

“I am unlucky.”

“I am a victim.”

“I am a bad parent.”

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Notice that these statements express general notions about the self, rather than defining specific abilities such as being a good piano player or having a good sense of direction.

View of Others

“People are . . . (unreliable) (essentially good) (selfish) (trustworthy) (kind).”

“Men are all alike.”

“People will take advantage of you if they can.”

“White people are . . .”

“Asians are . . .”

Beliefs about the Environment or the World in General

“It’s a jungle out there.”

“Life is a vale of tears.”

“You can’t get ahead.”

“It’s bad luck.”

“God punished you.”

“Things always turn out for the best.”

Values

“People should treat each other fairly.”

“Men should be the head of the family.”

“Family secrets should be kept in the family.”

“Conflict is bad.”

“You should always try to do your best.”

HOW TO UNCOVER MEANING IN THE STORY

So far, we have emphasized the importance of understanding and listening for meaning in the client’s story. In this chapter, we discuss a number of methods for accomplishing this but the two most basic are reflecting meaning and asking questions about meaning. Reflecting meaning is preferred to asking questions because of all the drawbacks ques-tions raise in slowing down and sidetracking the story. Still we describe both methods here because there will be times when reflecting meaning is difficult to achieve and ques-tions offer a shortcut.

Reflecting Meaning

Reflecting meaning is one technique that helpers use to restate the personal impact and significance of the event the client is describing. Reflection of meaning is difficult to learn because each person’s take on a situation is unique. For example, much work was done in the 1960s and 1970s on the effect of stressful life events (Holmes & Rahe, 1967). If you have ever been in a stress workshop, you may have taken a “stress scale” that lists life events such as moving, changing jobs, divorce, and so on. Each event is given a weight

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based on its predicted impact on your life. Initially it was thought that, by adding up the scores, one could anticipate how much stress a person would feel based on the number of changes during the past year. It turns out that it is not the number of events that is very predictive of stress or illness, but rather the meaning and importance you place on the events is significant. For example, although divorce is highly stressful to most people and gets a high score on the stress scale, in conflict-ridden relationships, divorce may actually lead to a reduction in stress. It is not really possible to know how an event has affected someone until you understand his or her experiences, basic beliefs, and values.

Because meaning is even deeper below our awareness than feelings, meanings are harder to detect. The meanings are implicit in the client’s story, but one must learn to read between the lines to unearth them. This sometimes involves employing intuition or hunches. The more you know about a client, the greater the likelihood that your hunches will be correct. Therefore, helpers are encouraged to be patient, using invitational skills, paraphrasing, and reflecting feelings to help the meanings emerge.

In the last chapter, you learned to reflect feelings using this formula or algorithm: “You feel _____________ when _____________.” The first blank was to be filled in with the client’s emotion and the second with paraphrased content—for example, “You felt angry when you didn’t get the promotion.” To reflect meaning, we use the same formula, but in this case, we place an accurate reflection of feeling in the first blank and a reflec-tion of meaning in the second blank. In addition, we link them with the word because, as in the statement, “You feel disappointed in yourself because being a good daughter is an important value to you” (see Table 6.1).

Sometimes it may be necessary to include both a reflection of feeling and a short paraphrase of content in the first blank so that the client knows exactly which event you are referring to—for example, “You were excited (feeling) when you received your driver’s license (paraphrase) because it meant you were becoming an adult (meaning).” The word because shows the connection between the content and feelings of the story and their relationship to the underlying meaning for the client. In other words, it is quite possible, as one goes deeper into the story, to choose among reflecting meaning, reflect-ing feelings, and paraphrasing as needed. They can be delivered alone or in combination. How do you know when to use each one? The answer is that you try to reflect as deeply as you are able. If you can only grasp the feelings, then reflect those feelings and wait until you know more before playing a hunch about meaning.

TABLE 6.1 Formulas for Reflecting Feelings and Meaning

Reflection Formula Example

Feeling You felt _____ (emotion) when ________ (event or thought)

You felt frustrated when you couldn’t seem to make him understandOr,You felt disgusted when you thought about how much effort you had wasted

Meaning You felt ______ (emotion) because ______ (meaning)

You felt really angry with yourself because this was the way you were going to prove to your parents that you were a success

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EXAMPLES OF REFLECTED MEANING Here are some examples of reflections of meaning (ROMs). Assume that each reflection of meaning comes after a longer period of listening during a helping session.

Example 1:

cLiEnt: “I don’t know what to do now. Everything I worked for is going down the drain.”

HELpEr: “You must feel pretty lost (feeling) because the dream of having your own business was so important to you (meaning).”

Here the helper reflects the feeling of being lost. The helper then ties this feeling with the unique meaning that the client’s dream has died. Notice that the word because connects the feeling and meaning logically: The client feels lost because the dream was so important. The helper may only make a reflection like this when he or she has ade-quate knowledge of the client’s hopes and ambitions from previous statements.

Example 2:

cLiEnt: “My daughter isn’t living right. She stays out late, and now she’s moved in with that boy, and I don’t have the heart to tell anyone where she’s staying.”

HELpEr: “You are a bit ashamed (feeling) about your daughter’s living situation (paraphrase) because you think you have failed as a parent to convey your values (meaning).”

The helper reflects the client’s feeling of being ashamed and briefly paraphrases by mentioning her “daughter’s living situation” in a nonjudgmental way. Then the helper connects the feelings to the underlying meaning: The client feels that she has failed.

Example 3:

cLiEnt: “When my mom died, at first I was disoriented, like I was in a haze. Now, my high school graduation is coming up, and she won’t be there.”

HELpEr: “In a way, your feelings have changed from shock to sadness (feeling), and because she will not be there for graduation (paraphrase), it seems less special (meaning).”

Can you see that the helper took a risk and played a hunch? The helper intuitively grasped what the client might be feeling now and what it meant not to have her mother at this milestone event.

Reflecting meaning requires that the helper think intuitively, and it also means that the helper must fully comprehend the client’s distinctive situation and values. Although we can guess what meaning most people might derive from a situation to accurately reflect the meaning of an event, we frequently must have some understanding of its cultural context. The surest route to reflection of meaning is to patiently and persistently use the basic invita-tional and reflecting skills. Doing so provides the best atmosphere for clients to tell their stories. The more fully we understand the content and feelings, the easier it will be to reflect the underlying meaning. We must plod away at our reflecting until the lightbulb comes on and we see the meaning. The main difference between a beginner and an experienced helper is that the experienced helper knows the lightbulb will come on, which reduces anxiety considerably.

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QUICK TIPS: REVIEW OF REFLECTING FEELINGS AND MEANINGS• The formula for reflecting feelings is “You feel (specific emotion) when (the facts of

the situation that account for the emotion).”• For example, “You felt embarrassed when your teacher saw you get a free lunch.”• The formula for reflecting meanings is “You feel (specific emotion) because (the

personal meaning behind the situation that accounts for the feeling).”• For example, “You felt embarrassed because you don’t want to be singled out as

someone that needs help.”

MyCounselingLab Application Exercise 6.1 Practice in Reflecting Meaning

MyCounselingLab Video Exercise 6.1 Identifying Reflections of Meaning and Depth in Helper Statements

Using Open Questions to Uncover Meaning

Open questions focusing on meaning can be useful, especially when a client is not very forthcoming. Note that some instructors may want you to abandon questions for a while in order to strengthen your reflecting skills. In that case, instead of using questions to try to reveal meaning, rely on reflecting skills for the time being. If you want to practice using open questions to get at meaning, consider the following exchange between a cli-ent, Sonia, and a helper, Chris:

soniA: “There was a big family problem because I told them I couldn’t pick up my sister at the airport. Everyone in the family jumped on me. I guess I was wrong, but I was busy and no one seemed to understand. Now my mom is mad at me and so is my brother.”

cHris: “You feel confused about what happened.” (reflection of feeling)

soniA: “Yeah, and I am mad!”

cHris: “What is it about this situation that makes you so angry?” (open question focusing on meaning of the event)

soniA: “My time isn’t important. The family is important. My sister Camilla is important, but I am not important to my parents.”

In this interaction, Chris correctly reflected a feeling of confusion, but Sonia added that she also felt angry, letting Chris know that she had only understood part of her emo-tions. Getting at these feelings seemed to pave the way for the client to expose more about the deeper significance of the problem. Because Chris could not quite identify and reflect the meaning in the client’s statement, she used an open question to try to under-stand the deeper issue. The client responded by revealing the meaning of the event: She does not think her family cares about her needs.

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STOP AND REFLECT

The Ultimate Meanings Technique

Leontiev (2007) devised a creative technique for identifying the meaning. The ultimate meanings technique consists of writing down your answer to a question with the stem, “Why do people . . . ?” and then following up with more “why questions” to the answers. For example, “Why do people watch TV (smoke cigarettes, have a long-term relationship, buy a house, etc.)?” Here is an example using the question “Why do people travel?”

Answer: “To see new things.”

Question: “Why see new things?”

Answer: “Because you can see different ways of doing things.”

Question: “Why see other ways of doing things?”

Answer: “Because then you will be able to think of new ideas.”

Question: “Why think of new ideas?”

Answer: “So that you can create new products at work and get an edge on other people.”

This example is truncated but perhaps you can see that this person may value creativity, suc-cess at work, and competing with others. Of course, you would need a longer series of questions and different topics to get a clearer insight. But perhaps you can see that each person’s answers to the questions will be different and based on what he or she believes to be important.

If you would like to try the ultimate meanings technique for yourself, respond to the following question: “Why do people work?” Write down your answer. Then ask a series of “why questions” based on your answers. Try to put down 20 or so answers, and then look through your answers to see whether you can spot some key values and meanings for yourself.

SUMMARIZING

Summarizing is the final reflecting skill you will need to learn. Although it is easier to learn than reflecting meaning, we place it here because you cannot really use summarizing until you have paraphrased and reflected feelings and meanings in a client’s story. Summarizing pulls together everything a client has said in a brief synopsis of the session up to that point. The summary helps the client make some sense of the tangle of thoughts and feelings just expressed in the session. In other words, it serves a reflecting purpose, letting the client hear his or her viewpoint in a more organized way. The summary ties some of the major issues that have emerged into a compact version of the story. It may include any of the fol-lowing: (1) content, (2) major feelings, (3) meaning issues and themes, and (4) future plans. Of all the reflecting skills, it could be considered the broadest brush, bringing together main content, themes, and feelings in the client’s story by concisely recapping them. But sum-maries are not to be used only at the end of a session. Summaries may be used at all points—beginning, middle, and end. Because summaries have different purposes, they can be divided into four types: focusing, signal, thematic, and planning summaries.

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Focusing Summaries

At the beginning of a session, a summary may help to focus the conversation before it begins. A focusing summary is an intervention that brings the discussion to bear on the major issues and themes, places the spotlight on the client’s responsibility for the prob-lem, and reminds the client of the goals. For example:

“In the last few sessions, it seems like we have been dealing with two major issues. The first is the way that you are trying to renew your social network and find some supportive friends since your breakup with Jesse. The other issue is your mixed feelings about living back home with your parents.”

Focusing summaries are not only to remind clients about their goals from previous sessions. They can even be used at the first session with a new client. For example, a helper says:

“Let’s review what I know so far. Your mother called and made this appointment for you because you were arrested about a month ago for public intoxication. One of the conditions of your probation is that you receive help for your drinking problem. Your probation officer referred you to our agency. So you’re here to do something about the problems you’ve been having with alcohol. Is this about right?”

Brammer (1973) points out that a focusing summary at the beginning gets the client on track immediately. Contrast this with the traditional opening statements such as, “How have things been going this week?” or “What would you like to talk about today?” When a client begins the session by reacting to a focusing summary, he or she immediately begins talking about the key issues and goals.

Signal Summaries

In the middle of a session, the signal summary tells the client that the helper has digested what has been said and that the session can move on to the next topic. If the helper does not summarize occasionally, the client may feel that it is necessary to go over an issue several times until full understanding is communicated. A good time for a signal summary is when the client seems to have come to the end of a story and pauses. In the example that follows, see whether you can spot the paraphrases (Ps), reflections of feelings (ROFs), and reflections of meaning (ROMs) in this parent’s story.

cLiEnt: “So that’s about it . . . (pause).”

HELpEr: “Before we move on, let’s just summarize where we’ve been so far. You have tried to get professional help for your daughter’s drug problem, and she has rejected it. Because she is an adult, there is not much force you can apply. This makes you feel helpless, and when you see her, your relationship is very superficial because you can’t talk about the drug issue without getting into a fight. You’ve always been the kind of person who likes to leap into action when a problem arises, and here is a situa-tion where there is little to do. That’s what makes it especially frustrat-ing.” (summary)

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cLiEnt: “Yes, but that’s the way it is. Now I guess I need to talk about how I can go on with my life under these circumstances.”

HELpEr: “Okay, let’s talk about that.” (door opener)

Thematic Summaries

A theme is a pattern of content, feelings, or meanings that the client returns to again and again (Carkhuff, 1987). The thematic summary is an advanced reflecting skill because it means that the helper has to be able to make connections among the content, emotions, or meanings expressed in many client statements or even over many sessions. When this kind of reflection is made, it often provides new information to the client, who may be unaware that the issue is resurfacing so often. Sometimes these themes are referred to as “core issues” because they represent problems that appear in a variety of circumstances.

Rather than signaling a transition to a new topic, the thematic summary tends to push clients to an even deeper level of understanding or exploration. Here are some examples of thematic summaries:

• “There seem to be two issues that keep coming up. One of them is the anger you feel in a number of different close relationships, and the other is your sense that you haven’t been able to reach your potential in your career.”

• “As you have been talking, I seem to notice a pattern, and I’d like to check it out. You seem to want to end relationships when they begin to lose their initial excite-ment and romance.”

• “From everything we’ve talked about over these past few weeks, one major issue seems to be that, over and over again, you hesitate to make a commitment to a career or to a relationship or to take any important action because you are afraid you might let your parents down by failing. Is this right?”

It is difficult to practice using thematic summaries because it presumes that you have seen a client for some time and usually for more than one session. It takes time for important themes to emerge. Identification of themes is an intuitive process. The helper must think back on the whole of his or her experience with the client and try to cull the big issues. Even though identifying themes is an advanced skill, it is placed here because it is possible you may notice these themes as you practice. You may also have the oppor-tunity to see advanced practitioners identify these themes in recorded sessions. Remem-ber, too, that themes are the helper’s constructions or interpretations; they should be used only when you have enough information to be fairly certain that you have identified a theme. It is best to propose themes tentatively, because if incorrect, a thematic summary can have the effect of making the client feel analyzed.

Planning Summaries

Planning summaries entail a review of the progress, plans, and agreements made dur-ing the session. The planning summary brings a sense of closure and ends the session on a hopeful note. Here are two examples:

• “Well, it seems like we’ve identified several things in this first session that we want to pursue. First, you are unhappy with the way you tend to become overly depend-ent on your friends. You want to follow your own interests. In fact, you want to get

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to know yourself better. With this in mind, we thought about your entering a coun-seling group at the local mental health center. Besides that, you’d like to identify some goals for your career. That is something you and I can begin to work on right away. We’ll set up an assessment program and talk more about this over the next several weeks. How does all this sound?”

• “Let’s recap what we have talked about so far. On the one hand, you have accom-plished your financial goals, but you are far from satisfied with your relationships with friends and family. You have said that this is because you are not very assertive. It sounds as though this is the area we need to discuss in our next session. What do you think?”

THE NONJUDGMENTAL LISTENING CYCLE ENDS WITH SUMMARIZING

Summarizing is the final step in the nonjudgmental listening cycle (NLC), which was intro-duced in Chapter 4. The NLC is a framework for understanding the sequence of skills through a particular topic of discussion between client and helper. The listening cycle is composed of basic skills or building blocks that you have already learned. The topic being discussed is symbolized by a circle and a suggested order of skills is listed clockwise around the circle. Each skill is most frequently used at its assigned position on the circle, although it is impossible to expect that every session will follow the same sequence. The NLC provides the beginner with some ideas about when to use certain skills. Figure 6.3 shows this graphical representation of the complete nonjudgmental listening cycle.

Following is an abbreviated example of helper responses to client statements that represent a complete nonjudgmental listening cycle. Although the helper summarizes here, actually, it may take more than one such cycle before the helper is able to summa-rize. The session is condensed to illustrate the major components in sequence:

1. Open question: “Would you tell me more about the accident?”2. Minimal encouragers: “Okay,” “Uh-huh,” “Yes,” “Can you tell me more about

that?”3. Closed question (important facts): “How badly were you hurt?”

Open Question(start)

Reflection of Feeling

Summary

Reflection of Meaning

Reflection of Feeling

Minimal Encourager

Minimal Encourager

Door Opener

Paraphrase

FIGURE 6.3 A Complete Nonjudgmental Listening Cycle Moving from Open Question to Summary

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138 Chapter 6 • Advanced Reflecting Skills: Reflecting Meaning and Summarizing

4. Paraphrase: “So you had to be in the rehabilitation center for several weeks and you’re still unable to work.”

5. Reflection of feeling: “You’re embarrassed about what has happened and a little afraid that people blame you.”

6. Reflection of meaning: “You’ve always been proud of the work that you do. Now that you have been unemployed for several months, it is hard to feel good about yourself.”

7. Summary: “Though you’re recovering on a physical level, there are several issues that continue to worry you, including how you might perform at your job and how other people will see you.”

MyCounselingLab Video Exercise 6.2 The NLC and Using Summaries

What Happens after the Nonjudgmental Listening Cycle?

The nonjudgmental listening cycle never goes away; it is the default position of any helper when a new topic is introduced, when the client reports new information, or when the client experiences a crisis. Many helpers are anxious to learn the more advanced skills and chafe at the repetitive nature of practicing these building blocks. Earlier in the book we used a metaphor of learning a sport like basketball to illustrate the sequence of the NLC. Players at all levels drill on the basics of passing, shooting, and rebounding. When these skills become second nature, then more advanced plays can be constructed. Think about the real purpose of the building blocks. It is to establish a therapeutic relationship with the client, which is the most significant predictor of success. The building blocks provide a foundation for that relationship, and the relationship makes change possible.

A Questioning Cycle Typically Found Early in Training

Because it takes time and experience to gain expertise in using the building block skills, a questioning cycle is a blind alley that is almost inevitable in your early training. A questioning cycle is an unproductive spiral that occurs when the helper does not follow the NLC but automatically reverts to closed questions when there is a pause in the con-versation. In the questioning cycle shown in Figure 6.4, the helper starts well, using an open question, and is even able to paraphrase the content. But because the helper is unable to use reflecting skills yet, he or she relies on a closed question to keep things moving. The question focuses the client back on content, and the helper follows this with a series of questions or minimal encouragers because the client’s responses become briefer and briefer. After several such cycles, the helper is tempted to give advice because he or she has understood essential facts and expects that the client is simply in need of direction. In fact, because the helper is engaging the client’s intellect with questions, the discussion does not deepen and the helper is surprised to find that they have not even scratched the surface of the topic.

THE TRAP Closed questions will lead to short answers that do not allow you any breath-ing room to construct a paraphrase or reflection. The client answers back right away in short sentences. In the following example, the helper has fallen into a questioning spiral.

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Note the client does not stay on the topic because the helper’s questions do not respond to the client’s last statement.

HELpEr: “Tell me more about the accident.”

cLiEnt: “It was horrible—what can I say? It was a financial problem, I felt terrible for months, and there were the physical problems, too.”

HELpEr: “Can you tell me more about the wreck itself?”

cLiEnt: “I ran into another car, and that car hit some people on the sidewalk.”

HELpEr: “How badly were you hurt?”

cLiEnt: “I spent 2 weeks in the hospital with a broken femur and a broken ankle. I had to go to the rehab center for the month of May. I’m still using a cane to walk. I don’t know when I can go back to my job.”

HELpEr: “Do you think you are getting better?”

cLiEnt: “Yes, but I am in no hurry to face people. I am a little afraid to see everybody.”

HELpEr: “What is it like being out of work for so long?”

cLiEnt: “I am bored, and I focus a lot on the pain in my legs.”

HELpEr: “Are they giving you some medication for that?”

Can you see that the helper’s fifth question, “What is it like being out of work for so long?” is not responsive to the client’s last statement, “Yes, but I am in no hurry to face people. I am a little afraid to see everybody”? Here the helper has a golden opportunity to reflect the client’s feelings of fear and embarrassment. Instead, the helper falls back on questioning, taking the client to a more superficial level. When the helper is struggling to understand but cannot make a quick response, he or she is better off using a paraphrase or open question as a delaying tactic.

GETTING OUT OF THE TRAP One way of escaping from the questioning spiral is to respond to the client’s last statement directly, using a paraphrase or an open question. This will

Open Question(start)

Closed Question

Closed Question

Paraphrase

Minimal Encourager

Door Opener

Closed Question

FIGURE 6.4 A Questioning Cycle Typically Found Early in Training

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buy a little time as you search for a reflection of feeling or meaning. Here is an example of how responding to the client’s last statement using encouragers, paraphrase, reflecting feeling, reflecting meaning, and a summary—in that sequence—can deepen the client’s self-examination.

HELpEr: “How badly were you hurt?” (closed question)

cLiEnt: “I spent 2 weeks in the hospital with a broken femur and a broken ankle. I had to go to the rehab center for the month of May. I’m not walking yet without a cane. I don’t know when I can go back to my job.”

HELpEr: “So you had to be in the rehabilitation center for several weeks, and you’re still unable to work.” (paraphrase)

cLiEnt: “Yes, but I am in no hurry to face people. I am a little afraid to see everybody.”

HELpEr: “Go on.” (door opener)

cLiEnt: “Well, I don’t know what they are thinking.”

HELpEr: “Okay.” (minimal encourager)

cLiEnt: “I think that everyone blames me for what happened.”

HELpEr: “You’re worried that some of your friends will reject you because of the injuries to the other people.” (reflection of feeling and paraphrase)

cLiEnt: “I guess it is not rational.”

HELpEr: “When you think about it, it doesn’t seem sensible, but all the same, it worries you.” (paraphrase and reflection of feeling)

cLiEnt: “Sure. I guess I would feel even worse if my own friends blamed me.”

HELpEr: “So it sounds like sometimes you blame yourself for what has hap-pened.” (reflection of meaning)

cLiEnt: “Sometimes I think like that.”

HELpEr: “So, as I understand it, you are still recovering from your accident, and you are still a little unsure about how others will feel about the accident. More important, you feel guilty about what happened.” (summary)

Notice that in the helper’s third and fourth statements; she does not know how to respond and so uses an encourager to keep the client on track. This buys her time until the client makes the statement, “I think that everyone blames me for what happened.” Now the helper can respond with a reflection of feeling plus a paraphrase.

Summary

In previous chapters, we identified that the compo-nents of a client’s message include content, feelings, and meanings. Reflecting content and feelings are im-portant tools for communicating to a client that you understand the story, but for a client to deeply sense understanding from the helper, it is also vital to iden-tify and reflect the meanings behind the client’s

experiences. Reflecting meaning is the first building block skill described in this chapter on advanced re-flecting skills. Meanings consist of the worldview and values that arise from upbringing, culture, family, and life experiences. There are a number of ways to un-earth the important issues in the client’s story, includ-ing the ultimate meanings technique and asking open

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questions about values, but the main emphasis should be reflection of meaning. Reflections of meaning are helper responses that go beyond the superficial, get-ting at the implicit messages rather than the explicit ones. This means that the helper must use intuition to plumb the depths of what the client says, extrapolating the underlying meanings. When the facts, feelings, and meanings of a client’s story are reflected, he or she feels that the helper has understood at a very deep level.

Summarizing is the second building block skill described in this chapter. Summaries pull together the content, feelings, and meanings in a distilled form. Summaries serve four purposes: to focus the client on

the major issues, identify themes, signal a transition in the session, and provide a basis for planning the next steps. At this stage, try to use summaries when you are stumped during your practice sessions. This can get the session back on track. Summaries should consist of about two or three sentences that encapsulate what you have heard so far. Summarizing is the final step in the nonjudgmental listening cycle (NLC). Understand-ing the NLC can help new learners decide which skills to use at various points. By analyzing the NLC in tran-scripts or in classroom practice, a helper can determine whether he or she is responding to the client’s state-ments with deepening responses or is falling into the mistake of shifting topics by the overuse of questions.

GROUP EXERCISES

Exercise 1: Reflecting Meaning

Form groups of three with a client, helper, and observer. The client is to pick a topic that is likely to evoke some deeper meaning such as:

“My greatest ambition is . . .”“My biggest disappointment has been . . .”“Something I am not very proud of is . . .”“My ideas about divorce (or marriage) are . . .”“Something I would like to improve about myself is . . .”

The helper is to use encouragers and open ques-tions to keep things moving, but the main goal is to advance hunches about the personal meanings that lie behind the client’s disclosures. The helper should re-view the “Quick Tips: Reflecting Meaning” section that follows and make reflections of meaning in response to the client’s story.

As the helper reflects, the observer is to write down all helper responses on a sheet of paper. Later, the helper can record any useful feedback on this same sheet and take this record home for further examination (similar to Table 6.2). After 5 minutes or 10 attempts at reflection of meaning, the observer calls time. Together, look at the helper’s responses and see how many of them are accurate reflections of mean-ing. The client, in particular, should give the helper feedback on key meaning issues that were missed. Group members then change roles and continue until each person has had a chance to take the role of the helper.

QUICK TIPS: REFLECTING MEANINGIf you are having difficulty identifying the meaning behind the client’s story, consider these tips:• Use the following plan in your practice sessions:

Ask an open question to start, use minimal encouragers as you get the details, and then strive for reflection of feelings. Whenever possible, make a reflection of meaning.

• Ask yourself, “Why is this story important to the client?” “Why is he or she telling me this?” “What is it that bothers the client so much about the event?”

• Be patient! Wait until you have heard enough of the story to understand its importance, and then reflect meaning.

• Think about the client’s background, and then tie in what you know about his or her unique viewpoint from previous topics.

• Are you responding to the last thing the client said, or are you looking ahead to what you are going to say? Think about the client’s last statement. If you stay with the client’s statements, one by one, they will lead you to meaning.

• When you have established a good reflecting relationship, and the client knows you understand the situation, take a risk and play your best hunch about some deeper underlying meaning that the client has not yet disclosed.

Exercises

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Exercise 2: Using Summaries

Students form groups of five individuals with two vol-unteers playing client and helper. The helper tries to use opening, invitational, and reflecting skills but does not summarize. The topic is “a brief history of my fam-ily.” The other members of the group listen to the en-tire dialogue, and after 12 minutes, they each write down a summary of the client’s history. Group mem-bers read their summaries to the client, who evaluates them based on their thoroughness. Did they capture content, feelings, and meanings? Were the summaries distilled or were they too lengthy?

Exercise 3: How Deep Was Your Session?

Table 6.2 is the Depth Scale, a tool for judging the overall depth of your session. The concept of depth refers to the helper’s ability to enable the client to ex-plore new feelings, values, or meanings behind the story. Conduct a practice session with helper, client, and observer. The observer writes down each of the helper’s interventions as close to verbatim as possible.

After the session ends, the observer and the client consider the following questions and rate each helper

response: (1) Do the helper’s words lead the client to make a more superficial response, are they judgmental, do they change the subject, or do they merely fail to respond to the client? If so, place an upward pointing arrow c next to that line indicating that the response is more superficial. (2) If the response by the helper is supportive, is an open question, is a paraphrase, is an encourager, or basically keeps the conversation going, place a sideways pointing arrow S next to that line. (3) If the helper response reflects unacknowledged feel-ings or meanings or in any way moves the client deeper, place a downward pointing arrow T. Tally the num-ber of each kind of arrow. Although there is no ratio that differentiates a deep session from a superficial session, where do the majority of your responses fall? The depth of the session is likely related to how well the relation-ship has gelled and how much trust the client feels.

SMALL GROUP DISCUSSIONS

Discussion 1: Planning and Focusing Summaries

Look back in this chapter to the scenario of Joan and Lynn. After reading that dialogue again, write down a

TABLE 6.2 Depth Scale

Make additional copies of this sheet for practice sessions or use lined paper.

Helper’s words as close to verbatim as possible (13 possible answers) Depth

Example: You feel that by revealing his secret you were letting yourself down. c S TExample: So, it was an accident. c S TExample: I’m sure you didn’t mean to hurt his feelings. c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T_________________________________________________________________________________________ c S T

Tally:

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brief planning summary and share it with your class-mates in a small group. The planning summary could be at the end of the session, identifying next steps. Then, write down a focusing summary that you might use to begin the next session. Summaries should be about two or three sentences in length. They should contain a brief synopsis of the thoughts, feelings, and meanings expressed by the client. Use the following criteria to give each other feedback on the summaries:

• Was the summary no longer than two or three sentences?

• Did the summary essentially capture the major points?

• Did the summary include the key events, feel-ings, and meanings expressed?

• Is there a hopeful tone to the planning summary?

Discussion 2: Creating a Presenting Problem

For this discussion, form groups of four. Each mem-ber is to write down a three- or four-line statement that a fictitious client might give as a statement of a presenting problem. It should be written in the first person, as follows: “I am having trouble getting my children to mind me. That’s not all. I’ve been very de-pressed, and I’m not going to be able to pay my bills this month. I try as hard as I can. What am I supposed to do?” When writing the example, students should remember to include enough information so that a reflection of meaning is possible. The trainer or leader reads each one anonymously, and the training group takes turns giving a reflection of meaning using the formula “You feel _______ because _______.” A good response to the preceding problem might be, “You are feeling really discouraged because your best does not seem good enough.” The trainer or leader asks for feedback from the group concerning the accuracy of the reflection. Another option is to ask one participant to reflect the meaning using the formula and the next participant to rephrase it in more natural terms.

QUICK TIPS: SUMMARIZING• Use a summary when the client appears to

be stuck. This will tend to get things back on track.

• At the end of a summary, it is often useful to finish with a quick “checking question” such as, “Have I got that right?” or “Am I correct?”

• When you feel like asking a question, try summarizing to signal the client to move on to the next topic.

• Use a summary when the client is moving too quickly and you want to slow the session down.

• Try to finish every session with a planning summary.

WRITTEN EXERCISES

Exercise 1: Identifying Meanings

In this exercise, you are asked to separately identify only meanings in a client’s statement. Take into account that there may be more than one possible answer be-cause, in practice, inflection or word emphasis would certainly change the meaning of these statements.

1. “I am extremely depressed and have been for about 6 months. I am now taking medication, and things are a little better. But every day I go to the refrigerator and look in. I can’t decide what to eat. In the morning, I can’t decide what to wear. This isn’t me. If a friend calls on the phone, I am not sure what I will talk about, so I dread anyone call-ing. How long do you think this is going to last? Never has anything like this happened in my fam-ily. I feel so bad that my daughter has to come and take care of me. She has a life, too. I even feel like I am a burden to you.”

Client’s underlying meanings or hinted, unspoken assumptions (why is this important?):

___________________________________________

___________________________________________

Your reflection of meaning (content, feeling, meaning):

___________________________________________

___________________________________________

2. “I am a 31-year-old construction worker. Lately I’ve had thoughts of hitting my child, Barbie. She is the light of my life. But she doesn’t mind me. I have to yell and scream. My wife and I don’t seem to see eye to eye on how she should be raised. Maybe we don’t agree on a lot of things. When I tell my daughter something, my wife rolls her eyes and belittles me. So, of course, Barbie won’t do what I say. I tried to talk to my wife, but she won’t

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listen any better than my daughter does. Now, I was brought up with a belt. But only when I needed it. I don’t necessarily think she has to be spanked, but she needs to learn to mind. I am embarrassed when I have to take her to my mom’s house or anywhere else because she won’t listen.”

Client’s underlying meanings or hinted, unspoken assumptions:

___________________________________________

___________________________________________

Your reflection of meaning (content, feeling, meaning):

___________________________________________

___________________________________________

3. “My main problem is that I am overweight. I know that. And I want to lose weight. Look at the televi-sion and magazines. Everybody’s skinny! I guess I am supposed to go along with the crowd. But my husband doesn’t realize that I have tried everything. He never says it, but I know he doesn’t find me attractive anymore. But is a slim body all that is important? How about unconditional love? If I lost weight, what would I have to do next? Dress some particular way? He says he is concerned about my health, but do you believe that? Last week, my 7-year-old son and I went to the mall, and one of his classmates was there. In front of everyone, the other kid said to my son, ‘You have a big fat mom!’ Children can be so cruel. And his mother didn’t even correct him. Don’t you think she should have?”

Client’s underlying meanings or unspoken assumptions:

___________________________________________

___________________________________________

Your reflection of meaning (content, feeling, meaning):

___________________________________________

___________________________________________

Exercise 2: Constructing a Nonjudgmental Listening Cycle

After each client statement, there is space for you to write a specific response. Record your answer as if you

were actually talking to the client. Your final response will be a summary. After you have completed the as-signment, go back and look over your responses and indicate how they could be improved.

Background: Jennifer, age 15, a high school sophomore, has problems with motivation. She is about to fail her social studies class, requiring her to attend summer school. Her main goal is to pass social studies, and you have agreed to help.

Identify an open question or door opener to start the interview:

___________________________________________

___________________________________________

JEnniFEr: “You probably know I’m failing social studies. That’s all my mom talks about. I am not studying as hard as she wants me to. But I can’t sleep very well. So I sleep in class sometimes. It’s really boring and I’m not going to need social studies. I am going to be a flight attendant. I can’t wait until I get out of high school and can run my own life for a change.”

Your paraphrase:_________________________________________

_________________________________________

JEnniFEr: “It’s like this all the time, people tell-ing me what to do. I want to pass but I just can’t sleep. Maybe if every-body would leave me alone. My friends are having trouble with Mr. Robinson, the social studies teacher. Everyone in the class is probably failing.”

Your reflection of feeling:_________________________________________

_________________________________________

JEnniFEr: “Yeah, that’s how I feel. But why can’t I be treated like an adult? At home, my mom is always after me. She and my dad are divorced. When I go to his house, he doesn’t pressure me. He lets me do what I want. I would go and live with him

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but when I bring it up, he changes the subject. If they make me go to summer school, I will really be hard to live with. They have no idea.”

Your reflection of meaning (or part of the meaning):

_________________________________________

_________________________________________

JEnniFEr: “The main thing is I have got to pass this class ’cause I can’t handle the whole summer in school again. The summer is when you’re supposed to go to the mall and the beach. If they make me go to summer school, I’ll probably sleep in class.”

Your summary:_________________________________________

_________________________________________

_________________________________________

_________________________________________

SELF-ASSESSMENT

A Midcourse Checkup

You have now learned most of the building blocks skills presented in this book. Although you have prob-ably not mastered all of them, it is time for a brief review and checkup. Try to be as honest as possible. This will help you identify areas where more practice is needed. Review the feedback you have received dur-ing group exercises. Then take a look at the building blocks that follow and rate your current level of mas-tery for each skill.

1 = I understand the concept.

2 = I can identify it and give examples.

3 = I can do it occasionally.

4 = I can do it regularly.

_____ Eye contact_____ Body position_____ Attentive silence_____ Voice tone_____ Gestures and facial expressions_____ Door openers and minimal encouragers_____ Open and closed questions

_____ Paraphrasing_____ Reflecting feelings_____ Reflecting meaning_____ Summarizing

Examine the pattern of your responses. If you are like most beginners, your invitational skills are strong. You may also be doing fairly well with paraphrasing, but you may well be at level 2 or 3 on reflecting feel-ings, reflecting meanings, and summarizing.

HOMEWORK

Homework 1: First Transcript

Now that you have read about and practiced the build-ing blocks of the helping relationship, it is time to make a record of your present skill level by recording a longer session (20–30 minutes). The next task is to convert the recording to hard copy, that is, a transcript.

Your goal as a helper in this transcript is to dem-onstrate your ability to move from cycles of question-ing and paraphrasing to the use of the higher skills of reflecting feelings and meanings. Rather than asking questions, fall back on paraphrasing, encouragers, and even silence until you are able to make a reflection.

Step 1 With a partner from your training group, con-duct and record a session based on a concern that he or she is willing to discuss. Alterna-tively, your fellow student may role-play the problem of a friend or acquaintance or fabri-cate a problem he or she might someday encounter in real life.

Step 2 Choose the best 15 minutes of the video you made and transcribe every word of both cli-ent and helper using the format shown in Table 6.3. It is important that the client’s com-ments appear directly below your helping responses, so that the connection between the two can be examined. Be sure you have permission from your client to record.

Step 3 Listen to the recording or read the transcript and make comments, naming each of the skills that your response exemplifies. Some-times students describe their responses rather than categorizing them. It is important to identify the skills you are using to determine their frequency and appropriateness. Use only the names of the building blocks you have learned. The comments section is a place for

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you to reflect on your responses. Do not just note weaknesses; identify strengths as well. In the comments section, you may also wish to reflect on how you might improve.

Homework 2: Alternative to the Transcript—Making a Video

Make a video as described in Homework 1. Instead of making a full transcript of the video, watch it again and classify each of your skills as you watch. The process of identifying skills can be a form of practice. Get feed-back from fellow students and your instructor on your progress. Try not to be judgmental. One of the big-gest mistakes at this point is to notice only your weak-nesses. For example, many students see themselves on video and do not like what they see. They see mistakes in body position or facial expression. Rather than re-acting on a purely emotional basis, try to think about the following questions: “Did I help the client to go deeper into the problem?” “In the brief encounter, did we form the basis for a therapeutic relationship?” Build on your strengths before focusing too much on your weaknesses. Here are some questions to ask yourself:

• Was I able to get the client to open up?• Are any of my gestures distracting to the client?• Are my body position, facial expression, and

voice tone inviting?

• Do I allow silence sometimes to urge the client to open up?

• Do I appear relaxed?• Do I seem engaged with the client, or am I too

passive?• How many paraphrases and reflections of feel-

ing did I use?• Did I rely too much on questions?• Did I reflect soon enough?• Did I overuse minimal encouragers rather than

reflecting?• How many reflections of meaning was I able to

attempt?• Are my words responsive to the client’s last

statement or to my own thoughts?• What are my natural strengths as a helper?

JOURNAL STARTERS

Reread the “Stop and Reflect: Secrets” section in this chapter. Dostoyevsky says in Notes from the Under-ground that there are things that we are afraid to tell even to ourselves and that every decent person has several such secrets stored away. Can you mentally identify one of these issues for yourself? Write a para-graph about your secret as if you were telling it to a nonjudgmental listener. What reaction do you imagine? Do you think such confessions are helpful?

TABLE 6.3 Transcript Example

In your write-up, include a short description of the client and the nature of the issue to be discussed. Note that each helper and client response is numbered so that the instructor can refer to them.

Client and Helper Responses The Skill You Used Comments

H1: “What would you like to talk about today?”

Open question Looking at this now, it seems a little trite. I think I will try something else next time.

C1: “Well, I have been having a problem with a nosy neighbor.”

H2: “Really? Tell me more.” Minimal encourager and door opener

Seems appropriate at this stage.

C2: “Well, she comes over every day. I can’t get anything done. I need to work on the computer. I need to do some work around the house. But she won’t let me.”

I notice that the client is blaming the neighbor. She is not owning the problem. Maybe next time I will get the client to focus more on that.

H3: “She doesn’t have anything else to do?”

Closed question Whoops, I missed the boat. I think it might have been better to reflect the client’s frustration.

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147

When Should We Use the Challenging Skills?

Giving Feedback• Why Is Feedback Important?• How to Give Feedback

Confrontation• What Is a Discrepancy? • Why Should Discrepancies Be

Confronted? • Cognitive Dissonance and Confrontation:

Why Confrontation Works• Types of Discrepancies and Some

Examples• How to Confront• Steps to Confrontation• Common Problems in Confrontation and

Their Antidotes• Final Cautions about Confrontation

Other Ways of Challenging• Relationship Immediacy• Teaching the Client Self-Confrontation• Challenging Irrational Beliefs• Humor as Challenge

Summary

Exercises• Group Exercises• Small Group Discussions• Written Exercises• Self-Assessment• Homework• Journal Starters

LEARNING OUTCOMES

By the end of this chapter, you will be able to:

7.1 Respond to client statements with a confrontation that highlights the discrepancies in the story.

7.2 Identify inconsistencies in a client’s story.7.3 Recognize confrontations in the context of a helping session.7.4 Evaluate confrontations using the Helper Competency Scale.

In his book Vital Lies, Simple Truths, Daniel Goleman (1998) relates the following story told by a woman at a dinner party:

I am very close to my family. They were always very demon-strative and loving. When I disagreed with my mother, she threw whatever was nearest at hand at me. Once it happened to be a knife and I needed ten stitches in my leg. A few years

Challenging Skills

C H A P T E R 7

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later, my father tried to choke me when I began dating a boy he didn’t like. They really are very concerned about me. (pp. 16–17)

Goleman claims this tale is a good example of how people deceive themselves. Because the client cannot face the fact that she was the victim of child abuse, she changes the story to its exact opposite, one of caring and concern. If a helper points out this inconsistency, he or she is using a challenging skill. Another way of looking at challeng-ing skills is that clients have multiple voices or stories that need to be told. By challeng-ing, the helper is asking whether the client is not paying attention to some aspect of the story. In the preceding excerpt, the client perceived her parents as caring, but she also must have been aware of the other voices saying their behavior was abusive. It is a human tendency to block out these voices and smooth over the competing ideas. Life is simpler that way. The helper awakens the client to unrecognized or purposely ignored aspects of the story through the use of challenging skills. Challenging skills are reflections that identify the conflict in the story. Helpers have a duty to point out discrepancies and not merely accept what is on the surface of the client’s story. The client has found a ref-uge, and the helper’s revelations kill off protective fantasies, potentially arousing resent-ment and discomfort. Sometimes it becomes necessary for helpers to “dare” clients to examine the inconsistencies in their stories by giving them feedback and, at other times, by confronting discrepancies.

Making clients aware of uncomfortable information motivates them to act to make changes in their circumstances. For most helpers, this step in the journey is a giant one. Whereas the invitational and reflecting skills are supportive and convince a client to open up, these two challenging skills, feedback and confrontation, push the client to critically examine his or her choices, feelings, and thoughts. When the helper uses challenging skills, he or she is giving the client an honest reaction or pointing out warring factions in the client’s story and encouraging action. Invitational and reflecting skills do not necessar-ily encourage the client to dig deeper or follow through with plans and commitments, but challenging skills do. Although there is an element of pushing on the part of the helper, it must be seasoned with a liberal amount of support.

Consider Figure 7.1, which depicts the relationship between support and challenge. Depending on the mixture you use, the client will see you as someone who is critical, as someone who is apathetic, as a helper person, or as a friend. The ideas behind Figure 7.1 are based on research in organizational settings that have identified managerial styles (Hersey, Blanchard, & Johnson, 2007). Supervisors in business situations can be roughly described as supportive or nonsupportive and challenging or not challenging. It appears that good managers find ways to balance pushing and supporting. Similarly, in the help-ing professions, much of what we do can be described as a combination of challenge and support (Keen, 1976) or “joining” and “kicking” (Minuchin, 1974).

The ratio of challenge to support has an effect on the client’s willingness to explore his or her own thoughts, feelings, motives, and actions. This ratio also affects the cli-ent’s willingness to trust the helper and to discuss either deeper or more superficial topics. On the bottom half of the chart in Figure 7.1, you can see that when a helper does not use enough challenging, the client does not engage in very much self- examination; yet when the helper is highly challenging, the client’s trust in the helper is reduced. When challenge is high, the helper is bringing up topics and inconsisten-cies that may be painful for the client, and this strains their relationship. On the

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Chapter 7 • Challenging Skills 149

left-hand side of the figure, it also becomes clear that without support, the client does not engage in self-examination, nor does the client wish to discuss deeper issues because the trust level is so low. Figure 7.1 suggests that the worst conditions for help-ing are high-challenge, low-trust situations. When there is high support and low chal-lenge (befriending), the client is probably encouraged to maintain his or her current behavior. It is high-support conditions along with moderate levels of challenge that lead to the best conditions for change.

WHEN SHOULD WE USE THE CHALLENGING SKILLS?

During the initial stages of the relationship, the helper strives to understand the client’s unique worldview by getting the client to open up. As a client tells the story, the helper listens attentively using the nonjudgmental listening cycle (NLC). After several cycles, the helper begins to detect distortions, blind spots, and inconsistencies. He or she may then use challenging skills to help clients function with more accurate information about them-selves. With heightened self-awareness, they are better able to make decisions and to operate free of illusions and “vital lies.” Challenging is consistent with the primary goal of helping: to empower clients by encouraging them to explore their thoughts, feelings, and behaviors and to take steps toward their dreams and goals.

When challenging skills are used, the aura of safety and support, so carefully con-structed by the helper, is at risk. There is a fundamental shift from relationship building to a focus on the goals set by the client and helper, conveying to the client that the help-ing relationship is not a friendship but a business partnership during which the helper

Low Challenge

Ignoring Befriending

LowSupport

HighSupport

Criticizing

High Challenge ModerateChallengeand HighSupport

Helping

FIGURE 7.1 Balancing Challenge and Support

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may have to hold the client’s feet to the fire in order to attain the agreed-upon outcomes. Clients need to be challenged when:

• They are operating on misinformation about the self. For example, a client may underestimate her intelligence, feeling that she is not capable of attending college when there is evidence to the contrary.

• They are operating with mistaken ideas and irrational beliefs. For example, the cli-ent believes she must be perfect.

• They misinterpret the actions of others. This tendency is called mind reading and is a common problem among couples. A client may act on assumptions without con-firming them, making statements such as the following: “I could tell by the way he acted that he did not want to date me anymore.”

• They are blaming others rather than examining themselves. For example, a client may blame the boss at work but refuse to look at his own responsibility for the poor relationship or his own work performance.

• Their behavior, thoughts, feelings, and values are inconsistent. For example, a client talks about how much she values honesty but, at the same time, discusses how she hides her financial difficulties from her husband.

• They are not operating according to their own values.• They are not working on the goals that they participated in setting.

In this chapter, we will focus on two building blocks, or basic skills, used to chal-lenge clients and help them deal with problems more consciously. The first of these is giving feedback: providing information and your honest reaction to the client. The skill of giving effective feedback is one that has wide application in helping, including group work, couples counseling, and individual and family therapy. Second, we tackle the skill of confrontation, the challenging skill that is the art of pointing out inconsistencies and blind spots in the client’s story.

GIVING FEEDBACK

Why Is Feedback Important?

Disclosing oneself to others and receiving feedback from others are the twin processes of promoting personal growth. The invitational, reflecting, and advanced reflecting skills that you have already learned are the primary methods helpers use to encourage client self-disclosure. We have discussed how the mere act of confiding in another person seems to have many health benefits (Pennebaker, 1990, 2004), and the ability to be “transparent” to others has also been linked with mental health (Jourard, 1971). Learning to receive feedback is the other key to self-awareness and growth. Clients need accurate feedback in order to confront inconsistencies in their own attitudes and to know how they are affecting others. Most problems that people face are “people problems.” People usually come for help when they experience pain in their interper-sonal worlds. Unfortunately, we often receive conflicting messages about ourselves from other people because even family members and close friends may be afraid to give us honest feedback. Many of the terrible singers on talent shows have been encouraged by their closest friends and family members to participate. Our significant others may withhold feedback because they do not wish to jeopardize the relationship.

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Rosen and Tesser (1970) call this unwillingness to transmit bad news the “mum” effect. Thus, we are often operating with incorrect or inadequate information. On the other hand, the helper has both the opportunity and the responsibility to deliver honest feedback even if it is uncomfortable to do and for the client to receive. Irvin Yalom (2000) compares the responsibility to give accurate feedback to the job of an execu-tioner because it is the helper’s duty to point out the holes and flaws in, and some-times to kill, the client’s most romantic ideas. Therefore, it is critical to deliver feedback in ways that benefit the client.

How to Give Feedback

In the helping relationship, giving feedback means supplying information to a client about what you see, feel, or suspect about him or her. Feedback helps people grow when they are receiving constructive, specific information about themselves. When a pro-fessional helper gives feedback, the sole purpose is to help the client. Feedback from a professional—unlike that from family and friends—does not take into consideration the needs of the helper or concern itself with whether or not this will produce a strain on the relationship. Helpers only give feedback when clients ask for it or when clients need information to progress. They give feedback for three purposes:

1. To indicate how the client’s behavior affects the helper

Example: “You say you want to be assertive, but I experience your behavior as pas-sive when you look away and avoid eye contact.”

2. To evaluate a client’s progress toward the goals

Example: “As I see it, you have now been successful in overcoming your anxiety by facing the situations you have been avoiding.”

3. To supply a client with information based on the helper’s observation

Example: “I notice that you never seem to talk about your father.”

Feedback may be rejected by clients because “the truth hurts,” because it is incor-rect in the client’s eyes, or because it is too harsh. Therefore, helpers endeavor to present feedback in ways that will make it more palatable. Here are some suggestions about how to give effective feedback in a way that others may accept. These are also good rules for trainees, who may be giving feedback to each other in group exercises.

1. Use I-messages.

In his classic book about raising children, PET: Parent Effectiveness Training (1975, 2000), Thomas Gordon described the process of delivering feedback as “I-mes-sages.” Most feedback statements delivered by helpers are I-messages because using the word I conveys that the helper is expressing his or her own perspective. When a person starts a conversation by saying, in effect, “This is my viewpoint,” we are more likely to listen nondefensively. For example, consider the following pieces of feedback:

“I am uncomfortable when you talk that way about women.”

“I am hurt that you did not seem to acknowledge my birthday.”

“I notice that you don’t seem to have any friends.”

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2. Do not give people feedback on their personality traits or something they cannot change.

It is hard to see how one can change one’s character and so such general remarks are easy to reject.

Poor feedback (boss to subordinate): “You are a procrastinator.”

Good feedback: “For the past 3 months, your report has been late.”3. Be specific, concrete, and nonjudgmental.

Poor feedback: “You’re bugging me.”

Good feedback: “I find it annoying when you whistle during my favorite music.” (I-message with specific content)

4. Always ask permission before giving feedback.

For example: “You say that people at work are angry about your behavior. Would you like some feedback?”

Or, “I would like to give you some feedback on something I have noticed. Is that all right?”

5. Sometimes feedback about touchy subjects is accepted more easily if it is offered tentatively.

You do not have to dilute the feedback; rather, find an acceptable route to get the client to think about what is being reported.

Poor feedback: “You are avoiding that issue with your father.”

Good feedback: “I got the impression last time that talking about your father was difficult for you and you seemed to steer away from that topic. Maybe it is because you think you deserted him when he was ill. Am I right about this?”

6. Give only one or two pieces of feedback at a time.

When too much feedback is given, client defenses rear up like impenetrable walls.

Poor feedback: “I think you should improve your appearance at work. You look disheveled, and you need to wear a more formal shirt. By the way, you left the copy machine on again last night, and you forgot to call Dodie back.”

Good feedback: “I think you should improve your appearance at work. For exam-ple, your pants are wrinkled, and a T-shirt really is not appropriate.”

7. Do not forget to give feedback that emphasizes the client’s strengths.

It is easy to assume that clients are aware of their strengths and that we should focus only on their foibles. Identifying strengths is part of “positive psychology” and focusing on positive character traits engenders hope (Lopez & Kerr, 2006; Ward & Reuter, 2011). We tend to give more feedback to uncover unknown weaknesses rather than to point out assets. More often, clients need to know what is going right, what is working, and what resources the client has to bring to the problem (see Wong’s [2006] strength-centered therapy and Ward & Reuter’s [2011] strength- centered counseling). Try focusing on the positive aspects first and bringing up the negatives later.

Poor feedback: “You asked someone out for a date, but you did not work on the other part of the assignment, where you were to confront your friend about her behavior. Let’s talk about that.” (only mentioning the negative)

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Good feedback: “Based on what you’ve said today, I’m picking up that you have made real progress. Even though it was a little scary, you asked two people for a date and one of them said yes.”

8. Use a follow-up question to determine whether the feedback was received and how it was accepted.

Helper: “A minute ago, I pointed out that you have spent the last few weeks talking only about your ex-husband. What is your reaction to that feedback?”

STOP AND REFLECT

There is a parallel in our own optic system that can demonstrate the existence of blind spots or holes in our view of the world, at least from a physiological viewpoint. You may know that the optic nerve attaches to the back of the eyeball. Where it connects, there is a small gap in the picture your brain sees. Because we have two eyes, the other eye takes over and corrects for this tiny blind spot and we never know that it exists. Take a look at the X and the large dot shown in Figure 7.2. Now hold this book with your right hand and stretch it out to arm’s length. Stare directly at the X on the left side of the page. Close your left eye and slowly move the book straight toward your face. At about 12 inches, the dot on the right side disappears.

The physical blind spot is only an analogy of the psychological phenomenon. Still, it alerts us to the fact that our knowledge about the world and ourselves is not complete. Because we are unaware of these hidden parts of ourselves, it takes some convincing before we believe what is revealed. Con-sider the following questions:

• In this experiment, you learned about your blind spot through actual experience. Suppose I had merely told you about the blind spot? Which information is the most powerful in convincing you of its existence?

• How can we help clients have experiences of their psychological blind spots rather than merely telling them?

• Suppose you gave the client some feedback that you were 98% sure was true and accurate, and the client’s response was to dismiss it completely. How do you think you might react? How could you get the client to consider it further without damaging the relationship?

• Suppose that a client feels rejected in her personal relationships. In her interactions with you and with other personnel, you notice that she talks constantly, rarely allowing anyone else to control the conversation. First, write down a nonjudgmental feedback statement exactly as you would deliver it. Next, identify one or two other situations where the client might get this kind of feedback. What assignments might you give the client to make her more aware of this tendency?

FIGURE 7.2 Blind Spot

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CONFRONTATION

Confrontation is the second challenging skill we will address in this chapter. Confronta-tions point out discrepancies in client beliefs, behaviors, words, or nonverbal messages. As a result of confrontation, client awareness of inconsistencies is stimulated, and the cli-ent is motivated to resolve them. In essence, it is an educational process that brings infor-mation to the client’s attention that has been previously unknown, disregarded, or repressed. The most powerful confrontation urges the client to resolve the inconsisten-cies. Confrontation creates emotional arousal and can lead clients to develop important insights and motivate them to change their behavior.

What Is a Discrepancy?

A discrepancy is an inconsistency, a mixed message, or a conflict among a client’s thoughts, feelings, and behaviors. In fact, every problem contains discrepancies. For example:

• A client says that she wants an equal, sharing relationship, but she only dates dom-ineering men.

• A client says that she loves her job, but she complains about it constantly.• A client states that he wants to improve his marriage, but he forgets to go to mar-

riage counseling sessions.• A client is intelligent and tenacious but is convinced he will not do well in school.

Why Should Discrepancies Be Confronted?

Ivey and Simek-Downing (1980) say that “the resolution or synthesis of incongruities may be said to be a central goal of all theoretical orientations” (p. 177). In fact, most well-known therapeutic systems use confrontation to some degree. The Gestalt thera-pist Fritz Perls confronted clients about incongruities in their nonverbal and verbal behavior (which he labeled “phony”). Albert Ellis, the founder of rational emotive behavior therapy, liked showing clients the gap between their beliefs and rationality by directly exposing them to the “nuttiness” of their ideas. Albert Ellis used loud voice tones or even curse words to intensify confrontations. Some early group therapy meth-ods for treating substance abuse (the Synanon approach, Straight Inc.) used personal attacks and abusive confrontation to create client movement in dealing with deeply ingrained behavior patterns. However, there is little evidence to support the use of such strong confrontation. In fact, it appears that, even with substance abusers, a con-sistent highly confrontational therapist style is not as effective as a moderately con-frontational one (see Figure 7.1 and Miller, Benefield, & Tonigan, 1993). This information has added support to a theoretical approach called motivational interview-ing (MI), which has been successfully practiced and researched in addictions pro-grams. In MI, helpers are careful to acknowledge the client’s point of view while pointing out the conflict. They use confrontations but qualify them as “double-sided reflections.” For example:

Client: “Everybody wants me to stop drinking. But I am not going to give up going with my friends for a beer or two. There is nothing wrong with that.”

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Helper: (Referring to things the client has said in the past) “Although you often talk about the many problems that alcohol has caused in your life, you just can’t see quitting and distancing yourself from your drinking friends.”

In this double-sided reflection, the helper acknowledges the client’s statement that he wants to continue to drink for social reasons and at the same time does not pull any punches by reminding the client of the problems alcohol has caused him. The helper’s agreeing with part of the client’s statement softens the blow of the confrontation, making it moderately challenging. To use anything stronger could create a rupture in the helper/client relationship, which is the very thing that keeps the client in treatment and engaged with the helper.

In this chapter, we urge you to consider how to raise inconsistencies in a client’s mind without alienating him or her. Confrontation is an advanced reflecting skill that should be developed after the early helping building blocks of invitational and reflect-ing skills have been firmly established. Research confirms that highly trained (doc-toral) counselors used confrontation more often than students (Tracey, Hays, Malone, & Herman, 1988). At the same time, doctoral-level counselors demonstrated less dom-inance and verbosity than student helpers. It appears, then, that as helpers gain expe-rience, they use confrontation more frequently, talk less, and are less pushy as they provide support.

Cognitive Dissonance and Confrontation: Why Confrontation Works

Do you remember the concept of cognitive dissonance from your first Introduction to Psychology class? Cognitive dissonance theory states that we are motivated to keep cognitions such as values, beliefs, and attitudes consistent (Festinger, 1957). When people experience inconsistencies in their thoughts, feelings, and behaviors, this cre-ates tension, and they are motivated to reduce the tension. As a consequence, we can either convince ourselves that the incongruity is unimportant or else change one of the incompatible elements. Let us take the example of quitting smoking. Smokers are aware of the health risks but also continue smoking. The conflict between smoking behavior and putting oneself at risk creates cognitive dissonance. Smokers may reduce the dissonance in a number of ways: to either ignore or misinterpret the facts about health risks or else tell themselves that they are “addicted” and therefore quit-ting is not under their control (self-handicapping strategy; Jenks, 1992). Either way, smokers are pushing the risks out of awareness. One study of college students who smoked asked them to view an online program about the effects of smoking ( Simmons, Heckman, Fink, Small, & Brandon, 2013). They were then asked to make a video recording of their own negative experiences with smoking and then they watched their recording. The researchers found that the students whose awareness of the risks had been heightened were more motivated and had higher rates of smoking cessation than those in comparable treatments. Heightening of awareness led to motivation.

Consider also the case of Donna, a 25-year-old woman who describes her job as good-paying but also as repetitive and boring. She needs the job to help her mother,

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who is struggling to survive on Social Security. Donna wants to go to college because she is not intellectually challenged in her present position, but the costs are too great. This creates dissonance. She deals with the tension caused by these conflicting thoughts by telling others and herself that education and intellectual challenge are not really important. We all use such defense mechanisms to distort reality so that we can reduce anxiety. In this case, the distortion masks the fact that Donna does really want to go to college and the lack of intellectual stimulation does bother her. For her, going to college may not be possible but pretending that her desire does not exist is creating a giant “blind spot” in her life. Many times, clients use defense mechanisms to escape disso-nance, rather than making choices based on thinking and planning. When helpers con-front people with these discrepancies, anxiety often resurfaces but so does awareness of choices. Donna may realize that there may be nontraditional and incremental ways of taking classes she has not considered, but first she must be confronted with her ten-dency to push the inconsistency out of awareness.

Kiesler and Pallak (1976) reviewed dissonance studies and found a link between dissonance and physiological arousal (Cooper, Zanna, & Taves, 1978; Croyle & Cooper, 1983; Pittman, 1975; Zanna & Cooper, 1974). It seems that clients actually change their attitudes in order to reduce the arousal caused when the helper makes the client aware of the two incompatible elements. The confrontation causes anxiety because the client then becomes aware of this split, which is normally kept out of awareness by his or her defenses. The client’s frozen position has provided some security, but now the client is acutely aware of both sides of the conflict again and becomes moti-vated to change (Elliott & Devine, 1994). In the case of Donna, the helper might encourage Donna to become more aware of her need to be intellectually stimulated and ask her to talk about it, explore it, and even investigate options to use her mind. Without blind spots and defense mechanisms, it is possible to make decisions that are more reality-based and personally satisfying (Claiborn, 1982; Olson & Claiborn, 1990).

Although we may use confrontation to bring buried elements into consciousness, we must remember that clients do not really like it because it produces negative emo-tions (Harmon-Jones, 2000; Hill et al., 1988). If the helper’s confrontation is too power-ful and the client’s emotional arousal is too great, the client not only will reject the message but also may be less willing to explore feelings and to trust the helper (Hill et al., 1988). Thus, therapists tend to use confrontations sparingly because doing so is strong medicine; and they should combine it with a liberal helping of support, or else they risk causing a rupture in the relationship (Barkham & Shapiro, 1986; Norcross, 2011; Strong & Zeman, 2010).

Types of Discrepancies and Some Examples

There are five elements of a client’s story that can come into conflict: the client’s worldview or beliefs, the client’s previous experiences, the client’s verbal messages, the client’s nonverbal messages, and the client’s behavior. It is not important to memo-rize each of the types of possible discrepancies. The examples that follow are simply meant to help sensitize you to the fact that discrepancies in a client’s story can take many forms.

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Incongruity between Verbal and Nonverbal Messages

Client: “It’s been hell. This whole thing. It’s almost funny [laughs]. You know. Sometimes he loves me, sometimes he hates me.”

Helper: “Your laughing and smiling make me think the problem is not serious, and yet I can tell by what you’ve said that it has been very painful for you.” (confrontation)

Incongruity between Beliefs and Experiences

Client: “I do the best I can. And I am a hard worker. But I am not as smart as my classmates. They are really smart. That bothers me. I am almost finished with my degree but I didn’t sail through like they did.”

Helper: “Okay, I am confused. You say you are not smart enough and yet you are almost finished with your degree.” (confrontation)

Incongruity between Values and How the Client Behaves

Client: “My son is the most important thing in the world to me. But I just don’t have time to see him every week. I need some recreation, too. If I want to get ahead at work, I have to put in the hours.”

Helper: “If I understand you, you say that your relationship with your son means a lot to you, but somehow you’ve let other things get in the way.” (con-frontation)

Incongruity between What the Client Says and How the Client Behaves

Client: “I’ve been going to Cocaine Anonymous as I said I would. But it’s not really helping. Every time I see one of my old friends, I’m back into it again.”

Helper: “I’m confused. You say that you want to give up cocaine, and yet you continue to see your old drug friends.” (confrontation)

Incongruity between Experiences and Plans

Client: “Sure, my girlfriend and I have been having a lot of problems lately. But if we moved in together, I think things would improve.”

Helper: “From what you told me before, isn’t one of the problems that when-ever you spend any length of time together, you fight even more? Yet, you are thinking that being together full time will make things better.” (confrontation or “double-sided reflection”)

Incongruity between Two Verbal Messages

Client: “My wife makes twice as much money as I do. It doesn’t bother me. But I always feel that she looks down on me because of it. I should be making a lot more than I do. I often think about starting a new career.”

Helper: “Okay, on the one hand, you say that it doesn’t bother you, and yet you also say that you feel inadequate in her eyes and talk about a career change!” (confrontation)

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ETHICAL ALERT

In our discussion of confrontation, some guidelines were given for its most effective use. But a few of these issues point to ethical issues as well. The codes of ethics do not specifically identify confronta-tion, but there are guidelines for use of emotionally arousing techniques and the training you should receive before using them. Consider the following:

1. It is unethical according to the codes of helping professionals to use a technique that you are unfamiliar with unless you are under the supervision of someone who is adept in its use. Strong confrontation, being a potent method, is a technique that should be discussed with a supervisor before it is applied.

2. Most ethical codes point to considering the cultural, religious, and spiritual background of a client before applying a technique such as confrontation. Confrontation is an excellent exam-ple of a technique with important cultural and developmental implications. For example, Lazarus (1982) discusses how this technique backfired with some Native American children in a school counseling setting. Others have recommended a gentle approach in using confronta-tion with African American and Asian American clients (Ivey, 1994). Schectman and Yanov (2001) found that confrontation was not effective with children in groups in Israel.

3. Using confrontation as a way to vent your frustration would not be ethical. Helpers may feel frustrated when the client is not progressing quickly enough, but the needs of the clients must take precedence over those of the helpers.

For more information, consult the following codes of ethics on association websites:

American Counseling Association’s 2014 Code of Ethicshttp://www.counseling.org/knowledge-center/ethics

American Psychological Association’s Ethical Principles of Psychologists and Code of Conducthttp://www.apa.org/ethics/code/index.aspx

National Association of Social Workershttp://www.socialworkers.org/pubs/code/default.asp

American Association for Marriage and Family Therapyhttps://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/code_of_ethics.aspx

National Organization for Human Services (NOHS)http://www.nationalhumanservices.org/index.php

How to Confront

The helper’s confrontational statement is a reflection that usually uses the following for-mula: “You (think, value, believe, say, experience, plan, behave, or show nonverbally) _____ but you also (think, value, believe, say, experience, plan, behave, or show nonver-bally) ________.”

“You said _____, but your nonverbals said _____.” (verbal versus nonverbal)

Example: “You said you were happy, but I don’t see that in your face.”

“You believe _____, but you possess _____.” (negative beliefs about oneself versus strengths)

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Example: “You say that you believe you aren’t very strong or tough, but the tenacity I saw when you dealt with the Veterans Administration does not seem to fit with that belief.”

“You value _____, but you act _____.” (values versus actions)

Example: “You obviously value your family, but you spend nearly 60 hours at work each week.”

“You said _____, but you acted _____.” (verbal versus actions)

Example: “You said you were excited about coming to counseling, but you haven’t been making your appointments.”

“You plan to do _____, but your past experiences tell you _____.” (plans or beliefs versus past experiences)

Example: “You plan to try to become more socially active, but there is a part of you that says you’ll be rejected like before.”

“You say _____, but you also say _____.” (verbal versus verbal)

Example: “Sometimes you say you are happy with your job, and other times you threaten to quit.”

As you begin to identify discrepancies and present them to a client, you might find it helpful to memorize the following phrase: “On the one hand, _____; on the other hand, _____.” This formula allows you to plug in any two discrepant elements without having to name which elements are in conflict (verbal vs. nonverbal, values vs. actions, verbal vs. actions, etc.). Although you do not wish to overuse this statement with clients, this formula will help remind you to look for the conflicting aspects of a client’s story. In Table 7.1, each of the major building blocks is described along with its purpose, when to use it, and a suggested formula. This chart may help remind you of the formulas that you have learned. It also shows how confrontation follows the relationship-building invitational, opening, reflecting, and advanced reflecting skills.

MyCounselingLab Application Exercise 7.1 Practice in Identifying Discrepancies

MyCounselingLab Video Exercise 7.1 When Worlds Collide

Steps to Confrontation

Step 1 First, take time to understand the issue and listen carefully, making sure the rela-tionship is well established before confronting. Move through the NLC to fully understand the client’s message and reflect feelings and meaning. Ask yourself whether the timing is right or whether a confrontation will prematurely place stress on the relationship. In other words, have you earned the right to confront (Egan, 1977)?

Step 2 Present the confrontation in a way that the client will most likely accept it. In other words, make your confrontations moderately challenging. The following

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example shows a helper using open questioning and reflection of feeling to gen-tly usher in confrontation and reduce the negative impact.

Jyoti (Helper): “You say that this hasn’t been a good school year for you and you are thinking about dropping your Advanced Placement class.” (paraphrase)

olivier (Client): “Yeah, it’s not going too well.”

Jyoti: “Well, if I understand it right, you’re discouraged because you are getting a ‘B.’” (reflection of feeling)

olivier: “Yeah, obviously I am not going to make it.”

Jyoti: “Okay, I’m confused. On the one hand you say it’s been a terrible year but at the same time a lot of good things have happened this year. We’ve talked about the fact that you’ve become more organized and gotten along better with your teachers. You’re doing better than passing in your AP class but you don’t want to recognize that.” (confrontation of cli-ent’s negative view of self and strengths)

olivier: “I guess so. But I still have a long way to go.”

Jyoti: “Sounds like it’s hard for you to pay attention to the strengths you have and the gains you’ve made this year. In a way, you seem to prefer to focus on what you’re not

TABLE 7.1 Building Block Skills, Formulas, and Timing

Building Block What It Reflects When to Use It Formula

Paraphrase (P) Most important events and thoughts

When you are trying to understand what is happening or what the client is thinking

None

Reflection of Feeling (ROF) Client feelings As soon as you sense the emotions behind the content

You feel ___ when ______.

Reflection of Meaning (ROM)

The meaning When you have understood the content, the feelings, and the meaning

You feel ____ because _____.

Confrontation (CON) Discrepancies in the story When the relationship is strong enough

On the one hand, you (think, value, believe, say, experience, plan, behave, or show nonverbally) _____, but on the other hand, you (think, value, believe, say, experience, plan, behave, or show nonverbally) _______.

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achieving.” (confrontation of client’s avoidance of strengths and focus on weakness)

olivier: “I’m afraid I would slack off if I patted myself on the back all the time.”

Step 3 Observe the client’s response to the confrontation. In this case, the client does not fully accept Jyoti’s first confrontation. The helper notes this and repeats her confrontation in a slightly different way.

Step 4 Follow up the confrontation by rephrasing or retreating. When the client does not accept or rejects the confrontation outright, the helper should try another tack. Because clients often respond to confrontation either by denial or by super-ficial agreement, the helper must be ready to follow up with additional explora-tion, another confrontation, or clarification. Jyoti’s second confrontation seems to be more acceptable to the client. He gains some insight into his situation.

MyCounselingLab Application Exercise 7.2 Practice Using the Helper Competency Scale (HCS) to Evaluate Confrontations

Common Problems in Confrontation and Their Antidotes

A good confrontation is one that the client responds to thoughtfully and that furthers the dialogue between helper and client (Strong & Zeman, 2010). If you want to see the effec-tiveness of your confrontation, examine the client’s response in a transcript. Did it push the client to examine the deeper issue? Unfortunately, many confrontations “bounce off” because the client is not ready to look at the discrepancy or because the confrontation either is worded too strongly or is too vague. In short, the aim of the confrontation is to examine both sides of the client’s view of the problem. That is what deepens the conver-sation. Here are three common problems in confrontation as well as some suggested ways of dealing with them (antidotes).

RESPONDING WHEN THE CLIENT DENIES THE TRUTH OF THE CONFRONTATION OR SHRUGS

IT OFF

Antidote: Follow up on the confrontation. For example:

Client: “When I first met my co-worker, Michele, I was excited about her because she seemed so nice but I soon caught on that she was just a fake. I guess I just can’t stand that in a person. She talks about me behind my back and although I never say anything, it makes me mad. But there are some other people in the office that agree with me and so I have support.”

Helper: “So you don’t like the fact that she talks about you behind your back but you can’t seem to be honest with her either.”

Client: “Yes, but she doesn’t listen to what anyone says and besides she has applied for a transfer and maybe that will solve the problem.”

Helper: (Following up) “What I said before was that on the one hand you can’t stand people who are not honest and I was wondering if you are little bit scared of broaching that issue.”

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RESPONDING WHEN THE CLIENT ACCEPTS ONE PART OF THE CONFRONTATION WHILE

REJECTING ANOTHER PART

Antidote: Having the client disagree with some of the confrontation but accept part of it can clarify this issue and lead to further dialogue. At such times, the helper is encour-aged to focus the discussion on the areas of agreement and press for a resolution of the conflict. The following is based on our previous example in which a helper confronted a client (1) who stated that he wanted to give up cocaine and (2) who continued to as-sociate with his old, drug-using friends. The dialogue shows how the client partially accepts the confrontation, and the client and counselor then begin a deeper dialogue.

Client: “I’ve been going to Cocaine Anonymous as I said I would. But it’s not really helping. Every time I see one of my old friends, I’m back into it again.”

Helper: “I’m confused. You say that you want to give up cocaine, and yet you continue to see your old drug friends.” (confrontation)

Client: “I do want to stop using. But what am I supposed to do? Stay by myself all the time? That I am not willing to do.”

Helper: “So on the one hand you know that your friends are the greatest risk fac-tor for using again but on the other hand the idea of being alone is scary. Do you think it’s possible to have friends and be sober?” (asking client to resolve the dilemma)

THE CLIENT APPEARS TO FULLY ACCEPT THE CONFRONTATION. NOW WHAT? When the client accepts the confrontation, another problem can arise. What do you do next? Sometimes the helper freezes because he or she is momentarily caught off guard by the client’s acceptance.

Antidote: The answer to this problem is to encourage the client to engage in some activity that helps resolve the two sides of the problem: something that reinforces the acceptance the client has identified. In the following example, the helper sug-gests that the client get ideas from fellow support group members.

Client: “I don’t know. I guess recovering addicts have new friends that don’t use. But how you do that?”

Helper: “I’m not an expert on this. But some people who have been off cocaine for a while must be familiar with this problem. It seems like it might be fairly common. Between now and when we next meet, would you be willing to think about this? Go to your next Cocaine Anonymous meeting and ask one or two people about this. Then let me know what they have to say.”

Client: “All right. And I’ll talk to my friend Michelle. She’s been sober for a year now.”

Final Cautions about Confrontation

One writer called confrontations the “thermonuclear weapons” of helping. They are pow-erful, and their force can help or harm. Confrontation may arouse negative emotions and the defenses of the client or damage self-esteem, rather than increase awareness and

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motivate action. Although the force of the confrontation should not be watered down with qualifiers, confrontation must be presented in a way that does not shame the client by saying “Gotcha!” We are aiming to deliver moderately confrontational statements with the client’s best interests at heart.

Earlier, we mentioned that the timing of the confrontation could be important. Tim-ing means knowing when confrontation will do the most good. Obviously, the time for confrontation is when the client/helper relationship is well established and the client trusts the helper’s motives. In general, strong challenges should not be made until the NLC has been firmly established. It has been my experience that frequent and premature confrontations based on very little information tend to erode the credibility of the helper and thereby damage the relationship.

MyCounselingLab Video Exercise 7.2 Regrets

OTHER WAYS OF CHALLENGING

Besides pointing out discrepancies using confrontation, there are other methods for getting clients to pay attention to discrepant, irrational, or troubling issues and focusing the conver-sation in that direction. Among these are relationship immediacy, teaching the client self-confrontation, challenging irrational beliefs, and using humor. These are more advanced skills but we mention them here because you will likely run into them early in your training through films or reading. We hope that you will mentally note that they fall in the category of challenging skills and that supervision is necessary as you learn to use them.

Relationship Immediacy

When you meet someone for the first time, think about what issues are the most difficult to discuss. It is easier to talk about past problems and previous relationships rather than present issues and relationships. It is easier to discuss issues that are positive and uplifting rather than those that are negative or depressing. It is also easier to talk about issues that concern neither of us, such as the weather, rather than talking about what is going on between us right now. By the same token, it is sometimes difficult for the helper to bring up issues affecting the helper or the relationship between helper and client. However, the ability to give honest feedback and discuss the helper/client relationship openly gives it a special meaning that separates it from other social interactions. The relationship can be a laboratory where the client can learn about his or her effect on others. Relationship immediacy (Kiesler, 1988) is a technique that helpers use to give clients here-and-now feedback about their effect on another person—the helper.

Relationship immediacy is a comment by the helper about what is happening in the relationship right now. Immediacy statements by the helper should have three characteristics:

1. The helper uses the word I in the statement to indicate that this is the helper’s per-spective.

2. The helper describes the client’s behavior or the helping relationship issue in non-judgmental terms.

3. The helper expresses his or her feelings in a way that does not overload or burden the client.

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164 Chapter 7 • Challenging Skills

These three characteristics are illustrated in the following helper statement: (1) “I am aware that (2) when I make a suggestion, such as the one just presented, we seem to end up in a struggle and the issue gets dropped. (3) I am a little concerned about this.”

Helpers use relationship immediacy because the client’s interactions with the helper are probably similar to the client’s interactions with significant others. For example, a cli-ent might talk incessantly, not leaving room for the helper to respond. Using an immedi-acy challenge, the helper might say, “You tell me that other people say you don’t listen to you. As I am sitting here, I don’t feel listened to either. Can we talk about that?” In this vein, Murray (1986) cites the example of a young woman who came to therapy because she felt she was overly dependent on her father. For example, whenever she had car trouble, she turned it over to him. After a month of therapy, she brought in her auto insurance policy, which she was having trouble deciphering, and handed it to the thera-pist who began reading it. After a moment, the therapist laughed and exclaimed, “Look, I’m behaving just like your father.”

Relationship immediacy is “you-me” talk. It challenges the client to focus on the helper’s impressions of the therapeutic relationship. Relationship immediacy can enhance intimacy in a relationship because it acknowledges the mutual bond and gives the client liberty to also look at his or her feelings toward the helper. It is one of the best ways of dealing with so-called resistance and transference reactions. Relationship immediacy is also an invitation to examine the client/helper relationship conflict as a microcosm of the client’s difficulties. It can be used to address or prevent ruptures by asking the client to honestly assess the quality of the therapeutic bond. It should only be used if it seems that the relationship issues between client and helper relate to the client’s goals or if the therapeutic relationship is strained and needs to be repaired. Relationship immediacy can be of the “here-and-now” variety such as, “Right now, I feel a lot of tension between us because we brought up the alcohol issue. What is your reading on that?” Alternatively, the helper can ask the client to reflect on the relationship as it has progressed up to that point. For example, “Over the past few weeks, I have found that our relationship seems to have changed. My experience is that the sessions are much more fun and productive. What do you think?”

Teaching the Client Self-Confrontation

Although it is good to have the input of others, it may be more useful to have the client learn to self-confront, a skill that could provide lasting benefit when the helping relation-ship is over. Self-confrontation has been studied as a complex assessment and research tool (Hermans, Fiddelaers, de Groot, & Nauta, 1990; Lyddon, Yowell, & Hermans, 2006). But the method can be applied more simply as a research project that the client conducts on himself or herself with the assistance of a helper. One way to do self-confrontation is for the client to write down everything that he or she considers to be a conflict in life. For example, “I am in love with this woman, but she has made it clear I am only a friend,” or “My parents want me to get better grades, but I really don’t want to go to college.” If given as a writing assignment, the client might be asked to respond to questions such as:

“What is it that I don’t really want to do?”

“What would it say about me if I changed in the ways people want me to?”

“In what ways am I lying to myself?”

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Chapter 7 • Challenging Skills 165

“What possibilities in my life am I not paying attention to?”

“What conclusions am I drawing about life that have no evidence to support them?”

The helper then guides the discussion of these issues in the past, present, and future and helps the client explore the issues collaboratively. Together client and helper try to identify key themes in the client’s life that come from this discussion. Finally, client and helper identify a plan to solve the dilemmas.

Challenging Irrational Beliefs

Some cognitive therapists challenge clients’ strongly held beliefs when these beliefs are responsible for clients’ emotional suffering. Challenging beliefs involves making the client aware of their irrational nature and teaching them to dispute these disturbing thoughts when they arise. Thus, although the helper highlights the irrational ideas in session, dis-puting and replacing irrational thoughts is ultimately a form of self-confrontation. The client learns to confront his or her erroneous beliefs. Following is a short list of irrational beliefs adapted from Ellis and Velten (1992). Ellis has longer lists of common irrational beliefs, but this will give you a feel for the general categories.

1. Shoulding and musting: “I must be the best in my class.” “I should have learned this by now.”

More rational challenge: “Have you ever tried saying, ‘I would like to be the best in my class’ without laying a ‘must’ or ‘should’ on yourself? I think it is those words that cause you to feel so upset when you can’t reach perfection.”

2. Awfulizing: “When I don’t get it right the first time, it is a tragedy, a catastrophe, and it is awful.”

More rational challenge: “Isn’t it more accurate to say that it’s unpleasant, but not the end of the world?”

3. Low frustration tolerance (“I can’t control myself”): “I can’t stop myself from calling my ex-girlfriend.” “I can’t wait to buy things when they are on sale, and I get myself into big credit card debt.”

More rational challenge: “So, it’s uncomfortable for you to wait, right? But is it really true that waiting is impossible or is it just annoying?”

4. Blaming: “No one even tried to help me. It’s their fault that I wasn’t able to register for classes, not mine. This is the worst school.”

More rational challenge: “I wonder about this idea that it is the responsibility of other people to get you registered and help you when you didn’t even request assistance.”

5. Overgeneralizing—“always” or “never” attitudes: “I went to one AA meeting and all they did was drink coffee and smoke cigarettes. The organization is crazy. No one gets helped there.”

More rational challenge: “I’d like to take issue with this idea that attending one AA meeting gives you enough information to make this blanket statement. Isn’t it pos-sible that there were some positive aspects of the meeting? Tell me why you think you must look at this in black and white. Is it really true that you get nothing from a meeting like this?”

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You can probably see how confronting a person’s beliefs can feel like a very strong intervention. It takes a great deal of skill to challenge a client’s beliefs in a way that does not alienate him or her personally. The goal is for both client and helper to gang up on the irrational beliefs while maintaining a good working relationship.

Humor as Challenge

Humor can be one way of relating to clients and teaching them to view situations in a dif-ferent way. It can possibly be a needless distraction. But humor can also be a way of mak-ing a confrontation, especially through exaggeration. Both stories and humor seem to bypass the client’s defenses. Clients tend to accept humorous stories because they are not seen as preachy or mean. Once, a client told me about her fears that, as a divorced woman, everyone would be looking at her and treating her differently. I responded by agreeing that although she lived in a city of one million people, that, at first, rumors would be spreading like wildfire. There would be newspaper headlines and, of course, television news. I reas-sured her that after the requests from talk shows were rebuffed, she would be able to resume her private life once again. She laughed with me and admitted that her fears were overblown as usual. I was able to get away with this because I knew the client well, and she did not perceive me as laughing at her. That is, of course, the primary precaution of using humor as confrontation. It could belittle the client or convey that you think his or her concerns are unimportant. Again, there is no substitute for knowing your client and having the kind of relationship where you can talk about ruptures when they occur.

The following is a story by Cindy Yee Fong about how she was brought up and how her family and cultural values helped her become a nonjudgmental listener and also presented a challenge when she was forced to confront her clients.

Respect is a core value in Chinese culture. “Respect your parents and do as they say.” “Respect your teachers and don’t question or challenge them.” “Respect your family and don’t discuss concerns or problems outside the family circle.” “Respect your elders and don’t talk back to them.” These were the values and expectations instilled in me by my parents, especially my mother. She was born in China and believed strongly in these rules.

When I first began working as a counselor, my job was to facilitate a group for court-ordered drunk drivers, one of the most angry and difficult client populations. You can imagine the challenges I had to face. For someone who is assertive, open, and willing to confront oth-ers, regardless of age or status, this would be a difficult job. For someone like me who was taught to listen, not interrupt, and agree with others, especially older people and those in higher positions, it was a daunting task.

Frequently, there were older clients in the group who tended to “ramble on” in their dis-cussions. Interrupting them, in Chinese eyes, would have been very disrespectful. When doctors, lawyers, and teachers were in the group and expressed opinions contrary to my curriculum, it was nearly impossible for me, at first, to disagree with them. It has taken quite a while for me to over-come this reluctance to be what my culture would consider “disrespectful” and to develop the necessary skills as a counselor to be assertive in confronting others. This is still an area I am trying to improve. My cultural style of passive acceptance has helped me develop unconditional accept-ance regardless of differences. This has facilitated my developing rapport with clients and getting to the point in a relationship where they can accept confrontation. Chinese cultural values and beliefs have been both helpful and challenging to me as an emerging helper.

CULTURE CHECK

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Chapter 7 • Challenging Skills 167

• Cindy Yee Fong indicates that respect is one of the core values in Chinese culture. Thinking back on your own upbringing, what cultural or family values would you describe as “core”?

• What were your family’s values about contradicting others, keeping the peace, and disclos-ing weaknesses? Was family business to be kept within the family? Do you think any of your own core values may have an effect on your willingness either to talk with clients about their deepest issues or to confront certain individuals?

• One of the most common difficulties for most of us is overcoming the “mum” effect, the social rule that says to keep feedback to yourself. As a helper, your contract with the client implies that you will give honest feedback despite your personal discomfort. Think about some specific situations that will create discomfort for you such as refusing an expensive gift from a client, informing a client that his or her personal hygiene is poor, dealing with tardiness, talking about sexual problems, discussing whether the client is having an affair, or asking whether the client is being honest with you. Which do you think will be the most difficult for you? How might you increase your comfort with these topics?

• Would you find it more difficult to confront someone of a different ethnic or racial back-ground, someone older or younger than you, someone who has a high-status profession, or someone of the same or opposite sex? How do you plan to overcome these limitations? Discuss with a small group some strategies for overcoming some of these roadblocks to feedback and confrontation.

SummaryMuch of the material in previous chapters has been devoted to learning how to use the nonjudgmental listening cycle and adopting the attitudes that create an accepting environment in which the client’s story can come out. However, the story also has inconsist-encies and conflicts, or else the client would not be seeking help. The problems the client is experiencing may be due to incompatible ideas and motivations. Inconsistencies are at the root of client problems be-cause they are blind spots, thoughts and feelings that they have pushed down. The helper brings these to the surface by using challenging skills and tries to make the client more aware of the discrepancies be-tween his or her values, actions, and words. Paradoxically, this places a strain on the therapeutic relationship because the client becomes uncomforta-ble, blames the helper for entering unsafe territory, and may feel that the helper has abandoned his or her supporting role.

There are two main ways that a helper can facilitate growth with challenging skills. First, the helper can provide the client with information through feedback. Feedback is data the helper pro-vides honestly to the client to help the client. An example of feedback is making the client aware of a

recurring tendency to give up before achieving a goal. In this chapter, we gave some guidelines for good feedback that included being specific, using I-messages, and asking for permission before giving feedback.

Compared with feedback, confrontation is a serious challenge to the client’s version of the story, and the client feels a strong push from the helper. Confrontation involves identifying discrepant ele-ments in the client’s story and asking the client to resolve them. The helper can use confrontation as a reflection of the underlying conflicts or use other methods to challenge the client, including humor and identifying irrational beliefs. Confrontation is an art because one must point out these discrepancies clearly, yet kindly and with respect for the client’s worldview. Moderately challenging confrontations are less likely to rupture the relationship. One reason that so much time has been spent on confrontation is that it is the stuff of therapeutic legends. Videos of famous therapists show them making startling con-frontations. The beginning helper is advised to use confrontation sparingly and softly, when the helper really knows the client, and only when the relation-ship is firmly established.

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168 Chapter 7 • Challenging Skills

Exercises

GROUP EXERCISES

Exercise 1: Feedback—The Fishbowl Activity

This exercise works best with groups of eight to ten people. Four or five people sit in chairs facing each other to form an inner circle. The same number of participants forms an outer circle. Each member of the outer circle is paired with an inner-circle member. The outer-circle members sit behind the inner circle and across from the members they are paired with so they can observe them (see Figure 7.3). For 10– 15 min-utes, the inner-circle members engage in a leaderless discussion on a topic such as “What are the most impor-tant personal characteristics of a helper?” or “What do you see yourself doing, personally and professionally, 5 years from now?” Members need not take turns but just hold an open discussion.

During the discussion, outer-circle members are instructed to carefully observe nonverbals and listen to the words of their counterparts in the inner group. At the end of the discussion, the groups break down into dyads of the inner-circle members and their outer-circle partners. Outer-circle members give feedback to inner-circle members about interpersonal style.

Interpersonal style means the verbal and non-verbal ways that a person communicates and includes the amount of time the person talks and how much he or she discloses. In this situation was the person open, warm, quiet, talkative? The outer-circle members of-fer their counterparts feedback using the “Quick Tips: Giving Feedback” section. Feedback should take about 5 minutes. Finally, inner-circle members identify, for their partners, any feedback that was especially accurate or helpful. If time permits, the exercise can be repeated

x = inner circleo = outer circleArrows show partners

o

x

o

x

x

o

x

o

FIGURE 7.3 Fishbowl Activity Diagram

with inner- and outer-circle members changing places. Following the feedback in dyads, a class discussion can be held in which members compare their experiences of giving and receiving feedback. Which role was more difficult, being the giver or receiver of feedback? Were you surprised by the accuracy of the feedback on your interpersonal style?

QUICK TIPS: GIVING FEEDBACK• Use I-messages.• Do not give people feedback on their

personality traits or something they cannot change.

• Be specific, concrete, and nonjudgmental.• Ask permission before giving feedback.• Sometimes feedback about touchy subjects is

accepted more easily if it is offered tentatively.

• Give only one or two pieces of feedback at a time.

• Give feedback that also emphasizes the client’s strengths, not just his or her weaknesses.

• Use a follow-up question to determine whether feedback was received and how it was accepted.

Exercise 2: Confrontation

Break into groups of three trainees, who will assume the roles of helper, client, and observer. As the exercise continues, each member should have the opportunity to assume each of the three roles.

The Client’s Role

Discuss a problem that is causing an internal conflict or moral dilemma. The problem might be the result of:

• Conflict about a job or whether to relocate• Conflict about whether or not to be honest in a

relationship; for example, whether to tell a friend she depends on you too much

• Conflict about something you have done that you do not feel good about, that you regret, or that you wish you could change

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Chapter 7 • Challenging Skills 169

The Helper’s Role

Review the “Quick Tips: Confrontation” section. Use the NLC to get the basics of the client’s story. Do not spend too much time on setting up the relationship. Although this is critical in real helping situations, in this exercise the main purpose is to practice identify-ing discrepancies and delivering them to a client. As soon as possible, identify discrepancies by pointing them out, and then encourage the client to resolve the inconsistencies.

QUICK TIPS: CONFRONTATION• Wait until you have heard the client’s whole

story before you identify discrepancies. What seems to be a discrepancy may be a minor point once you know more about the situation.

• If you are having trouble identifying discrepancies, remember that there would not be a problem if there were no discrepancy. Ask yourself, “What makes this a dilemma?” or, “What are the two sides to the client’s problem that make this situation so bothersome?” Use the formula “On the one hand, ______; on the other hand, ______.”

• Note the impact of your confrontation on the client. Does he or she deny, partially accept, or fully accept your identification of the discrepancy? Follow up denial and partial acceptance with invitational and reflecting skills to help resolve the dilemma.

• After you have identified a discrepancy, try using a question such as, “Am I on target?” Often the client will correct you and clarify the discrepancy.

The Observer’s Role

Write down verbatim the helper’s responses and then evaluate the helper on his or her ability to use confron-tation. Code the helper’s responses using P for para-phrase, ROF for reflection of feelings, ROM for reflec-tion of meaning, OQ for open question, CQ for closed question, and CON for confrontation. Do not include encouragers.

Feedback Checklist: Confrontation

Observer Name: _____ Helper Name: _____

Helper Statement Coding

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4.

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Postexercise Discussion

The observer shares feedback with the helper, based on the Feedback Checklist. The client gives feedback to the helper concerning the effectiveness of the confrontations and the degree of discomfort they caused. For example, were the confrontations presented as observations rather than accusations? Were they presented nonjudgmentally? Helper and observer can also attempt to recall the client’s reac-tion to the confrontation and see whether the dos-age was too strong or too weak for the client to accept.

SMALL GROUP DISCUSSIONS

Discussion 1: Collaborating to Identify Effective Confrontations

In groups of four, one member (the client) describes a problem situation to the group (choose from the suggestions described in Group Exercise 2). After the client has spent a few minutes describing the situ-ation, each remaining member writes down a con-frontation and delivers it verbally to the client. The client responds to each confrontation in turn. Follow-ing the client’s responses, the group discusses which

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170 Chapter 7 • Challenging Skills

confrontations seem to be the most effective and ac-ceptable to the client. After this discussion, members trade roles and continue until each has had a turn as client.

WRITTEN EXERCISES

Exercise 1: Identifying Discrepancies

Following are five client situations. Try to identify the discrepancy in each, using the formula “On the one hand, _____; on the other hand, _____.” In some of these situations, the conflict is implied rather than actually stated. Imagine what conflicts you might be experiencing if you were in that situation. When you have written your answers, meet with a small group and discuss them. Looking at both the clients and the issues, which would be most difficult for you to actu-ally confront?

1. An 18-year-old client describes how sad she is that she has to leave her parents and go off to college. She smiles as she talks about this.

2. The client is very religious and is very judgmen-tal about nonbelievers. At age 22, he has only a few friends and has never had a long-standing romantic relationship. He comes for help because he has become “addicted” to Internet pornography.

3. The client says that he loves his sister and that she is very important to him. During their last encoun-ter, she “exploded” because he did not attend her wedding.

4. The client states that she has just been offered a job as a manager at a new company. The com-pany is very excited about hiring her because of her years of experience. She has worked at her current company on weekends and during the summer since she was 17. She says that she feels the owner relies on her, but her pay and responsibilities there are unlikely to improve. She feels that she has made as much advance-ment as she can and would like a new challenge.

5. The client is a 17-year-old high school student in an alternative school. She has worked hard and improved her poor grades to Bs and Cs. She failed her high school equivalency examination by 1 point. She is discouraged and has decided to drop out of school. She plans to continue working at her job, even though her boss has indicated she must have a high school diploma.

SELF-ASSESSMENT

Using the HCSInstructions: By this point in the book, you should have a recording or transcript of a helper/client session lasting at least 20 minutes. Evaluate your session using the Helper Competency Scale below. First, go through and count the number of open questions (OQ), closed questions (CQ), reflections of feelings (ROF), reflections of meaning (ROM), summaries (SUM), and confrontations (CON) you used. These are the most important building block skills. It is important to get a picture of your present skill level so you can see areas that need improvement and present strengths. A score of 3 or less on any skill suggests that you need to iden-tify the problem you are having and then practice until you reach competency (a score of 4 or better).

Helper Competency Scale (HCS)

Scale Evaluation Guidelines:

• Exceeds Expectations/Demonstrates Compe-tencies (5) = the helper or trainee demonstrates strong (i.e., exceeding the expectations of a beginning professional helper) specified helping skills in this category.

• Meets Expectations/Demonstrates Competen-cies (4) = the helper or trainee demonstrates consistent and proficient ability in the speci-fied helping skill(s).

• Near Expectations/Developing toward Compe-tencies (3) = the helper or trainee demonstrates inconsistent and limited knowledge, skills, and dispositions in the specified helping skill(s), abil-ity to facilitate therapeutic conditions, and profes-sional disposition(s) and behavior(s).

• Below Expectations/Insufficient/Unacceptable (2) = the helper or trainee demonstrates an excess or deficit in the use of the specified helping skill(s).

• Harmful (1) = the helper or trainee demon-strates harmful use of the specified skill(s) because the skill is performed in a way that harms the therapeutic relationship, fails to invite or encourage the client’s disclosure, or focuses the client away from his or her goals.

Directions: Evaluate the helper or trainee’s helping skills, based on rubric descriptions, and record rating in the “score” column on the left. In a 20- to 30-minute session, the helper should be able to demonstrate most of the following building blocks.

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tions

are

use

d o

nly

w

hen

nee

ded

.

Dem

onst

rate

s in

consi

sten

cy

in u

sing o

pen

-en

ded

ques

tions

and m

ay u

se

close

d q

ues

tions

for

pro

longed

per

iods.

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s open

-en

ded

ques

tions

spar

ingly

. U

ses

most

ly c

lose

d

ques

tions.

M

ay a

sk t

wo

ques

tions

at

once

.

Rel

ies

on q

ues

tions

as t

he

prim

ary

inte

rven

tion.

Help

er

Co

mp

ete

ncy

Sca

le (

HC

S)

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172

Sco

reB

uild

ing

Blo

ck

Help

ing

Skill(

s)Sp

eci

fic

Help

ing

Skills

an

d D

esc

rip

tors

Exce

ed

s Exp

ect

ati

on

s/

Dem

on

stra

tes

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mp

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nci

es

(5

)

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Exp

ect

ati

on

s/

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on

stra

tes

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mp

ete

nci

es

(4)

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Exp

ect

ati

on

s/

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pin

g

tow

ard

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om

pete

nci

es

(3)

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w

Exp

ect

ati

on

s/In

suff

icie

nt/

Un

acc

ep

tab

le

(2)

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ful

(1)

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ect

ing

P

arap

hra

sin

gB

asi

c re

flect

ion

o

f co

nte

nt—

p

ara

ph

rasi

ng

Dem

onst

rate

s ap

pro

priat

e use

of

par

aphra

sing

as a

prim

ary

way

of

reac

ting

to c

lient

story

. In

ters

per

sed w

ith

oth

er in

vita

tional

, open

ing, an

d

reflec

ting s

kills

.

Use

s par

aphra

se

consi

sten

tly

to r

efle

ct t

he

import

ant

aspec

ts o

f th

e cl

ient’

s st

ory

in a

dis

tille

d f

ashio

n.

Para

phra

ses

are

brief

and

inac

cura

te.

More

par

aphra

ses

are

nee

ded

. Th

e hel

per

is

inco

nsi

sten

t in

par

aphra

sing.

Para

phra

ses

are

inac

cura

te

and r

arel

y use

d. Fo

cus

is

freq

uen

tly

on

oth

er p

eople

.

Para

phra

ses

are

judgm

enta

l or

abse

nt.

Pa

raphra

ses

may

hav

e th

e w

rong

focu

s.

Refl

ect

ing

R

efle

ctio

n o

f Fe

elin

gs

Refl

ect

ion

of

feelin

gs

Ref

lect

ions

of

feel

ing a

re r

egula

r,

accu

rate

, an

d

freq

uen

tly

incl

ude

a par

aphra

se.

Ref

lect

ions

of

feel

ing a

re

regula

r an

d

accu

rate

.

Hel

per

rar

ely

reflec

ts f

eelin

g.

Acc

ura

cy o

f re

flec

tions

is

inco

nsi

sten

t w

ith s

om

e ac

cura

te a

nd

som

e not.

Feel

ings

are

rare

ly r

efle

cted

an

d a

re e

ither

gen

eral

ly

inac

cura

te o

r to

o g

ener

al; i.e

.,

sad, upse

t, o

r under

shooting o

r ove

rshooting.

Abse

nce

of

reflec

tion o

f fe

elin

gs

or

are

inac

cura

te.

Ad

van

ced

R

efl

ect

ing

M

ean

ing

Ad

van

ced

refl

ect

ion

o

f m

ean

ing

in

clu

din

g

valu

es

an

d c

ore

b

eliefs

(ta

kin

g

help

ing

to

a d

eep

er

level)

Acc

ura

tely

ref

lect

s m

eanin

g s

ever

al

tim

es d

uring t

he

sess

ion. C

onsi

sten

tly

urg

ing t

he

clie

nt

to

des

crib

e “w

hy”

the

issu

e is

import

ant

to

him

or

her

.

Acc

ura

tely

re

flec

ts m

eanin

g

at le

ast

once

during t

he

sess

ion.

Unab

le t

o

reflec

t m

eanin

g

during t

he

sess

ion.

But

utiliz

es

ques

tions

to g

et

at m

eanin

g.

Does

not

move

th

e cl

ient

dee

per

by

reflec

ting

on v

alues

, co

re

bel

iefs

.

Ref

lect

ion o

f m

eanin

g a

nd

dee

per

ques

tions

abse

nt.

Help

er

Co

mp

ete

ncy

Sca

le (

HC

S)

(Co

nti

nu

ed

)

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173

Sco

reB

uild

ing

Blo

ck

Help

ing

Skill(

s)Sp

eci

fic

Help

ing

Skills

an

d D

esc

rip

tors

Exce

ed

s Exp

ect

ati

on

s/

Dem

on

stra

tes

Co

mp

ete

nci

es

(5

)

Meets

Exp

ect

ati

on

s/

Dem

on

stra

tes

Co

mp

ete

nci

es

(4)

Near

Exp

ect

ati

on

s/

Develo

pin

g

tow

ard

C

om

pete

nci

es

(3)

Belo

w

Exp

ect

ati

on

s/In

suff

icie

nt/

Un

acc

ep

tab

le

(2)

Harm

ful

(1)

Ad

van

ced

R

efl

ect

ing

Su

mm

ariz

ing

Su

mm

ari

zin

g

con

ten

t, f

eelin

gs,

b

eh

avio

rs, a

nd

fu

ture

p

lan

s

Use

s su

mm

arie

s during p

ause

s an

d

at t

he

end o

f th

e se

ssio

n t

o f

ocu

s th

e dis

cuss

ion, si

gnal

under

stan

din

g, an

d

pla

n f

or

the

futu

re.

Use

s su

mm

arie

s at

leas

t tw

ice

during t

he

sess

ion t

o s

ignal

under

stan

din

g,

focu

s th

e dis

cuss

ion, an

d

pla

n f

or

the

futu

re.

Use

s su

mm

ary

only

at

the

end

of

the

sess

ion,

or

sum

mar

ies

are

not

accu

rate

re

flec

tions

of

the

sess

ion t

o

that

poin

t.

Sum

mar

ies

tota

lly a

bse

nt

in

this

ses

sion.

Sum

mar

ies

are

judgm

enta

l or

conta

in e

xplic

it o

r ve

iled a

dvi

ce.

Co

nfr

on

tati

on

Ch

allen

gin

g c

lien

t to

reco

gn

ize

an

d e

valu

ate

in

con

sist

en

cies

Dem

onst

rate

s th

e ab

ility

to

chal

lenge

clie

nts

th

rough v

erbal

izin

g

inco

nsi

sten

cies

and

dis

crep

anci

es in

th

e cl

ient’

s w

ord

s an

d/o

r ac

tions

in a

su

pport

ive

fash

ion.

Bal

ance

of

chal

lenge

and s

upport

.

Dem

onst

rate

s th

e ab

ility

to

chal

lenge

clie

nts

thro

ugh

verb

aliz

ing

inco

nsi

sten

cies

an

d d

iscr

epan

cies

in

the

clie

nt’

s w

ord

s an

d/

or

actions

in

a su

pport

ive

fash

ion a

t le

ast

once

during t

he

sess

ion.

Use

s oth

er

met

hods

of

confr

onta

tion

such

as

hum

or

but

does

not

explic

itly

ref

lect

dis

crep

anci

es.

Abse

nce

of

confr

onta

tions

of

any

kind in

the

sess

ion.

Confr

onta

tions

are

har

sh o

r ju

dgm

enta

l and

thus

do n

ot

bal

ance

support

an

d c

hal

lenge.

_______: Tota

l Sc

ore

(ou

t of

a p

oss

ible

40 p

oin

ts)

*Num

ber

of: O

Q___ C

Q___ P

___ R

OF___ R

OM

___ C

ON

____

*Count th

e n

um

ber

of eac

h b

uildin

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lock

skill in

the tra

nsc

ript or

vid

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d r

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rd h

ere

for

com

par

ison w

ith o

ther

sess

ions.

Note

: The H

CS

is b

ased o

n the C

ounse

lor

Com

pete

nci

es

Scal

e b

y the U

niv

ers

ity o

f Central

Flo

rida

facu

lty a

nd the C

ounse

lor

Com

pete

nci

es

Scal

e–Revis

ed (

CCS-

R): s

ee L

ambie

, M

ullen, Sw

ank, &

Blo

unt, 2

015. The s

kills

portio

n o

f th

e C

CS-

R s

how

ed a

n inte

rrat

er

reliab

ility o

f .9

1 (

p <

.001).

Help

er

Co

mp

ete

ncy

Sca

le (

HC

S)

(Co

nti

nu

ed

)

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174 Chapter 7 • Challenging Skills

HOMEWORK

Homework 1: Identifying Discrepancies through Self-Confrontation

In a single page, identify an incongruity or discrepancy in your own life that you are willing to talk about. Alter-natively, you may write about, in a disguised fashion, a discrepancy you have noticed in another person. Write down the two sides of the dilemma. How deeply does this discrepancy affect your (or the other person’s) life? Do all problems contain discrepancies? Can you think of ways that you have used defense mechanisms to re-duce dissonance or other methods of self-deception to decrease your discomfort? What action steps would be needed now to resolve the discrepancy? Do you think this method of self-confrontation would work for an adult client? What about an adolescent?

Homework 2: Receiving Feedback

Think about a particularly difficult piece of feedback you have received. It may have been about a weak-ness in your appearance, a job evaluation, or perhaps even feedback you received in this class. How did you respond emotionally to the feedback? Did it make you angry, hurt your feelings, or just make you feel incom-petent? Did you try to protect yourself by denying or

discounting the feedback? Did you learn anything con-structive from the negative feedback?

Now think about a time when you received some positive feedback on a personal strength, for example, about a job well done or some aspect of your appearance or personality. What made the feedback positive? Finally, have you ever had an experience where you received no feedback after expending considerable time and effort? What effect do you think a lack of feedback would have on a person’s behavior in the long run? Of the three kinds of feedback mentioned here—positive, negative, and none—which helped you the most? How might you apply your reactions to your future dealings with clients? Summarize your reactions in two or three paragraphs.

JOURNAL STARTERS

Carl Rogers said that the greatest harm one can do to the self is to deny one’s own thoughts, feelings, and per-ceptions in order to gain the love of another. Reflect on Rogers’s idea. Can you think of an example of when you were not true to yourself in order to stay in the good graces of others? How do you think you might have re-sponded to a confrontation that highlighted the discrep-ancy between your actions and what you truly believed? How important do you think it is for a helper to con-front clients when they are not being true to themselves?

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175

Why Assessment?• Assessment Is a Critical Part of Helping• Reasons to Spend Time in the

Assessment Stage

Two Informal Methods of Assessment That Every Helper Uses: Observation and Questioning• Observation• Questioning

Conducting an Intake Interview: What to Assess?• A. Affective Assessment• B. Behavioral Assessment• C. Cognitive Assessment• 1. Developmental Issues• 2. Family History• 3. Cultural and Religious/Spiritual

Background• 4. Physical Challenges and Strengths

Categorizing Clients and Their Problems• Organizing the Flood of Information:

Making a Diagnosis

Goal-Setting Skills• Where Do I Go from Here? Set Goals! • Why Must We Set Goals? • When to Set Goals

What Are the Characteristics of Constructive Goals? • Goals Should Be Simple and Specific• Goals Should Be Stated Positively• Goals Should Be Important to the Client• Goals Should Be Collaboration between

Helper and Client• Goals Should Be Realistic

Resources for Identifying and Clarifying Goals

The Technique of Using Questions to Identify a Goal• Questions That Help Make the Goal

More Specific• Questions That Help Turn a Problem into

a Goal• Questions to Determine a Goal’s

Importance

LEARNING OUTCOMES

By the end of this chapter, you will be able to:

8.1 Identify the key areas of assessment in an intake form.8.2 Recognize questions that clarify a client issue and the technique

of boiling down the problem in a helper/client dialogue.8.3 Identify well-formed behavioral objectives.

Up to this point, we have been looking at creating a therapeutic relationship using the nonjudgmental learning cycle (NLC) and challenging skills to produce a supportive environment that also pushes the client to be aware of all aspects of the problem. Figure 8.1 shows the road map of the helping process. It illustrates that the next stages are assessment and goal setting. You will likely take an entire course devoted to assessment and so the major focus in this chapter will only be to highlight its importance and connect it to goal setting.

Assessment and Goal Setting

C H A P T E R 8

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176 Chapter 8 • Assessment and Goal Setting

Both of these activities provide the basis for deciding which techniques you will choose to help the client in the intervention and action stage. If you do not understand the client and the client’s problems, you will not be able to set realistic goals. If you have fuzzy goals, then you may choose the wrong interventions to try and achieve them. Let us look first at assessment and the crucial role it plays in setting achievable goals with the client.

WHY ASSESSMENT?

Assessment means gathering information about a client and his or her problems. Helpers collect information in a variety of ways, beginning with the first contact as the helper observes the client’s behavior and listens to the story. Formal assessment methods include testing and filling out questionnaires and forms. Informal assessment encompasses all the other ways a helper learns about a client, including observing and questioning. Formal assessment may occur at a specific time in the helping relationship, but infor-mal assessment is an ongoing process. In this book, I recommend that the helper set aside time for an initial assessment during the second stage of the helping process (Figure 8.1).

• Questions to Enhance Collaboration on Goal Setting

• Questions That Help Confirm That the Goal Is Realistic

The Technique of Boiling Down the Problem

Summary

Exercises• Group Exercises• Small Group Discussions• Written Exercises• Self-Assessment• Homework• Journal Starters

STARTHERE

STOP

Relationship Building

Assessment

GoalSetting

Interventionand

Action

Evaluationand

Reflection

FIGURE 8.1 Road Map of the Helping Process

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Chapter 8 • Assessment and Goal Setting 177

Because each client’s situation is unique, it is impossible to predict how much time to give to each stage of the helping process. Still, a rule of thumb is to spend one session primarily in relationship building, with the only assessment activities being the collection of basic demographics, observation of the client’s behavior, and whatever else you can glean from the client’s story. The second and possibly a third session are spent in more in-depth assessment before moving on to a goal-setting phase, which might include test-ing. Therefore, if a client is seen for 10 sessions, about 10% of the time may be devoted to assessment. Beginning a relationship with formal assessment can be a mistake because the initial moments of any human encounter are so important. Imagine how you would feel if you went for a doctor’s appointment and were asked only to fill out forms, contrib-ute blood samples, and answer questions, but were not allowed to talk about the reason for your visit.

When clients have been invited to tell their stories, they give much more informa-tion during the formal assessment period that follows. They leave the first session believ-ing that they have made a start on solving problems, instead of feeling dissected by tests and probing questions. Key data need to be collected at the first interview, but there are several ways to handle this. For clients who can read and write, asking them to come in early or stay later than the session can be an effective way of collecting information about their background and current functioning.

Assessment Is a Critical Part of Helping

Sometimes you will hear that gathering a lot of historical information about a client is not worthwhile. Certain theories emphasize the present and the future rather than the past, and so they ignore history and personality data. It is true that some helpers do spend an inordinate amount of time gathering background information and administering tests. On the other hand, by failing to collect critical data, one takes the chance of making a serious mistake. You must know your customer thoroughly (Gelso, Nutt Williams, & Fretz, 2014; Lukas, 1993).

Once I interviewed a 65-year-old man who had been a shoe salesman in Cleveland. He had led an interesting life before retiring about 2 years before we met. He reported no real difficulties, and, as he was very convincing, I couldn’t understand why he had con-sulted me. As a courtesy, I talked separately to his 28-year-old son, who had waited patiently outside. The son told me his father had been a physician in Texas and 5 years ago developed a syndrome, which was thought to be Alzheimer’s disease, a severe brain disorder with a deteriorating course. The client had simply filled in the gaps of his history with very convincing fiction. That incident taught me that it is best to get as much infor-mation about a client as possible and information from a variety of sources. If I had tested the client’s memory or talked to his son first, I might have saved some time. More important, had I relied on the client as the sole source of information, I might have sent him away without treatment.

Conducting superficial assessments, however, does not always lead to such spec-tacular embarrassment. It is very common, though, for helpers to accept the client’s story without a critical thought. Even the most astute helper can make drastic mistakes. It is important to listen to what clients leave out and where they minimize or deny. Also, it is easy to forget to ask specific questions, so using a structured form for assessment is advised. Just because a client is well groomed and comes from a prominent family does

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178 Chapter 8 • Assessment and Goal Setting

not mean that he or she should not be asked about drug abuse or suicidal thoughts. Our prejudices and worldview color our definition of pathology. Even the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association, the diagnostic bible, recognizes that misdiagnosis can occur when the helper is not familiar with a client’s cultural background and interprets symptoms within his or her own cul-tural context (Alarcón, 2009). The next section indicates how assessment can provide the helper with critical information about the client for his or her best treatment.

Reasons to Spend Time in the Assessment Stage

ASSESSMENT HELPS YOU DETERMINE WHETHER THE CLIENT IS A GOOD CANDIDATE FOR THE HELP YOU CAN PROVIDE Therapeutic help from a trained professional is not the best treatment for everyone. The client must have the capacity to form a relationship, be moti-vated to change, and be able to attend sessions and understand what is going on (see Truant, 1999). There may be better avenues of help for the client than “talk therapy.” Clients with fewer verbal skills might benefit from art or music therapy. There are also educational, online learning, occupational, chemotherapy, and support group alterna-tives. When a client arrives for treatment, the first thought should be: Is this the right place for this client? For example, in our university clinic, counselors are only available one day each week. Thus, we need to assess clients to make sure that they are stable enough to get along on their own between sessions. We refer those who are not to a more intensive treatment center.

ASSESSMENT GIVES CRUCIAL INFORMATION TO PLAN USEFUL AND REALISTIC GOALS The main purpose of assessment is to gather information that will be useful in planning the goals that will guide the helper and the client. Assessment must have both breadth and depth. As far as breadth is concerned, the helper must throw the net broadly enough to make sure nothing crucial escapes. That is why many treatment facilities use a standardized assessment or psychosocial intake form that requires details about the client’s medical, psychological, and social history as well as current functioning. Depth refers to focusing on specific issues such as suicide, the existence of mental disorders, and the “presenting prob-lem” or specific issue that acted as a catalyst for the client’s decision to seek help.

ASSESSMENT HELPS CLIENTS DISCOVER EVENTS RELATED TO THE PROBLEM A woman came to a community clinic asking for help in dealing with problems at work. She recog-nized that her job was stressful, but she found that she was unusually irritable with her co-workers and wanted to work on that problem. After some reflection and homework by the client, we discovered that her angry outbursts all happened between 1 p.m. and 2 p.m. on days when she had not eaten lunch. The client knew that she became grumpy when she was hungry, but she had never connected this with her behavior on the job. A physician helped the client to deal with a problem of low blood sugar, and her extreme irritability diminished, which in turn helped in her relationships and her work.

ASSESSMENT HELPS US UNDERSTAND THE IMPACT OF THE CLIENT’S ENVIRONMENT ON HIS OR HER MENTAL HEALTH For example, is the client living with family, in a shelter, or alone? Does the client suffer isolation because he or she does not speak the dominant language or belongs to a religious minority? If the client is a child, what is happening at

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Chapter 8 • Assessment and Goal Setting 179

school every day that might be affecting the problem? Is the child bullied, rejected by classmates, or encouraged by a teacher?

ASSESSMENT HELPS US RECOGNIZE THE UNIQUENESS OF INDIVIDUALS We all have the tendency to generalize and stereotype. Unless we ask clients about family and cultural background issues, we may make assumptions about them through our own cultural lens. The behavior of people from different cultural groups may be judged as being more pathological than of those who share our own background. A systematic assessment helps us be less manipulated by these strong social influences and more objective because we are recording the answers to standard questions rather than merely relying on our own impressions. Assessment can also be useful in helping clients recognize their unique personality, values, and interests (Armstrong & Rounds, 2010).

ASSESSMENT UNCOVERS THE POTENTIAL FOR VIOLENCE Assessment can identify indi-viduals who are at risk for violence toward self or others, especially by collecting a thor-ough history. Although it is not possible to always accurately predict violent behavior, a history of self-inflicted injury or harm to others can cue us to examine the client’s situation more thoroughly and take precautions (see Granello & Granello, 2007; Juhnke, Granello, & Granello, 2011). (See also Table 8.1.) School counselors are recognizing the need to assess for violent behavior in the aftermath of school shootings and in the wake of renewed interest in bullying (Bernes & Bardick, 2007; Felix, Sharkey, Green, & Tanigawa, 2011).

TABLE 8.1 Is Path Warm?

When you suspect suicide, you should ask the client directly about his or her thoughts about hurting himself or herself. Then, take it seriously and get immediate help. IS PATH WARM (see below) is an acronym that was developed by the American Association of Suicidology (2006) to gauge suicidal risk (see Juhnke, Granello, & Lebrón-Striker, 2007). It must be remembered that these are guidelines based on risk factors and that there is no foolproof method of determining how suicidal a client might be. However, the rule of thumb is to err on the side of caution, and a client who is exhibiting any of these symptoms (especially ideation) should be further evaluated.

Ideation: Does the client think, talk, or write about a desire to self-destruct or to purchase the means to do so? Does the client show an intention to carry out the plan?

Substance Abuse: Is the client intoxicated or has he or she been abusing alcohol or other drugs?

Purposelessness: Is the client adrift, without a sense of meaning and purpose in life, seeing no meaning to keep living?

Anger: Is the client’s mood angry or hostile? Is he or she feeling vengeful toward someone?

Trapped: Does the client feel there is no way out of the present situation and that he or she is better off dead?

Hopelessness: Does the client have a negative view of the future and feel that he or she is a lost cause or beyond help?

Withdrawal: Has the client withdrawn from family, friends, and other supportive people?

Anxiety: Is the client experiencing anxiety that interferes with sleep and daily functioning?

Recklessness: Does the client engage in risky behaviors, such as driving at high speed or taking other chances?

Mood: Is the client experiencing drastic mood swings? Is the client feeling depressed?

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ASSESSMENT REVEALS CRITICAL HISTORICAL DATA Figure 8.2 shows a simple assess-ment device called a time line. Rafael was asked to fill in the boxes with critical life events in sequential order. His choice of key interpersonal events gave a glimpse of his world-view and his major concerns.

ASSESSMENT CAN HIGHLIGHT STRENGTHS, NOT JUST WEAKNESSES AND PATHOLOGY More and more helpers are using assessment tools that identify client strengths and competencies (Flükiger, Wüsten, Zinbarg, & Wampold, 2010; Kiselica & Englar-Carlson, 2010; Lopez & Sny-der, 2009; Ward & Reuter, 2011). Strength-based assessment instruments such as the Behavio-ral and Emotional Rating Scale (Epstein, 2004; Epstein, Harniss, Pearson, & Ryser, 1999) have been developed in recent years in response to this need. Strength-based assessment is, in part, a reaction to medical models based on pathology. It is also being recognized that build-ing on client strengths enhances client self-esteem and helps client and helper use time more effectively (Miller, Hubble, & Duncan, 1996). Another emphasis for assessment is to base it on a wellness philosophy. A wellness philosophy also emphasizes strengths, but its holistic point of view advocates evaluation of clients’ physical, mental, emotional, social, cognitive, occupa-tional, and spiritual resources (Myers & Sweeney, 2005; Witmer & Sweeney, 1992).

ASSESSMENT HELPS CLIENTS BECOME AWARE OF IMPORTANT PROBLEMS Frequently, painful issues are pushed out of awareness or remain unrecognized until brought to the surface through assessment procedures (Granello, 2010). A common example of this is substance abuse. When clients are asked to list and discuss the problems that alcohol has caused, the results can be an eye-opener. Many alcohol treatment centers take thorough histories and use motivational interviewing as a beginning step in breaking down the alcoholic’s denial system (Miller & Rose, 2009).

ASSESSMENT HELPS THE HELPER CHOOSE WHICH TECHNIQUES TO USE When you think about learning helping techniques, chances are that you have not considered assessment as a critical part of that process. Yet how do you know which techniques to use? The answer is derived from two sources of knowledge: information about your client and information about the client’s problems. If you know that your client is very religious, for example, you will be able to select techniques that the client will embrace. If you know when and where your client has panic attacks, you will be better able to identify an effective plan. Thus, it is difficult to discuss helping techniques without thinking about how we choose which methods to use with which clients for what particular problem (Paul, 1967). The next section covers the basic techniques of assessment that are appropriate to use at all stages of treatment to gain knowledge about clients.

Age 15Met Future

Wife

Age 12ParentsDivorced

Age 21Married

Rafael

Age 23SonBorn

Age 25Divorced

FIGURE 8.2 Time Line Assessment

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TWO INFORMAL METHODS OF ASSESSMENT THAT EVERY HELPER USES: OBSERVATION AND QUESTIONING

By using the informal assessment techniques of observation and questioning, the helper is able to screen for major problems and determine whether the help he or she has to offer fits the client’s needs.

Observation

Yogi Berra once said, “You can observe a lot just by watching.” His statement underlines the fact that observation is something of a lost art. It also emphasizes that observation is not a passive process, but a conscious, concerted effort. Experienced helpers are able to detect patterns in clients from a number of small clues that, on the surface, may seem inconsequen-tial to someone else. For example, some helpers can catch signs of alcohol abuse from a client’s hand tremors, jaundiced and dry red skin, finger swelling, and changes in the nose. Recently, a registered nurse, Ryan Read, was watching her favorite show, Flip or Flop. Ryan e-mailed the show’s host, Tarek El Moussa, after she noticed a lump on his thyroid. It turned our Tarek had thyroid cancer, which has since been successfully treated. In conjunction with experience and training, observation can be just as crucial in the helping professions. Clients often carry the clues to their problems on their faces and in the way they walk and speak. We need to be aware of how we interpret what we observe in our clients.

Assumptions in Assessment

Our own cultural biases, assumptions, worldview, and experiences color what we observe. Our family backgrounds and culture shape what we remember and pay attention to. We see clients through our own cultural lens and judge their behavior according to our standards. Freeing our-selves entirely from this conditioning is nearly impossible, but we can become more aware of our own limited cultural vision.

Although it is enlightening to be a visitor to another culture, we can also become students of every culture we encounter. For example, on a trip to Europe, my companions and I met a large group of Japanese tourists taking hundreds of pictures of a Dutch windmill. We found this to be, on the one hand, amusing, and on the other, excessive and annoying. I began talking with the Japanese tour guide about this. She explained that living on an island means that travel is more restricted, and off-island vacations are relatively rare for most people in Japan. In addition, she indicated that pic-tures are a way of sharing experiences with family and friends back home, who may expect and eagerly await a slide show. Even more important, it is a way for the tourists to relive that moment. When we heard these explanations, my colleagues and I were embarrassed by our cultural encapsu-lation, and we began to see the behavior in a completely different light. Since then, I have tried to take special care in recording and reflecting on my observations when a client is culturally different.

In the following sections, remember that your impressions come through your own cultural point of view. Most of the assessment methods we use, both formal and informal, rely on our own cultural concepts about mental health and values. When you have the chance to record your observations and assessments of real clients, revisit this section and reflect on what you may be bringing to the picture you are painting.

CULTURE CHECK

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WHAT TO OBSERVE Speech. Note all aspects of a client’s speaking voice. Does the client’s voice annoy

or soothe? Is the client’s tone slow and monotonous or excessively labile (variable)? Does the client have an accent of any kind? Does the client’s voice reflect alcohol abuse or smoking? Is the client’s speech hurried or forced? Does the client have a speech impedi-ment of any kind? Does the client speak without listening?

Client’s Clothing. Does the client wear expensive, stylish, well-coordinated, seduc-tive, old, or outmoded clothing? Is there anything odd or unusual about it? Does the client reflect a particular style (artistic, conservative, etc.)? Is clothing inappropriate for the weather (several layers on a hot day), and is it appropriate to the occasion? Does the cli-ent wear jewelry? A lot of jewelry? Does the client wear appropriate amounts of makeup? Does the client wear glasses or a hearing aid? Does the client’s clothing suggest a different cultural background?

Grooming. Is the client clean? Does the client exhibit body odor and a general disregard for personal hygiene? Even if the client shows concern for cleanliness, is there a disorganized appearance to the hair and clothing, perhaps suggesting disorderliness, depression, or lack of social awareness? Do cultural differences in grooming account for the client’s appearance? If the client is a child, what does grooming suggest about family environment?

Posture, Build, and Gait. What is the client’s posture during the session? What is the position of the shoulders and head? Does the client sit in a rigid or a slouched position or with head in hands? Does the client’s posture reflect the present emotional state, or is the client’s posture indicative of a more long-term state of anxiety, tension, or depression?

Build refers to the body habitus. Is the client physically attractive? Is the client obese, muscular, or thin? Are there any unusual physical characteristics, such as excessive acne, physical disabilities, or prostheses?

Gait means the person’s manner of walking. Does the client’s manner of walking reflect an emotional state, such as depression or anxiety? Does the client’s walk seem to indicate confidence or low self-esteem? Is the client tentative and cautious in finding a seat?

Facial Expressions. Facial expressions include movements of the eyes, lips, fore-head, and mouth. Do the client’s feelings show, or are the client’s expressions flat, devoid of any emotion? Does the client maintain direct eye contact or avoid it? Do the eyes fill with tears? Does the client smile or laugh during the session? Is the brow wrinkled? Could the client’s facial expressions be due to cultural injunctions about eye contact or posture in the presence of an authority figure like the helper?

Other Bodily Movements. A client may show anxiety by twisting tissue or by tap-ping restlessly with fingers, toes, or legs. One important way in which people express themselves is through their hand movements. Fritz Perls, the founder of Gestalt therapy, was fond of making clients aware of how bodily movements expressed their inner con-flicts and impulses (Perls, 1959, p. 83).

General Appearance. In recording an assessment of the client, it is sometimes useful to note initial holistic impressions, which may become less noticeable as treat-ment progresses—for example, “The client appeared much older than his stated age,” “The client appeared to be very precise and neat and seemed to carefully consider all

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of his statements before speaking,” “I had the feeling that the client was a super sales-man.” Many of these holistic impressions can be stereotypes, although sometimes they give insight into the impression the client is trying to make. Are you judging the client based on your own upbringing?

Feelings of the Helper. Basing his observations on Harry Stack Sullivan’s theo-ries, Timothy Leary (1957; before he took LSD) hypothesized that we react automati-cally and unconsciously to the communications of others. Our reaction, in turn, triggers the other person’s next response. We tend to instinctively react in a positive, friendly manner to individuals whom we find attractive and friendly. Similarly, we instinctively respond in a negative way to individuals who are combative or aloof. They, in turn, become more abrasive and the cycle continues. These interpersonal reflexes (Shannon & Guerney, 1973) occur outside of awareness and are rarely dis-cussed, but they can be very important in the helping relationship and in the client’s social world.

If the helper finds himself or herself becoming annoyed with the client, is it possible that most of the client’s social contacts might have the same response? What would moti-vate the client to push people away? Is the client even aware of his or her effect on oth-ers? According to Ernst Beier (Beier & Young, 1998), the helper can learn to use his or her personal feelings as an assessment instrument. It requires detaching and not reacting to the client’s overtures but, instead, thinking about how others in the client’s world must feel about the client and recording this information.

Questioning

Previously we cautioned not to ask too many questions as it tends to disrupt the bond-ing between client and helper. In fact, the most common mistake for beginning helpers is relying on questions in the relationship-building stage, rather than taking the neces-sary time to understand the client and provide an atmosphere of openness and trust. However, as the helper/client relationship develops, the helper then uses the second basic assessment technique of questioning. During the assessment stage, questions are necessary because they expedite taking personal and sexual histories, drawing the fam-ily tree (genogram), and allowing the client to elaborate on his or her construction of the problem. It is not that questions are inherently bad; it is just that they are used too often by beginning helpers and at the wrong time.

Questioning is an art (Goldberg, 1998). When used artfully, questions can even be therapeutic devices to spur the client’s thinking or stimulate action. Questions can also be used to gain valuable information and to focus the client on the agreed-upon goals. They serve an “orienting” function in that they tell the client what is important (Tomm, 1988). We call these assessment questions. Following are some assessment questions frequently asked by helpers early in the assessment stage in order to identify important aspects of the client’s concerns:

“How can I help you?”

“Where would you like to begin?”

“What prompted you to make today’s appointment?”

“Has something happened in the last few days or weeks that persuaded you that help was needed?”

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“What is it that you want to stop doing or do less of?”

“What is it that you want to begin to do or do more of?”

Next is a different sort of question that pushes clients to dig deeper and challenges them to act. We call these challenging questions. They differ from assessment questions in that their purpose is not to gather information but to expand the client’s thinking.

“What effect do you think your depression has on your spouse?”

“What would your life be like if the problem were solved?”

“What does that do to the relationship between you and your stepmother?”

“Where did that idea come from, that you are not capable of being a good father?”

CONDUCTING AN INTAKE INTERVIEW: WHAT TO ASSESS?

One way of getting started in the assessment process is to systematically record your impressions about a client on some kind of standard form. A form is a good training device because it ensures that you have not missed the big problems. The format we are suggesting is an inventory of the client’s (A) affective or emotional issues and status; (B) behavior deficits, excesses, and strengths; and (C) thinking or cognitions. These three items will be referred to as A, B, and C, for short. In addition, you are asked to record data about the client’s (1) developmental level, (2) family history, (3) cultural and reli-gious/spiritual background, and (4) physical challenges and strengths. When you practice in class, you can make your own form on a blank sheet of paper and record the informa-tion under the categories ABC-1234 using the book to help you address each area. Let us take a brief look at each of the seven elements and why it is critical to collect these data on each client during a screening or intake interview.

A. Affective Assessment

Clients come for help because of overwhelming and confused emotions. They are seek-ing relief from anxiety, grief, depression, and anger. Whether these are disabling or merely uncomfortable conditions, the helper assesses the intensity, frequency, and duration of these negative emotions in order to plan effective treatment. It is similarly important to identify the client’s positive affective states. If clients can identify the times when they feel satisfied and happy, they can attempt to re-create those states.

B. Behavioral Assessment

Many people are seeking assistance for excessive behaviors, ranging from smoking to sexual addiction. Others need help in learning and increasing new behaviors such as social skills, relaxation, communication, or time management. Clients also have “positive addictions” or healthy habits that should be noted. If a client has a regular exercise regime, meditates, or is very organized, these behaviors can be identified and encouraged.

C. Cognitive Assessment

Cognition includes the client’s thinking, images, and meanings (the client’s worldview). For example, a client may be engaging in negative thinking and negative imagery about

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an upcoming event. By uncovering this in an intake interview, the helper can help the client find specific constructive thoughts and images as an antidote. In this section of the intake form, the helper records intellectual deficits and strengths, any specific learning problems, delusions or hallucinations, or head injuries.

1. Developmental Issues

Helpers must have a basic knowledge of human development as major theorists such as Pia-get, Erikson, Loevinger, and Kohlberg have described it. Then assessment and helping tech-niques can be modified to deal with life-stage differences. In this section, people are grouped according to the common age-related categories of children, adolescents, college students, and older people. The descriptions of these life stages are generalizations about groups of people. The discussion is meant to urge you to consider critical developmental issues. However, it is also important to remember that each person is unique. There are some octo-genarians who are physically and intellectually younger than their chronological ages; some 9-year-olds demonstrate an unusual amount of intellectual and emotional maturity.

CHILDREN There are many specialized assessment and helping techniques that are spe-cific to children (Sattler, 2014). School functioning for children is analogous to occupa-tional functioning for adults and is an indicator of overall adjustment. Contact the teacher for insight into a child’s behavior toward adults and peers. To understand a child’s family and his or her relationship with parents, interview parents, grandparents, and siblings.

ADOLESCENTS Adolescents are challenging but also intriguing and rewarding to work with. Issues of trust and betrayal, freedom, autonomy, dangerous behavior, and anger are just beneath the surface of their words. When assessing adolescent problems, it is particu-larly important to touch on drug and alcohol abuse, sexual behavior, and relationships with parents and siblings. Most adolescent deaths are due not to medical problems but to automobile accidents, suicide, homicide, and substance abuse. These areas must be care-fully addressed in the assessment stage.

COLLEGE STUDENTS College students are characterized by their focus on issues of self-esteem, separation from their family of origin, and their strong need to form close bonds with others. The helper who works with college students deals with alcohol and drug abuse, suicide attempts, eating disorders, intense love relationships and their dismal after-math, problems with parents, pregnancy, and sexually transmitted diseases.

OLDER PEOPLE Understanding the problems of older people requires consideration of their unique histories. The oldest people today lived through the Great Depression and World War II. These two events shaped their thinking and worldview. It instilled in them a cautious approach to life, especially where money is concerned. In short, to know older people, it may be important to get a sense of the time they grew up in because it affected their perspective on life and is the basis for their view of the future. Helpers who work with older people deal with issues of loss, deteriorating health, thoughts about lost oppor-tunities, regrets, and fears associated with loneliness. Helpers frequently also assist older people who are trying to create new lives following the death of a spouse, who need to let go of past experiences, or who have disappointing family relationships.

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2. Family History

Our family histories provide a deep insight into who we are. Our ideas of gender roles, parental roles, and what is normal and good all come from our original family groups, or our families of origin. The visual nature of a genogram makes it an efficient way to under-stand a client’s family history. In the absence of a genogram, you may simply want to question clients concerning important stressors in their family now and in the past.

A family history of depression, suicide, anxiety disorders, substance abuse, or sex-ual abuse is valuable information, as it may shed light on the client’s current concerns. Our ideas about normal family functioning, what it means to be a spouse and parent, are based on our own families. Taking the time to get a sense of the client’s family will be rewarded by insights into the forces that have shaped the client’s worldview.

3. Cultural and Religious/Spiritual Background

Besides identifying a client’s ethnicity, race, or class, it is important to understand the cli-ent’s acculturation. A client’s acculturation is the degree to which he or she personally identifies with a particular culture. For example, two children in a bicultural family may feel close to one parent’s culture but not the other’s. In addition, a girl whose parents are Russian Jews but who was born in the United States might conceivably have a minimal relationship to her family’s culture and religion. Following are some additional questions that stimulate thinking about the degree of a client’s cultural identity and its impact on the helping process:

• What is the client’s cultural/ethnic identity?• What is the client’s religion or spiritual orientation? How closely does he or she fol-

low that belief? (See Leighton, 2014.)• How much does the client identify with his or her cultural or ethnic background?• According to the client, how is seeking help from a helper viewed within his or her

culture?• How can the client’s goals and problems be viewed in a way that is compatible with

his or her cultural background?• How does the client’s upbringing regarding appropriate gender roles relate to the

presenting problems?• Is the client’s culture a source of pride or shame?

4. Physical Challenges and Strengths

For our purposes, physical challenges include medical diagnoses, physical abilities and dis-abilities, and drug and alcohol use and abuse. All these may have physical, social, and psychological effects. Focus on the client’s physical assets and abilities in this category, too.

MEDICAL DIAGNOSES A number of physical disorders have psychological effects. A helper can go wrong by trying to work on a symptom that turns out to be the result of a treatable medical condition (Pollak, Levy, & Breitholtz, 1999). For example, a brain tumor or other serious problem, rather than stress, may be the cause of a client’s headaches. Symptoms of depression, anxiety, sexual disorders, irritability, weight gain or loss, head-aches, and fatigue suggest that the client should receive a thorough medical checkup as part of the helping process. It is irresponsible and unethical to treat someone for these

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symptoms until medical causes have been ruled out. When in doubt, helpers should refer clients for medical evaluation. On the other side of the coin, be sure to note positive health and wellness behaviors such as good diet and physical exercise.

PHYSICAL ABILITIES AND DISABILITIES The term physical disabilities suggests that there are normal-functioning people and people with disabilities. Perhaps the term should be physical differ-abilities, because abilities are probably better described on a continuum rather than within an abled/disabled dichotomy. It is not as important to know that a person is in a wheelchair as it is to know how he or she sees himself or herself in relation to other people, how he or she functions, and how this way of getting around affects that person socially and professionally. Also, assess what the person can do.

Not all challenges to physical ability are as obvious as a prosthesis or wheelchair. Heart conditions, multiple sclerosis, arthritis, diabetes, and myriad other problems have an effect on mood, behavior, and thinking. It is helpful to know the normal psychological effects of common diseases, and it is important to explore with a client the impact of the disease on his or her overall functioning (Barden, Conley, & Young, 2015).

DRUG AND ALCOHOL USE AND ABUSE Alcohol and other drug use is difficult to assess because clients consciously and unconsciously minimize the amount they report. Prescrip-tion and nonprescription drug taking must also be recorded because the mental, emotional, and behavioral effects of certain drugs can make other issues worse. Even medically required medication can affect school or work functioning and family relationships.

When substance abuse is identified, many helpers try to treat this first because con-tinued substance abuse undermines clients’ progress on other issues. Because clients may not want to bring up substance abuse, one way to start a discussion and gain important information is by asking direct questions or by asking the client to fill out a questionnaire or rating scale (see Evans, 1998; Sajatovic & Ramirez, 2012). Table 8.2 contains a list of additional questions that you might use to follow up on suspected substance abuse.

TABLE 8.2 Some Key Interview Questions for Substance Abuse

“Do any of your friends and family think you have a substance abuse problem?”

“Have you ever been arrested for driving under the influence?”

“Have you ever been physically injured or had an accident while drinking or using?”

“Have you ever broken any bones as an adult? If so, how?”

“How much do you drink or use each day?”

“Have you ever had a blackout or amnesia while using?”

“Has your substance abuse changed any of your close relationships or affected your work?”

“Looking back at your family tree, which relatives have had a substance abuse problem?”

“Have you ever felt the need to cut back on your use of substances?”

MyCounselingLab Application Exercise 8.1 The ABC-1234 Assessment

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CATEGORIZING CLIENTS AND THEIR PROBLEMS

Organizing the Flood of Information: Making a Diagnosis

Through the combined use of formal and informal assessments, helpers are in a better position to service their clients’ needs. In addition to observation and questioning and conducting an intake interview, professionals use paper-and-pencil tests, questionnaires, drawings, and similar instruments to gather data about clients and their problems (Gelso et al., 2014). Besides formal testing, there are six other important sources of information to consider, most of which have been covered in this chapter. Key information comes from things the helper observes, from information provided by friends and family, from what the client supplies (verbal descriptions, journals, recordings, and genograms), from medical history, from other agencies, and from the legal system. Because there is so much information that can be collected, it may be confusing to know which sources to tap and how to manage the incoming data. As you learn to be a helper, you will take a course in evaluation and assessment or tests and measurements and probably one on diagnosis. These courses will provide you with a more complete background. However, at this point, it is important that you recognize that all assessment tools are attempts to simplify the process by placing clients or their problems in categories.

Figure 8.3 shows the downward flow of information from the seven sources entering a funnel that narrows as the data are examined and organized into categories. Diagnosis is the simplifying process we use to organize the results of our examination. Diagnosis is identifying the overriding issues or problems that seem to encompass a large number of the client’s complaints. It should not focus solely on mental disorders but should also sum-marize all of his or her problems (Hohenshil, 1996; Johnstone & Dallos, 2014).

Figure 8.3 also shows how the client’s problems or diagnoses are placed on a treatment planning list, something like an in-basket to be sorted out during the goal-setting stage of the helping process, which is discussed next in the chapter. For example, a typical client’s in-box might contain marital problems, career confusion, and low self-esteem, which become the focus of the client/helper discussions. Once the client’s prob-lems are identified, it is the helper’s job to consult with the client and place them in order of priority, noting those issues that will take precedence and those that will be placed at the bottom of the box. The helper selects methods and techniques to treat each problem on the list. These methods might include referral to a physician, assertive-ness training, group therapy, or any other method that the helper suggests. Typically, the treatment plan is constructed in conjunction with the client, who signs an agreement to be treated according to the plan.

Having looked first at the many facets of assessment and its crucial role in setting achievable goals with the client, we continue this chapter by examining the next stage on the road map of the helping process: goal setting.

GOAL-SETTING SKILLS

Where Do I Go from Here? Set Goals!

At this point in training, many students make the following statement: “I seem to be able to empathize with the client through the nonjudgmental listening cycle, and I understand something about the client’s problems and background, but where do I go from here?”

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The helper feels that after a session or two, he or she has exhausted the client’s story and explored the client’s distress, but the helper does not believe that he or she has really helped. More than ever, the helper is tempted to give the client advice, ask questions, or introduce a new technique of some kind. The best answer to the question “Where do I go from here?” is “Set goals!” When you have set goals, it will be easier for you to identify

Data Collection

Diagnosing or IdentifyingMajor Issues

Placing Problemsin Priority Order

Matching Problemswith Treatments

Information from family and friends

Observations by the helper

Formal testing

Information from social service agencies

Data supplied by the client

Medical history

Information from the legal system

In-Basket

A BC

D

Out-Basket

A BC

D

C

A

B

D

1

2

3

4

Problems Appropriate TreatmentInterventions

FIGURE 8.3 Process of Gathering, Sorting, and Matching Problems with Interventions in the Assessment Stage

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compatible techniques and the plan will make sense to the client. If these goals are mutu-ally formed, the client will feel that he or she is part of the team and a partner in the therapeutic project. Partners are much more likely to make contributions than patients.

Why Must We Set Goals?

If we are to really help the client, not only must we understand his or her problems, but we must also decrease client demoralization and ignite hope. Identifying and achieving goals help the client gain confidence even if the objectives are rather modest. If one can achieve a small goal, then discouragement, the biggest enemy of change, is diminished (Frank & Frank, 1991). Moreover, goal setting separates the tangled mass of a problem into manageable units. Once a few goals have been identified, helping has a focus and the client begins to see the light at the end of the tunnel. Hope begins to dawn because the client now views what was an amorphous mass of trouble as a set of solvable prob-lems. Figure 8.4 shows the client’s difficulties as they first appear in the opening sessions and later after the assessment and goal-setting stages. Through this process, the intangible cloud of problems has been broken into manageable segments.

Besides decreasing demoralization and clarifying the issues, goals get us to make a commitment. To use an analogy, frequently clients have started digging a number of dry holes in their life, never sticking with something but trying many different options. If you commit to a goal, you are digging deeply in the same place, and you will eventually hit water. Thus, I believe that every helping session should focus on the client’s goals. When every session begins with a review of goals, the client is much more likely to think about those goals and to work on them between sessions (Matre, Dahl, Jensen, & Nordahl, 2013).

Finally, goals help us know when the helping relationship should end. Steve de Shazer says that one of the most important questions a helper can ask is, “How will we know when we are done?” (de Shazer, 1990). Sometimes helpers answer this question by

Solving this pieceis our goal

The Problem

The Problem

FIGURE 8.4 Breaking the Problem into Parcels and Working on One Part

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using a time-limited approach, where the client attends for a certain amount of time or attends a specific number of sessions. Many college counseling centers limit clients to 6 or 10 sessions. One of the reasons that time limits help is that the threat of termination tends to focus the mind. Setting a date for termination of the relationship motivates helper and client to work quickly to solve problems.

The problem with the time-limited approach is that we terminate the relationship regardless of success or failure. Alternately, allowing the client to discontinue the helping process unilaterally makes the process seem haphazard as the relationship just peters out. On the other hand, if we have formulated goals at the beginning of the helping relation-ship, client and helper will have a shared vision throughout the relationship and will know when it is time to end. The best measure of whether the work is done is to deter-mine whether the treatment goals have been reached. In this part of the chapter, you will be learning about when to set goals and how to know whether the goals you and your client devise are constructive. In addition, we will look at two skills that help us arrive at usable goals: (1) using questions to identify a goal and (2) boiling down the problem.

When to Set Goals

It is possible to begin setting goals prematurely when you have neither the client’s trust nor a clear understanding of the problems. The preferred time to set goals is after the helper has established a relationship with the client and conducted a thorough assessment. We have said that helping progresses through five basic stages, as shown in Figure 8.5. At the initial relationship-building stage, most of the helper’s activities are based on the invi-tational, reflecting, and challenging skills, which invite the client to open up and engage in self-examination within the confiding relationship. Early in the relationship, the helper does not narrow the field of discussion, but dares the client to go deeper and broader and disclose more about a number of topics. In the assessment stage, the helper gets informa-tion about the client, the client’s problems, and the environment. Without this knowledge, the goals might turn out to be irrelevant or the efforts ineffective if the client is not moti-vated, is being influenced by others, or is in a nonsupportive environment. As was men-tioned earlier, hidden areas of a client’s life might not come to light without a thorough look at the client’s history. These secrets, such as substance abuse, could seriously under-mine the therapeutic plans.

Interventionand Action

Assessment

Outcome Evaluationand Termination Goal SettingRelationship Building

FIGURE 8.5 The Therapeutic Relationship Is Central to Goal Setting

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Although invitational, reflecting, and challenging skills encourage clients to open up and assessment provides crucial data, the skills of the goal-setting stage are methods for narrowing down the information into a few specific tasks and goals. In other words, help-ing begins with wide-ranging discussions, but eventually it narrows to focus on certain particular areas. Goal setting is the stage where the helper begins to change the focus of the sessions from the introduction of new topics and assessment to the identification of the most crucial issues to be addressed in later sessions.

WHAT ARE THE CHARACTERISTICS OF CONSTRUCTIVE GOALS?

This section is an argument for selecting goals that are simple and specific, stated posi-tively (reflecting the presence of something rather than the absence of something), impor-tant to the client, collaboratively developed, and realistic.

Goals Should Be Simple and Specific

Sometimes clients have difficulty in selecting clear projects to work on. Their goals when stated are vague and elusive (Rule, 1982). For example, “I don’t really know what’s wrong; it’s just that I am uneasy with everything,” or, “I haven’t been feeling right for about a year.” A specific, clear, and easily restated goal sounds more like this: “I want to be able to be more assertive with my friends and co-workers.”

When clients have clear goals, they make better progress (Borelli & Mermelstein, 1994; Hart, 1978). Having clear goals may be more challenging but is more likely to lead to progress than having fuzzy goals or having no goals at all (Mackrill, 2011; Ponte-Allan & Giles, 1999; Smith, Hauenstein, & Buchanan, 1996). Specific goals make the direction of the helping process clear to the client. Clients then begin to feel that they have a han-dle on how to begin making changes. The client who is clear about goals will be able to work on them in and out of session.

It is not only clients who have trouble setting goals. For one reason or another, some helpers prefer to focus on the process of helping, letting the client deal with issues as they arise, rather than establishing landmarks of progress. This book argues that help-ing has changed radically in recent decades. Nearly all helping is now brief. Focusing on specific issues allows helpers to make the best use of therapeutic time. Besides these general advantages, at least four other favorable outcomes accrue from negotiating spe-cific goal statements with your clients:

1. When goals are clearly understood by client and helper, the helper can deter-mine whether he or she possesses the requisite skills to continue with the help-ing relationship or whether a referral is needed. Sometimes it is only during the goal-setting process that the helper realizes that the client needs some special-ized assistance such as sex therapy, couples counseling, or substance abuse treatment.

2. Many clients have problems imagining or envisioning success. Thinking about and imagining specific, positive outcomes have the effect of focusing the client’s resources and energies and increasing hope. For this reason, goals that are stated positively, such as the acquisition of skills, are considered to be more useful than goals that are only focused on eliminating a negative behavior.

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3. Identifying specific goals provides a rational basis for selecting treatment strategies that agencies, third-party providers, and supervisors can understand. Specific goals reassure others that the outcomes of helping will result in measurable changes.

4. Specific goals enable helpers to determine how successful helping has been for the client. Both clients and helpers have a clearer idea whether progress is being made and can determine when termination is imminent.

GOALS, OBJECTIVES, AND INTERVENTIONS One way to make goals more specific is to break them down into subgoals or objectives. Many agencies, schools, hospitals, and third-party payers want helpers to link goals, objectives, and interventions. The interven-tions you choose are the techniques selected to achieve the objectives. In Table 8.3, these three terms are shown with examples.

BEHAVIORAL OBJECTIVES As we have indicated, one of the characteristics of effective goals is that they are simple and specific. Table 8.3 shows that objectives are really just more specific goals. Many workplaces also require that helpers make these objectives behavioral. Behavioral objectives are concrete, measurable, and observable. They specify the client’s current behavior (baseline) and the target or goal behaviors that indicate suc-cess. Here is an example of how you can develop a behavioral objective:

Client’s Stated Goal (Client’s Description of the Goal): The client would like to increase comfort and decrease anxiety in social situations. The client’s job entails attend-ing several social functions each week, and they are necessary for his employment.

Target Behaviors (Described in Frequency, Duration, and Intensity): The client would like to be able to attend a social gathering; hold two or more conversa-tions (frequency), at least one of these with a woman; stay for a period of more than

TABLE 8.3 Goals, Objectives, and Interventions

Goal Objective Intervention

1. To be more assertive 1a. To be able to return an unwanted item to the store1b. To be able to say “no” to two people this week when someone asks me something I can’t do or don’t want to do (except my boss)

1a. Role-playing and imagery as practice in session1b. Discuss the elements of assertiveness in session and give homework assignment

2. To make more friends 2a. To ask one person this week to go for coffee and talk2b.To join a yoga class and talk to one person after class

2a. Role-playing in session

2b. Practice art of small talk in session

3. To improve relationships with my family

3a. To call my sisters once each week3b. To visit my mother one time each week and talk about positive things

3a. Helper will send e-mail reminder3b. Discuss the visit during each session, and examine and change the negative self-talk

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1 hour (duration); and maintain a subjective distress level (SUDS) of 3 or 4. (The SUDS level is the client’s feelings of discomfort in the situation and is measured on a 10-point scale of intensity, with 10 being the most uncomfortable and 1 being mildly uncomfortable.)

Baseline (Current Level of Target Behaviors): The client states that he can cur-rently remain at a party for only about 15 minutes before he has to leave. He can hold a brief conversation with a male co-worker, but has not recently talked to a woman in this setting. He currently experiences a SUDS level of 8 or 9 during social conversations with any woman.

Behavioral objectives have advantages in that they specify exactly what must be achieved in the helping process. Many helpers will be required to set behavioral objec-tives at their place of work because agencies use the numbers to quantify success.

MyCounselingLab Application Exercise 8.2 Identifying Well-formed Behavioral Objectives in a Case Example

ARE BEHAVIORAL OBJECTIVES THE ONLY WAY TO BE SIMPLE AND SPECIFIC? Various agencies seek to verify goal attainment in other ways, including client feedback forms, client satisfaction, and self-ratings by the client (Brady, Busse, & Lopez, 2014). Even when helping goals are not behavioral, they can still be simple and concrete (Goodyear & Bradley, 1986; Proctor & Hargate, 2013). For example, improving one’s relationship with a family member could be the goal but the specific objective might be, “Well, I would like to be able to politely stop her when she starts trying to give me advice.” As you can see this goal is not described in terms of frequency, duration, or intensity but it is simple and specific. Whether goals are described quantitatively or not, simple, specific goals make it easier for both helper and client to identify when helping is on the right track.

Goals Should Be Stated Positively

Frequently you will hear clients say they want to get over depression, stop drinking, stop binging on food, stop feeling anxious in social situations, reduce arguing, and so on. When goals are stated as negatives, they have less power to influence and motivate us. For example, I have heard it said that the goal of Alcoholics Anonymous is not “stopping drinking.” AA’s goal is to help people lead happy lives without alcohol. If you think about it, if we focus all our attention on “not drinking,” we are still focusing on drinking! Instead, setting a goal to lead a happy life without alcohol allows us to consider what things we would like to have in our lives, what people we would like to interact with, and many other possible futures.

Another way of looking at this is that the helper should try to turn problems into goals. It seems like a small difference, but it would be much better to develop a list of goals than a list of problems. Although we must be willing to understand what problems brought a client for help, we should eventually focus on where we want to go. Otherwise we spend too much time mapping the prison and too little time planning our escape. When a clear vision of success is formulated, it is easier to see the steps needed to attain it (O’Hanlon & Weiner-Davis, 1989). Here is a list of client problems and then the goals that a client might pursue to address these problems.

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Client Problem Changed to a Goal

Shyness I will be able to meet people and operate comfortably in social situations.

Low self-esteem I will be able to develop a list of positive mental sentences and encourage myself when needed.

Feelings of hopelessness I will pay attention to signs of hope and recognize positive emotions when they arise.I will be able to ignore negative thoughts and dispute them so that feelings of hopelessness are prevented.

Nervousness I will be able to calm myself in anxiety-provoking situations by relaxing.I will be able to recognize nervousness as a normal reaction and give myself positive messages to help me cope with these feelings.

Goals Should Be Important to the Client

Clients will be successful when they are pursuing goals that are important to them (Barbrack & Maher, 1984; Bruce, 1984; Evans, 1984; Hart, 1978; Lee, Uken, & Sebold, 2007; Miller & Rollnick, 2002; Schöttke, Trame, & Sembill, 2014). It seems obvious that clients will work harder when they are focusing on a goal that really matters to them. However, many peo-ple are referred by friends, families, courts, principals, or student judiciary boards to solve problems that the client has little or no interest in solving. In cases where the court orders treatment for a particular problem, neither client nor helper has participated in the goal-setting process, and neither may feel personally involved or motivated to achieve the aims. Clearly, the likelihood of success in these conditions is low. The third-party problem is evident in the example of a client who has been referred by a probation officer following an incestuous relationship. The probation officer wants the client treated for sexual dys-function to ensure that this kind of thing does not happen again. The client is divorced now and has had no contact with his teenage daughter, the incest victim. At this point, the cli-ent’s concerns center on forming new relationships and dealing with family members’ rejec-tion. He is not willing to rehash the incestuous relationship and is resentful of the helper’s intrusions. I use the example of incest because it seems so clear that this client has a prob-lem that needs to be treated, and yet we have little hope of making a difference if the client is not a partner in the process (Ritchie, 1986; Young & Robert, 2014). By enhancing the helper/client relationship and working on goals important to the client, the client with this kind of problem may open up later and deal with the problem. Goal setting that involves the client has ethical advantages as well because we are doing not only what we think is best for the client but also what the client wants to do (Brace, 1992; Tjeltveit, 2006).

Goals Should Be Collaboration between Helper and Client

Although helping should focus on what is important to the client, the evidence is clear that when helpers and clients reach consensus and collaborate on goal achievement, the chances of success are greatly enhanced (Tryon & Winograd, 2011). This means that helper and client have developed a joint project upon which they both agree, and this happens even when working with young clients (Rupani et al., 2014; Strong, 2009). Still,

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agreement upon goals is not a one-time event. Throughout the helping process, the best practice is to continually seek information from your client about his or her progress and the current relevance of the goals (Tryon & Winograd, 2011).

Goals Should Be Realistic

The helper’s expertise is important in defining goals when a client has unrealistic aims. Some-times the client has insufficient information about the self or about the issue. At other times, the client wants to accomplish two incompatible aims. For example, a client recently said, “I want to be better paid at my job, but I don’t want to work harder or give up my free time.” One method of dealing with unrealistic goals is to confront the client with the discrepancy. Another way is to invite him or her to explore the goal and collect information to see whether the goal is really possible. In some cases, it may be necessary for the helper to express doubts about the goal. Consider the following client statements and possible helper responses:

Example 1:

HigH ScHool Student: “I don’t like science or math, and I am not very good at them. My aptitudes in those areas are not very good, accord-ing to the national exams. I want to be a doctor because I need to have a good salary and I want to be respected as a professional.”

Helper: “It sounds like you want the status and the money that being a physician might bring, but you are not sure you have the ability or the interest needed for the training. Perhaps we need to look at both of these things a little closer.”

Example 2:

client: “I want to get my girlfriend back. She’s living with someone else right now, and she won’t even return my calls. She hates me because I was dating other people behind her back while we were going out. I still have a problem with being faithful to one person, but I know if I got her back, we could make it work.”

Helper: “I’m not sure that reuniting with your ex-girlfriend is a realis-tic goal. For one thing, you say you’re having trouble being with only one person, and, second, she is showing no inter-est in getting back together.”

Example 3:

client: “I want to stay married and enjoy the safety and security of the married relationship. Myra and I have a problem with communication, and that is something we can work on. But there is someone else that I am seeing right now. The excite-ment and romance is something that is missing in my mar-riage. I can’t hurt Myra or the kids by letting it come out in the open. So I have decided to keep it a secret. When Myra and I come in for marriage counseling, I don’t want to bring up this other relationship.”

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Helper: “I would like to help, but I don’t believe you can improve your marital relationship while you are carrying on a secret affair.”

When a client is operating with faulty information or is engaging in self-deception, as in the preceding cases, the helper uses challenging skills and helps the client gain self-knowledge or information about the problem that will help him or her set better goals. For example, in the case of the student who wants to be a physician, the helper might suggest the client gain experience and knowledge of medicine in several ways, including volunteering in a hospital, looking at the courses medical schools offer, and asking physi-cians directly about how important it is to enjoy and do well in math and science.

RESOURCES FOR IDENTIFYING AND CLARIFYING GOALS

Before leaving this discussion about the characteristics of goals, let us mention some tools that you might use if you were having difficulty identifying goals. These resources have a common purpose: to assist clients and helpers in evaluating and choosing clear, positive goals.

1. Books. A number of books are available that can help you find reasonable goals for all sorts of problems (e.g., Pascual-Leone, Singh, Harrington, & Yeryomenko, 2015). The Child Psychotherapy Treatment Planner by Jongsma, Peterson, McInnis, and Bruce (2014) lists a variety of problems that the helper might have identified during assessment, including depression, fire setting, low self-esteem, and school refusal. Goals, measurable objectives, and interventions are identified for each cli-ent problem.

2. Personal Projects Analysis (Little, Salmela-Aro, & Phillips, 2007; Salmela-Aro, 1992). Personal projects analysis is a fascinating system for analyzing and selecting one’s own personal goals. These goals may range from “being a better husband” to “improving my score on a video game.” Using a template, you select goals that you want to work on and then evaluate them based on their importance to you, the emotions involved, the effect on others, and other categories. For more information see: http://www.brianrlittle.com/Topics/research/personal-projects-analysis/

3. Identifying and Measuring Positive Life Goals.a. A measure to elicit positive future goals and plans (see Vincent, Boddana, &

MacLeod, 2004).b. The Self-Development Project List–90 (Braaten, 1989).

4. Measures That Help in Finding and Monitoring Goals for Counseling and Psychotherapy.a. Simplified Target Complaints Measure (Deane, Spicer, & Todd, 1997).b. Bern Inventory of Treatment Goals (Berking, Holtforth, Jacobi, & Kroner-Herwig,

2005).c. Simplified Personal Questionnaire Procedure (Elliott, Mack, & Shapiro, 2000).

This is a system for generating goals by using the clients’ own words, refining them, and prioritizing them.

Now that we have identified the aspects of constructive goals, we next discuss two goal-setting skills that helpers can develop to promote effective goals: using questions to identify a goal and boiling down the problem.

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THE TECHNIQUE OF USING QUESTIONS TO IDENTIFY A GOAL

During the goal-setting stage, helpers can use questions to home in on the problem. Questions can be used to reveal or uncover an underlying goal, make a goal more spe-cific, turn a problem into a goal, find out how important the goal is to the client, enhance collaboration on setting goals, and ensure the goal is realistic. Using questions to identify a goal helps to make vague goals clearer and is the first goal-setting skill covered in this chapter. Unfortunately, most helpers start questioning clients much earlier than at the goal-setting stage. You cannot set appropriate goals until after the client has told his or her tale and you fully understand the context. Then when you reach the goal-setting stage of the helping process, questions can help you get closer to what is really bother-ing the client. Keep in mind that the end goal of questioning is to arrive at a clear and concise goal.

Questions That Help Make the Goal More Specific

The following questions can help clients become more specific about both their goals and their objectives. Instead of the helper setting the goals, it is usually best to get the client to specify what he or she wants to achieve. The client is usually the best judge of what the next step should be.

• “What activities would help you reduce stress?”• “How often would you like to engage in stress-reducing activities?”• “How long would you like to meditate?”• “If your stress level at work is a 10 now, what level of stress would represent an

improvement to you?”• “I understand that you want to be ‘happy,’ but if you were happy, what would you

be doing that you are not doing now?”• “When you say things are not going well, specifically what things are you talking about?”• “You say you want things to be better in your relationship with your husband.

Specifically what would you like to be better?”• “You have said that you want higher self-esteem. How would you like to see your-

self exactly?”• “Once you said that you live in the past. Where would you like to live?”• “If we were going to make a small dent in this problem, what would it be?”

Can you see that these are reactions to vague client statements such as “I want to have better self-esteem”? The helper’s response of “How would you like to see yourself exactly?” requires the client to construct a clearer image of the future.

Questions That Help Turn a Problem into a Goal

These questions are useful when the client is clear that there is a problem but has not yet identified a goal. The helper can use these questions to change the focus away from the problem to a future without the problem.

• “If a miracle occurred while you were asleep and during the night your problem just vanished, what would be some of the things you would first notice that let you know the problem had disappeared?” (the miracle question; O’Hanlon & Weiner-Davis, 1989).

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• “You say that you and your husband argue constantly. If you were not arguing, what would you like to be doing?”

• “If the problem were solved, what would you be feeling, doing, or thinking that you are not now?”

• “If you were not procrastinating, what kinds of things would you be doing to get your work in on time?”

• “Suppose I gave you a job with all the money, benefits, and resources you required. Think about this for a moment and design your own job. Where would it be? With whom would you be working, and what would you be doing?” (Beck & Hoppock, 1998)

Questions to Determine a Goal’s Importance

Hidden in each of the following questions about a goal’s importance is an embedded message from the helper to the client. The message is, “We need to set goals that make a difference in your life.”

• “How likely are you to follow through with this goal?”• “How important is this goal to you?”• “If we accomplished this goal, what difference would it make in your life?”• “How likely are you to talk yourself out of trying to accomplish this goal?”• “Is this your goal, or is it something other people want you to accomplish?”

Questions to Enhance Collaboration on Goal Setting

We have said that collaboration leads to goal attainment. Here are some questions that helpers use to affirm that both parties are part of the goal contract.

• “I believe that it very important for both of us to be of the same mind when it comes to the goals we set. That is our best chance for success.”

• “I believe we both agree on the goals now. Do you think so?”• “Can you put the goals we have agreed upon into words so we both are on the

same page?”• “How do you think we could work together as a team on your goals?”• “Now that we have set some goals, what additions or corrections do you have to the

goals we have agreed on?”

Questions That Help Confirm That the Goal Is Realistic

Consider the following dialogue where the helper quizzes the client as to whether the solution he has chosen is realistic.

client: “So what I really want to do is move to Texas. Everything here has dete-riorated. I don’t have a job, no real relationship, no friends. I need to start over.”

Helper: “So is the real problem that you don’t think you have any direction in life right now and you think any change might help?”

client: “I don’t have anything to hang on to right now.”

Helper: “Do you think that moving to Texas will give you something to look for-ward to?”

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client: “I guess that’s it. I need to have some kind of future. Ever since my mother died, I don’t seem to have anyone to guide me. That’s why I came for help in the first place.”

Helper: “Would you say that the thing you need to do is find a direction in life more than just moving to Texas?”

client: “Yes, Texas just sounded nice. It was something to latch on to.”

Helper: “I am not trying to talk you out of moving to Texas. I just want to know what kind of goal makes the most sense. What would make the most dif-ference in your life right now?”

client: “I need to find a job with a future or go back to school for a different career.”

In this dialogue, the client has identified a solution to the problem of not having a direction in life. The helper uses questions to make sure that this goal is in keeping with what the client really wants. We have said that goals should be simple and specific, stated positively, important to the client, and realistic. It is this last criterion, a goal being realis-tic, that the helper is asking about. Is moving to Texas a realistic solution to the problems the client is facing? Rather than giving the client advice or being judgmental, the helper asks questions to make sure the client’s goal matches the proposed solution.

STOP AND REFLECT

There is a saying among career- and life-planning counselors that if you do not know where you are going, you will arrive somewhere else. The meaning is that if we do not set goals for our lives, other factors besides our own plans will intervene. A well-known football coach, Lou Holtz, has said, “Write down everything you hope to achieve in life, then make sure you do something every day to realize one of your dreams. You are going to encounter adversity but you will also . . . take big, sat-isfying bites out of life” (1998). At age 27, Holtz set 107 personal goals, which included meeting the pope, being on the Tonight show, having dinner at the White House, winning a national champion-ship, and coaching at Notre Dame. At last count, he had accomplished 102 of his goals. Now, think about your own life and write down a goal under each heading that you would like to accomplish in the next 5 to 10 years:

1. A job I would like to have:2. A project I would like to be involved in:3. The kind of friendship or intimate relationship I would like to develop:4. An area of learning I would like to master or a formal degree program I would like to complete:5. A hobby or interest I would like to develop:6. A way I would like to improve myself:

Next evaluate each of the goals that you have identified according to the following criteria:

a. Is the goal specific? Is it simple enough for an 8-year-old to understand?b. Is the goal stated in positive terms?c. How motivated are you to accomplish the goal?d. Is the goal realistic considering your abilities?

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• Choose one of the goals that appears to meet some or all of the preceding criteria and rewrite it in a simple, specific sentence or two. List the steps you must go through to accomplish this goal.

• As you look at the steps that you have identified, does the goal seem more manageable or more difficult now that it has been broken down into parts?

• Discuss this exercise with a friend who knows you well. Ask him or her to evaluate the goal as to how realistic it is and how clearly it is stated.

THE TECHNIQUE OF BOILING DOWN THE PROBLEM

Earlier, we identified some of the characteristics of constructive goals. Goals should be simple and specific, stated positively, important to the client, agreed upon collaboratively, and realistic. As you might expect, though, clients do not normally arrive with clearly defined goals. More often, they present tangled stories of feelings, people, and events that spiral in different directions. At some point, the helper must choose areas to develop and others to set aside for the moment. Just sorting the work into “piles” or cutting the job into “pieces” reduces client anxiety and offers fresh hope. Most of us are aware of the experience of motivation and relief that accompanies making a to-do list when we feel overwhelmed. Similarly, clients need to narrow down the list of issues and focus on one or two to begin with. This is the accomplished by boiling down the problem, the sec-ond goal-setting skill covered in this chapter.

One therapist used to say to clients, “Well, we’ve chased a lot of rabbits out of the bush; now let’s track down one or two of them.” This metaphor worked well to signal that a more specific focus was needed. Boiling down the problem is also a metaphor for this process. First, the client is encouraged to open up, and then specific issues are iden-tified and evaluated. Finally, the list is narrowed to a couple of the most critical. This process of eliminating some and focusing on others is particularly useful in crisis situa-tions. For example, in my work on a crisis hotline for 5 years I realized that clients were so oppressed by the weight of multiple problems that they could not see a way out. They found that just identifying the most crucial difficulty provided immediate relief and gave them hope that their other issues could also be attacked. The steps in boiling down the problem are as follows:

Step 1: Summarizing and Enumerating All the Issues. The helper uses summaries, reflecting skills, and paraphrasing to determine agreement on the overall content of the session to this point.

Helper: “So let me pull this together a little. You’re living at home and feel embarrassed because you think that you should be out on your own. The man you have been dating for a year has called it quits, and in the middle of all this upset, your teenage sister is causing turmoil in the home. Meanwhile your mother’s illness worries you. You’re feeling overwhelmed because everything has happened at once.”

tricia: “That’s about it. I’m living at home. My life is going nowhere, and right now everyone needs me to be strong.”

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Step 2: Asking the Client to Identify the Most Crucial Problems. Next the helper uses one or more closed questions to ask the client to evaluate which prob-lems are the most critical, thereby narrowing down the number of issues to be addressed.

Helper: “I realize that all these issues—your mother’s health, your sister’s prob-lems, getting over your boyfriend, and becoming financially able to have your own place—are important issues to you. Of these, which do you think are the most critical and are ones that we can deal with in these sessions?”

tricia: “There is nothing I can do about my mother’s illness, and, unfortu-nately, there is not much I can do about my sister, either. But I want to get on my feet financially and emotionally. I need help in thinking about where I am going in my career so I can earn enough to live on, and I’ve got to think about how I am going to make it through the next few months without my boyfriend. I need to focus on myself for a little while.”

Step 3: Selecting the Focal Problem. In this activity, the helper uses a mental checklist to evaluate client goals and advocates for those that are:

• Simple and specific• Important to the client• Mutually agreed upon by helper and client• Realistic

Helper: “So it sounds like one of the emergency issues is to help you find some ways to take care of yourself emotionally so that you can cope with your loss. At the same time, you want to look at the future a little bit, too. You want to explore some career ideas.”

tricia: “I know I can get some help with the career thing. I have an appointment with the community college to do some career coun-seling. The main thing is how I can deal with my angry and depressed feelings all the time. I am bored and angry and alone. I feel like a baby.”

Step 4: Changing the Problem to a Goal. In this step, the helper encourages the client to think about success. What will the problem look like when it is solved? This step helps us make sure that the goal is stated positively, one of the criteria for constructive goals.

Helper: “You have told me that you are in a lot of distress about losing your boyfriend, and we have discussed that topic pretty thoroughly. As you think about the future, I wonder if you can envision your life when this is no longer a problem. What would you be doing then that you are not doing now? What would you be feeling and thinking?”

tricia: “I would be going out with my friends and enjoying life again. I wouldn’t be thinking about him all the time, sitting there waiting for him to call. I would be able to concentrate at work.”

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Helper: “So these are the goals that you would like to work toward.”

tricia: “Sure!”

Step 5: Making Sure Client and Helper Are Clear and in Agreement. Here the helper summarizes the mutually agreed-upon goals. In addition, the helper may ask the client to state them aloud or write them down, so that the agreement is clear. At this point, clients often need encouragement and a message from the helper that the goals are reachable.

Helper: “Let’s see if I can restate the goals: You would like to go out with friends and enjoy life again, instead of spending so much time rumi-nating about your ex-boyfriend. Is that about right?”

tricia: “Yes, but it is not that easy.”

Helper: “I agree. It won’t be easy. Are we on the right track though? Are these your goals?”

tricia: “Yes.”

Helper: “Would you mind restating the goals as we talked about them so that I am sure we are both operating with the same understanding?”

tricia: “Okay, I am going to find a way to have fun again and spend time with friends again.”

Helper: “Like you said, it won’t be easy, but I am confident that you can make this happen. Let’s talk some more about how you can actually go about making this happen.”

MyCounselingLab Video Exercise 8.1 Identifying Well-formed Behavioral Objectives in a Case Example

SummaryThis chapter addresses two stops on the road map of the helping process—assessment and goal setting. Both precede the selection of specific techniques to achieve the client’s goals. We need information about the client and his or her problems in order to develop a uniquely tailored treatment plan. Gathering informa-tion begins the moment a client calls or walks through the door. We observe, ask questions, review tests, and receive medical data and reports from social service agencies. We may even interrogate family and friends. One of the pressures from the beginning is to organize the flood of information from multiple sources. This process involves listing problems and then organizing them in priority order. This is the process of treatment planning.

Assessment helps both client and helper. Assess-ment helps the client discover events that may be

related to the problem that he or she may never have identified or recognize issues that were previously hid-den. The helper uses assessment data to plan useful and realistic goals, identify the best treatment for the client’s particular problem, determine whether the cli-ent is suicidal or dangerous, and become aware of cli-ent strengths and unique attributes.

In this chapter, we also discuss the stage of goal setting and provide the following guidelines about appropriate goals: They should be simple and specific, positively stated, important to the client, set collabora-tively between helper and client, and realistic. In order to reach workable goals, we presented the techniques of using questions to identify a goal and “boiling down the problem.” Boiling down the problem is the step-by-step process for deconstructing a larger problem and targeting its most important aspects.

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Not all helpers agree that goal setting should be such an integral part of the helping process. We have tried to argue that goals provide structure for helper and that identifying goals makes problems seem man-

ageable. When helper and client agree upon the goals, they will know when it is time to end the helping rela-tionship. They are also creating a vision of success that will guide and motivate them.

Exercises

GROUP EXERCISES

Exercise 1: Practice Interviewing

In groups of three, one student acts as the helper, an-other as the client, and a third as the observer. Be-fore the interview, the client and observer identify and agree on a problem that the client is hoping to work on or that is fabricated for this exercise. The client should take a moment to look over the general categ-ories of the interview (ABC-1234) and think about an-swers to key questions. The client should retain his or her real identity so that the other aspects of the intake are authentic even if the problem itself is concocted. An ethical alert is necessary at this juncture. Collecting information about another person requires a reassur-ance that what you say will not be passed on to any-one else. Still, you must warn even a fellow classmate that you would have to report to your instructor any potential danger to self or others, the commission of a crime, or abuse of a child or elder. States vary slightly on what must be revealed but giving your fellow stu-dent this warning will be good practice and will pro-tect you and others. After the exercise, the client gives specific feedback to the helper on the following issues:

1. Was the helper able to intersperse questioning and listening? Or did the client find that the interview was too businesslike or too familiar?

2. Did the helper find the key problems? If not, why not?

3. What other suggestions do you have for the helper in terms of the quality of the interview?

Within your group, discuss the following questions:

• What important areas do you think are missing that you would have liked to explore?

• How long did it take to complete the interview?• Did the client react negatively to answering so

many questions? If so, how might this be handled better?

Exercise 2: Boiling Down the Problem

The purpose of this exercise is to practice the process of boiling down the problem to a workable agreement between helper and client. The activity involves a help-er and client and one or two observers.

To complete this exercise in a short period of time, the helper and client should spend only a small portion of the interview (perhaps 5 minutes) on the invitational and reflecting skills—just enough to enable the helper to understand the basics of the problem. The helper should then jump immediately into a discussion of goals. While client and helper are engaged in goal setting, one observer (see “Instructions to Observer 1” below) can write down any of the helper’s interventions that seem to help the client in setting the goal. A second observer (see “Instructions to Observer 2” below) writes down the final goal verbatim and facilitates a discussion about how closely the goal matches the ideal characteristics.

Part I: Instructions to Observer 1

Record what you believe are the key statements by the helper that help the client boil down the goal to a workable contract.

1. ___________________________________________2. ___________________________________________3. ___________________________________________4. ___________________________________________5. ___________________________________________

Part II: Instructions to Observer 2

Write down your understanding of the goal finally arrived at by client and helper.

Read this to the client and helper to determine whether your articulation of the goal is accurate. Then give the helper feedback on how closely the goal matches the following characteristics. Is the goal:

• Simple and specific?• Positively stated? (the presence of something

versus the absence of something)

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• One that the client is motivated to achieve?• Set collaboratively?• Realistic?

Exercise 3: Using Questions to Identify a Goal

Step 1 Form a group of at least seven students. The exercise begins with a helper and a client hold-ing a session about the client’s problem. The helper uses invitational, reflecting, advanced reflecting, and challenging skills where possible. After about 8–10 minutes, when the client has fully explained the problem, the action pauses.

Step 2 Each of the remaining members of the group is assigned to write down two questions that will help to refine the goal in each of the following categories:

Simple and Specific

For example, “You said your child’s behavior is ‘just awful.’ Can you tell me which behav-iors you are talking about?”

Stated Positively

For example, “What kind of interactions with her would you like to be having?”

Important to the Client

For example, “How motivated are you to achieve this goal?’

Set Collaboratively between Helper and Client

“Are we in agreement then, that this will be our approach to achieving your goals?”

Realistic

For example, “Will the goal you have set re-ally solve the problem?”

Step 3 The helper then asks these questions to the client in order. They may seem disjointed in this exercise because they are not part of the flow of the conversation.

Step 4 The entire group discusses whether these ques-tions helped to move the client to some clear, specific, positive, important, and realistic goal.

SMALL GROUP DISCUSSIONS

Discussion 1: Religious and Spiritual Beliefs

Religion is the social body associated with a set of beliefs whereas spirituality is an individual’s beliefs

about and experiences with a higher power. This chapter recommends asking clients about their reli-gious and spiritual beliefs. In a group of four or five, react to this suggestion. How comfortable would you feel assessing this area—even if you were an atheist or not religious or spiritual? How would you approach a client who is antireligious or simply nonreligious? Under what circumstances would you refer a client to clergy? If you were a client, how important would it be to discuss spirituality? For more information see the spiritual competencies on the website of ASERVIC, the Association for Spiritual, Ethical, and Religious Values in Counseling (www.aservic.org).

Discussion 2: Gender Issues in Assessment

Conduct a classroom discussion on gender issues in assessment. How does the interpretation of data vary based on gender? Are some behaviors seen as more pathological depending on the person’s gender? Are women generally seen as unhealthier than men? In your group, discuss the importance of including a discussion of gender-role issues in the assessment process.

Discussion 3: Constructing Behavioral Objectives

In a small group, see whether you can set one behav-ioral objective for each of these clients. Use the guide-lines given earlier in the chapter. To do so, you may have to invent some additional details.

1. Jack, age 11, is doing poorly in school, and his grades have dropped to “Ds.” He has difficulty paying attention for long periods and often gets out of his chair at inappropriate times. Jack says that he does not want to get into so much trouble in class and he wants to get at least “B” grades at school.

2. Mike came to see his helper due to problems man-aging his anger. He loses his temper with his wife, often yelling at her during disagreements over minor issues. His wife is considering separation. Mike wants to learn anger management and con-flict resolution skills.

Discussion 4: Ethical Issues in Setting Goals

There is an ethical principle that suggests we should respect a client’s autonomy or ability to decide for himself or herself what treatment to receive and what choices to make (Brace, 1992; Kitchener, 1984). Some

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206 Chapter 8 • Assessment and Goal Setting

helpers believe that no one should be forced to receive help by the legal system or those in authority. In your small group, discuss whether the helper has the right to set goals for the client. What if the person is ordered into treatment by a judge for a particular problem such as alcoholism or domestic violence? What is the ethical thing to do in such situations?

WRITTEN EXERCISES

Exercise 1: In-Basket–Out-Basket

It is important to reduce assessment data to a set of major issues, which is then placed on a problem list or in-basket (see Figure 8.3). When a list has been compiled, the help-er arranges the issues in order of importance and places the list in an out-basket. Items arranged in the out-basket list represent a treatment plan or goals placed in priority order. Consider the following issues in a client’s in-basket. Arrange them in the order that you would address them in an out-basket list. One guide for treatment planning is to think about Maslow’s hierarchy of needs. Maslow suggested that basic physiological issues such as food, clothing, and shelter must be dealt with before higher needs such as belongingness, love, and self-actualization.

In-Basket

a. The client wishes to develop a better relation-ship with his two children who live with his ex-wife.

b. The client is a recovering alcoholic but has not been attending support group meetings.

c. The client has been experiencing mild depression.

d. The client has difficulty with his supervisor and is considering changing jobs.

e. The client has an interest in drawing and paint-ing and would like to consider a career in this area.

f. The client indicates he feels lonely and isolated since his divorce one year ago.

Defend your choices in a sentence or two.

SELF-ASSESSMENT

Self-Assessment 1: Assessment

In reviewing my assessment skills, I feel I need more work on: (Check all that apply.)

1. Using questions appropriately2. Observing

3. Interviewing and recording information4. Using standardized tests

For those items that you checked, indicate how you might gain additional experience or training.

Self-Assessment 2: Goal Setting

1. On a scale from 1 to 10 (1 = just beginning and 10 = mastery), indicate how well you think you have developed the skill of using questions to identify a goal. When answering, think about your practice sessions as well as your answers to the exercises in this chapter.

1 2 3 4 5 6 7 8 9 10

Just beginning Mastery

2. Indicate how well you think you are able to nar-row the client’s story to simpler goals or “boil down” the problem.

1 2 3 4 5 6 7 8 9 10

Just beginning Mastery

3. Now rate yourself on your ability to write construc-tive goals.

1 2 3 4 5 6 7 8 9 10

Just beginning Mastery

4. State two things you feel that you were able to improve upon this week. Recall feedback from fel-low students or instructors and write it down. Include all feedback even if it does not relate to the skills of this chapter.

5. Which skills are you finding to be the most difficult to understand and practice?

6. Identify two steps you can take to help you improve your skills further. Identify concrete actions you are willing and able to take.

HOMEWORK

Homework 1: HIV-Positive Client

Search the Internet for reputable resources for dealing with people who are HIV positive (www.kidshealth.org or www.aids.gov are good places to start). What limita-tions do such people experience? What mythologies affect the way people look at them? What challeng-es would this present socially and professionally for an affected person? Looking at the various websites,

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what must a helper know about current treatment, test-ing, and prevention? How would you feel about work-ing with someone who tested positive for HIV? What issues might you expect him or her to bring to the helping session?

Homework 2: Assessment of Children

Do a brief research study on the symptoms of de-pression in children. Use articles, books, and Internet sources. What is different about the way that children express and experience depression? What treatments are available?

Homework 3: Changing a Problem to a Goal

When you are learning to boil down a problem, one aspect that takes practice is changing a problem to a goal. Create two short dialogues between client and helper whereby the client is helped through the five steps of boiling down the problem: (1) summariz-ing all the issues, (2) asking the client to identify the most crucial problems, (3) selecting the focal problem, (4) changing the problem to a goal, and (5) making sure that the client and helper are clear and in agree-ment. After each dialogue, identify the problem as

stated by the client and the goal as reformulated by the helper.

JOURNAL STARTERS

1. Think back on assessment experiences in your own life. These may range from encounters with a high school guidance counselor to an intake inter-view at the college counseling center to a College Board Examination (GRE, SAT). What important decisions have you made based on testing or assessment results? What decisions have others made about you based on testing? Discuss any negative or positive experiences. How do these affect your views and feelings about testing clients?

2. Consider a personal problem that is currently trou-bling you. Respond to the question “How will I know when the problem is gone?” Reflect on what you will be doing differently, what you will be thinking, and what others will notice that is differ-ent about you. How will you feel when the prob-lem is gone? Comment on this exercise. Do you think it might be helpful in goal setting for a client to imagine a future without the problem?

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208

What Are Change Techniques?

REPLAN and the Common Therapeutic Factors• Understanding the Factors or Major

Components of the REPLAN Model• How the REPLAN System Helps You Plan

Treatment• Using the Common Therapeutic Factors• Steps in Treatment Planning Using the

REPLAN Model

Enhancing Efficacy and Self-Esteem• Sources of Low Self-Esteem• Silencing the Internal Critic: The

Technique of Countering

Practicing New Behaviors• Role-Playing• Giving Homework Assignments as

Practice

Lowering and Raising Emotional Arousal• Reducing Negative Emotions• Reducing Anxiety and Stress• Raising Emotional Arousal and

Facilitating Expression• Creating Positive Emotions

Summary

Exercises• Group Exercises• Small Group Discussions• Self-Assessment• Homework• Journal Starters

Change Techniques, Part I

C H A P T E R 9

LEARNING OUTCOMES

By the end of this chapter, you will be able to:

9.1 Use the REPLAN system for treatment planning in a case example.

9.2 Understand and practice the steps for performing the following techniques: role-playing and relaxation training.

9.3 Identify the steps for teaching clients countering, thought stopping, meditation, and gratitude.

9.4 Formulate homework plans for clients based on case studies.

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Chapter 9 • Change Techniques, Part I 209

WHAT ARE CHANGE TECHNIQUES?

We have thus far focused on the helping skills that involve inviting, opening, reflecting, challenging, and goal setting. Each of these categories has smaller building blocks. When the honest, collaborative relationship is established, and a treatment plan has been devel-oped, helper and client turn to the business of accomplishing the agreed-upon goals. Figure 9.1 shows the next stop on the road map of the helping process: intervention and action. This is when appropriate change techniques are implemented. Change techniques are helping skills employed during the intervention and action phase that are designed to create movement and growth toward the achievement of the client’s goals.

As the road map indicates, selection of an intervention is not the initial thing that you do in the helping process. First you develop a relationship, then do an assess-ment, and then select goals. Only after these things have been accomplished are you able to identify the tools necessary for a successful outcome. But there are literally thousands of techniques. Where should you start? If you are comfortable working with a particular theory, the techniques you select will most likely be associated with that theory. But if you want to utilize techniques from other theories, you must find a way to incorporate them in a rational and systematic way. So, is there a method of reviewing a variety of sources to then choose what is best for the client without being haphazard?

STARTHERE

STOP

Relationship Building

Assessment

GoalSetting

Interventionand

Action

Evaluationand

Reflection

FIGURE 9.1 Road Map of the Helping Process: Intervention and Action

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210 Chapter 9 • Change Techniques, Part I

One metaphor for analyzing your selection of techniques comes from quilt making. There are two ways to make a quilt. Either you pick up the pieces nearest to you and sew them together, hoping they will fit when the quilt is done, or you start with a pattern and find the pieces that fit into your design. Creating a design at the very beginning is the systematic kind of treatment planning we recommend in this book. It begins with the agreed-upon goals chosen by helper and client and leads to selecting methods and tech-niques that are aimed at those goals. This is not a trial-and-error method that starts when a helper hears about a new technique and just starts experimenting with it. Instead, according to this method, called the REPLAN system, the helper looks to the six common therapeutic factors that we discussed in Chapter 2 as a way of fulfilling the client’s goals. The REPLAN method of treatment planning recommends that the helper reflect upon the background of the client and the client’s problems and initially choose the common therapeutic factors to employ before identifying a specific technique.

REPLAN AND THE COMMON THERAPEUTIC FACTORS

As we discussed in Chapter 2, a common therapeutic factor is a common or underlying element that explains why many different techniques seem to be effective. This theory suggests that all the methods that helpers use are actually evoking the healing potential in one or more of these common factors. The concept of common therapeutic factors is useful simply because it provides a way of organizing the techniques you are learning and because it will help you to think about the purpose of the techniques you are choos-ing. The whole range of helping skills and techniques can be linked to one or more of these six factors, and this provides you with a rational way to home in on the special techniques that might be effective for your client. These are the big things or macro skills that all helpers use. For the sake of convenience, we refer to each of the factors by a let-ter. Together, they form the acronym REPLAN, which is a way of remembering them when we think about planning the course of helping.

Understanding the Factors or Major Components of the REPLAN Model

R 5 MAINTAINING A STRONG HELPER/CLIENT RELATIONSHIP The therapeutic alliance was discussed in Chapter 2 and in later chapters when you learned invitational and reflecting skills. Enhancing the helper/client bond involves both the helper’s use of the nonjudgmental listening cycle (NLC) and the client’s willingness and ability to enter the relationship. Differences, transference, countertransference, and misunderstandings can cause ruptures in the therapeutic alliance, which must be repaired. Not only must the helper provide a therapeutic atmosphere, but he or she must also take into account the client’s unique background, family, religion, and culture that can influence his or her reaction to the helper and to the helping process.

E 5 ENHANCING EFFICACY AND SELF-ESTEEM There are techniques to improve a client’s confidence in his or her abilities and also aid in dealing with an underlying lack of self-worth. Nearly all helpers agree that improved self-esteem is a desired goal, but changing a client’s long-held beliefs about the self is a challenge. In this chapter, you will learn the change techniques of countering, a form of positive self-talk, and thought stopping to silence the internal critic.

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P 5 PRACTICING NEW BEHAVIORS Just like playing the piano, many newly acquired skills need practice. For example, clients may learn communication techniques to improve the couple relationship, but they need to practice both within sessions and between sessions so that the new skills are firmly established. Many practice techniques are available to strengthen fragile new learning. In this chapter, you will learn the change techniques of role-playing and giving homework assignments to help clients practice new behaviors.

L 5 LOWERING AND RAISING EMOTIONAL AROUSAL Clients are often struggling to quell strong emotions and to express hidden feelings. But clients also need to build a bank account of positive emotions to counteract negative feelings and broaden their coping repertoires. In this chapter, you will learn the quieting techniques of deep muscle relaxa-tion and meditation and the change technique of gratitude to increase positive emotions.

A 5 ACTIVATING CLIENT EXPECTATIONS, HOPE, AND MOTIVATION The next chapter addresses how a helper can motivate a demoralized client. Here you will learn the change technique of encouragement as well as the use of questions to motivate change.

N 5 PROVIDING NEW LEARNING EXPERIENCES Also in the next chapter, we look at the vast category of change techniques that give clients insight and information. A great deal of what helpers do involves stimulating new learning and creativity by provoking insight, directly teaching social skills, and getting clients to see their problems from a more con-structive perspective. The major techniques you will learn in this category are giving advice (which is often misused), giving information, brainstorming, and reframing.

How the REPLAN System Helps You Plan Treatment

There are many different methods for treatment planning. Most people are familiar with the diagnostic treatment planning method. This is the medical methodology that begins by assessing the client and arriving at a diagnosis. The diagnosis then becomes the basis for determining what treatment the client will receive. For example, if you have major depression, you receive a certain treatment; if you have obsessive-compulsive disorder, you receive another. In this model, accurate diagnosis is crucial because it determines treatment (cf. Antony & Barlow, 2010; Frances, 2013).

Alternatively, many clinicians construct treatment plans based on the theory to which they subscribe. The techniques one eventually chooses may come from the person-centered, gestalt, Adlerian, psychodynamic, or behavioral theories. As indicated earlier in the book, there is good reason to think that an integrative approach to treatment planning is useful, particularly early in training. Even before a helper is entrenched in a particular theoretical viewpoint, he or she can utilize the techniques of different theories with a systematic framework as a guide.

The REPLAN system does not conflict with making a DSM diagnosis or using theo-retically oriented models, but it does assert that even clients with the same diagnosis may need different treatments. Therefore, using REPLAN, treatment strategies must be tailored to the client’s goals and unique characteristics rather than to a specific diagnosis.

Finally, I believe it is critical that to take into account whether or not a technique is backed with some kind of supporting evidence. Such evidence might be research,

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acceptance by experts, or information that a new technique is a very promising practice (Boyd-Franklin, Cleek, Wofsy, & Mundy, 2013). By all means no technique on a list of discredited treatments should be considered (e.g., Norcross, Koocher, & Garofalo, 2006).

Using the Common Therapeutic Factors

This brings us to how the six common therapeutic factors can help us structure a gen-eral treatment plan. Previously, we stated that the first step in treatment planning is to make a list of problems collaboratively with the client. The next step is to order the problems in priority, choose one or more problems to focus on, and then identify techniques to address these problems (Woody, Detweiler-Bedell, Teachman, & O’Hearn, 2003). Take a look back at Figure 8.3 where the process of placing prob-lems in priority order and matching them with treatments is shown graphically. But how do we match them with treatments? The REPLAN model’s spelling out of the common therapeutic factors in a certain order provides a framework for the big aims of helping.

The REPLAN system is distinguishable from other forms of treatment planning because it focuses on relatively few client goals, using strategies associated with one or two common therapeutic factors. This makes it a brief treatment model. This approach has the benefit of focusing clients on a few goals at a time, rather than planning an elaborate treatment regimen that may collapse over time as the client’s situation changes. The approach is not incompatible with long-term therapy, but it approaches client prob-lems as distinct goals that must be regularly evaluated and replanned. Replanning occurs frequently during the helping process because client goals shift as some problems are resolved and new insights on old problems emerge.

Steps in Treatment Planning Using the REPLAN Model

The three basic steps in REPLAN treatment planning are:

1. Formulate mutually agreed-upon treatment goals, as a result of assessment, that are understandable to both client and helper. These goals are then boiled down to a workable, solvable form and placed in priority order.

2. Use the common therapeutic factors (maintaining a strong helper/client relation-ship; enhancing efficacy and self-esteem; practicing new behaviors; lowering and raising emotional arousal; activating client expectations, hope, and motivation; and providing new learning experiences) to generate a list of possible treatment strategies or techniques to achieve the goals.

3. Replan the treatment on a regular basis, say, every 6 weeks, to move new problems into focus as old issues are resolved.

Once an overall treatment plan has been constructed, the helper generates a list of potential techniques by asking two questions:

1. “What common therapeutic factors are most likely to help the client reach the goals?”

2. “What strategies, methods, or techniques will be most effective (based on research or wide acceptance by the therapeutic community), culturally appropriate, and acceptable to the client?”

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To illustrate how this works in practice, let us look at the case example of Matthew, a 25-year-old single white male, a chemist, who is shy and wishes to meet and date women but has not been successful. Matthew’s main problem is anxiety in social situa-tions. Together he and the helper, Nadia, identify the following positive goal: to be able to go out with a woman and have fun. To initiate the REPLAN method, Nadia asks herself, “Which common therapeutic factors would be most helpful for Matthew in achieving his goal?” She believes that the therapeutic relationship is firmly established, but because of the nature of the problem and her knowledge of Matthew, she develops a treatment plan that also reminds her to keep tabs on ruptures in the relationship.

It also seems clear that practicing new behaviors and providing new learning expe-riences would be critical because the client’s goals involve acquiring new behavior and new ideas. Now that Nadia has identified the major common therapeutic factors, she asks herself the second question, “What specific methods under these common thera-peutic factors would be most effective with Matthew?” She consults her initial assess-ment, taking in all that she knows in terms of his abilities, culture, religious background, and history (ABC-1234). She then selects strategies to evoke the common therapeutic factors. Table 9.1 shows the first draft of the treatment plan that she developed for Mat-thew using the REPLAN method. Note that the treatment plan contains explicit goals for the relationship as well as other common therapeutic factors.

In summary, the notion of common therapeutic factors is a way of identifying what the client needs and selecting a general approach to attending to the client’s problems. The use of REPLAN is a way of reflecting on what would best help the client. It is a heuristic, or a method for stimulating thinking about possible techniques to employ. Then the helper nar-rows down the list of potential techniques based on the client’s needs and background. The rationale for this kind of approach is that it encourages the helper to consider a wider variety of planned interventions than a theoretically oriented or a diagnostically oriented treatment planning model, and it asks the helper to be culturally sensitive, thinking about what will work for this unique client. In this chapter, we will be looking at three common therapeutic factors. Table 9.2 shows the factors and the associated techniques you will be learning.

TABLE 9.1 Treatment Plan for Matthew

Goal First Objective Common Therapeutic Factor Change Technique

Possess better interpersonal skills

Be able to demonstrate nonverbal listening skills

Providing New Learning Experiences

Teach basic communication theory, listening, and self-disclosure

Be able to ask someone out for a date

Ask someone out for coffee

Practicing New Behaviors Role-playing in the office prior to homework

Maintain an honest relationship with the helper

Client will report both successes and failures in his attempts to deal with anxiety

Relationship Remain vigilant to ruptures in the relationship because the client is sensitive to being pushed

MyCounselingLab Video Exercise 9.1 Writer’s Block

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ENHANCING EFFICACY AND SELF-ESTEEM

Although the REPLAN system starts with “R” for relationship, we have already discussed the importance of the therapeutic alliance in Chapter 2 and presented techniques to enhance the relationship using the nonjudgmental listening cycle (NLC). The next com-mon therapeutic factor we take up is “E,” which stands for enhancing efficacy and self-esteem (see Figure 9.2). Gordon Allport highlighted the importance of self-esteem in mental health in 1955, and now there is wide agreement that a positive self-concept is a

TABLE 9.2 Common Therapeutic Factors and Associated Techniques

Common Therapeutic FactorTechniques Associated with the Factor in This Chapter

E 5 Enhancing Efficacy and Self-Esteem CounteringThought Stopping

P 5 Practicing New Behaviors Role-PlayingHomework

L 5 Lowering and Raising Emotional Arousal Deep Muscle RelaxationMeditationGratitude

Loweringand RaisingEmotionalArousal

Activating ClientExpectations, Hope,

and Motivation

EnhancingEfficacy

andSelf-Esteem

PracticingNew

Behaviors Maintaining aStrong Helper/

Client Relationship

ProvidingNew

LearningExperiences

FIGURE 9.2 Therapeutic Factors in the REPLAN System: Enhancing Efficacy and Self-Esteem

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keystone of mental health and that raising self-esteem is a fundamental task of helping (Carlock, 1999; Dubois, Flay, & Fagen, 2009; McKay & Fanning, 2005; Nordstrom, Goguen, & Hiester, 2014). For example, Carl Rogers focused on reducing the gap between one’s perceived self and one’s ideal self. Adler felt that a clear sign of mental health was defined as “faith in oneself.” Likewise, low self-esteem has long been identified as a cause of or contributing factor in many psychological diagnoses and symptoms, especially depression and anxiety (Michalak, Teismann, Heidenreich, Ströhle, & Vocks, 2011; Rosenberg, 1962; van Tuijl, de Jong, Sportel, de Hullu, & Nauta, 2014). Improvements in self-esteem have been associated with greater psychological health in relation to a wide variety of stressors and psychological problems (Dubois et al., 2009; Hewitt, 2009), includ-ing substance abuse (Backer-Fulghum, Patock-Peckham, King, Roufa, & Hagen, 2012; Sharma, 2013).

Despite high interest and considerable research, the concept of self-esteem has been attacked as too vague, as over popularized, and as a cure-all for problems. One way of clarifying the concept is to recognize that self-esteem has two aspects: efficacy (com-petence) and self-worth (Branden, 1969, 1971, 1994; Witmer, 1985). Efficacy or self-efficacy is an expectation that one can perform a specific task (Bandura, 1982, 1997). For example, when an experienced driver sits behind the wheel of a car, he or she feels a sense of confidence or expectation that driving a car is a manageable task. Efficacy is tied to specific activities, though it may generalize to similar situations. It is also subject to modification by experience. Having an auto accident could undermine one’s sense of efficacy as a driver. Many clients are afraid to try new activities because of past failures. Likewise, individuals with low self-esteem often do not pay sufficient attention to suc-cesses and improvements, tending to focus on their losses and failures. They may possess needed skills but do not recognize these abilities and strengths. The helper, by focusing on strengths and competencies, enhances the possibilities for success and improved self-esteem (Thompson, 1991).

In contrast to efficacy, self-worth is a global feeling that one has the right to exist, that one is basically good and is worthy to live. In short, it is self-approval. It is the sum total of one’s attitudes about the self: the fundamental belief that one is “okay” or “not okay” (Berne, 1972). It is possible to have efficacy (feel competent) in a number of skills and still experience low self-worth. As helpers, we often meet intelligent, attractive, and talented individuals whose major problems are deeply held negative beliefs about them-selves, despite their obvious competence.

STOP AND REFLECT

Ten Things I Can’t Do

Self-esteem can be improved by increasing client self-efficacy and self-worth. For a moment, let us focus on efficacy, the feeling of competence. Efficacy is increased when clients recognize their current abilities or learn new skills. Helpers give clients these opportunities in session and in homework. The chances that a client will attempt a new activity are increased if he or she engages in warm-up activities,

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including thinking about, talking about, and visualizing the new behavior. To become more familiar with this process, try the following:

1. Make a list of 10 things you cannot do at the present time but would like to be able to do. For example, your list might include:

“I would like to learn to swim.”

“I would like to ask someone out on a date.”

“I would like to be able to use a spreadsheet on the computer.”

“I would like to be able to learn ballroom dancing.”

“I would like to be able to speak a little Spanish.”

For this exercise, do not include personal qualities that you would like to develop or global statements about self-worth such as “I would like to be more patient” or “I would like to be a better person.”

2. Once you have developed a list of 10 items, place the letter T next to each item if you have talked to a friend or family member about engaging in this activity. Place the letter V if you have ever visualized or daydreamed about yourself performing this task. Place the letter M for “models” if you have seen other people perform this task on several occasions. Place the letter A next to each task that you have attempted to perform in the last year.

3. It is thought that a person is more likely to engage in a new behavior if he or she gets ready by talking about it, visualizing it, and watching the behavior being modeled. Conversely, when we have not readied ourselves through these activities, we are farther away from actually attempting the behavior. Look at your list and decide whether your answers confirm this “readiness hypothesis.” Identify one or two behaviors that have the fewest letters next to them. Which letters are missing? The missing letters should indicate which activities you can initiate if you wish to increase your readiness.

4. Do you think you might experience any change in your self-esteem if you were able to engage in all the activities on your list? What factors impede a person’s ability to recognize his or her competence?

5. Compare your answers and your reactions with those of others in your training group.

Sources of Low Self-Esteem

IRRATIONAL BELIEFS Irrational beliefs are self-destructive ideas that lead to low self-esteem (Daly & Burton, 1983). They cause us to suffer emotionally, but they are so firmly entrenched that they are difficult to challenge and expunge. Albert Ellis (1973) ascribes low self-esteem to a set of “nutty beliefs” about the self and the world. It is not our expe-riences that keep us in a state of low self-esteem, but our ideas that hold us there. For example, Ellis asserts that it is not a black cat that makes us afraid but the belief that a black cat causes bad luck. If we rid ourselves of irrational beliefs and develop more real-istic ones, we reduce our emotional turmoil.

Although we each probably have something unique about our belief systems, Ellis found that most people’s irrational ideas fall into some broad categories, and he has iden-tified seven of the most common:

1. The idea that it is a dire necessity for an adult human to be loved or approved of by virtually every significant other person in his or her life

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2. The idea that one should be thoroughly competent, adequate, and capable of achieving in all possible respects to consider oneself worthwhile

3. The idea that certain people are bad, wicked, or villainous and that they should be severely blamed or punished for their villainy

4. The idea that it is awful and catastrophic when things are not the way one would like them to be

5. The idea that human unhappiness is externally caused and that people have little or no ability to control their terrors and disturbances

6. The idea that it is easier to avoid life’s difficulties and self-responsibilities than to face them

7. The idea that one’s past history is an all-important determinant of one’s present be-havior and that, because something once strongly affected one’s life, it should defi-nitely continue to do so (Ellis, 1973, p. 37)

In order to improve client self-esteem, helpers assist clients to identify and chal-lenge irrational beliefs and to replace them with more reasonable and realistic ideas. Try to counter the preceding ideas with something more rational. For example, one could substitute Irrational Idea 1 with “I would like it if most of the people I value, loved or approved of me in return, but that is not something I can control.”

BODY IMAGE Psychological literature tells us that attractiveness is a valuable social asset (Adams, 1977) and that feeling unattractive is often equated with low self-esteem (Greenspan, 1983). Those with high self-worth generally feel good about their bodies. Those who do not like their bodies tend to be negative about themselves as a whole. An individual may have poor body image because of a physical disability, a difference, or a lack of attractiveness by media standards. Although, in the past, low self-esteem associ-ated with body image may have been mainly the province of women, men’s magazines now reflect that society has chosen some male ideals as well. Today men are expected to have “washboard abs” and other perfect features that provide a negative comparison for the average person. Body-image dissatisfaction is a particular problem of adolescent girls because of weight gain at that time of life (Choate, 2013).

On the other hand, some clients have the wrong perception of their bodies; for example, seeing themselves as fat when they are thin. This kind of distorted body image might be a symptom of more serious psychological syndromes, especially eating disor-ders (Baird & Sights, 1986; Choate, 2008, 2013). The belief that one must be perfect is probably behind this powerful dissatisfaction that propels starvation, causes self-induced vomiting in extreme cases, and engenders low self-esteem, anger, and distress even in those without major emotional problems (Thompson & Thompson, 1986).

STOP AND REFLECT

One way to increase self-esteem is to ask clients to pay more attention to their strengths and abilities. Because helping is a profession where success with clients is not often immediate, even helpers need to pause and reflect on their accomplishments and positive qualities from time to time. Take this moment to reflect on your own personal assets.

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A Self-Esteem Personal Inventory1. Write down eight personal characteristics that you are proud of. For example, you may be

creative, organized, humorous, goal oriented, and so on.2. List eight things that you do well.3. Write down a few compliments about yourself that you hear from friends and family. What are

the good things people say about you?4. List three occasions when you feel that you have truly helped another person.5. List the top three accomplishments of your life so far.6. Write down three things that you like about your body.7. When you wrote these down, there may have been an internal critic that argued that these

things are unimportant, common to everyone, or in some way disqualifying your strengths. Did you hear this voice?

Keep your answers in mind when you answer this next set of questions:

• Now that you have completed this exercise, conduct a brief scan of your emotional state. Do you notice any difference in the way you feel?

• Were there any answers you felt reluctant to write down? Were you apprehensive about “bragging”? What are the rules in your own family or culture governing when it is all right to give yourself a compliment?

• If you were given this assignment as a client, how do you think you might have reacted?• Which question was the most difficult to answer? Why?• If you had been asked to list your negative qualities, would it have been easier or more difficult

to answer?

Silencing the Internal Critic: The Technique of Countering

In this section, we will learn one key method for increasing client self-esteem: countering, which is a cognitive therapy technique for decreasing the internal critical voices that depress performance and create negative emotions. Certainly many clients will also ben-efit from assertiveness training and other behaviors that silence external critics, but the first step is to decrease the disapproval that is coming from our own mental activity. The change technique of countering means finding alternative thoughts to combat self- disapproval.

Before one can experience self-worth, it is often necessary to silence the internal critic, the “voice in the head” that reproaches and finds fault. This critic is probably cre-ated early in life through interaction with family and failure to meet self-imposed stand-ards (McKay & Fanning, 2005). These irrational beliefs persist as silent sentences that the individual repeats in the mind and sometimes even aloud. Characteristically, these thoughts tend to occur automatically. For example, before giving a speech, the following thought might occur: “I am going to get up and make a fool of myself.” The negative thought leads to negative emotions of anger, depression, and lowered expectations of the self. Thus, before self-esteem can be built, it is often necessary to reduce the power of the internal critic and to modify these self-statements (Dowd, 1985). As we mentioned earlier in this chapter, Ellis’s method (called rational emotive behavior therapy, or REBT) helps clients classify their beliefs as one of about seven major persistent irrational ideas. Then

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the helper uses rational argument to try and convince the client to abandon his or her “nutty thinking.” The technique of countering is a constructivist version of Ellis’s tech-nique. By that I mean that instead of asking the client to use rational arguments against nutty ideas, the countering technique is based on the idea that each person’s belief struc-ture is different and the most effective arguments will be found in the client’s unique worldview. In countering, clients experiment with different arguments and use those that work for them.

HOW TO COUNTER Countering is a term coined by McMullin (2000). Countering means identifying the discouraging or self-downing statements a person says to himself or her-self and replacing them with equally powerful affirmations. The countering method has five steps:

Step 1: Do a brief assessment. Once helper and client have agreed that negative self-talk is a problem, it is critical to determine the frequency of the negative self-statements and their effects on the client. For this purpose, ask the client to engage in self-monitoring activities, writing down the frequency and types of self-downing thoughts. Typically, the client carries an index card in a pocket, wallet, or purse and notes each time a self-criticism is made. The client writes down the exact words of each self-criticism and the negative emotions these thoughts provoke. The client brings the card back to the next session and dis-cusses the thoughts he or she has noticed. The self-criticism card serves three functions: It gives client and helper more data about the problem; it helps the client make the connection between negative self-statements and the feeling states they produce; and it makes the client become aware of the thoughts. Just as noting the number of calories consumed per day can decrease snacking, becoming aware of self-downing can lead to less negative thinking. Clients begin to “catch” themselves.

Step 2: Identify the negative thought patterns and core beliefs. Once the client has completed at least a week’s worth of self-monitoring, the major negative thought patterns and core beliefs about the self may be identified. Together, helper and client look at the self-monitoring material and choose a few negative patterns to focus on. Often three or four general ideas (or core beliefs) about oneself come to the surface—for example:

“I am not disciplined and never get anything accomplished.”

“I am disorganized.”

“I’ll never be able to reach my goals.”

Step 3: Identify effective counters. The counter can be a phrase, a sentence, or a single word such as “nonsense.” The counter is a way of talking back to one-self and disputing the self-criticism. A counter is considered to be effective if it neutralizes the criticism. Effective counters are usually those that are consist-ent with the client’s own beliefs rather than those on a list supplied by the helper.

Together, client and helper brainstorm a number of possible counters, and the client selects several with which to experiment. Here is an example of a self-criticism and a list of counters generated by client and helper:

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Self-Criticism Counters

“I am stupid.” 1. “I have always performed well in school; there’s no evidence for this.”2. “Feeling stupid doesn’t mean I am stupid.”3. “That’s something my dad always told me. But it’s not true!”4. “Not true!”

Step 4: Test counters and modify them. The next stage in the process of eliminating self-criticism is to evaluate the effectiveness of the counters that the individual has practiced since the last helping session. One method for evaluating the potential effectiveness of a counter is for the helper to test the counter with the client during a session. First the client selects a statement from a list of self-criticisms and reads it aloud to the helper. After making the self-criticism, the client rates his or her emotional reaction to the criticism on a 10-point or 100-point SUDS (Subjective Units of Discomfort Scale). On the SUDS, a score of 100 (or 10) equals high emo-tional distress and 0 equals no emotional distress. Next the client reads a counter from the list that was brainstormed earlier and again rates his or her feelings of distress after saying the counter. In the following example, the client learned that this self-criticism was very disturbing (80) and that the counter was very effective because it reduced the strength of the emotional reaction to about 20.

Self-Criticism Counter

“I am stupid.” “I have always performed well in school; there’s no evidence for this.”

SUDS after self-criticism—80 SUDS after counter—20

Step 5: Practice and report. Once the client has identified some effective counters for one or two negative thoughts, the client is asked to practice countering and report at the next session. At follow-up sessions, the helper and the client gauge progress and continually seek more effective counters. The client is asked to notice whether negative thoughts have become less frequent.

MyCounselingLab Video Exercise 9.2 Countering

PROBLEMS AND PRECAUTIONS WHEN TEACHING THE COUNTERING TECHNIQUE Ineffec-tive counters should be discarded, and the client should be prepared for the fact that some counters are more potent than others. The client can be asked to modify the coun-ter slightly in any way that might refine it or make it more effective. The helper should also suggest any personal words or phrases that might produce more self-confidence. For example, one client found that introducing each counter with “Clearly . . .” gave the counter more power for her.

Counters should be realistic. They should not be simply positive thinking or “affir-mations,” but should actually dispute the negative ideas. A statement such as “Every day, in every way, I’m getting better and better” is a “pep talk” without real substance; it is not tied to any particular self-criticism. Remember that some negative self-statements are quite persistent, and it may take months to eliminate these insidious automatic thoughts.

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McMullin (2000) suggests that the counter should be in the same mode as the thought it is disputing. Negative visual images should be countered with positive visual images. Angry thoughts should be countered with compassionate ones and “passive thoughts with assertive ones” (p. 5). Also, shorter counters tend to be more effective than longer ones.

A VARIATION ON COUNTERING: THOUGHT STOPPING Sometimes clients are troubled by unwanted thoughts and images that create anxiety and depression and damage self-esteem. Unwanted thoughts and images may be memories of failure or concern about upcoming events. We are all familiar with lying in bed at night thinking about all the upcoming responsibilities. Once such thoughts get started, they snowball, creating more and more anxiety unless we have the skills to suppress our thinking when it gets out of control. Thought stopping has been used to treat all kinds of recurring thoughts, includ-ing about smoking (Dodgen, 2005) and obsessive-compulsive disorder (Hannan & Tolin, 2005). Experienced therapists use thought stopping to treat their own distracting thoughts, boredom, and negative self-talk during therapy sessions (Bakker, 2009; Williams, Polster, Grizzard, Rockenbaugh, & Judge, 2003).

Compared with the developing of counters, thought stopping can be considered more of an emergency measure to halt the flow of negative messages. The helper teaches the client the technique in the office, and the client practices it whenever a severely dis-turbing thought arises. Three steps in the thought-stopping technique have been identi-fied (Davis, Eshelman, & McKay, 2000; Lazarus, 1971; Witmer, 1985):

1. Stating the thought2. Creating a startling interruption3. Substituting a new thought

Once the troubling thought has been identified, the client is asked to label and state it either mentally or aloud—for example, “I have to get an A on this paper!” This repeti-tion brings the thought into clearer focus. The client then creates a startling response strong enough to interrupt the negative thinking pattern. One practical method when practicing thought stopping privately is to yell “Stop!” as loudly as possible. In public, it is best to say “Stop!” mentally. You also might want to imagine a huge red stop sign. Some helpers suggest wearing a rubber band around the wrist and snapping it along with a mental “Stop!” to produce the startle effect.

The final step in thought stopping is to insert a positive thought to replace the irra-tional, self-downing thought. This can be either a spontaneous or a planned counter that the client produces to counteract the negative thought. In this case, the substituted thought might be something such as, “I’m not going to worry about the grade. I’ll do the best that I can.” But the selection of the proper counter is based on what works for the client.

PRACTICING NEW BEHAVIORS

The third common therapeutic factor in the REPLAN system is “P” for practicing new behaviors (see Figure 9.3). Practice has always been a part of a “psychoeducational” approach to helping (Guerney, Stollack, & Guerney, 1971; Schutz, 1981; Young & Rosen, 1985). The major idea is that many client problems are due to skill deficits. Clients need to gain some basic knowledge about the problem, see models of the behavior they are

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trying to acquire, and then rehearse. They may use imagery as a rehearsal (McEvoy, Erceg-Hurn, Saulsman, & Thibodeau, 2015; Pierce, 2006; Suinn, 1996; Witmer & Young, 1985) or even technology such as video and computer simulation (Smokowski, 2003).

Some of the skills that clients need to practice include parenting, communicating better as a couple, facing fearful situations, dealing with anger, and developing more effective ways of thinking. As an educator, the helper cannot be content for the client to temporarily eliminate a problem behavior or merely gain insight into the fact that he or she is operating in a self-defeating manner. Clients must overcome the force of old habits by establishing a new pattern of behaviors through practice and rehearsal.

The best instruction for any skill includes the following sequence: (1) The helper explains a theory or rationale for learning the new skill, (2) the learner views a model (helper or group member) who correctly demonstrates the skill, (3) the learner demon-strates the behavior in the real or simulated situation by practicing in class, and (4) the learner practices through homework assignments. For example, if you were learning to play the guitar, the instructor might explain the fingering using a chart or graph. Then the instructor would probably demonstrate how the piece is to be played, or you might listen to a recording of the selection. You would then attempt the music with the instructor present, and later you would be sent home to practice. The process of acquiring a new behavior or a new thinking pattern takes place in much the same way. Helpers use each of these steps when teaching a new skill: explanation of theory, modeling, in-session practice, and homework. In this chapter, we will focus on two specific methods used to aid clients in practicing new skills: role-playing and homework.

PracticingNew

Behaviors

ProvidingNew

LearningExperiences

EnhancingEfficacy

andSelf-Esteem

Loweringand RaisingEmotionalArousal

Activating ClientExpectations, Hope,

and Motivation

Maintaining aStrong Helper/

Client Relationship

FIGURE 9.3 Therapeutic Factors in the REPLAN System: Practicing New Behaviors

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Role-Playing

Role-playing is a change technique commonly used by helpers for social skills train-ing and in helping clients face situations they are avoiding (Kipper, 1986, 1996). It involves practicing a behavior in a contrived situation with the helper playing an aux-iliary or observer role. It may also take place in a group setting with other participants who can give valuable feedback and act as auxiliaries or actors in the play. For exam-ple, clients might wish to learn to refuse requests, express themselves to others, talk in front of an audience, confront someone, or tell someone their true feelings. Role-playing can be used as a rehearsal for these new behaviors. It has been employed in a variety of settings with many different types of clients from group work with children (Borbely, Graber, & Nichols, 2005) to training students in family therapy (Browning, Collins, & Nelson, 2005) to working with clients with phobias (Martinez, 2002). Virtual role plays utilize computer technology or video and allow clients to learn in a simu-lated environment about issues such as how to cope with anxiety (Powers & Emmelkamp, 2008) or respond to sexually threatening situations (Jouriles, Rowe, McDonald, Platt, & Gomez, 2011).

Role-playing was introduced by the creative genius J. L. Moreno, a Viennese psy-chiatrist who formulated the psychodramatic method (see Blatner, 2000). On one occasion, following a lecture by Freud, Moreno is said to have responded, “Well, Dr. Freud, I start where you leave off. You meet people in the artificial setting of your office. I meet them on the street and in their home, in their natural surroundings. You analyze their dreams. I try to give them the courage to dream again” (Moreno, 1964, pp. 5–6). Moreno’s response reflects his belief that helping should involve learning in as naturalistic a setting as possible. Part of what Moreno objected to in traditional therapies was the separation of a client’s problems from the natural environment, just as a religious sculpture or painting cannot be fully appreciated in a museum but must be seen in a church or temple. Because it is not always possible to see individuals in their natural contexts, the psychodramatic method proposes to re-create an individu-al’s joys and sorrows on the psychodramatic stage (Starr, 1977). Moreno’s famous dic-tum was, “Show me; don’t tell me!” He felt that most “talk therapies” relied on the client’s descriptions of problems. Because we cannot reach into the subjective experi-ence of the person through words, we should transfer the mind onto the stage where the person’s total behavior, including thoughts, feelings, and intuitions, is observable and changeable. Those who want to learn more about the basics of psychodrama should consult Adam Blatner’s book, Acting-In: Practical Applications of Psychodra-matic Methods (1996), and Show and Tell Psychodrama by Carnabucci (2014). Kipper and Ritchie (2003) have summarized research on the effectiveness of psychodramatic techniques.

ELEMENTS OF ROLE-PLAYING The technique of role-playing is a limited form of psycho-drama, and an understanding of the whole theory of psychodrama is not necessary. Role-playing can be performed by a single individual (the protagonist), who plays all the roles in the drama, or with the help of other individuals called auxiliaries. Role-playing has always been conceived of as having three phases: warm-up, action, and sharing and analysis (Yablonsky, 1976).

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THREE PHASES OF PSYCHODRAMATIC ROLE-PLAYING

Warm-up. The warm-up is any activity that helps the client get in touch emotion-ally with the experience he or she is trying to express. The warm-up decreases stage fright and allows the protagonist to develop readiness and involvement in the process. If you think about it, most of us have warm-ups, or rituals, we use to prepare for action. For example, the runner does stretching exercises, the actor rehearses lines, and the com-petitive skier mentally runs the course. In role-playing, proper warm-up is crucial to the success of the technique. Warm-up might include asking the protagonist to discuss the situation or encouraging some physical activity, such as pacing back and forth.

Another way of warming up is to use role reversal. In role reversal, the helper instructs the client to pretend to be the other person and respond as he or she might. For example, the client changes places and sits on the chair that previously repre-sented his mother. He responds as his mother might in a similar circumstance. Role reversal is one of the most effective ways of getting the client involved in the role play. Besides, role reversal makes the situation more real. The client is required to construct possible responses of a significant other and devise strategies to cope with them.

“Move from the periphery to the center” is a tip for helpers about how to get a client more involved in the role play. It is a suggestion to begin with tangential events before moving to more significant or central issues. For example, if the role play involves return-ing home to see a dying grandfather, the helper would not begin with the deathbed con-frontation, but would move the client through several less potent scenes. In this case, these scenes might include driving to the house while reminiscing about the relationship or replaying previous encounters between grandparent and grandchild. This method also gives the helper more information about the client and the client’s relationships and life circumstances. With sufficient warm-up, the client overcomes stage fright and is more in tune with the actual role play when it takes place.

Action. After the warm-up, the helper asks the client to take on his or her own role and enact the situation. Scene setting is the preliminary step of this action phase. It involves asking the protagonist to set up the stage to resemble the actual setting where the incident took place or where the behavior will possibly occur in the future. The client is given free rein to use available props and to orient the stage in whatever way feels comfortable. The helper assists the client in defining the stage, designating the time of day and date, describing the situation verbally, using props, and identifying important people to be portrayed.

Sharing and Analysis. In group therapy, the sharing phase of role-playing allows the individual to reenter the group situation; that is, to get out of the spotlight. Instead of the client sharing more about his or her experience, the other group members use this opportunity to relate personal experiences evoked by the client’s role play. This tech-nique re-involves the audience and helps the client feel less alone and exposed. At some later time, a feedback or analysis session is held, during which members give feedback to the client and the role play is discussed, but not immediately after the action phase.

HOW TO CONDUCT ROLE-PLAYING Role-playing is one of the most effective ways of prac-ticing a new behavior. The immediate observation and feedback allow for actual practice,

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not simply talking about problems. At a deeper level, role-playing and role reversal can help the individual to become more fully aware of feelings and to explore the phenome-nological worlds of the significant people in his or her life. The method described here is a generic role-playing technique for practicing new behavior. To make the method easier to understand, a hypothetical example unfolds throughout the explanation. For the sake of simplicity, this example will show what it is like for a helper to conduct role-playing in an office setting rather than in a group session. The client, Martin, is anxious because he has to give a presentation to his board of directors concerning progress on his yearly goals. The helper, Patrick, suggests that they role-play the situation to rehearse his talk.

Step 1: Warm-up. In the warm-up, Patrick previews and explains the purpose and the elements of role-playing. Using the principle of proceeding from the periphery to the center, Patrick begins the warm-up by asking Martin to discuss aspects of his job that he will be presenting, details of the workplace, and other tangential top-ics. The most important aspect of this step is for Patrick to get Martin to describe the target behaviors very specifically. In this case, Martin wants to:

1. Maintain eye contact with his audience2. Speak from notes in a loud, clear voice3. Smile when questions are asked4. End the session by thanking the audience

Step 2: Scene setting. After Martin has discussed the situation, he appears more relaxed. Patrick then invites him to describe his own office (peripheral) and later the board meeting room (central). Patrick lets Martin set the scene, rearranging Pat-rick’s office furnishings to approximate the setup of the boardroom. Patrick encourages Martin to point out various features, such as the color of the walls and the furniture, to establish the scene.

Step 3: Selecting roles and role reversal. In this step, the client identifies important people in the scene and briefly describes them. In a group setting, other mem-bers of the group would be assigned to these roles. In an individual session, empty chairs represent these significant persons. For example, Patrick asks Martin to reverse roles and pretend to be his boss to get a sense of the boss’s demeanor and attitude. He also asks him to point out the chairs of some of the other board members and briefly describe those people.

Step 4: Enactment. At this point, the helper asks the client to briefly portray the target behaviors as described during the warm-up. In Martin’s case, the scene begins in his office and culminates with his entrance into the “boardroom.” Patrick acts as a coach during the first run-through, prompting Martin to display each identified behavior. The helper is dissatisfied with Martin’s portrayal of the final behavior, thanking the audience. Patrick stops the action and takes on Martin’s role to model an effective closing statement. Following the modeling, Patrick asks Mar-tin to try the closing a second time in his own way using whatever parts of Pat-rick’s closing he liked.

Step 5: Sharing and feedback. In this step, the helper shares feedback with the client. The feedback should be specific, simple, observable, and understandable to the client. It should mainly reinforce positive aspects of the behavior. In our example, Patrick tells Martin, “Your voice was very strong and clear. I think you got your

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points across very well. I would like to see even more eye contact with the board members during the next run-through.”

Step 6: Reenactment. Reenactment is a repetition of the target behavior from entrance to exit. The sequence is repeated until the client is confident that each of the behaviors in the target list has been mastered.

Step 7: Homework and follow-up. At the next session, the client is asked to report practice results. Martin has practiced the behavior by giving the presentation to some family members, and he describes this to Patrick. Further role-playing prac-tice may be given during the session, if necessary. When the helper feels that the client has consistently demonstrated the target behaviors, the helper urges the client to attempt the behaviors in a real situation.

PROBLEMS AND PRECAUTIONS WITH ROLE-PLAYING

1. The most frequently encountered difficulty with the role-playing technique is stage fright. Resistance to the technique is ordinarily the result of insufficient warm-up, inadequate preparation time, the client’s lack of confidence, or inadequate reassur-ance by the helper.

2. Because of the power of the technique, both the helper and the client may be unprepared for the strength of the emotion that is sometimes evoked. This is unlikely when using role-playing for practicing a new behavior. Beginning helpers should not attempt to reenact traumatic scenes from the past.

3. Because most helpers focus on the client’s thoughts and feelings, we sometimes have trouble thinking in dramatic terms. Usually the client is encouraged to describe an encounter and the client responds with something like, “I was angry because she neglected me.” In a role-playing session, the client would be instructed, “Show me how you expressed your anger to her.” By creating a dramatic situation, the helper learns a great deal about the quality and context of the behavior, rather than just the client’s description of it.

Giving Homework Assignments as Practice

Homework has been identified as a crucial tool in effective helping (Kazantzis & L’Abate, 2011; Miller, 2010). Homework refers to any tasks or assignments given to clients to be completed between sessions (Last, 1985). More than 80% of mental health practitioners in one study used between-session homework (Kazantzis, Busch, Ronan, & Merrick, 2007). Some tasks are used for assessment purposes; others are used to increase client aware-ness of the behavior (Martin & Worthington, 1982); still other homework assignments are designed as independent practice sessions. In this section, the main emphasis will be on homework that is used to practice new behaviors, in other words to serve as a change technique (Kazantzis & Lampropoulos, 2002). These new behaviors are normally learned during the therapeutic session and may be modeled or rehearsed in the office before they are assigned as homework. Review of homework provides a starting point for each new session with a review of progress made and problems encountered in the assignment.

REASONS FOR USING HOMEWORK A major advantage of using homework assignments is that they provide follow-up or treatment continuance between sessions. When one real-izes that a client spends 1 hour out of about 112 waking hours per week in a therapeutic

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session, it is easy to see how insights from the helping session can be diluted by other activities. Homework assignments, especially if they require some daily work, can enhance treatment (Cronin, Lawrence, Taylor, Norton, & Kazantzis, 2015; Strong & Massfeller, 2010).

In addition, homework assignments turn insights into tangible behaviors and pre-vent helping from being only a place to unload one’s feelings. Transfer of training or generalization of learning is facilitated by applying descriptions and models of behavior to real-life situations as soon as possible. Homework practice also begins the shift of con-trol from the helper to the client. If the client attributes progress to his or her own effort in outside assignments, greater efficacy and self-esteem will result.

EXAMPLES OF HOMEWORK ASSIGNMENTS

Use of Aides. One way to increase the efficacy of homework practice is to enlist the help of a client’s friend, spouse, or family member as an aide who provides either feedback or support for completing assignments. Generally, an aide comes to at least one session with the client. The helper specifically identifies the aide’s role as either feedback or support. Let us say that the client is attempting to become more assertive. The helper gives the aide specific verbal and nonverbal behaviors to observe and to report observa-tions to the client. Alternatively, the aide might simply be enlisted to provide support or to accompany the client while he or she completes assignments. The client who is attempting to exercise regularly may use an aide as a regular walking partner. The aide would help the client increase regularity and provide encouragement from session to ses-sion. The major pitfall of using aides is that they must be supervised by the helper. Some-times aides are too helpful and wish to take excessive responsibility for the client. If this behavior cannot be modified, the client should proceed alone.

Self-Monitoring Assignments. Journaling is a daily writing assignment given to the client by the helper. Ordinarily, the client brings the journal to the next session for the helper’s reaction. Journals usually serve one of two purposes. First, helpers use this kind of journaling for spiritual issues (Wiggins-Frame, 2001), in school counseling (Zyromski, 2007), and even in couples work (Lemberg, 1994). In addition to written journals, thera-peutic blogs are now common (Lent, 2009; Strang, 2013), and e-journals are used in counselor training to reflect on personal growth experiences (Haberstroh, Parr, Gee, & Trepal, 2006; Miller, 2014).

Although expressive journaling can be beneficial, because we are focusing on prac-ticing new behaviors, let us instead discuss the second purpose of journaling as a way of recording practice sessions or self-monitoring. In this type of journaling, the client keeps track of practice successes and also reflects on progress. This might include writing down negative thoughts (cognitive), recording the amount of emotional discomfort (affective), or noting the number of times a new behavior was actually practiced (behavioral). In this vein, consider the following case study of Joe, a 29-year-old administrator for an insur-ance company who has come for help to deal with problems associated with “stress.” He has borderline high blood pressure, is often tense and angry after work, and as a result, sometimes becomes rude to his fiancée, alienating her. He plays racquetball competi-tively, and last week he purposely broke an expensive racquet after a bad shot. He wishes to control his anger and feel less “stressed” at work. During the assessment, the counselor identified negative self-statements as a major cause of the client’s stress and felt

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that, in general, the most useful path for Joe was to increase the common therapeutic fac-tor of self-esteem. Joe agreed but also felt he needed better organizational skills. The initial plan was negotiated as a two-pronged attack: to decrease self-criticism and to develop better time management and organizational skills. Joe enrolled in a 3-day time management workshop sponsored by his company and, at the same time, began keeping a record or Self-Criticism Homework Card, as shown in Table 9.3. Figure 9.4 contains two graphs. The first is of Joe’s SUDS levels, and the second shows negative self-statements over the first 10 days. (As noted earlier, SUDS is an acronym for the Subjective Units of Discomfort Scale.) In this case, 0 represents no discomfort, and 100 represents extreme distress. Using a homework card, Joe found that he was producing anger by his self-statements, which were first aimed at himself and sometimes directed at innocent bystand-ers. Joe agreed to continue to monitor his self-statements for 2 more weeks and noticed a marked diminishing of his self-criticism. In Joe’s case, there seemed to be a correspond-ence between his self-criticism and his emotional discomfort. Although the major purpose of keeping this journal was to encourage practice, the client also developed insight into the way he maintained his anger. Notice also that, like most people, Joe’s emotional dis-comfort did not take a steady downward course but shows the normal ups and downs of the change process.

PROBLEMS AND PRECAUTIONS WITH HOMEWORK

1. Choose homework assignments that have a high probability of success (Dyer & Vriend, 1977). This is true especially early in the helping relationship in order to keep the client’s hope alive. Also, by promoting small, easily completed goals, the client begins to learn that most change is gradual, not an overnight phenomenon.

2. Homework strategies should be individually tailored for each client (Miller, 2014; Scheel, Hanson, & Razzhavaikina, 2004) and should be co-created with the client

No. Time Self-Statement Feeling SUDS

1. 8:15 I’ll never get all this work done. Discouraged 85

2. 9:00 I didn’t do a good job on that report. Disgust 50

3. 10:00 I’ll never be good at this job. I’m just average and that’s all. Self-pity 60

4. 10:35 I’m daydreaming again. Why am I so lazy? Anger 35

5. 12:00 I offended the secretary again. Why can’t I just keep my mouth shut? Anger 45

6. 1:00 I feel fat after eating so much. I’m turning into a blimp. Disgust 35

7. 2:40 Another day almost done, and I’ve completed nothing. Anger 40

8. 3:30 My desk is a mess. What a slob! Discouraged 50

9. 5:15 Even my car is full of trash. I wish I were more organized. Anger 25SUDS 5 Subjective Units of Discomfort Scale0……………………………………………………………………………………………………………………………………………………………………………..100No emotional distress Extreme emotional distressEmotions 5 fear, anger, sadness, guilt, interest-excitement/boredom, joy, disgust, surpriseSummary 9 5 negative self-statements; average SUDS 5 47 (approx.)Most prevalent emotion 5 self-anger/disgust

TABLE 9.3 Self-Criticism Homework Card for Joe

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100

90

80

70

60

50

40

30

20

10

Average SUDS Level

Day10 2 3 4 5 6 7 8 9 10

20

18

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14

12

10

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NegativeSelf-Statements

Day10 2 3 4 5 6 7 8 9 10

FIGURE 9.4 Graph of Daily SUDS Levels and Critical Self-Statements for Joe

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whenever possible. Too often, the helper uses a standard homework assignment that, to the discouraged client, may feel impersonal. By stretching one’s creativity, some assignments can incorporate more than one of the client’s goals. If the client likes to read, recommending self-help books as homework might work well. If the client enjoys writing, assign a journal.

3. Practicing regularly is important. It would be better, for example, if the client per-forms a rehearsal for 10 minutes once per day, rather than practicing for an hour once per week.

4. Homework should be simple and fit easily into the lifestyle of the client. Compli-cated homework involving extensive record keeping may not be completed.

5. As the client progresses, homework should increase in difficulty or discomfort. Clients usually have a feel for when they are ready for more challenging tasks and for tasks that are presently beyond them.

MyCounselingLab Application Exercise 9.1 Selecting Practice Methods and Choosing Homework

LOWERING AND RAISING EMOTIONAL AROUSAL

The fourth common therapeutic factor in the REPLAN system is “L” for lowering and rais-ing emotional arousal. The overall purpose of this set of change techniques is to reduce the impact of negative emotions and to increase positive emotions. This is accomplished in three different ways:

1. Reduce negative emotions: Helpers are called upon to help clients reduce over-powering feelings of depression, anger, stress, and fear, primarily through methods of stress reduction and cognitive techniques.

2. Facilitate expression of strong emotions that are being ignored: At other times, helpers arouse emotions to act as catalysts for change: for example, helping a client get in touch with repressed anger or sadness and allowing him or her to recognize the powerful nature of unresolved feelings.

3. Activate positive emotions: Helpers also facilitate positive emotions such as joy, gratitude, serenity, interest, hope, pride, amusement, inspiration, awe and love, trust/faith, compassion, gratitude, and forgiveness (Frederickson, 2009; Vaillant, 2013). Positive emotions also tend to weaken negative ones.

In this section, we will address each of these methods for raising or lowering emo-tional arousal and identify some key techniques that helpers use in each circumstance.

Reducing Negative Emotions

The three most common negative emotions that clients seek help for are depression/guilt, anxiety, and anger. Earlier in this chapter, you learned the countering technique, which is used to help clients reduce self-criticism. Reducing negative thinking also tends to reduce depressive feelings, and cognitive therapy has been a well-researched method for treating depression, by psychological means, since the early 1990s.

Although depression, anxiety, and anger are treated differently, we only have room here to talk about one of these troubling emotional states, so we have chosen to present

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techniques for coping with anxiety. Anxiety is a very common complaint, and there are several basic anxiety-reducing techniques that can be learned and applied rapidly. In this section, we present two methods, relaxation training via muscle relaxation, and medita-tion, which are both effective and low-risk.

Reducing Anxiety and Stress

Although a little anxiety may actually enhance performance at times, it can easily run out of control, causing distress and interfering with relationships and job performance. Modern life, with more crowding, more work pressure, and more choices, has led to greater stress levels for just about everyone. The emotional arousal associated with anxiety or fear may have been useful in more primitive times because the “fight or flight” syndrome chemically sparked physical readiness to deal with potential harm. What once may have increased the chances for survival now threatens our health, because the physiological by-products of stress cannot be easily dissipated in a sedentary lifestyle. Today’s helper is frequently called upon to help clients learn to reduce the causes of stress by helping them acquire time man-agement skills; develop habits for self-care, including exercise and good nutrition; and gain a healthier outlook on life. In addition, helpers assist clients in lowering stress by reducing emotional arousal through quieting techniques. Helpers also need to sustain their own mental health by utilizing stress-reducing resources (Lawson & Myers, 2011).

Some of the better-known methods for reducing anxiety and stress are systematic desensitization for phobic anxiety (Wolpe, 1958), applied relaxation (Clark et al., 2006; Donegan & Dugas, 2012), progressive relaxation (Jacobson, 1938), coping skills training (Frydenberg & Brandon, 2002; Tubesing, 1981), guided imagery (Apóstolo & Kolcaba, 2009; McEvoy et al., 2015; Singer, 2006; Witmer & Young, 1985, 1987), confession/ ventilation (Menninger, 1958; Pennebaker, 2002), enhancing social support (Gilliland, James, & Bowman, 1989), stress inoculation (Israelashvili, 1998; Meichenbaum, 1993; Novaco, 1977, 1983), biofeedback training (Fair, 1989; Fedotchev, 2010; Stevens, Hynan, Allen, Beaun, & McCart, 2007), mindfulness (Call, Miron, & Orcutt, 2014), and meditation (Aftanas & Golosheykin, 2005; Bogart, 1991; Burns, Lee, & Brown, 2011; Carrington, 1998; Gutierrez, Conley, & Young, 2016; Shapiro, 1994; Singh, 2012; Young, de Armas DeLorenzi, & Cunningham, 2011). These techniques are frequently combined and offered in a psych-oeducational format as stress reduction or coping skills training courses (Nickel, 2007).

The most fundamental and time-honored method for helping clients reduce arousal is relaxation. Relaxation training brings about relief from symptoms of anxiety and lets clients experience the positive sensations associated with lowered muscle tension (Pag-nini, Manzoni, Castelnuovo, & Molinari, 2013). This technique is explained in detail here because it is part of most stress reduction programs and forms the basis of systematic desensitization and biofeedback training.

RELAXATION TRAINING Edmund Jacobson’s progressive relaxation technique (1938) was, for many years, the favored method for teaching clients deep muscle relaxation. Muscle relaxation had been found to reduce anxiety in clients with phobias by pairing relaxation with exposure to fearful stimuli, a process called systematic desensitization. Jacobson’s method, if faithfully followed, enables the client to identify and relax every major muscle group in the body. The traditional training process may actually take sev-eral months in weekly sessions, although abbreviated versions have been used success-fully (Gatchel & Baum, 1983; Harris, 2003). Following is a simple and even briefer format

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developed by Witmer (1985), which can be learned in three or four sessions, each lasting about 20 minutes. Every session is identical and provides a complete tensing and then relaxing of all the major muscle groups (see Table 9.4). Please note that for most prob-lems, relaxation alone is probably not as effective as a treatment program that also incor-porates mental or cognitive control of anxious thoughts such as thought stopping or countering (Donegan & Dugas, 2012; Hinton, Hofmann, Rivera, Otto, & Pollack, 2011; Stevens et al., 2007). Still, relaxation training has been consistently shown to work as a treatment for various kinds of anxiety and can easily be included as an adjunct to other quieting strategies.

The Technique of Deep Muscle Relaxation.

Step 1: Preparation. Ask the client to find the most comfortable position with eyes closed. This may be sitting or lying down, but in either case, there should be sup-port for the head. The legs and arms should not be crossed. The procedure is

A. Hands and Arms

Hand: The back of your hand, fingers, and the wrist

Lower Arm: The forearm and the wrist

Upper Arm: The bicep muscles

B. Head, Face, and Throat

Forehead and Scalp: The entire forehead and scalp area

Eyes and Nose: The eyelids and muscles around the eyes, nose, and upper cheeks

Mouth and Jaw: The area around the mouth and the lower face

Throat and Jaw: Muscles inside the mouth and throat

Entire Head and Facial Area

C. Neck and Shoulders

Neck: The muscles in the back of the neck, at the base of the scalp, and across the shoulders

D. Chest, Shoulders, and Upper Back

Muscles in the Chest, Shoulders, and Upper Back Area

E. Lower Back, Stomach, and Hips

Lower Back: The muscles across the lower back area

Stomach and Hips: The muscles in the abdominal area and hips

F. Hips, Legs, and Feet

Hips and Upper Legs: The muscles in the upper and lower parts of the thighs

Lower Legs: The muscles from the knees to the ankles

Feet: The muscles around the ankles, over the top of the feet, the arch and ball of the feet, and the toes

G. Body Review

Sense any places where tension still resides and then tense and relax that area again.

TABLE 9.4 Areas to Tense and Then Relax

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best practiced without the distractions of noise or glaring lights. Instruct the client to speak as little as possible and to avoid moving except as necessary to achieve a more comfortable position. The client may be instructed to raise one finger to indicate when an instruction has been understood or completed.

Step 2: Tighten and relax. Ask the client to progressively tighten and then relax each muscle group in Table 9.4. There are a variety of ways to move the body to tense each area. Experiment and allow the client to try out his or her own ways of tens-ing that area but not to hurt himself or herself. Encourage the client to hold each tensed muscle about 6–7 seconds until the experience of tightness is fully felt. If the posture is held too long, cramps and spasms may result. While a muscle group is tensed, ask the client to focus attention on that area, simultaneously relaxing other parts of the body and holding the breath. After tensing the muscle group, the client is asked to relax and breathe diaphragmatically to let go of all muscle tensions. It may take some time to learn how these muscle groups are properly tensed.

Step 3: Relax fully and breathe. Following the tensing of a muscle group, instruct the client to exhale and relax fully and completely. This relaxation is to be accompa-nied by slow, deep, diaphragmatic breathing and should last 20 seconds or so. The tension and relaxation of the same muscle group is then repeated before moving on. Diaphragmatic breathing consists of inhaling and exhaling below the ribs rather than in the upper chest. It is the relaxed breathing demonstrated by sleeping babies and practiced by singers. Help clients learn diaphragmatic breathing by placing one hand on the chest and the other on the diaphragm/stomach area. Diaphragmatic breathing occurs when the stomach hand goes up and down but the chest hand remains relatively immobile.

Step 4: The body scan. The most important phase of the lesson is the body review, or body scan. This phase is critical because the client is learning to self-monitor. In this step, the client is asked to return to specific, discrete areas of tension during the relaxation procedure and to relax them. This allows the helper to individual-ize the relaxation so that the client can spend time on the areas that he or she tends to tighten. Tell clients that a body scan can be used on their own, at any time during the day, to check bodily tension.

Step 5: Assign practice. The first administration of the relaxation technique should be recorded for the client, or a standardized commercially available version of the technique should be provided. Ask the client to practice the relaxation technique twice daily, usually once upon rising and once in bed before falling asleep. Have the client note which of the six areas of the body show the greatest sources of tension during the day, and ask the client to report this information at the next session.

MEDITATION FOR LOWERING EMOTIONAL AROUSAL AND INCREASING POSITIVE EMOTIONS Meditation may be one of the most effective means for decreasing anxiety, panic, and persistent anger and depression (Burns et al., 2011; Kabat-Zinn et al., 1992; Lane, Seskevich, & Pieper, 2007; Young, 2012). Moreover, meditation is not merely a method for reducing tension; it actually produces positive states of happiness, alertness, improved concentration, fearlessness, optimism, joy, and feelings of well-being (Chandler,

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Holden, & Kolander, 1992; Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008; Singh, 2012; Smith, Compton, & Beryl, 1995). Meditation has been used to treat and prevent substance abuse (Dakwar & Levin, 2009; Gelderloos, Walton, Orme-Johnson, & Alexander, 1991; Shafii, 1974, 1975; Young et al., 2011; Zgierska et al., 2009). Along with prayer, meditation is a key tool in the 12 steps of Alcoholics Anonymous. Meditation is utilized in about 60% of addiction treatment programs (Priester et al., 2009).

There are several forms of meditation, but we will talk about two: mantra medita-tion and mindfulness. Mantra meditation has a long history in Western and Eastern thought. A mantra is a word or phrase repeated slowly and at intervals, mentally, not aloud but with the “tongue of thought” (Singh, 2012). For those who are spiritually inclined, any name of God can be used. Others have found it effective to repeat a word such as one or peace (Benson, 1984). If you are interested in learning more about mantra meditation, read Rajinder Singh’s book Inner and Outer Peace through Meditation (2003). It contains complete and simple instructions for spiritual meditation for people of all faiths and exercises for getting started. A recent study of this technique finds that it is an effective way for counselor trainees to reduce stress (Gutierrez et al., 2016). For those who are not attracted to a spiritually oriented meditation, Patricia Carrington’s The Book of Meditation (1998) and Meditation for Dummies (Bodian, 2006) are good resources.

Mindfulness is a form of Theravadin Buddhist meditation that has found its way into a number of new therapies without its religious accoutrements. These include mindfulness-based stress reduction (Kabat-Zinn et al., 1992), mindfulness-based cognitive therapy (Segal, Williams, & Teasdale, 2002), dialectical behavior therapy (Heard & Linehan, 1994), and acceptance and commitment therapy (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Mind-fulness is not merely an activity conducted in a meditation sitting; it is also a way of life. It involves paying strict attention to what is happening in the present moment without judg-ing. Mindfulness as a therapeutic tool contrasts with traditional cognitive therapy because mindfulness does not challenge or replace negative thoughts. It substitutes “present aware-ness” for negative thinking. As a negative thought enters, it is noted without judgment and allowed to pass through. Mindfulness practitioners think that arguing with thoughts tends to strengthen them while allowing them to flow through consciousness reduces their potency.

Whether one uses mantra or mindfulness-based meditation, a noticeable benefit is a reduction in the constant chattering of the mind and the mental images that produce anxiety. For example, have you ever tried to sleep and found plans for the next day going around in your head? Meditation is a means of putting such thoughts to rest for a while. Unlike relaxa-tion techniques, meditation has the effect of producing mental quietude, not just physical rest. Like relaxation, meditation must be practiced on a regular basis for at least 15 minutes per day for several weeks before real benefits can be realized (Benson, 1984). After that, at least 30 minutes per day should be devoted to meditating. Regularity is crucial, and longer meditations are considered to be more beneficial than several short meditations. Like any skill or technique you learn, a teacher is essential (Singh, 2003). Clients should be referred to a class if you are not qualified to teach them or you do not practice meditation yourself.

Raising Emotional Arousal and Facilitating Expression

Be aware that emotionally stimulating techniques can be traumatic and potentially harmful to clients. Arousing techniques, in their simplest and most benign form, include encouraging clients to talk about troubling experiences and feelings rather than avoiding them. At the

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extreme, helpers may evoke powerful emotions that make the client feel out of control. Because some arousing techniques can produce harmful reactions, we will discuss moder-ately arousing methods that encourage clients to focus on their emotions but do not pressure them to do so. The more confrontational and cathartic methods require very advanced skills to be used only by experienced practitioners within strict ethical guidelines and in conjunc-tion with close supervision (Young & Bemak, 1996). They are mentioned here because, sooner or later, every helper will see these methods on films or at conference workshops.

Besides the risks associated with arousing and expressive techniques, there is what Goleman (2006a) calls a ventilation fallacy. Because expressing anger feels so good immediately, we are seduced into thinking that we have dispelled it. In fact, the opposite may be true (see Tavris, 1989). Expressing anger tends to arouse a person more, making him or her more likely to feel anger later, whereas managing or reducing anger may be more effective in preventing outbursts (LeCroy, 1988).

TECHNIQUES THAT STIMULATE EMOTIONAL AROUSAL AND EXPRESSION The term catharsis is the most commonly used term in the context of arousal and expression, but it has become a catchall that actually encompasses two separate activities: (1) stimulating emotional arousal of the client and (2) encouraging emotional expression by the client (Young & Bemak, 1996). Arousing techniques put the client in touch with deeply held emotions. Expressive techniques, on the other hand, allow the client to communicate these emotions to the helper.

The nonjudgmental listening cycle (NLC) and especially reflection of feelings are the primary methods that helpers use to allow clients to experience and express their emotions as deeply as possible. More advanced methods for enhancing emotional awareness and emotional expression are often used in gestalt therapy (Perls, 1977; Prochaska & Norcross, 2009), psychodrama (Moreno, 1958), and a number of group approaches. Emotional arousal has been activated through hypnosis and drugs (Wolberg, 1977), psychodramatic methods (Moreno, 1958), guided imagery (Witmer & Young, 1985), free association in psychoanalysis, the empty-chair technique (Polster & Polster, 1973), focusing (Gendlin, 1969, 1978), flooding and implosive therapy (Stampfl & Levis, 1967), bioenergetics (Lowen, 1967), play therapy (Schaefer & Mattei, 2005), and many others. Research has generally supported the use of emotional expression as a therapeutic change technique (Rosner, Beutler, & Daldrup, 2000) even if many of the more radical approaches have been discredited (Norcross et al., 2006).

Because these listed techniques are advanced and require thorough training and supervision, we will focus on one specific method that most helpers can incorporate immediately: journal writing. Using the “Stop and Reflect” section, you can experiment with this method yourself.

STOP AND REFLECT

Journal Writing to Increase Emotional Expression

Journaling is usually assigned as an open-ended writing assignment to help the client do more in-depth examination of his or her thoughts, feelings, and behaviors (Cummings, Hayes, Saint, & Park, 2014).

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Writing down our inner thoughts is a different activity from merely thinking about them or talking about them. In writing, we have the opportunity to really examine thoughts in detail and to challenge them. We admit things to ourselves that we may never have been aware of before. We may record dreams, daily feelings, reflections on self-concept, or spiritual progress, or we may write about particu-larly troubling or significant periods of change in our lives. All these activities may help us become more deeply aware of emotional issues behind these events.

In this activity, called a “period log” (Gladding, 2010b), the client is asked (1) to indicate a particular interval of life during which he or she experienced a number of changes or personal growth and (2) to reflect on the experiences in writing. The client is instructed “Once you have identified a particular time period, begin writing and do not stop to edit your thoughts. Because you need not show this work to anyone, turn off the internal censor and try to write whatever comes up or emerges without stifling your thoughts or feelings. This is a free association, or stream-of-con-sciousness, method that psychodynamic therapists have found to be effective for uncovering under-lying issues. Some practice is required before one can really let go and allow thoughts and feelings to flow. One way of doing this is to place your pen on a blank sheet of paper with a headline indi-cating the particular time period and write without picking up the pen for about 5 minutes. Start with the words ‘I felt . . .’ and continue writing for the allotted time. When you have finished, answer the following questions.”

• “What were the major feelings you experienced during this period in your life? Did you reex-perience any of them while writing?”

• “Did you find it hard to write in a stream-of-consciousness style?”• “How did you block yourself from letting the ideas flow out?”• “Did you encounter any personal reluctance to look at this period in your life?”• “Do you see any value in reviewing the past, or would it be best to let these issues lie?”• “What does your writing indicate about how comfortable you are now with this important

period in your life?”• “What other artistic media would you personally be most likely to use if it were suggested by

a helper?”

Creating Positive Emotions

Positive psychology is a term that was coined by Abraham Maslow in 1954. Maslow and other humanistic psychologists were concerned about the overemphasis on pathol-ogy and diagnosis. Since that time, focusing on strengths has remained alive in the work of Carl Rogers and many others who have studied “positive emotions, positive character traits and enabling institutions” (Seligman, Steen, Park, & Peterson, 2005, p. 410). More recently, positive psychologists have begun to accumulate a body of research support-ing the use of strength-based helping techniques including gratitude, meditation, for-giveness, utilizing personal strengths, humor, creativity, optimism, humility, authenticity, and many others. One of the most important voices in this movement is Barbara Frederickson (2001), who has found that these methods evoke positive emotions and that is why they work. She states that creating positive emotions both broadens one’s ability to see alternative solutions and builds resistance to negative feelings. Her popular book, Positivity (2009), is not about how to maintain a positive attitude but how to pro-duce positive emotions as a bulwark against the stresses of the world and one’s own negative emotions.

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GRATITUDE TO INCREASE POSITIVE EMOTIONS Gratitude is a feeling that results when one recognizes a benefit that is unwarranted and unexpected. It involves feelings of won-der, thankfulness, and appreciation (Emmons & McCullough, 2003). Gratitude may be directed toward others or a higher power. Inducing gratitude has been found to be asso-ciated with happiness, decreased depression, relationship satisfaction, improved sleep, and better social functioning (Young & Hutchinson, 2012).

The timing of a gratitude intervention is important. Getting clients to focus on grati-tude following a major calamity is a mistake. Gratitude is something to build into one’s life over the long term, not something to distract or cheer up someone after a serious loss. Clients who are prescribed gratitude interventions should not be instructed to ignore or gloss over problems, but they should also be aware of good things that are happening in their lives. For example, we saw a client named Portia who had been out of work for some time, but recently found a job as a retail manager in an upscale shop. Although the pay is low, she receives good benefits, including health insurance and retirement. At her counseling visit, the client discussed the fact that she finds her job boring. She resents having to put up with rich clients whom she says do not respect her. She feels that her talents are not being recognized by her boss. I was aware that Portia had said 2 months before that having a job was crucial to her happiness and financial well-being. She was elated when she signed on, but is now unhappy with her work. We discussed alternatives to her present situation and developed a plan to help her look for a new job. In the meantime, Portia was asked to keep a gratitude journal about the good things in her life in order to counteract some of the negative thoughts and feelings she was experiencing. Those negative thoughts could impede her present job functioning as well as her ability to find a new job.

Techniques for Increasing Gratitude. The gratitude journal is the most popular method for practicing gratitude. A client can be instructed to write daily or weekly and record five things for which he or she is grateful. These can be simple things such as “no lines at Walmart.” Sometimes, clients seem to write the same things and do not pay atten-tion after a few entries. To counteract this, clients are instructed to use a different letter of the alphabet each day and write five things to be grateful for that begin with that letter. In addition, clients may need reminders to work on gratitude. These can be sticky notes, automated text messages, or e-mails. Clients can set up reminders and even journal on their smartphones using a number of available gratitude applications such as Gratitude!, Live Happy, and Daily Gift from Deepak Chopra. Another widely used method is the gratitude visit. Clients are instructed to write and then deliver a letter to someone to whom they feel grateful but whom they have never acknowledged.

SummaryThis chapter introduced the idea of using common therapeutic factors as a method for planning treatment and understanding the reasons to use different thera-peutic techniques. The REPLAN system is a method of treatment planning that utilizes six common therapeu-tic factors to organize our therapeutic efforts. We examined three of these factors more closely: “E,”

enhancing efficacy and self-esteem; “P,” practicing new behaviors; and “L,” lowering and raising emotional arousal. Each of these factors has its place in treatment based on the problem that the client is facing.

Clients with better self-esteem are more likely to succeed in accomplishing other goals. Clients can learn to enhance efficacy by attempting new behaviors

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and by paying attention to successes and their present strengths and skills. Low self-worth is a general atti-tude that the self is “not okay,” and is responsible for a number of serious psychological conditions, negative emotions, and a demoralized attitude toward life. This chapter covered two change techniques for enhancing self-esteem: countering, a fundamental cognitive ther-apy technique aimed at reducing negative self-talk; and thought stopping, an associated technique used in ending the chain of negative thinking.

Practicing new behaviors is a common thera-peutic factor that helpers promote to help clients put insights into action and try out new behaviors experi-mentally. In this chapter, we looked at two change techniques for practice: role-playing and homework. Role-playing involves re-creating the context of a desired behavior right in the helper’s office and then

acting out that new behavior as practice. Helpers also use homework assignments to prolong treatment between sessions as well as to establish new behav-iors. Helpers who regularly utilize practice in the office or as homework are more likely to increase their cli-ents’ transfer of training to real-life situations.

Finally, this chapter introduced the category of techniques that focus on the common therapeutic fac-tor of emotional arousal and quieting. Relaxation reduces physical and emotional arousal; journaling instead allows clients to express their feelings. Medita-tion increases physical and emotional relaxation and, like gratitude, produces positive emotions. In sum, this category of techniques is designed to reduce negative emotions, help clients express withheld feelings and increase positive emotions to increase well-being, and achieve emotional regulation.

Exercises

GROUP EXERCISES

Exercise 1: Identifying Irrational Beliefs for Enhancing Self-Esteem

The technique of countering described in this chapter involves identifying specific thoughts and finding effective arguments. That countering process is diffi-cult to simulate in class because it is time-consuming to ferret out the specific thoughts and identify effective counters. Yet, you can learn a first step in cognitive therapy by listening for errors or counterproductive thinking in a client’s story. One focus in this chapter is on enhancing self-esteem, so pay attention to any self-downing messages that you hear in the client’s statements. In this exercise, we will be trying to find irrational beliefs in the client’s statements. Do not be afraid to share a real story; we all have irrational beliefs and engage in irrational behavior.

Part I: Listening for Irrational Beliefs

First, form groups of four, with each student, in turn, taking on the roles of client, helper, and two observers. The client discusses one of the following topics with the helper:

• A time when the client was very angry at someone• A time when the client was very angry at himself

or herself• A time when someone disappointed the client• Something the client has a difficult time f orgiving

The helper’s job is to listen, using all the skills in the nonjudgmental listening cycle, for 5–10 minutes. The helper is not asked to specifically identify irrational beliefs but simply to try and get the client to talk about the beliefs behind his or her actions. Neither is the helper to make an effort to challenge the client’s beliefs, but simply to help the client become aware of them.

Observer 1 writes down all the helper’s interven-tions verbatim. Observer 2 reviews the list of Ellis’s seven irrational beliefs described earlier in the “Sources of Low Self-Esteem” section. During the session, Observer 2 listens carefully to the client’s statements and records the gist of those that seem to indicate an underlying irrational belief.

Part II: Debriefing

1. Take a couple of minutes to allow client, helper, and observers to share their thoughts about this exercise.

2. Observer 1 gives the helper the list of interventions and feedback about his or her performance on using the skills of the nonjudgmental listening cycle. Was the helper able to remain in a nonjudg-mental stance, neither supporting irrational thinking nor judging the client for these ideas? The helper can keep the list of interventions and review them later. At this point, the list of interven-tions should include several paraphrases, reflec-tions of feeling, and perhaps a reflection of meaning or two, depending on the depth of the

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client’s story. If questions predominate, the helper should return to previous chapters for review and should schedule additional practice sessions with classmates.

3. Observer 2 indicates any irrational ideas that he or she identified in the client’s statements. As a group, the helper and the two observers can identify some counters that might be used by the client as an anti-dote to these beliefs. The client either confirms or disagrees with the observer’s ideas and then indicates which he or she feels might be the most effective.

Exercise 2: Role-Playing for Practicing New Behaviors

Role-playing as a rehearsal technique sometimes fo-cuses on situations in the past that clients would like to resolve. By attempting to bring them to closure in a role-play situation, the client is rehearsing for a later time when the issues can be addressed in real life. Issues from the past are addressed in terms of how similar situations can be handled in the future.

The exercise begins with the client, who identi-fies an individual in the past or present with whom he or she has “unfinished business.” Unfinished business refers to a relationship or an issue that he or she was unable to adequately resolve in the past, but would like to bring to a positive conclusion. Then, the helper directs a role play in which the client encounters this person and tries to express himself or herself in a posi-tive way. It is recommended that participants use one of the following situations or a minor issue in their own lives such as:

“My friend did not invite me to her wedding.”“My boyfriend criticized me in front of his mother, but I did not mention it.”“A teacher treated me unfairly, and I was never able to explain.”“I was attracted to someone in the past, but I never told her.”

For this exercise, students form groups of four with roles of helper, client, and two observers. Observer 1 gives the client feedback, and Observer 2 gives the helper feedback on his or her ability to dem-onstrate the skill of role-playing.

Briefly, this exercise has the following phases:

1. The roles of helper, client, Observer 1, and Observer 2 are assigned.

2. The client thinks of a situation involving unfin-ished business.

3. Following a review of the “Quick Tips: Role- Playing” section, the helper directs the client through the first five steps of role-playing. The steps are summarized below from the earlier sec-tion called “How to Conduct Role-Playing.”

4. Observer 1 and the helper give the client feed-back on the practice session. Was it realistic and assertive?

5. Observer 2 gives the helper feedback and discusses the exercise.

STEP 1: WARM-UP. As a warm-up, the helper invites the client to explain the situation and uses the non-judgmental listening cycle to get a clear understanding of the situation.

STEP 2: SCENE SETTING. The helper asks the client to briefly describe where and when a meeting with the affected individual might take place. The client sits in one chair, and the other chair is left empty for the person with whom the client has unfinished business.

STEP 3: SELECTING ROLES AND ROLE REVERSAL. In this exercise, the client will play both himself or herself and the other person with whom the client has unfinished business. To begin, the helper asks the client to reverse roles and sit in the empty chair while completely tak-ing on the identity of the other person. The helper asks this significant other to describe himself or herself and to give a little bit of background about the situation from that person’s perspective.

STEP 4: ENACTMENT. Once the client has presented the other person, the helper asks him or her to return to the original chair and resume his or her natural iden-tity. Now the client expresses some of the thoughts and feelings that he or she has wanted to get out into the open. The helper facilitates the client to express this in any way the client wishes. The client speaks these thoughts and feelings to the empty chair as if the other person were actually present.

Once the client has had the opportunity to ex-press his or her thoughts and feelings, the client re-verses roles again and becomes the other person, re-sponding to the charges leveled against him or her. The enactment ends when the client returns to his or her natural role and original seat and responds to the other person’s reaction.

STEP 5: SHARING AND FEEDBACK. In this step, the helper and Observer 1 give the client feedback on how well the client was able to finish the unfinished business. For ex-ample, was the client able to express everything he or she

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intended in an assertive and straightforward way? Was the client overly aggressive or too tentative and passive? What behavior does the client need to practice in the reenact-ment step to cope with similar situations in the future?

QUICK TIPS: ROLE-PLAYING• Help the client overcome stage fright and

initial discomfort by using a warm-up process such as a discussion of the situation before the role play begins.

• Getting the client to physically move around, arrange chairs, and set the scene helps to warm up the client.

• If clients resist the role-play technique, you may have to abandon it until trust is better developed. On the other hand, your confidence in the procedure will encourage them, and reassurance that “you’ll get into it” may help them to get over their initial reluctance.

• Repeat the action phase several times if needed to help the client feel comfortable with the new role.

• If clients experience emotional arousal as a result of the role play, the helper may find it necessary to implement the nonjudgmental listening cycle instead of continuing with the role play.

Exercise 3: Relaxation Training for Lowering Emotional Arousal

For this exercise, the training group divides into dyads. Each person has a turn as either client or helper. Each dyad finds as quiet a spot as possible to practice the training. The helper takes the client through deep muscle relaxation of the muscle groups given in Table 9.4. The cli-ent is instructed to tighten and relax muscles starting with the toes and moving up to the neck and shoulders. For time considerations, each muscle group is to be tightened and relaxed only once rather than twice, as one would do in normal practice. Before starting the relaxation pro-cess, the helper should ask the client to rate the current level of present tension on a scale from 0 to 100 (0 5 most relaxed you’ve ever been; 100 5 extremely tense).

Following the relaxation sequence, take 5 min-utes to discuss the effectiveness of the procedure. The client should answer the following questions:

• Using the 100-point scale (0 5 most relaxed you’ve ever been; 100 5 extremely tense), rate

your present level of tension. Subtract this score from your original estimate. How deeply were you able to relax using this exercise?

• Were the helper’s instructions presented in a calm and methodical way?

• Did the helper allow sufficient time for relax-ation before proceeding to a new muscle group?

• What might the helper have done to deepen your relaxation?

After this feedback, client and helper switch roles and repeat the exercise.

QUICK TIPS: RELAXATION TRAINING• Ask the client to rate tension based on a

100-point scale.• Ask the client to move around slightly and

find the most comfortable seating position before you begin the relaxation instructions.

• Keep your voice tone modulated and soothing.• Watch the client for signs of tension or

discomfort. When the procedure is complete, ask the client to do a body scan by returning to those areas where the client has difficulty relaxing, and ask the client to tense and relax those areas again.

• Make sure that you suggest deep diaphragmatic breathing as a transition between tensing and relaxing muscle groups.

• Ask the client to again rate himself or herself on the 100-point scale and compare this with the pre-relaxation score.

SMALL GROUP DISCUSSIONS

Discussion 1: Practical Problems

In a small group of fellow learners, discuss one of the following topics:

1. Meditation and to some extent, gratitude, have spir-itual implications. When you teach these methods to clients, should you emphasize the spiritual side or should you wait to see whether the client objects? What might happen if you fail to discuss this issue?

2. Suppose you give a client homework and he or she does not complete the homework. How should you respond? Could this failure on the cli-ent’s part lead to a rupture in the therapeutic rela-tionship? Review the problems and precautions for homework in this chapter. Could any of these be a

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reason for the client not to have completed the homework assignment?

3. This chapter suggests using the common therapeutic factors to plan treatment not just a diagnosis. Does this mean that diagnosing a mental disorder is not a useful thing for a helper to do? What are the pros and cons of using a diagnostic model to plan treatment?

SELF-ASSESSMENT

On a scale from 1 to 10 (1 5 just beginning and 10 5 mastery), indicate how well you think you have devel-oped the skills described in this chapter. Consider your practice sessions as well as the exercises in this chapter.

Rate yourself on your ability to identify irrational beliefs.

1 2 3 4 5 6 7 8 9 10

How confident do you feel in being able to:Assign appropriate homework assignments?

1 2 3 4 5 6 7 8 9 10

Give a gratitude assignment?

1 2 3 4 5 6 7 8 9 10

Teach countering or thought stopping?

1 2 3 4 5 6 7 8 9 10

Now rate yourself on your ability to direct a client in a role-playing activity.

1 2 3 4 5 6 7 8 9 10

Identify two things you learned while practicing these skills. You may include things that others may have noticed you doing well that indicated your progress. Include positive comments from instructors or class members.

HOMEWORK

Homework 1: Diary: Keeping Track of Practice

Select a personal goal for yourself that involves practic-ing a new behavior. For example:

“I would like to play my guitar every day.”“I would like to cook regular meals to combat my tendency to snack throughout the day.”“I would like to take time every day to improve my relationship with people at work.”

• At the end of each day, for 1 week, write down the number of times you engaged in the behavior,

or indicate whether you did not practice during the day. Use a blank journal, your smartphone, or a secure journal online. Write down any ideas you have about why you did or did not practice the behavior during the day.

• At the end of a week, summarize your conclu-sions in a half-page reaction. Do you think that self-monitoring by keeping a journal was help-ful to you? What kinds of clients might benefit from this approach? What kinds of problems are best suited to keeping a diary such as this?

Homework 2: A Collage as a Stimulus for Emotional Expression

A collage is a visual collection of words and images as a means of self-expression. Assemble two separate collages using photos, drawings, and words cut from newspapers, magazines, and other print media. The first collage should represent a time in your life when you were experiencing troubling or conflicting emo-tions. Prepare a second collage that represents your feelings and experiences during one of the best times of your life. Identify these feelings in writing beneath each picture. As you look back at each period of your life, does it reawaken any of these feelings in you? How might a collage such as this be useful for a client who is trying to deal with conflicting emotions from the past? Collages are often used with adolescent cli-ents. How might you develop a conversation with an adolescent client using the collage as a stimulus?

Homework 3: Relaxation Techniques for Lowering Emotional Arousal

The skill of relaxation requires the common therapeu-tic factor of practice to make it a part of one’s life. Find a way of building relaxation practice into your daily routine. Consider the following suggestions and then implement one in your own life. Report on your attempts in a paragraph or two.

• Every time you stop at a traffic light, do deep diaphragmatic breathing to lower your tension.

• Use small colored dots, available in office sup-ply stores, to remind you to do a body scan. Place these dots on your computer screen, watch, or appointment book. Whenever you see one, tense and relax those muscles that seem the most uncomfortable.

• Before going to sleep each night, do a complete body scan and note the areas where the most

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tension resides. Keep a diary for a week and see whether the same areas tend to hold much of your tension.

• Using the instructions in this chapter, meditate for 10–15 minutes each morning. What effects does it have on your level of tension and your mental attitude?

Homework 4: Keep a Gratitude Journal to Increase Positive Emotions

Earlier, we described how research has supported the use of a gratitude journal to improve mood and in-terpersonal functioning. In this homework assignment, keep a gratitude journal in which you count your blessings each night before bed. Try to identify five

positive things in your life each night for a week and note the effects. Record the results of your experience in a paragraph or two.

JOURNAL STARTERS

Sometimes helpers ask clients to consider incidents in their lives in which low self-esteem might have origi-nated. For example, was the client affected by excessive criticism or perfectionistic expectations? Harry Stack Sul-livan said that self-concept is the reflected appraisals of others. On the other hand, Eleanor Roosevelt believed that no one can make you feel bad about yourself with-out your permission. Think about your own life experi-ences and decide which view is closest to yours. Is your self-concept based on your own or others’ opinions?

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Activating Client Expectations, Hope, and Motivation• The Demoralization Hypothesis• Motivation and Readiness• Increasing Expectations and Fostering

Hope

Providing New Learning Experiences• Definitions of New Learning Experiences• What Client Problems Are Helped

through New Learning?• Common Methods for Providing New

Learning Experiences

Summary

Exercises• Group Exercises• Small Group Discussions• Written Exercises• Self-Assessment• Homework• Journal Starters

LEARNING OUTCOMES

By the end of this chapter, you will be able to:

10.1 Identify a client’s stage of change in case examples.10.2 Recognize the difference between praise and encouragement.10.3 Identify the steps in brainstorming and reframing.10.4 Recognize the appropriate situations in which to give

information, advice, and ask change questions.

This chapter completes our description of the REPLAN system, a treatment planning model that focuses on six common therapeutic factors. The therapeutic factors in the REPLAN model provide a basis for understanding the common purposes that lie at the roots of the various theoretical systems. As we saw in Chapter 9, the factors also provide one way to reflect upon what change techniques are most

Change Techniques, Part II

C H A P T E R 10

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likely to be useful in helping a client reach his or her goals. Here, we take up the last two common therapeutic factors: “A,” activating client expectations, hope, and motivation; and “N,” providing new learning experiences. In this chapter, you will learn six change techniques associated with these factors: asking change questions, encouragement, giving advice, giving information, brainstorming, and reframing. Figure 10.1 shows the REPLAN therapeutic factors and emphasizes the next factor: activating client expectations, hope, and motivation.

ACTIVATING CLIENT EXPECTATIONS, HOPE, AND MOTIVATION

Before learning the techniques for activating expectations, hope, and motivation, it is important to recognize the immediate obstacles most clients are experiencing when they first come for help: discouragement, lack of confidence, and demoralization. Remember that seeking professional help is often a last resort. The clients have already tried several ways to solve their problems before coming to the helper. They have probably consulted clergy, family, and friends. They have come to believe that there may be no way out of their difficulties. Therefore, before the clients can attack their problems, they must first overcome the conviction that their situation is hopeless.

The Demoralization Hypothesis

According to Jerome Frank (de Figueiredo, 2007; Frank & Frank, 1991), those who seek professional help are demoralized. Demoralization is described by Frank as a “state of

PracticingNew

Behaviors

Loweringand RaisingEmotionalArousal

Activating ClientExpectations, Hope,

and Motivation

EnhancingEfficacy

andSelf-Esteem

Maintaining aStrong Helper/

Client Relationship

ProvidingNew

LearningExperiences

FIGURE 10.1 Therapeutic Factors in the REPLAN System: Activating Client Expectations, Hope, and Motivation

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mind characterized by one or more of the following: subjective incompetence, loss of self-esteem, alienation, hopelessness (feeling that no one can help), or helplessness (feel-ing that other people could help but will not)” (p. 56). Frank also proposes that client symptoms and mental demoralization interact. In other words, according to the demoralization hypothesis client problems and symptoms are worsened by the sense of discouragement and isolation. For example, sleeplessness may be seen as a minor annoyance by one person, whereas the demoralized individual sees it as yet another sign of the hopelessness of the situation. Seligman (1975) experimentally discovered an aspect of demoralization called learned helplessness, which is a state analogous to depres-sion. In his research Seligman found that dogs and people exposed to unsolvable prob-lems became so discouraged that their later performance on solvable problems was negatively affected. Many clients do not give the helping process their full effort because they have little confidence that anything can be done to help them. Thus, it is often a first task of the helper to instill some hope that the issues that motivated the client to seek help can be solved and that the client will be fully invested in that project.

Motivation and Readiness

Instead of classifying demoralized clients as resistant or unmotivated, you can think of people as being at various stages of readiness for change. Steve de Shazer (1988) classi-fied clients as visitors, complainants, or customers. The analogy is that clients who come to a professional helper are similar to clients in a retail store. Some are browsing (visitors), others have a need to buy something and are checking out the prices and options (complainants), and still others have come to the store looking for a specific product, planning to buy something right away (customers). Salesclerks know they need to treat each kind of shopper differently, from giving a brief greeting to describing options and features to finalizing a sale. Similarly, helpers who do not recognize these differences in readiness will try to force a client into a particular treatment. For example, not every-one is ready, in his or her own mind, to enter substance abuse treatment on day one. Some clients need education (visitors), and others require help thinking about the prob-lem and weighing their options (complainants). Only customers are prepared to take direct action to solve the problem.

One readiness approach that has shown considerable success is motivational inter-viewing (MI) (Miller & Rollnick, 2012; Miller, Rollnick, & Butler, 2008). This person- centered/cognitive approach has been used most often with addictions. The method is based on the idea that clients come for help at different stages of readiness. Using a non-judgmental, nonadversarial approach, practitioners try to help clients become more aware of the issue surrounding a problem behavior and explore the costs, benefits, and risks associated with it. Special training is required to practice motivational interviewing, but you already know the first step––listen with empathy. After that, motivational interviewers carefully use confrontation, accept client resistance, and allow the client to be self- directing. As you can see, the process is composed of many of the building blocks you have already learned. The client’s motivation is unique to that person and so each case must be under-stood individually. Still, MI has often been used with the stages of change approach.

THE STAGES OF CHANGE Another way of looking at readiness is the stages of change theory (Norcross, 2012; Prochaska & DiClemente, 1983). According to this approach, as a

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person gets ready to change, changes, and tries to maintain change, he or she needs a different kind of help at each step of the process. It states that there are five stages of change. In the stage of precontemplation, the person is not even thinking about taking action; for example, not even thinking that he or she needs to quit smoking or drinking. In the contemplation stage, clients are planning to change within 6 months. At this point they have become conscious of both the positive and negative consequences of potential change. Yet clients at this stage are ambivalent about making a change and are not ready to take direct action to address the problem. People can be aware of the problem and yet remain stuck in this stage for years. The preparation stage describes clients who have taken some steps toward change during the last 12 months and are ready to consider a specific action plan. For example, a client who needs to exercise has joined a gym and is planning to begin a program. The client may have obtained a self-help book and seems to be taking some small concrete steps. But it is really in the action stage that we find clients who have already made specific changes in their lives. For example, the client has stopped drinking, started attending AA meetings, or entered a treatment program. Although treatment has begun, the process is not complete. The final stage of change is maintenance, which characterizes individuals who have already changed their lives and behavior, such as by quitting smoking or having instituted better communication in their relationships. The Maintenance stage may be the most critical and can last from 1 to 5 years. It is critical because relapse is a constant threat. Although these stages are pre-sented as distinct periods, it is likely that people move back and forth between the stages, especially as they experience relapse. The most important implication of this theory is that people benefit from different interventions depending on which stage of change they are in. Clients do better in programs that tailor their treatments to the clients’ stage of change than in those that do not (Noar, Benac, & Harris, 2007). Table 10.1 shows how a helper might think about selecting treatments based on the client’s readiness or stage of change.

MyCounselingLab Application Exercise 10.1 Identifying Stages of Change in Client Statements

MyCounselingLab Video Exercise 10.1 Identifying the Stage of Change

FINAL THOUGHTS ON MOTIVATING CLIENTS In this section, we discussed de Shazer’s characterization of client readiness, motivational interviewing, and the stages of change theory. All these views agree that the client’s motivation must be taken into account when planning treatment. In the next section, we discuss increasing expectations, which really means helping clients overcome demoralization, and increasing hope.

Increasing Expectations and Fostering Hope

Many clients improve radically early in the helping process. Even those on waiting lists show improvement! This has been attributed to the placebo effect, a medical analogy that has been unfortunately applied to the psychological realm. The placebo effect implies that the helper is fooling the client with an imaginary treatment like a sugar pill. In actual-ity, the placebo effect, or expectancy effect, is tapping well-established factors in social influence. For example, if clients find the helper attractive and trustworthy, their expectations of successful treatment and hope rise (Frank, Nash, Stone, & Imber, 1963;

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Greenberg, Constantino, & Bruce, 2006; Patterson, 1973). It is the expectation itself that is healing. Faith is powerful medicine (Siegel, 1986).

What can the helper do to increase the client’s expectation that treatment will help without being unrealistic? Helpers need to inform their clients about the problems they are facing. People seeking help may have already looked at Internet sources and, thus, have conflicting ideas about treatment and the possibility of success. For example, if you have a client suffering from depression, it is important to let him or her know that there are effective treatments. Providing information can increase hope. In addition, by outlin-ing the steps of treatment, the client understands the treatment ritual and does not develop unrealistic expectations that change occurs overnight. Many helpers have handouts that explain the nature of the therapeutic process, how the client can make the most of the opportunity, and what background and training the helper has to assist with the client’s problem.

ASKING CHANGE QUESTIONS One of the ways that helpers foster hope is to encourage clients to think about a time when the problem has been resolved and change has occurred. By asking stimulating questions, the helper encourages the client to think about a better future. Up until this point, we have largely discouraged informational or closed questions because they tend to put the client on the defensive and do not further the purpose of the nonjudgmental listening cycle (NLC), which is to establish the therapeutic alliance. But just as questioning in the goal-setting stage of the helping process is appro-priate, some types of questions are useful in the intervention and action stage. These

TABLE 10.1 Tailoring Interventions to Client Readiness

Stages of Change (Prochaska, Norcross, & DiClemente, 1994)

de Shazer’s Stages (1988)

What Promotes Growth? General Approach by the Helper

Precontemplation Visitor Raising awareness Relationship building; understanding client’s perceptions; maintaining an open door; using readings, audio, or video to raise awareness

Contemplation Complainant Resolving ambivalence

Helping client consider pros and cons; highlighting discrepancies; emphasizing client choice and responsibility

Preparation Identifying specific and appropriate change techniques

Goal setting; engaging support system; helping client make a decision to change and publically announce it

Action Customer Helping client Helping client carry out the treatment plan agreed upon; preparing client for realities of treatment; using encouragement to reinforce commitment

Maintenance Learning skills to maintain recovery

Helping client develop a healthy lifestyle and recognize the rewards of change; helping client recognize relapse triggers

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special questions are called change questions, or strategic questions because they are not utilized for the purpose of gathering information but to influence or persuade (Tomm, 1988). There are literally scores of these but we will talk about only three: embedded questions, scaling questions, and the miracle question.

Embedded Questions. Embedded questions have a hidden suggestion and an expectation that things are going to get better. Consider the following:

“When the problem is resolved, what will you be doing then that you are not doing now?”

“When you decide to learn to get along with your ex-wife, will you feel that you have achieved something?”

“When you let go of your anger and forgive your father, what will change in your family?”

Can you see that these helper changes are future-oriented, optimistic messages that the client will change and that the client is expected to act?

Scaling Questions. Scaling questions were devised and tested by solution-focused therapists. Their purpose is to encourage action and motivate change. Here is a dialogue with one member of a couple that illustrates how scaling questions might be used.

Helper: “On a scale of 1 to 10, with 10 meaning that you believe that you can improve your couple relationship and 1 meaning that you think that it is hopeless, where are you right now?”

Client: “Right now, I’d say about a 4, but I was at a 2 last week.”

Helper: “What was it that you did that moved your level of hope from a 2 to a 4?”

Client: “I’m not sure, but I think that I put in more effort into trying to under-stand what she was saying.”

Helper: “And what would it take to move you from a 4 to a 5?”

Client: “I guess I could continue to listen more and maybe we could take some time in the evenings, not just to talk but just be together.”

The Miracle Question. The miracle question, like scaling questions, is designed to get clients moving toward their goals (de Shazer, 1988; O’Connell, 2005). The miracle question takes clients by surprise, and perhaps this makes it easier for them to talk about changes they need to make. Let us use the miracle question in the same example with a member of a couple who is complaining about communication problems in the relation-ship. To get the client to identify a course of action, the helper asks the following ques-tion slowly and carefully so that the client has time to think:

Helper: “I want to ask you a question that’s a little unusual. Just think about it before you respond. Let’s suppose that tonight, when you get home, you go to bed and sleep and when you awake, the problem that brought you in here has been solved. Now here’s the important part. Because you were asleep, you didn’t know that the miracle had occurred. What would be the first thing you noticed that let you know that something had dras-tically changed?”

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Client: “I would go into the kitchen and my partner would smile at me.”

Helper: “Well, that would be different. And how would you respond to that smile?”

Client: “I would probably smile, too, and ask if I could fix my partner a cup of tea.”

Helper: “How do you think your partner would react to that?”

Client: “I think she would be shocked and not sure what to do.”

This brief example shows that the miracle question gets the client on a new track. Instead of talking about the problem-saturated story of their discord, the client is now discussing changes in behavior that might lead to intimacy. The miracle question is not a miracle cure, but it is a tool that focuses clients on a world where the problem no longer exists. This helps the client envision such an outcome, enhancing expectations, fostering hope, and suggesting ways to reach that world.

ENCOURAGEMENT As we discuss demoralization and enhancing client expectations, our thoughts naturally turn to encouragement, giving clients courage. Encouragement is a change technique that is closely aligned with Alfred Adler’s theory of individual psychol-ogy (1954). Yet, the use of encouragement is not limited to Adlerians (Watts & Pietrzak, 2000). In a national survey conducted by the author (Young & Feiler, 1993), encourage-ment was the second most frequently used counseling technique. It was utilized by 90% of the mental health counselors and counselor educators surveyed. We cannot be certain from these data whether all respondents were operating under the same definition of encouragement; however, the survey supports the notion that encouragement is an essen-tial therapeutic ingredient for most helpers. In addition, encouragement is probably inte-gral to what most people today call “coaching.” As we said earlier, our definition of coaching is “counseling with an emphasis on encouragement.” If you learn to effectively and appropriately utilize encouragement you will have learned a valuable and marketa-ble skill. Moreover, Wong (2015) claims that encouragement is a common element of self-help books, leadership skills, parenting, treatment of childhood disorders (Silk et al., 2013), family resilience, and strength-based approaches to counseling and supervision. It is foundational to solution-focused therapy, narrative therapy, and positive psychology. Encouragement is the primary way in which we give each other support.

Encouragement Versus Praise. Earlier, we mentioned that praise can be a road-block in the helping process. For some helpers, this idea goes against the grain, espe-cially those who work with children. We sincerely want to uplift clients’ spirits, and we want them to pay attention to their positive attributes, so we utilize one of our favorite social tools, the compliment. There certainly are times when praise is useful. However, praise definitely puts the helper in the role of a judging parent and the client in the role of an obedient child. Most adults do not need a cheerleader; instead they need to develop faith in themselves. This is where encouragement comes in. Through encouragement, the helper focuses on respectfully pushing the client to develop a more positive view of life rather than merely giving the client approval or a pat on the head—what some counse-lors call “throwing the client a marshmallow.” Encouragement seeks to modify motivation rather than behavior (Sweeney, 2009).

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To better understand encouragement, look at Table 10.2, which compares the con-cepts of reinforcement from the behavioral tradition and the Adlerian concept of encour-agement. The table makes the argument that praise (positive reinforcement) and encouragement both have important but distinct uses. In general, encouragement is designed to inspire, to foster hope, to stimulate, and to support (Pitsounis & Dixon, 1988), whereas praise is designed to increase the likelihood that a specific behavior will be repeated. Encouragement focuses on developing autonomy, self-reliance, cooperation

TABLE 10.2 Comparison of Encouragement and Praise/Reinforcement

Dimension Encouragement Praise/Reinforcement

Purpose To motivate, inspire, hearten, instill confidence To maintain or strengthen a specific behavior

Nature Focuses on inner direction and internal control; emphasizes personal appreciation and effort more than outcome

Focuses on outer direction and external control; tends to emphasize material appreciation; emphasizes outcome

Population All ages and groups Seems most appropriate for children, situations with limited self-control and development, and conditions of specific problem behavior

Thoughts/Feelings/Actions

A balance of thinking, feeling, and actions with feeling underlying the responses; i.e., satisfaction, enjoyment, challenge

Attending primarily to an action (behavioral) response that is observable

Creativeness Spontaneity and variation in how encourager responds; encouragee has freedom to respond in spontaneous and creative ways; however, it may be difficult to understand the expectations of the encourager

Reinforcer responds to very specific behavior in a specific way; reinforcee is expected to respond in a specific and prescribed way; little doubt about the expectations of the reinforcer; helpful in establishing goals

Autonomy Promotes independence, less likelihood of dependency on a specific person or thing; more likely to generalize to other life situations

Tends to develop a strong association, perhaps dependence, between a specific reinforcer and a behavior; less likely to generalize to other life situations

Examples: You have been working hard on that project for a month. You really stayed with it.I noticed that you used a lot of different colors and patterns in this picture. It must have been difficult.It sounds like you’ve done a lot to make sure that you are not falling back into your old pattern. How have you done that?Looks like you have made about 80% of the way to your goal. I believe we are going to get there.

You are a hard worker!

That is a very pretty picture.

You are doing great.

80% is good.

Source: Modified from Witmer, J. M. (1985). Pathways to personal growth. Muncie, IN: Accelerated Development. Copyright J. M. Witmer. Reprinted with permission.

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rather than competition (it avoids comparisons), and an internal locus of control (Hitz & Driscoll, 1988). Praise is a reward that strengthens a behavior when it occurs. In sum-mary, praise has several drawbacks in the helping relationship because it only recognizes success, not intentions, and it places the helper in a position of superior judge (see Punished by Rewards by Alfie Kohn, 2000). On the other hand, encouragement positively affects the therapeutic relationship (Wong, 2015).

Who Benefits Most from Encouragement? According to Losoncy (1977), persons who are dependent, depressed, cut off from social support systems, or suffering from low self-esteem are best suited for encouragement. Encouragement also helps clients who have an excessive need for attention, for power, for control of situations and people, and for revenge. It is useful with clients who avoid participation and responsibility, who are perfectionistic, or who tend to be close-minded. If we analyze these situations, it may be obvious that these are clients who have given up on the world or other people or are fearful that things will spin out of control. Encouragement is helping someone discover the courage to be imperfect.

Types of Encouraging Responses. Some of the major writers in the area of encour-agement have been Dinkmeyer and Losoncy (1996), Losoncy (1977), Sweeney (2009), Witmer (1985), and Wong (2015). Together, they identify 14 types of effective encourag-ing behaviors:

1. Acknowledging the client’s efforts and improvement2. Concentrating on the client’s present capacities, possibilities, and conditions rather

than on past failures3. Focusing on the client’s strengths4. Showing faith in the client’s competency and capabilities5. Showing an interest in the progress and welfare of the client6. Focusing on those things that interest or excite the client7. Asking the client to evaluate his or her own performance rather than comparing it

with another standard8. Showing respect for the client and the client’s individuality and uniqueness9. Becoming involved with the client through honest self-disclosure

10. Offering assistance as an equal partner in the helping process11. Using humor12. Providing accurate feedback on deeds rather than on personality13. Confronting discouraging beliefs14. Lending enthusiasm and asking for commitment toward goals

Summarizing these 14 interventions may oversimplify the Adlerian concept, but it may also give some general direction to helpers and improve the understanding of the method. I have collected these interventions in three major helper activities: focusing on the positive and the changeable, emphasizing equality and individuality, and pushing with enthusiasm.

Focusing on the Positive and the Changeable. Optimism is the tendency to view the world as a benign, friendly source of support. Not everyone shares this view of

MyCounselingLab Application Exercise 10.2 Recognizing the Difference between Praise and Encouragement

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life, but optimism can be learned (Carver, Scheier, & Seggerstrom, 2010; Seligman, 1998), and it has a strong relationship with emotional and psychological well-being. On the other hand, research indicates that pessimism correlates with depression, lowered achievement, and health problems (Seligman, 1998).

In the preceding list of 14 characteristics, interventions 1 through 4 are grouped together into the encouraging helper behavior of focusing on the positive and the change-able. All foster development of an optimistic attitude by helping to shift the client’s atten-tion from the deficits to the strengths in his or her life. Such encouragement entails noticing the client’s success as well as showing faith in the client’s ability to succeed. Focusing on the positive and the changeable also includes redirecting the client’s discus-sions from the past to the present. Note the positive, optimistic interventions in the fol-lowing client/helper dialogue:

Client: “I feel like I’ve totally messed up my future. I don’t like the job or the life I have right now, and I am not sure that I can turn things around.”

Helper: “Tell me what you really enjoy doing.” (focusing on the positive)

Client: “What? . . . Oh, well, I really enjoy working in the garden.” (The client goes on to describe the feelings he enjoys, and the helper encourages him.)

Helper: “How do you feel now as you think about gardening?”

Client: “Better. But I always feel better when I think about good things like that.”

Helper: “Yes, so do I. I prefer to feel good.”

Client: (Laughing) “Me, too. But it isn’t always easy.”

Helper: “You’re right. I was wondering what was going on in your life besides the problem areas, what is going well and what makes you feel optimistic.”

This dialogue shows a helper who is a little abrupt in shifting the focus to the posi-tive. This was done to help the client understand that he or she can push the positive button, not just the negative one. Encouragement should not be seen as trying to get the client to ignore difficult issues; instead, it asks the client to develop a balanced view that includes the positive aspects of life. In addition, it helps to focus the client on the parts of the problem that can be changed, rather than ruminating over the unchangeable. Here is an example:

Client: “We went to the picnic, and it was a total disaster just like I said it would be. Her mom started criticizing us again, so my wife and I ended up spending most of the time playing with the kids and talking to each other.”

Helper: “It sounds like there were some uncomfortable moments, but it also sounds like you did something positive to deal with her mother’s criticism.”

Client: “What?”

Helper: “Well, instead of getting involved in the argument, you got away from it and spent some time with each other and some with the kids. It sounds like you hit on a good strategy. Do you agree?”

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Emphasizing Equality and Individuality of the Client. The essence of interventions 5 through 10 on the list of encouraging responses is to communicate to the client that the helper and client are on equal footing and that each is unique. Through encouragement, the helper teaches the client to challenge the idea that the worth of a person is judged by external standards. The client must come to evaluate performance against internal standards and to appreciate his or her personal strengths and distinctive approach to life, as in the following client/helper exchange:

Client: “I finally got off drugs, got a job and an apartment. My life is back on track, but it’s still not good enough.”

Helper: “What do you mean, it’s still not good enough?”

Client: “My mom won’t let up about how I disappointed her, how I was sup-posed to finish college 2 years ago. Even though I’m back in school in the fall, all she can say is, ‘Two years too late.’”

Helper: “What about you—how do you look at it? Are you proud of what you’ve accomplished in the last 8 months?”

Client: “Well, don’t you think I’ve done a lot?”

Helper: “You tell me.” (asking the client to self-evaluate)

Client: “I have. I have come a long way. It was hard, too.”

Pushing with Enthusiasm. Interventions 11 through 14 demonstrate that encour-agement is not merely support; it does not mean believing that the client’s troubling situation should be accepted. There is an element of confrontation and a sincere effort to produce movement in the client. Discouragement can be a self-perpetuating defensive maneuver that seeks to maintain the status quo through inaction. Encouragement pushes the client by giving accurate feedback, confronting the private logic of the client, asking for a commitment, and using humor to turn the client around (Mosak, 1987). The follow-ing example continues the client/helper dialogue from the previous section. Notice the confrontation and the helper pushing the client to make a commitment:

Helper: “So although you know you’ve overcome a lot, sometimes you still use your mother’s yardstick on your life rather than your own. Would you agree?”

Client: “That’s when I get depressed. I’m not sure I can ever please her, but that’s not going to stop my recovery.”

Helper: “So you are determined to succeed. But how are you going to stop get-ting depressed when you hear her criticism?”

Client: “Well, first of all, I will try to let it go in one ear and out the other. But really, I think I’ll just spend less time over there.”

Helper: “That sounds like a good start. Let’s consider that as a plan for this week, and when we get back together, you’ll let me know what happens, right?”

Client: “Right.”

How to Encourage. Following are general guidelines for encouraging a client. The accompanying example illustrates that encouragement consists of giving the client

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directives to pay attention to his or her strengths and to focus on what can be changed. Notice that the nonjudgmental listening cycle (NLC) forms the foundation for the encour-aging remarks of the helper.

Step 1: The Helper Uses the Nonjudgmental Listening Cycle to Gain Rapport and Understand the Problem. Encouraging responses will not be appropriate if the helper does not fully understand the client’s problem. The NLC is, in itself, an encour-aging process because it promotes a relationship based on equality and respect.

Herb was a furniture salesman out of a job. He was very pessimistic about getting hired again after being out of work for 4 months. Although he had initially been rather active, recently he had spent more time driving around in his car than actu-ally looking for a position. His wife accompanied him to the first session, but she refused to return for later appointments. During that session, she strongly expressed her worry, anger, and frustration. According to Herb, he had lost all ambition, was embarrassed, and he feared he would never be able to locate a new job.

Helper: “So tell me, what it is like to be out of a job?”

Herb: “It is hell! Everyone blames me. I get depressed and resentful, but mostly I am angry.”

Helper: “You’re mad at yourself for being in this situation.”

Herb: “Exactly. What kind of a man am I? My father never lost a job. Neither did my father-in-law.”

Helper: “You mention your father and father-in-law. You seem to be saying that working is an important part of being a man.”

Herb: “Of course. I am supposed to be the provider. Now my wife is taking care of me.”

In this part of the dialogue, the helper begins with an open question, reflects feelings, and finally reflects meaning about assumed gender role. These reflec-tions of feeling and meaning convince the client that the helper understands the situation at a fairly deep level.

Step 2: The Helper Offers to Be an Ally.Helper: “Herb, my feeling is that what you really need right now is an ally in

this process. You seem to have job-seeking skills, a good work history, and a positive attitude about your chosen profession. You’ve shown a lot of success in sales previously. Perhaps together we can help you find your enthusiasm again.”

Herb: “I guess you’re right that I have had success in the past, but I am at a dead end now. Sometimes I think it is hopeless.”

Helper: “My thought is that we begin to look at this thing from a different angle. Perhaps if we put our heads together, we might be able to find a solution.”

Step 3: The Helper Focuses on the Positive and Notes Client Attempts, However Small, to Accomplish the Goal.

Herb: “I still get up at 6:30 a.m. like I did when I was working. I get dressed and start out all right. First, I read the paper and start to make a call or two. That’s when I start getting down. I end up driving around town,

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killing time until dinner, making my wife think that I am out looking for a job. Why am I doing this?”

Helper: “Well, one of the things I notice is that the rhythm is still there. You are set to get back into a work routine, and you seem to like that. Even though you are not making the contacts, you are practicing, rehearsing for that day when you are back to work. That is a good sign and some-thing we can build on.”

Step 4: The Helper Offers Feedback or Confrontation and Pushes for Commitment.Helper: “I’ve got some feedback for you if you want it.”

Herb: “Okay.”

Helper: “It seems like one of the problems is that you are not being honest with yourself or your wife about what you do all day. I would like you to keep track of your activities a little better. I think this would help you feel better about yourself, and it might help the rela-tionship, too.”

Herb: “It is hard to do when I get nothing back.”

Helper: “I agree. It is difficult. But I am only asking that you begin to keep a log of what you’re doing toward finding a job each day, and we will see if we can increase that or make some changes in the direction of your search.”

Herb: “All right. I can do that.”

Step 5: The Helper Shows Continued Enthusiasm for the Client’s Goals and Interest in the Client’s Feelings and Progress.

Herb: “Since the last time we talked, I didn’t do what we decided.”

(One Week later): “I didn’t make two calls per day looking for a job. I guess I averaged about one call per day. The first day I did three, then one, then one again, and I took the weekend off. I got no response.”

Helper: “I am very glad to hear about this. That kind of progress is what we’ve been looking for. It seems that getting off dead center is the hardest part, and you’ve gotten through that. Besides, by being honest about it, you’ve now included me in what’s going on. Now what is needed is keeping up your efforts. Right?”

Herb: “I guess so. I’m afraid that this won’t work, that it will be just like last time and fizzle out.”

Helper: “Yes, it can be scary, but let’s try to focus on the present if we can, rather than look back. I have been hoping that you’d make this beginning and then hang in there until something breaks. Let’s continue with this plan. I’ll call you about Wednesday to see how things are going. Again, I feel good about these first steps.”

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PROVIDING NEW LEARNING EXPERIENCES

In this section, we want to explore the techniques included under the final therapeutic fac-tor—providing new learning experiences, which is highlighted in Figure 10.2. Learning is not just instruction. New learning, in a therapeutic session, can be sparked through mod-eling, and it can also be stimulated through techniques such as stories, metaphors, inter-pretation, and reframing. In addition, new learning is not merely acquiring facts. It may be a shift in perspective. Gaining a new perspective is one of the most frequently mentioned therapeutic experiences cited by clients (Elliott, 1985). Clients have been able to recall insights and learning up to 6 months following therapy (Martin & Stelmaczonek, 1988).

Definitions of New Learning Experiences

A number of terms have been used to describe this common therapeutic factor, such as changing the worldview, redefining personal mythology, developing insight, developing out-look skills, perception transformation, cognitive restructuring, reframing, meaning attribu-tion, perception shifts, the “aha!” experience, relabeling, and redecision. All these terms seem to involve two basic helping techniques: (1) imparting to clients new information or skills and (2) helping clients to change inappropriate or ineffective beliefs, perceptions, and outlooks. Let us look at a couple of client stories in order to demonstrate how these two types of new learning experiences are commonly embedded in a treatment plan.

• Maritza is a 23-year-old woman who was admitted for substance abuse problems following her arrest on a charge of driving while intoxicated. On the first day, the

PracticingNew

Behaviors

Loweringand RaisingEmotionalArousal

Activating ClientExpectations, Hope,

and Motivation

EnhancingEfficacy

andSelf-Esteem

Maintaining aStrong Helper/

Client Relationship

ProvidingNew

LearningExperiences

FIGURE 10.2 Therapeutic Factors in the REPLAN System: Providing New Learning Experiences

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goal of the staff is to introduce clients to a “disease concept” model of alcoholism. Maritza attends a class where she learns that she is genetically predisposed to addic-tion based on her family history and that she cannot help the effect alcohol has on her. The result of this information is that Maritza begins to stop thinking of herself as “weak” or as morally unworthy. Instead, she starts to realize that she has a bio-logical weakness. This new perspective has been stimulated by learning. It reduces guilt, changes her attitude about herself, and increases her hope for recovery.

• Dujuan is a 30-year-old man referred for help with panic attacks. During moments of high anxiety, he has been experiencing shortness of breath, rapid heart rate, and intense fear. At their first session, the helper identifies a core belief that seems to be at the root of his anxiety, “I could lose control over myself and go crazy.” During the next 3 weeks, the helper encourages Dujuan to examine and modify this core belief. The goal is to help him to focus on the evidence for and against this belief and then to develop a more reasonable point of view. After a month, Dujuan is able to say, “Watching for danger actually increases my fear rather than reducing it. It is better to have a panic attack once a month than to spend every day worrying about it.” Six months later Dujuan claims that he rarely finds himself falling into his old way of thinking and he has had fewer attacks. He feels that he has modified a core belief.

What Client Problems Are Helped through New Learning?

A number of client problems are the result of inadequate training or lack of knowledge and these deficits can be addressed in group or individual settings. In psychoeducational seminars and workshops, one can learn to cope with stress, and hear about alternatives to addictive behavior, how to improve communication with a partner, career building, and parenting skills. In a one-on-one session, clients can change their thinking about painful remembered events and rethink their sense of guilt and failure. They can see themselves and others in a new light, and they can discover that situations that they have feared and avoided are not really so dangerous.

Common Methods for Providing New Learning Experiences

This section presents a few of the many tools helpers use to assist clients in seeing things in a different way and creating new visions for the future.

INTERPRETATION Interpretation is one of the oldest therapeutic techniques (Clark, 1995; McHenry & McHenry, 2007). Interpretation consists of encouraging the client to look at the problem in the context of the theoretical orientation of the practitioner. Once the helper explains the reason for the problem, a client develops insight and is then presumably better able to change. For example, from a psychodynamic perspective, a client’s reaction to his boss may be a carryover from his lifelong issues with his own father. Once this reaction is interpreted, confronted, and clarified, the client may start to see the unconscious motives behind his actions. Insight may occur (an aha! moment), or it may dawn gradually. The client’s transference reactions toward the helper are a pri-mary focus of interpretation. Thus, the client may even see the therapist as a punishing figure. Once insight occurs and the client acknowledges that he or she is bringing this projection to the therapeutic relationship, that learning may be applied to other situations. In this example, the client may become aware of similar tendencies in his relationships

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with other authority figures. The psychodynamic technique of interpretation is an advanced method that cannot be grasped in a few paragraphs and must be learned in an extended training program.

Perhaps the most common use of the term interpretation is in the context of dream interpretation. Originally, the therapist listened to and then interpreted the meaning behind the client’s dream. Today interpretation is a controversial technique because it firmly places the helper in the role of expert; thus, it is not entirely compatible with an emphasis on collaboration in the helping process. In addition, research has provided mixed results (Høglend et al., 2006; Levy, Hilsenroth, & Owen, 2015). A postmodern or constructivist point of view believes that it is often better to help the client find a view-point that works with his or her unique understanding of the world (Siegel, 2010).

BIBLIOTHERAPY Bibliotherapy means assigning readings to clients to help them achieve their goals. Numerous studies have found it to be an effective treatment for dis-orders ranging from alcohol addiction to sexual disorders (McKenna, Hevey, & Martin, 2010). In general, bibliotherapy has been supported for clients with mild to moderate problems. This method should be contrasted with merely recommending a self-help book. Many of the offerings in trade books are oversimplified, unscientific, and based on opinion or a few anecdotes. Before recommending a book to a client, the helper should have read the book and should carefully think about whether it will be acceptable to the client’s frame of reference and is in tune with the client’s goals. Once a helper has recom-mended a book or audio assignment, he or she should follow up in subsequent sessions to discuss the client’s reading and go over important points, perhaps even asking a few relevant questions about how the assignment fits the client’s current dilemma.

Although it is not possible here to provide an exhaustive list of good bibliographic materials, resources for selecting books and manuals are available (cf. Gladding & Gladding, 1991; Jackson, 2001). Many children’s libraries, such as the Carnegie Library of Pittsburgh, have online bibliotherapy booklists for kids on special topics such as divorce, adoption, fears, bullies, and so on (see also Karges-Bonee, 2015). One good self-esteem book for kids is called Stick Up for Yourself (Kaufman, Raphael, & Espeland, 1999), and Schiraldi, McKay, and Fanning’s (2005) Self-Esteem Companion is better for adults. The Courage to Heal (Bass & Davis, 2008) is often prescribed to women who have survived child sexual abuse. A very good stress management workbook, Kicking Your Stress Habits (Tubesing, 1981), is older but useful for a broad audience. Many clients with marital problems have benefited from Michele Weiner-Davis’s Divorce Busting (1992) and The Divorce Remedy (2001). David Burns’s (2008) Feeling Good contains an excellent cognitive approach to depression that the average person can easily grasp. The influential “Big Book” of Alcoholics Anonymous provides a number of true accounts of individuals who have successfully overcome drinking problems.

Besides informing the client, bibliotherapy can provide covert practice by exposing the client to a fictional or historical model of a desired behavior. The Novel Cure (Elderkin & Berthoud, 2013) addresses specific problems and developmental issues such as adoles-cence by recommending specific books. Clients may identify with case studies or with fictional characters who face similar problems. For example, the Harry Potter books have been used to help grieving children (Markell & Markell, 2008).

MODELING AS NEW LEARNING When we want to learn something, we watch others and copy them. Bandura (1971) is responsible for recognizing the potential power of

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modeling in the helping process. Modeling has been used extensively to help children learn prosocial behaviors, to assist developmentally delayed adults in skill develop-ment, to teach alcoholics methods of relapse prevention, to train helpers, to instruct parents, and to help clients deal with fearful situations (Perry & Furukawa, 1986; St. Onge, 1995). In group therapy, it is common for members to copy the helper or other group members who are functioning more effectively. Clients learn to be more self-disclosing, assertive, and spontaneous by seeing examples of these behaviors and try-ing them in the safe environment of the group. Yalom (1995) found that group therapy participants identified interpersonal learning as one of the most important common therapeutic factors.

Modeling takes place in the helping arena, either as an intentional process or as an unexpected by-product. An example of the latter occurs when clients take on the man-nerisms or copy the clothing of the helper. Intentional modeling is exemplified by a helper role-playing a specific behavior while the client watches or by exposing clients to symbolic, biographical, or fictional models in books, videos, and movies (Erford, Eaves, Bryant, & Young, 2010; Milan, 1985). Through modeling, clients are able to see a success-ful performance of a skill. The client then attempts to reproduce the skill, getting feed-back from the helper (Mitchell & Milan, 1983).

STOP AND REFLECT

Think about three of your favorite teachers. Write their names in the following chart and describe them as best you can in the space provided:

Name

Personal Trait You

Most Admired

Subject Taught

Values Modeled

by Teacher

Most Important Thing You Learned

How Did the Teacher

Influence You?

Ways the Teacher Went

beyond the Traditional

Relationship

• As you look over your answers, how do you think the teacher influenced or changed you? Was it primarily through modeling, or was it through the subject matter that he or she taught? Or was it something beyond the curriculum?

• Look over the list of personal traits. Are these traits you have tried to develop in yourself?• Which of your favorite teachers would you consider to be a helper and not just an instructor?

Why?

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METAPHORS AND STORIES Metaphors, stories, and parables are common ways of stimu-lating new learning in clients (Barker, 1985; Gordon, 1978; Sims, 2003). For example, a helper once came up with this little aphorism for a client who was stewing about a situation over which he had no control: “You know, worry is like a rocking chair. It doesn’t get you anywhere, but it’s something to do.” The purpose of the metaphor was to teach the client something about worry. It gently points out that the client might need to find another way of dealing with the problem rather than trying to solve it when it is not immediately solvable.

Metaphors and stories engage the listener with imagery, suspense, and humor. Con-sequently, the client is not always aware that he or she is learning something. A story bypasses some of a client’s resistance to new ideas; the client is too engaged to fight. This was true in the case of Judie, a 35-year-old woman living in New York City who had grown up on a farm. Judie had considered marriage to several different men in her twen-ties. Each time, she had ended the relationship when marriage seemed to be the next step. Judie was an only child and was close to her parents, whose relationship with each other was quite poor. They had fought bitterly for years, and she believed that they had stayed together for her sake. She admitted that she saw love as “chains.” Judie came for help because she had finally met a man whom she wanted to marry. She was filled with confusion and had changed the date of the wedding twice. In the first few sessions, reflective listening uncovered her fears about relationships. She felt better about her deci-sion to get married after these sessions, but one night (a week before the wedding), she telephoned the helper in a crisis of doubt about whether to go through with the cere-mony. On the telephone, her helper told her the following story:

When I was a boy, we lived on a farm, and we had a very healthy and strong mare. She was high spirited, but gentle. She also had one peculiarity. She hated it when we closed the gate of the corral. In fact, she would run around in circles, rearing up, sometimes even hurting herself on the wooden fence. One day, we discovered by accident that if we left the gate open, she calmed down. And she never ran away. She didn’t mind being in the corral. She just wanted to make sure that she could leave at any time.

The helper credited this story as the turning point in Judie’s treatment and in restor-ing her sense of control. Although no interpretation was made, she apparently grasped that she did not have to feel imprisoned by her relationship and that she could retain a sense of freedom. The helper used the farm story because of his knowledge about Judie’s background. He used the metaphor of the corral because she saw marriage as a form of prison. Through the image of the open gate, he was telling her that she could retain the option of leaving. Knowing that she had this option would help her stop worrying about being trapped. The story seemed to be much more effective than giving advice because it allowed her to decide for herself how to act. Of course, there is danger in overuse and in telling stories that clash with the client’s worldview.

EXPOSURE TO AVOIDED STIMULI There is a story about a woman who sees a man rubbing a rabbit’s foot furiously and asks what he is doing. “I am keeping the tigers away,” he replies.

“But there aren’t any tigers around here,” she argues.

“See,” he says, “it’s working.”

Many clients come for help because of avoidance of social situations, fear of dogs, fear of airplanes, or a feeling of discomfort at being far from home. Like the man in the

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story, they are not willing to give up avoidance behaviors even when those behaviors are superstitious or ineffective. Because a client has learned to reduce anxiety by avoidance, he or she must be taught that the feared object or situation is not really harmful.

Exposure is the technique of helping clients to gradually face feared stimuli (Emmelkamp, 1982; Foa & Goldstein, 1978; Thomas, 2009). Exposure is extremely effec-tive but is often neglected as new therapeutic fads come along (Schare & Wyatt, 2013). To safely and gradually expose clients to fearful situations, helpers set up hierarchies of feared situations (least anxiety provoking to most anxiety provoking) and, step-by-step, encourage clients to face more and more difficult scenarios. Clients learn important les-sons from facing rather than avoiding these situations. They learn that many of their fears are groundless and that their perception of how people will react to them may be errone-ous. For example, many people fear that being more assertive will worsen relationships in their families. As they become more assertive, they find that most of the feared conse-quences of assertiveness never occur and that their relationships actually improve.

HUMOR We know that learning is facilitated in a light atmosphere (Gardner, 1971). Humor also offers a subtle way to shift a client’s viewpoint (Ansbacher & Ansbacher, 1956; Goldin et al., 2006; Mosak, 1987; Shaughnessy & Wadsworth, 1992). Jokes can be used in individual, group, couple, or family work (e.g., Ricks, Hancock, Goodrich, & Evans, 2014). Like a metaphor, a joke tells a story and sometimes contains a philosophical shift, interpretation, or message. It can also increase rapport if the client does not feel that the helper is trivializing his or her concerns (Goldin et al., 2006). Humor is often cultur-ally defined (Maples et al., 2001), and this should be taken into consideration. Before using humor, it is imperative that you understand your client (Thomas, Roehrig, & Yang, 2015; Vereen, Butler, Williams, Darg, & Downing, 2006), but the very nature of humor is that it is spontaneous. Most humor is part of a conversation, not a planned joke. For this reason, humor that is inappropriate or that falls flat is quite likely. The helper can only cautiously hope that the therapeutic relationship is strong enough to sustain it.

DIRECT INSTRUCTION Direct instruction is one of the most often used methods in help-ing. It is frequently called psychoeducation. Direct instruction involves lecturing, discus-sion groups, modeling, and the use of films and demonstrations to provide new information to clients. Research indicates that brief psychoeducation is effective for a variety of mental disorders, improves medication compliance, and reduces relapse in people with serious mental disorders (Zhao, 2015). Psychoeducational seminars are the stock-in-trade of par-ent education programs, stress reduction groups, anxiety management training, cognitive therapy for depression, couples enrichment seminars, substance abuse education, and myriad other programs. Besides the educational material that is presented, clients benefit from the support of others who are experiencing the problem, and they learn vicariously from the experiences of fellow learners. Many clients would rather attend a class than go to “therapy.” In addition, psychoeducation is less expensive to deliver because it can be given to a group.

Direct instruction can just as easily take place in the helper’s office. For example, couples counseling may involve training in effective communication skills right in the office. Helpers often assign books and other reading material to educate clients about specific topics such as stress, substance abuse, anxiety or depression, sexual abuse, proper parenting procedures, and other social skills that a client needs to acquire.

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GIVING ADVICE Like salt, advice is beneficial, but only in the right amount. Giving advice can be crucial in emergency situations when a client is engaging in dangerous behavior, such as practicing unsafe sex or using drugs, or when a client is being exposed to physical violence. Because beginning helpers like to give advice too liber-ally, many teachers ban it outright in the initial stages, and, as a consequence, text-books often have little to say about it. There is no doubt that it is a complex subject (Couture & Sutherland, 2006). However, because advice giving is rarely addressed, students tend not to be aware of its drawbacks and may find it an easy habit to fall back on. For example, when college students come for help, they typically expect advice, and they freely dispense advice to their friends in an attempt to help. They view it as tangible assistance. In fact, advice giving is a veritable minefield. It lures us into think-ing that we are actively helping a client. This section explains some of the reasons for leaving this skill out of your practice sessions for the present. If you have a tendency to give advice, we urge that you consider “retiring” that skill at this point and develop other alternatives.

Why Are Professional Helpers Reluctant to Give Advice? In the Peanuts cartoons, Lucy sits at the psychiatrist’s booth with a sign that says, “Advice: 5 cents.” Generally, this is how the media portray the helping professions. The client pays, and the helper gives a good dose of advice. If helping were merely giving advice, we could set up such a booth at the local grocery store. However, as one writer notes, “Clients can get all the advice they want from acquaintances, friends, and family members. They hardly need to pay a therapist to tell them what to do” (Kleinke, 1994, p. 9). To give exactly the same advice as everyone else in the client’s world makes the helper seem impotent.

Another reason that professional helpers avoid giving advice is that although clients may listen to it politely, they simply do not act upon these suggestions. There is not very much research on advice giving, but even in medical settings it seems to have a rather small effect (Sutton & Gilbert, 2007; Tymms & Merrell, 2006). Recent studies suggest that advice giving is not as effective as other brief interventions at least in the treatment of addictions (Meyer et al., 2008; Pal, Yadav, Mehta, & Mohan, 2007).

Perhaps some of the clearest evidence against advice giving is that about 50% of all medication prescribed by doctors is not taken (Brown & Bussell, 2011). It is thought that a major reason that medical patients do not follow physician recommendations is that they have private medical beliefs that are more influential than the doctor’s sugges-tions. Similarly, when helpers give clients advice and homework assignments, the help-ers can expect no better than 50% compliance. Are we then to blame the clients or to recognize that the art of helping is more challenging than this? Real helping is an art that involves getting people to solve their own problems and is much more difficult than supplying solutions by giving advice. Sometimes advice does stimulate a client’s think-ing about the problem, but more often it is simply disregarded (Mallett, Spokane, & Vance, 1978). Eric Berne (1963) identified a “game” that illustrates this point. Games are sequences of behavior that are frequently repeated and involve a payoff for at least one of the players. This advice-giving game involves a routine set of transactions between client and helper called “Why don’t you . . .? Yes, but . . .,” or WDYYB. The game goes like this: When the helper gives advice, he or she begins, “Why don’t you . . .?”; the cli-ent responds, “Yes, but . . .” and then gives reasons why the advice will not work. Most of us are familiar with this “game” from work and social situations, and we may feel

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confused and frustrated when good suggestions are rejected. What we need to remem-ber is that although a client may appear to be asking for advice, he or she is really look-ing for opportunities to think aloud, be understood, explore the options, and find his or her own solutions.

Another crucial drawback to advice giving is that if the client follows the helper’s advice, then the helper is responsible for the resultant change. If the helper gets the glory for having supplied good advice, how has this empowered the client to solve future life problems? There is an aphorism that states, “Give me a fish and I will eat today; teach me how to fish and I will eat forever.” The long-term goal of helping is not to supply a quick fix, but to help the client, even when the helper is no longer in the picture. Sometimes advice may be needed to solve emergent problems, but when clients resolve their own difficulties, they gain confidence and skills for dealing with future issues.

By solving a client’s problem through advising, you may also be sending the client an embedded message. Thomas Gordon (1975, 2000) considers lecturing and preaching to be among the “dirty dozen” of bad communication practices because they communi-cate to a client that he or she is incapable of solving the problem. Lecturing and preach-ing are advice giving in disguise (Patterson & Eisenberg, 1983). For example, during the goal-setting stage of the helping process, a client identifies excessive anger as one of the areas she wishes to work on. Frequently, beginning helpers launch into a “sermonette” on expressing anger and self-acceptance. The effect on the relationship is that the helper moves into the role of expert and begins to speak in generalities, rather than focusing on the client’s unique situation. If you can identify a sermonette in your practice sessions, you are probably using disguised advice giving.

Another persuasive argument against giving advice is that the consequences of giv-ing the wrong advice can be severe, both to the client’s life and to the client’s faith in the therapeutic relationship. A final reason to avoid advice giving is that it may violate the values of an individual’s family, culture, or religion. Such advice will probably be rejected, and it may also harm the therapeutic relationship. Consider these examples of potentially inappropriate advice:

“I advise you to quit your job and go back to college.”

“I suggest you learn to be more assertive with your mother.”

“If you don’t like all the arguing, why don’t you get a divorce?”

When Is Advice Appropriate? A helper who gives advice must have the following knowledge or experience:

• Special knowledge and training in the specific issue the client is facing• Firsthand experience or experience helping many people deal with the particular

issue• Understanding that the helper’s experiences are not the same as the client’s

experiences• Ability to give advice in a way that outlines the risks as well as the opportunities

that following a certain course of action entails• Thorough understanding of the client’s history, including the client’s ethnic, reli-

gious, and cultural background• Ability to see advice as a two-way interaction between helper and client (Couture &

Sutherland, 2006)

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Appropriate advice is concrete and invites reaction and discussion. It is presented as one alternative along with other solutions generated by the client. It suggests that the cli-ent should alter the instructions to fit the circumstances. Advice about what to expect from certain courses of action may be quite helpful. Advice is also appropriate when the client is in some physical danger and a helper’s directive can reduce the risk.

Here are some examples of advice that might be appropriate:

“Your statement that you are drinking too much has me concerned, especially because you drive in that condition. If you continue to drink, you can expect to be in an accident or in court. I want you to go to an alcohol treatment center for an assessment interview. Would you be willing to do that?” This advice to get an assessment is designed to inform the client about the likely outcomes of drinking and also identifies potential physical danger.

“You know, my partner and I always try to spend 20 minutes together every morning over coffee, talking about the upcoming day. It has been a way of building in a moment of contact in our hectic lives. Do you think something like that might work for you?” This advice invites discussion and asks the client to tailor the advice to fit his or her particular situation (see Butler, Potter, Danby, Emmison, & Hepburn, 2010).

“You’ve outlined several possibilities. Let me add one more. Have you considered directly confronting your co-worker about her unsafe behavior on the job? What effect do you think that might have?” This advice asks the client to think and to dis-cuss the alternative suggested by the helper.

On the other hand, in certain situations advice is inappropriate and could be harm-ful to the therapeutic relationship:

• When the client seems to be dependent on others to make decisions and needs to learn to choose his or her own course of action. He or she might ask, for example:

“Do you think I need a new haircut?”“Do you think I should go home this weekend as my parents ask, or should I do what my boyfriend wants?”

• When the client has not heeded advice previously.• When the client is asking for assurance on issues with unpredictable outcomes, such as:

“Should we have a baby?”“Should I get married?”“Should I move to Saudi Arabia?”

• When the purpose of obtaining advice is to influence another person:

“My husband believes in spanking our child, but I don’t. What do you think?”“My mother thinks I am too young to date. Do you agree?”

• When the client has information available and is capable of solving the problem without advice.

• When the advice conflicts with a client’s basic values, upbringing, or culture. The helper is giving inappropriate advice, for example, when he or she says: “You may come from an East Indian culture, but you live in America now. You have to do what you want, and your parents will have to understand.”

Clearly, the times when advice giving is useful are quite limited. Giving advice is appropriate only at carefully considered moments rather than as standard procedure. If

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advice giving is something you rely on in your natural helping style, try this experiment: Avoid advice giving altogether until you have learned to conduct an entire session using invitational and reflecting skills. There is an analogy in boxing training in which a left-handed puncher ties that hand behind the back in order to learn to operate only with the right arm. By letting go of an old way of responding, a new set of skills has the chance to take hold and become stronger. Similarly, if you can let go of your tendency to sermonize and give advice, you will have the chance to develop the subtler skills of helping the client find his or her own solutions.

STOP AND REFLECT

Think back for a moment on pieces of advice you have received from teachers, school counselors, friends, parents, grandparents, or other family members. It might have been about the purchase of a car or house, about which college to attend, or about what to do in a relationship. Identify one piece of good advice and one that was not very helpful, and then consider the following questions:

• What was it about each piece of advice that made it helpful or not helpful?• When considering the helpful advice, did the person giving it have particular expertise in that

area?• What other characteristics did the person giving the advice have that encouraged you to

accept it?• If you cannot recall any advice given by friends, teachers, professional helpers, parents, or fam-

ily members, what conclusions might you draw from this?• When you have a problem, do you want advice, or is it more important to have someone listen

so that you can figure things out for yourself?• Have you ever given a friend advice that was really heeded? How did it turn out?• What can you conclude about the role of advice in helping you to make decisions in your own

life? Will your conclusions have a bearing on your willingness to give advice as a helper?

Discuss your answers with a small group of classmates.

GIVING INFORMATION Giving information is the change technique a helper uses when he or she is supplying data or facts to help a client reach his or her goal. Informa-tion giving might include making referrals to social services or community resources. It differs from advice giving (Prochaska & Norcross, 2009) because it means offering facts rather than opinions. It can include correcting erroneous ideas about topics such as sexu-ality, drugs, parenting, and stereotypes about different ethnic groups. Information giving can also take the form of a planned psychoeducational program such as teaching the cli-ent assertiveness training.

Like advice giving, a helper uses information giving sparingly because too much data will overload the client who is already struggling with ideas from significant others. Information at those times will likely be ignored. Information giving can also subtly change the relationship between client and helper by emphasizing the helper’s superior

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knowledge. The helper must avoid the temptation to give “sermonettes” on topics like relationships or parenting unless he or she is providing important information or a refer-ral. Here is an example of an appropriate use of giving information:

“Based on what you have told me, your financial problems are significant and you could use some professional help. I would like to refer you to the Consumer Credit Counseling Service. This agency can help you make the decision about whether bankruptcy is a good answer for you. Would you be willing to go?”

Most information we give clients does not sink in. Medical patients remember less than half of what the doctor tells them, and helpers can expect the same (Brown & Bussell, 2011). Although the helper feels effective when referring or providing informa-tion, it is important to find out whether the client has really been helped. Therefore, the helper must follow up with clients to see whether information or referrals have had an impact. We will talk more about the topic of referral and follow-up when we discuss ter-mination of the helping relationship in the next chapter.

BRAINSTORMING

Creativity and the Art of Helping. Helpers are often creative people. They are flex-ible and open to a variety of options when problems arise (Gladding, 1995). They try to help clients devise novel ways of thinking and problem solving. Indeed, they may at times use artistic media—drama, poetry, painting, sculpture, and music—to help clients express themselves (Gladding, 2005, 2010a). Helpers also encourage their clients to think creatively when they have problems. A major difficulty in problem solving is that we tend to see things through the lens of our outmoded ideas, social conventions, and personal history. As Emerson noted, consistency can be a hobgoblin, leading us into foolish repeti-tions when what we need is to break out of our old ways of thinking.

Perhaps you have heard the story of the man who takes his son to the emergency room, and the doctor exclaims, “I can’t operate on this child, he’s my son!” We do not automatically recognize that the doctor must be the child’s mother. Because of our train-ing and the pervasive influence of the media, we unconsciously fall back on our usual way of thinking, that a doctor must be a man. During crisis states, we become even more conservative and less creative. A sort of tunnel vision develops that narrows our thinking. For example, people with suicidal thoughts may have concluded that killing themselves is the only option available. The concept of learned helplessness has been advanced to explain why people fail to look for alternatives following experiences of failure (Seligman, 1991). When people seem to find that nothing works to solve their dilemmas, they stop trying, even when circumstances change. The job of a helper is to be an “expander” (not a “shrink”) who urges clients to enlarge their viewpoint, jump-start their thinking, and engage their creativity.

What Is Brainstorming? Brainstorming originally was developed by Madison Avenue advertising firms to increase the creativity of staff members responsible for commercials. To brainstorm, a group of people sit around a table and generate ideas. The conditions and ground rules, however, are a little different from those of an aver-age meeting: The atmosphere is relaxed and even playful. Cooperation rather than competition is encouraged. Everyone in the group is called upon to participate, and no one is allowed to dominate. All ideas are recorded, but the focus remains on a specific

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problem that the group wants to solve. Beyond these general conditions for brain-storming, there are some specific rules that differentiate it from other problem-solving activities:

1. No ideas generated by brainstorming are evaluated. They are simply brought before the group and recorded. Evaluation involves a critical function of mind rather than a creative one. Creativity flows best in a nonjudgmental atmosphere.

2. Freewheeling is encouraged. Practical considerations are not brought up during a brainstorming session. In fact, the wilder the ideas the better, so that the limits of creativity can be reached. A playful attitude by the facilitator can increase freewheeling.

3. The quantity of ideas is more important than the quality. A large pool of ideas is needed as a source of good solutions. Seemingly unimportant ideas actually can spark thoughts from other members of the group, and small ideas can be used to improve bigger ones.

4. Hitchhiking is encouraged. Hitchhiking, or piggybacking, is building on the ideas of other people. By combining ideas, a concept grows and develops. Thus, brain-storming is a creative and cooperative process that has the power to unearth hidden solutions and engage both helper and client.

Research has suggested that sometimes when two or more people brainstorm together, they do not generate as many new ideas as they do when they compile their lists separately (Diehl & Stroebe, 1991; Mullen, Johnson, & Salas, 1991). The reason is “production blocking.” Production blocking means that people are sometimes too polite in a group situation to spontaneously blurt out their ideas while others are talking. They are also taking time to listen to the ideas of others instead of formulating new ideas. The flow of ideas dries up. Brainstorming requires that each person be allowed to express his or her ideas without having to wait for others to stop speaking (Johnson & Johnson, 2008). The contributions of women may be limited in brainstorming sessions because men tend to interrupt more. Production blocking can also occur in a therapeutic relation-ship. The client is reluctant in that setting to really think in a spontaneous and freewheel-ing way because of the weight that he or she places on the helper’s ideas. Sometimes it is more effective for both helper and client to write down their ideas or to have the client generate ideas and the helper record them. This allows for more freewheeling than the start-and-stop approach that a conversation entails.

How to Brainstorm. Brainstorming is also a change technique in the helping pro-cess. Conducting brainstorming between a helper and a client involves the same basic activities that groups use, with only slight modifications. The helper acts as a facilitator and participant, but a major aim is to help the client develop skills of creative thinking, which can generalize to other situations. While we are trying to help the client arrive at a solution, we are also teaching a valuable life skill. But developing a creative list of ideas is not the ultimate aim. At the end of a brainstorming session, both helper and client should have a clear idea about the next steps to take to solve the problem. Brainstorming takes a client through three basic steps:

1. Challenging the client’s assumptions and asking the right question2. Generating ideas3. Evaluating and agreeing upon potential solutions

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In the first step, the client carefully considers the assumptions he or she has about the problem and tries to shake free of them. Otherwise, preexisting ideas will color the next idea-generating step, leading the client to substitute previous solutions rather than to think creatively. One tactic for dealing with assumptions is to reverse them. For example, while designing an innovative program for training school counselors, participants listed all their assumptions about school counselors. One of them was “School counselors work during school hours.” This assumption was then reversed and rewritten, “School counse-lors do not work during school hours.” Ideas based on this new concept were then gen-erated. Participants began thinking about how school counselors should be available to parents after school and in the evenings. This led them to include family counseling train-ing as part of the curriculum. A nearby public school system is now incorporating this idea in its new school. The plans allow flexible working hours for school counselors so that they can meet with parents in the evenings.

Another story illustrates how assumptions about problems can be challenged and how, in turn, creative thinking leads to better solutions.

David and Gloria have been married for 5 years. David’s job requires that he move to another state for a 2-year period to work on an exciting project. If David refuses the assignment, he risks losing his job. The couple came for help because they have come to an impasse in their decision-making process. David wants Gloria to quit her job as a part-time graphic designer and move with him. Gloria wants to stay where she is, and she wants David to stay, too, even if he gets demoted or loses his job. Neither wants to live alone for the 2-year period.

Acting as a facilitator, the helper took them through the three basic steps of brain-storming to help them arrive at a solution.

Step 1: Challenging Assumptions and Asking the Right Question. The first step is to ask the right question. This can be determined by asking what is to be achieved in the end. What is the goal? The reason this step is so crucial is that often clients are examining previous solutions rather than the current problem. A good example of how this happens comes from the food industry. For several years, the question was often asked in this way: “How can we make a better can opener?” This formulation generated a number of new can openers, both manual and electric; however, a can opener is a previous solution, not the real problem. Someone ultimately was able to ask the question in a different way: “How do we open a can?” When the problem was stated in this way, a whole new set of creative opening features developed. Helpers assist clients in identifying the key issues by asking closed questions such as:

“What do you want to achieve by solving this problem?”“What is it you are afraid of losing?”“What is the most important thing you want to accomplish?”

Similarly, David and Gloria might argue over who is going to move, but what is the real question? With the assistance of the helper, the couple realized that the question that really needed to be asked was, “How will we be able to spend enough time together and feel close to each other if David goes out of state for 2 years?” Previously, the couple had assumed:

“Someone is going to have to move.”“Someone is going to be unhappy.”“Someone is going to lose his or her job.”

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Once the problem assumptions had been put aside and the real problem identified, the couple were ready to start generating ideas.

Step 2: Generating Ideas. In a freewheeling and cooperative atmosphere, David and Gloria took a few minutes to identify creative answers to the question “How can we remain close if David takes the job for 2 years?” Because quantity is encour-aged, the helper insisted that they generate at least 10 ideas. They came up with the following list:

1. We will e-mail every day.2. We will Skype every day.3. We will meet halfway every weekend.4. David will come home once a month and Gloria will travel to see David

once a month.5. We will spend our vacations and holidays with each other for the next

2 years, not with other family members.6. We will Skype every evening.7. We will send video recordings to each other.8. Gloria will take some of her work with her to David’s place and stay for a

week at a time.9. David will ask the company for time off to come home.

10. We can take pictures of things that happen and share them with each other.11. We could both take a class to fill our time and discuss it with each other.12. We can send smoke signals.13. We can meet halfway in Mexico.

As the ideas got crazier, they began to hitchhike on each other’s ideas. When Gloria said, “We could take a class,” David suggested that they take a Spanish class and share their learning when they meet in Mexico.

Step 3: Evaluating and Selecting a Solution. The final step of brainstorming is evalu-ating and selecting a solution. David and Gloria went through the list at this point and discussed each possibility. They settled on four or five suggestions to imple-ment that best fit the goal of keeping their relationship vital while they lived separately.

Although the case of David and Gloria may seem too good to be true, many clients and helpers have learned to use brainstorming in just this way. When a client and helper devise a creative solution to a knotty problem, the therapeutic relationship is enhanced and the client’s confidence and sense of hope is increased. Not only have the clients been fully involved in the solution, but they also have learned or relearned an important problem-solving skill.

MyCounselingLab Video Exercise 10.2 Identify the Steps in Brainstorming

THE TECHNIQUE OF REFRAMING There was an advertisement for the Peace Corps that ran on television during the 1960s. It challenged viewers to determine whether they saw a glass as half empty or half full. This commercial points out that there are two ways of looking at a situation: in terms of its assets or in terms of its deficits. When a helper asks

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a client to see the problem situation in a new, more solvable or positive way, he or she is using the change technique of reframing. An even better example of reframing comes from Mark Twain’s story of Tom Sawyer, who convinces his friends that painting a fence is fun and a privilege, not work. Helpers use reframes like this to guide the client to see the problem in a more constructive and responsible way (Long & Young, 2007; Osborn, West, Kindsvatter & Paez, 2008).

STOP AND REFLECT

The technique of reframing is based on the constructivist assumption that there are many different ways to understand a problem—there is not just one correct viewpoint. One easy way of understand-ing the idea of multiple viewpoints is a technique called relabeling. We use relabeling in career coun-seling to help clients recognize their personal strengths (see also Ward & Reuter, 2011). Have you ever noticed it is easier to get people to identify their weaknesses than their positive qualities? In this exercise, clients make a list of their own undesirable traits and a list of some undesirable traits of someone else they know. Then they try to think of another descriptor that puts a positive spin on the very same trait.

Take a look at these examples that have been given a “positive spin.”

Negative Viewpoint Positive Viewpoint

Compulsive Organized

Sloppy Casual, relaxed

Loud Enthusiastic

Now make a list of your own negative traits and another list for someone you know. Relabel each trait in a more positive way as shown above. Then consider the following questions:

• Is reframing like this just putting a happy face on a negative trait, or does it really uncover something positive about the characteristic?

• As you look over your own list, would you really want to lose this quality? What would you be giving up?

• When you relabel another person’s traits, do you see that person differently?

Discuss some of these issues and your own reactions with your classmates.

How to Reframe According to Watzlawick, Weakland, and Fisch (1974), reframing means coming up with a new, more constructive definition of the problem that fits the facts just as accurately as the old definition. To reframe a client’s problem, the helper must appreciate the client’s worldview and then replace it with an acceptable alternative. Reframing fails when helpers do not take the time to make sure that the new viewpoint is accurate and that it does not clash with the client’s perspective. For these reasons, it is best to proceed as follows:

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Step 1: Use the Nonjudgmental Listening Cycle to Fully Understand the Problem. The nonjudgmental listening cycle gives the helper a firm grasp of the details of the problem, including the people involved, their relationships, and the environ-ment where the problem exists. Before reframing, it is especially helpful to reflect meaning to get a grasp of the client’s worldview and values. In the following example, the helper summarizes a number of the feelings and meanings the cli-ent, Marlene, has expressed during the session.

Marlene: “So that’s the story. I have to move whether I like it or not. It’s like being fired and I have no control over it. Either I move or I am out of work. I’ve never lost a job before. Sometimes I think it’s their way of telling me they want me to quit.”

Helper: “From what I have heard so far, what bothers you the most is the lack of control over the decision. That makes you mad. But sometimes you see this situation as your failure and, at the same time, a personal rejection.” (reflection of feeling and meaning)

Step 2: Build a Bridge from the Client’s Viewpoint to a New Way of Looking at the Problem. Develop a reframe that bridges the client’s old view of the prob-lem with a new viewpoint that stresses the positive aspects of the problem or presents it as solvable. The important point is to acknowledge some aspect of the client’s viewpoint while, at the same time, suggesting another way of look-ing at it.

Helper: “I wonder if you could start thinking about this move in a different way? You have always wanted to travel. A few months ago, you were even considering a new job or moving to another state. Although you feel uneasy about this because you don’t like it when the decision is made for you, I wonder if this may not be a blessing in disguise. How might this job actually give you a little more freedom?” (reframe)

Step 3: Reinforce the Bridge. A shift in perspective, stimulated by reframing, is often something that develops slowly. One way of sustaining the shift is to assign homework that forces the client to see the problem in a new light. Marlene, for example, might be given a homework assignment to do more research on the positive aspects of the move.

Problems and Precautions with Reframing. Reframing is most likely to be success-ful if the client is able to relate the significant aspects of the new frame of reference to corresponding features of the old frame of reference. For example, one of my statistics teachers used to try to reframe his examinations as “sharing experiences.” The analogy was not successful, and everyone groaned because “sharing” is not a graded activity (an important feature). Unfortunately, it may be impossible to identify all aspects of a prob-lem that might be important to the client, but every effort should be made to imagine those that could be crucial. In a metaphor or story told by the helper, the basic ele-ments of the tale must conform to the client’s situation, or else the reframe may be rejected.

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SummaryIn this chapter, we looked at the last two common therapeutic factors in the REPLAN model: “A,” activat-ing client expectations, hope, and motivation, and “N,” providing new learning experiences. We presented methods for determining motivation, activating expec-tations and hope, and highlighted the foundational technique of encouragement. Under the heading of new learning experiences, we touched on the tech-niques of interpretation, bibliotherapy, modeling, met-aphors and stories, exposure to avoided stimuli, humor, and direct instruction. We spent the most time on the change techniques of giving advice, giving in-formation, brainstorming, and reframing.

Before leaving the change techniques that com-prise the final common therapeutic factors in the REPLAN system, let us recognize again the impor-tance of the helping relationship in making change

happen. The nonjudgmental listening cycle allows the client to develop a sense of trust, and that begins to pay off as the client takes tentative first steps in changing his or her life. More important, as the client encounters obstacles on the path to solutions, the basic relationship skills will be needed again and again. You must go back and forth between listening nonjudgmentally and working on solutions as long as a helping relationship lasts. Thomas Gordon (1975) used to call this “shifting gears.” There are times to push forward and break new ground, and there are times to “downshift” and return to a listening stance. In other words, be patient when using change tech-niques. One cannot go full speed ahead at all times. The therapeutic relationship requires that the helper abandon forward progress at times to reestablish the vital therapeutic bond.

Exercises

GROUP EXERCISES

Exercise 1: Reframing with a Reflecting Team

A special technique that originated in family therapy is the reflecting team. A helper meets with a client, couple, or family and gets their perspective on the problem facing them. Midway through the session, the helper stops and consults with a group of observers who have been watching through a one-way mirror or on a monitor. The observers (the reflecting team) sug-gest alternative ways of looking at the client’s problem. The helper then returns to the client and presents a reframe of the problem based on the suggestions he or she has heard. This exercise gives a small group the opportunity to think aloud, create, and evaluate pos-sible reframes.

Instructions

For this exercise, assemble a group of six to eight mem-bers to practice reframing. One person is designated as the helper, one acts as the client, and the remaining members form the reflecting team. The team makes suggestions but also allows the helper to think aloud and consider various ways to reframe the problem.

STEP 1: The client discusses a real or role-play situ-ation with the helper, who uses the nonjudgmental

listening cycle to understand the problem as com-pletely as possible in the 5–10 minutes allotted for this activity. The team watches but does not interact with the client or the helper. Team members may wish to take notes.

STEP 2: Once the helper feels that he or she has a good grasp of the client’s viewpoint, the helper finishes with a summary. Then the client is asked to move out of earshot or leave the room for approximately 5 minutes. During this time, the team conducts a group discussion about alternative ways in which the client’s problem might be viewed. The team is encouraged to identify reframes that are consistent with the client’s worldview and values, but that are more positive and hopeful than the client’s current way of looking at the problem.

STEP 3: The helper brings the client back into the pres-ence of the reflecting team and delivers a reframe to the client. The helper chooses the best reframe for the client based on his or her own thinking and the thoughts of the reflecting team. The client is encour-aged to respond to the reframe. When this has been completed, the role play is over.

STEP 4: The client gives written feedback regarding the reframe that was presented by the helper and team us-ing a 5-point scale, as shown in the Feedback Checklist.

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The exercise continues by changing roles and allowing several members the opportunity to play the role of the helper who makes the reframe.

2. The helper and client brainstorm solutions.3. The helper and client agree on a solution.

Following the brainstorming session, the client and observer(s) give the helper general feedback on:

1. The handling of the nonjudgmental listening cycle.2. The helper’s success in getting the client to think

creatively.3. The final solution. Was it realistic and appropriate

for this client?

Feedback Checklist: ReframingClient Name: ______ Helper Name: _______

Use the following number codes to rate the four questions below:

1. Strongly disagree

2. Disagree somewhat

3. Neutral

4. Agree somewhat

5. Strongly agree

_____ 1. The helper understood my problem completely.

_____ 2. The reframe was a more positive viewpoint than the original statement of the problem.

_____ 3. The reframe was a more constructive way of looking at the problem.

_____ 4. The reframe fit with my own personal outlook and values.

Exercise 2: Practicing Brainstorming

Students work in groups of three or four. One student takes on the role of a client, another becomes the helper, and the others act as observers. The client discusses a dilemma with a helper. The dilemma should be a situ-ation in which the client is forced to make a difficult choice between two alternatives. It may be a current dilemma or one that the client faced in the past. Sugges-tions of possible topics for the client to discuss include:

• Whether or not to commit to a relationship• Whether or not to end a relationship• Whether to move or stay in the same place• Whether or not to begin an academic degree

program

Before beginning the brainstorming process, the helper first reviews the “Quick Tips: Brainstorming” section. Then the helper uses the nonjudgmental listen-ing cycle for several minutes to understand a little more about the client’s problem. Next the helper moves with the client through the three steps of brainstorming:

1. The helper challenges the client to review his or her assumptions about the problem and to identify the real issue.

QUICK TIPS: BRAINSTORMING• Use closed questions to help the client

pinpoint the real problem.• Create a playful and cooperative atmosphere

in the session by modeling freewheeling.• Come up with a few unusual ideas yourself

to encourage the client’s creativity.• The helper should take the role of facilitator

and write down all the ideas that are generated.

• Make sure that the final creative solution between helper and client meets the “reality criterion”: It must effectively address the problem.

Exercise 3: Giving Advice

This activity can be used as a whole-class activity or for groups of at least six or eight students. One student acts as the client and describes a real problem to the group. The client is asked to identify a problem that is not too personal so that he or she does not feel uncomfortable discussing it in some detail. The helper (student or teacher) uses the nonjudgmental listening cycle to understand the issue. When the story has been fully articulated to the helper, the group thinks about the client’s story, and each person writes down a piece of advice.

In the second part of the exercise, the helper collects the written advice and reads each student’s ad-vice to the client. After hearing the advice, the client discusses with the class which advice he or she is most likely to follow and why.

In the third part of the exercise, the helper uses a brainstorming approach to get the client to think about the issue and to come up with his or her own plan. Finally, the client is asked to review both the advice-giving and brainstorming sessions and indicate what

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course of action he or she is most likely to take. The class or group discusses the results. If possible, the fol-lowing week, the student client is asked to report on what action he or she actually took.

SMALL GROUP DISCUSSIONS

Discussion 1: Motivation

Motivation is a knotty issue in helping. There are important ethical issues concerning treating clients who are unwilling or unmotivated to change. How would you feel about having a client who was forced to come to counseling and so was unmotivated? What do you think about requiring counseling? Should chil-dren be forced to receive help by schools or by their parents? Should counseling be mandated if a college student develops problems with alcohol?

Some helpers say that clients must be “ready, willing, and able” to participate in the helping process. That is, clients must be motivated (a customer), be vol-untary, and possess the skills and abilities to participate in the helping process. If these criteria were applied, some clients would not participate in group, individual, couple, or family work. Discuss your thoughts on this topic with a small group.

Discussion 2: Change the Viewing or Change the Doing?

In this chapter we discussed techniques that involve getting clients to act (advice giving and brainstorm-ing) and also a technique that encourages a client to see the situation differently (reframing). Under what circumstances do you think it is useful to help the cli-ent change perceptions and when should the client be encouraged to act to change the situation?

Discussion 3: Reversing Assumptions and Brainstorming

In groups of five or six, begin listing of ideas about how to improve a common household item such as a clothes hanger or a microwave or any other product of the group’s choosing. The task is to produce as many ideas as possible in 2 minutes. These are recorded on a piece of paper. For this first part of the activity, remem-ber that it is important to let go of the mind’s evalua-tive function and allow creativity to flow. Do not think about how practical the ideas are at first. Give equal time to wild ideas.

Now make a separate list of assumptions you have about the item you chose—for example, clothes hang-ers are made of wire, hang in a closet, are for hanging

clothes, and so on. Next to each assumption write a re-versal of the assumption—for example, “Clothes hang-ers are not in a closet,” “They are not made of wire,” and so on. Then brainstorm any ideas that arise as a result of the reversal. For example, if they are not wire, they are made of hardened paper and can be recycled. Add any new ideas to the list of improvements. Now see whether you can force-fit any two ideas on the list together, or hitchhike (combine ideas), to devise any new creative ideas. If so, add them to the list. As the final step in the process, evaluate each idea and select the best. Can any of the good ideas be combined to create a new product? The final design should meet the reality criterion: Is the product really an improvement?

WRITTEN EXERCISES

Exercise 1: Identifying Levels of Client Motivation

Review Steve de Shazer’s classification of clients into visi-tors, complainants, and customers described in the section “Activating Client Expectations, Hope, and Motivation.” Then, identify each of the following clients as either a visitor (V), complainant, (Com), or Customer (Cust). Dis-cuss your answers with the class or small group.

1. _______ A couple comes for relationship help, and it turns out one of the members has what you believe to be a severe alcohol problem. When confronted she says, “It’s not an issue. The rela-tionship is the issue.”

2. _______ A 16-year-old girl comes to her school counselor indicating that she is considering run-ning away to California with her boyfriend. She recognizes the possible legal consequences and her parents’ objections, but doesn’t want to lose her boyfriend. She has talked to her friends, both about leaving and about staying.

3. _______ A man comes to couples counseling with his wife because he is having an affair. He wants to repair his relationship with his wife and will end the affair, but claims he should not have to give up his “friendship” with the other person.

4. _______ Parents come to a school counselor con-cerning their son’s argumentative behavior at school. During the session, the parents squabble and verbally abuse each other. When the school counselor suggests some couples counseling, they indicate that they only want help for their son.

5. ________ A client comes for help to learn better communication skills. He lost his previous job due to poor relationships with co-workers. His present

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boss has suggested some kind of training because he is encountering the same sorts of problems. Previously, he blamed his co-workers; now he is coming to the realization that the problem lies in the way he talks to people.

SELF-ASSESSMENT

Using Praise

Review the difference between praise and encourage-ment in Table 10.2. Do you tend to use praise in your sessions, saying “Good,” and “That’s great,” when a client makes a positive step? When do you use praise in interacting with friends and family?

I overuse praise, evaluating the client too much. _________

I use praise about the right amount, maybe once during a session. __________

I use encouragement rather than praise most of the time. _________

I do not use much encouragement or praise at all. _________

Assessing Your Skills in This Chapter

Take a moment and think about the skills in this chap-ter (excluding advice giving). Indicate any success or difficulty you had in learning each of them, either in the exercises in the book or in your practice sessions with fellow students.

• Encouragement: (successes and difficulties)• Brainstorming: (successes and difficulties)• Reframing: (successes and difficulties)• Which of the techniques presented were most

useful or appealing to you?• Identify two ways you could learn more about

the skills in this chapter.

1. ___________________________________________

2. ___________________________________________

HOMEWORK

Homework 1: Knowing Sources of Information and Referral in Your Community

Helpers regularly give clients information about other sources of help. They refer clients to agencies and to

other individuals who have specialized services or knowledge. Review the following list of services. See whether you can identify someone in your commu-nity who delivers them or provides information about them.

1. A crisis hotline, suicide prevention service, or 24-hour emergency line

2. A nonprofit consumer credit organization that pro-vides help for people with financial problems

3. Parenting classes4. Help for domestic violence5. Treatment for substance abuse6. Couples and relationship education classes7. Information for families who have a child with cer-

ebral palsy or autism

Homework 2: Personal Experiments to Develop New Perceptions

Personal science is a term for the technique of getting clients to do action research on their problems. Do people really think you are aloof? Go ask 20 people you know. Personal science asks you to test your per-ceptions by getting feedback from others or by con-ducting an experiment. Try to apply this to yourself by thinking about something that you don’t do very well, or think about a part of your body that you do not feel is very attractive. Get opinions from eight friends or family members whom you believe will be hon-est. How accurate is your self-concept? If they do not agree, why do you cling to this belief? In what ways have you distorted your view of the self? Write a half-page reaction to this exercise. Do you see how clients might benefit from personal science?

JOURNAL STARTERS

Reread one of your journal entries from the beginning and another from the middle of this class. What do you notice about your development? Have you noticed any such changes in your confidence over the course of your training? Review Table 1.2, which shows the levels of expertise, beginning with naivette and end-ing with master. Where do you place yourself on this chart? What training experiences will help you develop to the next level?

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LEARNING OUTCOMES

By the end of this chapter, you will be able to:

11.1 Identify and differentiate between different kinds of outcome measures for evaluating progress.

11.2 Use criteria to make a decision about terminating the helping relationship.

11.3 Identify techniques for maintaining progress following termination.

11.4. Evaluate one of your transcripts or recorded sessions to gauge progress to this point.

The final phase of the road map of the helping process (Figure 11.1) is evaluation and reflection, a time when helper and client look at progress and consider terminating the relationship. One potential

Evaluating the Effectiveness of Helping

Basic Outcome Evaluation Methods• Use Progress Notes to Track

Improvement on Goals• Use a Global Measure to Detect Overall

Improvement• Consistently Assess the Client’s View of

Progress and the Therapeutic Relationship

• Use a Specific Measure• Use Subjective Scaling and Self-Report

to Measure Improvement• Use Another Person to Monitor Change• Use Client Satisfaction Scales• Use Goal-Attainment Measures

Termination• How to Prevent Premature Termination• How to Tell Whether Termination Is

Needed• How to Prepare a Client for Termination• Dealing with Loss at Termination• The Helper’s Reaction to Termination

How to Maintain Therapeutic Gains and Prevent Relapse Following Termination• Follow-Up• Booster Sessions• Engaging Paraprofessionals• Self-Help Groups• Continue Self-Monitoring Activities• Role-Playing for Relapse Prevention• Letter Writing

Summary

Exercises• Group Exercises• Small Group Discussions• Written Exercises• Self-Assessment• Homework• Journal Starters

Evaluation, Reflection, and Termination

C H A P T E R 11

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decision by helper and client is that more work needs to be done or that additional goals should be pursued. In fact, the end becomes a beginning. When goals have been reached, and termination seems advisable, both helper and client may experience strong feelings about the end of the road. In this chapter, we look at ways of determining and reviewing success and progress toward goals, and we also address both the emotional and practical aspects involved in terminating the helping relationship.

EVALUATING THE EFFECTIVENESS OF HELPING

Because of the emergence of managed care and a growing awareness that many unsound treatments have been used, there has been growing interest in outcome evaluation in the medical and other helping professions (Asay, Lambert, Gregersen, & Goates, 2002; Norcross, 2011; Sexton, 1996; Sexton, Whiston, Bleuer, & Walz, 1997). Outcome research is at the heart of this new trend toward scientific helping. Outcome research is the gen-eral term for studies that look at whether what we do actually benefits the client. Surpris-ingly, these studies are conspicuous by their absence. Yet, insurance companies and researchers are now asking clinicians to show through data that they are using proven practices and that the client was actually helped by the therapeutic process. Today, whether you work in a school, hospital, agency, or private practice, someone wants to

STARTHERE

STOP

Relationship Building

Assessment

GoalSetting

Interventionand

Action

Evaluationand

Reflection

FIGURE 11.1 Road Map of the Helping Process: Outcome Evaluation and Termination

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278 Chapter 11 • Evaluation, Reflection, and Termination

know whether you can demonstrate that what you do is actually working (Granello & Granello, 1998; 2001).

The extremists in this evidence-based practice camp suggest that we should only use treatment methods that we can back up with research. This is using research as a prescription for practice. Unfortunately, this idea is also limited. We know from medicine that two clients will react to the same prescription differently. Second, we also know that two depressed people are depressed in different ways. No treatments (including medica-tions) work for 100% of the clients. So the helper’s task is a complex one: to determine “what treatment, by whom, is the most effective for this individual with that specific prob-lem or set of problems, and under which set of circumstances” (Paul, 1967, p. 111). We must be able to tailor the treatment to the individual person and circumstance (Roth & Fonagy, 2005). This is why, as clinicians, we value research as a reflective tool rather than as a prescription. It helps us evaluate and think about what we are doing in practice. Third, we have only studied a fraction of thousands of available change techniques. Stick-ing to what has been fully studied would handicap the helper as promising strategies emerge. Still, this does not exonerate the helper from recognizing that some approaches have been better studied than others and have more to recommend them. We should primarily use proven and promising techniques. Let me give an example. For more than 2 years, I utilized relaxation procedures to help clients with panic disorder because I had been trained in stress management and it seemed logical to do so. I had very little suc-cess. These clients had trouble reaching deep states of relaxation through progressive relaxation procedures. I did not know whether to attribute this to the technique or to the intransigence of the mental disorder. Years later, research confirmed that other tech-niques are likely to be more effective (Beamish, Granello, & Belcastro, 2002). The com-petent, ethical helper must stay abreast of research and be constantly watching the professional literature.

But you do not have to wait for research to inform you. You can regularly monitor progress and make adjustments. This might be called using practice-based evidence (McLeod, 2007). You are already familiar with practice-based evidence because in this course you have been trying out the basic helping skills using a partner or small group. You receive feedback by noting what works and what falls flat. You should have received data, both qualitative and quantitative, from fellow students and from your instructor. This feedback is the kind of evidence you can also obtain from clients. You can ask, “Are we going in the right direction? What has changed since we started meeting? What is not working for you?” This kind of questioning assists the helper as well as the client. It keeps us from wasting our time or from potentially damaging the helping relationship.

Another reason for collecting practice-based evidence is to maintain helper self-confidence. Because of the wide variety of clients, disorders, problems, and treatment options, it is hard to feel effective, especially as a beginner. Frequently, clients have very high expectations of the helping relationship and may not recognize when progress has occurred. Information about progress, or “outcome evaluation,” can give you periodic encouragement, and you can grow in confidence as you see the actual data accumulate, rather than only listening to your fears, guesses, and discouraging thoughts. If you track outcomes, you can gain a personal sense of power and confidence that you are doing something that works.

Even if you are not particularly attracted to the scientific or research aspects of the helping profession, you can utilize some very simple methods to keep track of what

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works. In the first section of this chapter, we discuss the use of progress notes, global measures, specific symptom measures, client satisfaction forms, and goal-attainment measures. All of these are minimally intrusive in the helping process and push both client and helper not only to dream but also to fulfill dreams.

BASIC OUTCOME EVALUATION METHODS

Use Progress Notes to Track Improvement on Goals

When you begin seeing clients in a clinical, agency, hospital, or academic setting, you will be asked to document progress by the client using some sort of progress note form. A variety of systems for note taking exists including computer programs such as Athena and TheraScribe, which keep records for individual therapists or large organizations. The standard formats for notes in some agencies are the SOAP format (subjective, objective, assessment, and plan; Cameron & Turtle-Song, 2002) and the DAP (data, assessment, plan) format. These commonly used methods are throwbacks to treatment planning sys-tems that focused on diagnosis and collecting data each session. Instead, I recommend a system that tracks the client’s goals. This is sometimes called a problem- (or progress-) oriented case record (POCR). These notes should (1) restate the goals, (2) indicate what progress has been made during the week (outside of the session) that was relevant to the goals and the results of any homework assignments, (3) contain any new information or relevant events that occurred this week including crises or new problems, (4) state what was talked about in the session that relates to the goals, and (5) specify what plans have been made for the coming week and next sessions as they relate to the goals. In short, the progress note should keep the helper on track, focusing on the agreed-upon aims and not becoming waylaid by tangential conversations. Figure 11.2 shows a sample case note that utilizes this method of evaluating client outcomes relative to goals at each session. In a problem-oriented case record, the helper evaluates progress toward the goals at every session. A goal-oriented note also reduces the time it takes to do paperwork because the focus is so specific. It is not a blank page that the helper must puzzle over.

This goal-oriented approach helps avoid some of the pitfalls of writing case notes. One of the drawbacks is a tendency to write personal reflections or reactions to the client. Clients have a right to read these records and to have them sent to third parties like courts or employers. If you want to keep a journal of “process notes” or reflections, keep them separate from your progress notes (Moline, Williams, & Austin, 1998). You should also omit personal opinions, discussions about other people that might be embarrassing if revealed, or any sensitive information that is not relevant to treatment.

MyCounselingLab Video Exercise 11.1 A Heart Person

Use a Global Measure to Detect Overall Improvement

There are a number of global measures of psychological distress and psychopathology. Utilizing these measures periodically can help you chart whether the client is generally improving or deteriorating. The Brief Symptom Inventory (BSI; Derogatis, 1975) and the OQ-45 (adult and youth versions; Lambert et al., 1996) are two well-established

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paper-and-pencil instruments containing 60 and 45 items, respectively, used to identify global change. Both can be administered and scored in just a few minutes. In our clinic we give every client the OQ-45.2 every 4 weeks and track the results over the course of treat-ment using a computer program. This offers us another way of making sure we do not miss a positive or negative change. A brief alternative to the OQ is the 4-item Outcome Rating Scale, which was actually adapted from the OQ-45.2 (Miller & Duncan, 2000).

Consistently Assess the Client’s View of Progress and the Therapeutic Relationship

There is a growing literature suggesting that client feedback about the effectiveness of the sessions and the working relationship between helper and client (the therapeutic alliance) is important to good outcomes and prevents dropouts (Lambert & Shimokawa, 2011). We have long known that client estimates of the alliance are more predictive of success than helper ratings (Bachelor & Horvath, 1999). The Session Rating Scale (Johnson, Miller, & Duncan, 2000) is an extremely brief measure of the therapeutic rela-tionship that can be given at every session to prevent ruptures from curtailing the client’s

Client Name John Doe Session No. 3 Date 4 / 18 / 2016 Client/Counselor Negotiated Goal Statements

1. Decrease depression and suicidal thoughts.2. Resolve family problems. Increase brief contacts.

Any Progress in Goals Since Last Session

1. Client indicates that depression decreased significantly but still having suicidal thoughts1 time per day.

2. No effort or progress toward this goal.

New Information (Changes in Client’s Situation or Mental Status)Denied that suicidal thoughts were intense or increasing.Denied any planned method or available suicide means.

Counseling Activity During This Session

Goal 1. During session, client was confronted on self-downing and was taught tochallenge negative self-statements.

Goal 2. We did not address this goal except for client to indicate that he is not quiteready to work on this issue. I suggested he consider attending Adult Childrenof Alcoholics as a preliminary step. He agreed.

Homework Assignments, Referrals, and PlansGoal Plan

1. Client to challenge negative self-statements as homework and call if suicidalthoughts increase.

2. Will call friend to accompany him to first ACOA meeting.

Counselor Signature B. B. James REPLAN date 6 / 9 / 2016

FIGURE 11.2 Sample REPLAN Record and Case Notes

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progress. The measure asks the client to rate (1) whether or not goals are shared, (2) whether techniques and procedures in the sessions are mutually agreeable, and (3) the strength of the emotional bond. This four-item scale is minimally intrusive and quickly accomplished.

Use a Specific Measure

Sometimes you are looking for a specific change such as a decrease in depression, anxi-ety, couple distress, and the like. For example, there are a number of brief measures of depression such as the Beck Depression Inventory–II that can be used routinely (Beck, Steer, & Brown, 1996). The 21-item Beck has been used extensively in research, and many clinicians like to administer it every week when they are seeing a depressed client because it appears to be sensitive to improvement in mood.

Use Subjective Scaling and Self-Report to Measure Improvement

SUDS SUDS, the Subjective Units of Discomfort Scale, was described earlier in this book. Basically SUDS asks the client to indicate on a scale of 1 to 10 or 1 to 100 how physically or emotionally uncomfortable he or she currently feels. In general, the research supports the validity of SUDS as “global measures of both physical and emotional discomfort” (Tanner, 2012, p. 31). The clinician regularly requests an update from the client and records changes in SUDS on the progress notes. Besides the fact that helpers can see and inform clients of improvement, keeping track of SUDS gets the clients thinking about their goal and about the changes they are making.

SELF-RECORDING OF SPECIFIC BEHAVIORS The Pew Research Center (Fox, 2011) col-lected statistics on self-tracking of health data and found that 21% of adults tracked data about their health. Since that time, new products for smartphones and wristwatches have mushroomed, and self-tracking of distances walked, heart rate, blood sugar, and the like is possible on these devices. In addition, a number of smartphone applications are avail-able to track moods, goals, energy, habits, stress—even alcohol consumption. Many of these apps allow users to share data about themselves as well as store and graph data. Because this self-recording of behaviors is in its early days, none can be recommended especially because we do not yet know about risks to privacy.

Helpers might also ask clients to keep written logs of specific behaviors in terms of frequency, intensity, or duration such as:

• How many cigarettes did you smoke?• How many times did the child pull out his or her hair (trichotillomania)?• How many times did each member of the couple give the other a compliment dur-

ing the session?• How intense was this marital argument (on a 10-point scale)?• How intense was your fear of dogs in this situation (on the SUDS)?• How long were you able to meditate today (see Insight Meditation Timer app)?

When a client tracks his or her own problems or successes, he or she has a more accurate understanding of the specific problem and is more aware of the situations in which it occurs. The helper will probably get more accurate information from these applications than the client’s guesses about the frequency of the behaviors.

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Use Another Person to Monitor Change

Often someone in our social circle is better able to identify change in us than we are. For example, suppose a college student is trying to become more outgoing and talk more in class and in social situations. Rather than rely on client reports, the helper may utilize an ally of the client—a friend who will give the client periodic feedback when the friend sees the client behaving in a different manner or sees evidence of avoidance. There are pitfalls to the use of allies or aides, including the fact that they may take too much responsibility or they may not respect confidentiality. In addition, if the ally is a spouse or parent, his or her own needs and desires for the client can complicate matters. Still, hav-ing someone in the client’s daily life report on a specific change can be extremely useful and can also motivate the client. Obviously whether or not to use an aide or ally and the choice of the ally should be the client’s.

Use Client Satisfaction Scales

Client satisfaction scales are measures of how happy the client is with the services ren-dered. Most of these are developed by agencies and schools to answer specific questions, but others are nationally normed and can give feedback on how satisfied clients are com-pared with other clients around the United States. It may be useful to look at overall sat-isfaction from a program evaluation standpoint, but helpers can also look at client outcomes by including a few useful statements to be rated (say, on a scale from 1 to 7), such as:

• I was able to achieve my goals as a result of these sessions.• My relationship with the helper was important in helping me improve.• I have a more positive view of the future because of these sessions.

Use Goal-Attainment Measures

One graphic method for evaluating progress is goal-attainment scaling (Brady, Busse, & Lopez, 2014; Kiresuk & Sherman, 1968; Newton, 2002). Goal-attainment scaling allows helpers in schools and agencies track client goal achievement and also provides another measure of effectiveness (see Table 11.1).

The goal-attainment worksheet in Table 11.1 is used in the following way:

1. Each goal is briefly described in the goal statement section. In the table, one goal is filled out as an example, “Maintain social support for sobriety.”

2. Specific indications of success, or goal achievement, are noted in the sections just beneath the goal statements. In this case, it is, “Regular attendance at support meetings.”

3. Then the least through best possible outcomes are specifically described. In this case, the least favorable outcome is one meeting this month and the best outcome is 15 meetings this month.

4. The client’s actual outcome (3 meetings per week) is recorded for each of the goal statements and given a rating of 1–5. In this case, 3 meetings per week rate a score of 4.

5. Finally, on a monthly basis, an average for all goals is calculated to get an idea of how the client is progressing overall.

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6. Besides the ability to monitor progress, the goal-attainment worksheet provides a tool for review of therapy during the termination process. At times, the client may be discouraged because one of the goals has not been achieved. The worksheet may be able to show that even if the best outcome was not achieved, some progress was made.

TERMINATION

Termination is the word helpers use to denote the period of time when client and helper negotiate the end to the helping relationship. Even the word termination evokes dread or at least an Arnold Schwarzenegger movie. Termination is a loss and potentially a crisis but it is also an opportunity for growth because the client is challenged to apply the learning from the therapy hour to the future (Gelso & Woodhouse, 2002; Quintana, 1993). If handled well, termination is a time for celebration as the client reviews progress made and together helper and client make plans to keep the momentum going when they are no longer meeting on a regular basis.

How to Prevent Premature Termination

Frequently our issue is not how to exit the relationship but rather how to restrain the cli-ent from terminating until real progress has been made (Swift & Greenberg, 2015). Two

TABLE 11.1 Goal-Attainment Worksheet

Client Name __________________________________________________________________

Goal Statement A Goal Statement B Goal Statement C

Maintain Social Support for Sobriety

Specific Indicator of Goal Achievement

Specific Indicator of Goal Achievement

Specific Indicator of Goal Achievement

Regular Attendance at Support Meetings

Least Favorable (1) One Meeting This Month

Less than Expected (2) One Meeting Per Week

Expected (3) 2 Meetings Per Week

Better than Expected (4) 3 Meetings Per Week

Best Outcome (5) 15 meetings this month

Actual Outcome 3 Meetings Per Week

Score for each Goal 4

Average Score for All Goals ______________

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meta-analyses found the premature dropout rate to be between 20% and nearly 50% (Swift & Greenberg, 2012; Wierzbicki & Pekarik, 1993). Even a dropout rate of 1 in 5 is a significant problem.

No single client characteristic can predict premature termination (Connell, Grant, & Mullin, 2006). Certainly clients “vote with their feet”; that is, they leave the helping rela-tionship when they feel it is not helping them meet their goals. But there are a number of reasons that clients terminate prematurely that have little to do with how much progress they are making. They also leave the helping relationship due to dissatisfaction with the helper or the process and because of circumstances such as travel time and financial con-straints. Clients seem to be making a cost-benefit analysis. On one side are the potential benefits of change and on the other the costs in time, money, and emotional pain (Roe, Dekel, Harel, & Fennig, 2006; Swift, Greenberg, Whipple, & Kominiak, 2012). Unplanned endings can be due to a deterioration of the therapeutic relationship, or they may be the result of progress leading to feelings of relief that reduce motivation (Connell et al., 2006). Dropout rates are higher in younger clients, with younger therapists, clients with person-ality disorders, and those with eating disorders (Swift et al., 2012).

In addition to the risk factors mentioned above, here are some recommendations from the literature concerning ways of preventing clients from terminating prematurely (Joyce, Piper, Ogrodniczuk, & Klein, 2007; Mennicke, Lent, & Burgoyne, 1988; Ogrodniczuk, Joyce, & Piper, 2005; Pekarik, 1985; Piselli, Halgin, & MacEwan, 2011; Swift & Greenberg, 2015):

1. A major reason for premature termination is a rupture in the therapeutic relation-ship. Use client feedback and assess client progress. Provide a safe environment so that clients can talk about the therapeutic process and how it is fitting their needs. Create a strong working alliance early on and fix ruptures as they occur.

2. Avoid delays in seeing clients. Although some clients seem to come only during emergencies and fail to follow through, clients who must wait 2–3 weeks for an appointment may not arrive at all or may be hostile and less motivated.

3. In cases and settings where clients might be expected to drop out early, make con-tracts with clients for completing a small goal or a small number of sessions (6–10).

4. Do not process clients through several channels. Clients who are interviewed by an intake counselor or clerical person for screening and then referred to their perma-nent helper may not return because they have been treated impersonally. It is dif-ficult enough for many people to reveal their need for help by making the phone call for an appointment. Asking them to disclose their problems to several people may be too much.

5. Provide an orientation to the helping process, and offer information about the qual-ifications of the helper. If it is written as a handout, the client can read it as he or she waits for the first appointment. Orienting the client to the process can develop positive and realistic expectations and diminish client fears. Fees, billing proce-dures, expectations of client behavior, confidentiality, and other issues can be included in the handout. It is also a good idea to go over this again in the first ses-sion. If clients are not appropriate for the services you are offering, they should be referred to the proper setting.

6. Use reminders to motivate client attendance. Obtain the client’s permission to call or to write a brief reminder just before the next session. This simple suggestion can

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improve attendance significantly. Think about your dentist. Do you get a call the night before reminding you of the appointment? A phone call midweek may also serve to remind the client of homework and encourage the client to work on thera-peutic issues without the helper even mentioning them.

7. When a client terminates early, call him or her and find out why. There may be several unexpected reasons for the client’s termination other than a feeling that the therapy is unproductive. These reasons range from the embarrassment of having seen an acquaintance in the waiting room, difficulty with transportation, or rude-ness from support personnel. Help the client overcome these barriers.

8. In cases where the client decides to terminate before goal completion, the helper should try to go the extra mile (Kaplan & Sadock, 1998) by making it easy for the client to return at a later time. This may mean agreeing with the client’s idea to interrupt therapy (assuming this is appropriate) and directly inviting the client to set a follow-up appointment.

9. Consider negotiating a treatment plan with the client that includes time limits. Brief treatment tends to have fewer dropouts.

How to Tell Whether Termination Is Needed

Clients should be terminated when they have attained their goals, when they have been receiving counseling or psychotherapy for some time and have not made progress, or when there are signs that they can handle their issues independently. Most professional organizations, including the American Counseling Association, the American Psychologi-cal Association, the American Association for Marriage and Family Therapy, and the National Association of Social Workers, state in their codes of ethics that a client should be terminated if he or she is not making progress. In such cases, the client should be made aware of alternative sources of help, and a referral should be made. The decision about whether a client is making progress is not always easy. Some of the signals that suggest a client is ready for termination, such as missing sessions, coming late for ses-sions, or failing to do homework, can also be due to contextual factors such as a change in working hours, physical health, or finances. In addition, all helpers have a duty not to abandon clients seeking help, and therefore terminating a client who does not seem to be making progress is a delicate process.

How exactly do we know when helping has been successful? Should we consider success from the standpoint of the client or from the standpoint of the helper? Should we define success in terms of societal standards (dangerousness, employment, school grades) or from some ideal of mental health advanced by theorists? Mathews (1989) suggests reviewing one’s caseload and asking oneself, “If I had a waiting list right now, would I be seeing this client?” (p. 37). Based on Maholich and Turner (1979), Sciscoe (1990) identi-fied five questions a helper might consider in order to assess a client’s readiness for termination:

1. Is the presenting problem under control?2. Has the client reduced the initial level of distress by developing better coping skills?3. Has the client achieved greater self-awareness and better relationships?4. Are life and work more enjoyable for the client?5. Does the client now feel capable of living without the therapeutic relationship?

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The first four of Sciscoe’s questions highlight improvements that have been made and goals that have been achieved. The last question is especially important because it asks the helper whether or not the client is able to maintain the gains of helping without the therapeutic relationship. Answering these questions in a dialogue with the client and arriving at a mutual decision can help in working out the knotty question of termination.

MyCounselingLab Application Exercise 11.1 Is the Client Ready for Termination?

How to Prepare a Client for Termination

Most experts agree that sudden termination is not advisable (Knox et al., 2011; Macneil, Hasty, Conus, & Berk, 2010; Swift & Greenberg, 2015), but how soon should the topic of termination be brought up? Dixon and Glover (1984) recommend that at least three ses-sions in advance of termination be devoted to issues of termination, whereas Lamb (1985) recommends at least seven sessions. As much time as was spent in relationship building in the beginning of the therapy should be devoted to termination, say Cormier and Cormier (1985); and one-sixth of the time spent in therapy should be devoted to termination, according to Shulman (1979). In other words, there should be a period of preparation. During the preparation period, the helper leads the client in a discussion that reviews the counseling process and progress made (Fragkiadaki & Strauss, 2012). In general, it is important to emphasize the client’s strengths and to end on a positive note; however, areas left untreated or unresolved must also be discussed (Anderson & Stewart, 1983). One way to review is simply to compare before-and-after client functioning from the viewpoint of both helper and client. This is where outcome evaluation using client goal-attainment or testing can be extremely informative. At times, it is useful to discuss an ear-lier session when the client was at a different stage of functioning in order to examine the contrast. Some helpers like to read case notes that they wrote early on and other notes written later in the relationship to highlight changes. Any unfinished business between cli-ent and helper should be addressed, and the client should be encouraged to think about how he or she will look back on the experience in the future (Swift & Greenberg, 2015).

Dealing with Loss at Termination

Clients may be upset by termination because they associate it with other historical losses (Macneil et al., 2010; Ward, 1984). Some suggestions to help prevent, explore, and resolve these feelings include the following (Cavanagh, 1982; Dixon & Glover, 1984; MacCluskie & Ingersoll, 2001; Macneil et al., 2010; Swift & Greenberg, 2015):

1. Bring termination up early.2. Help the client think of termination as an opportunity to put new learning into practice.3. Specify the number of sessions at the very beginning, so both helper and client are

prepared for termination.4. Use a fading procedure; that is, space appointments over increasing lengths of time.5. Help the client to see his or her own actions that led to success and that the client

has the personal resources to deal with future issues.6. Play down the sadness of termination; play up the sense of accomplishment and the

value of independence.7. Use reflective listening to allow the client to express feelings of loss.

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The Helper’s Reaction to Termination

Kanfer and Schefft (1988) suggest that helpers need to accept the fact that termination inevitably occurs at a point far short of perfection. Many clients leave with the helper feel-ing that the solutions are still under construction. Besides the fact the helper must fre-quently let go of what seems to be an incomplete project, the helper may have also become deeply involved in the client’s life. Helpers may even postpone termination because of their own attachments and feelings of sadness and loss (Fragkiadaki & Strauss, 2012; Gladding, 2008).

Goodyear (1981, p. 348) lists several possible reasons that helpers have trouble letting go:

1. The relationship may be quite significant to the helper.2. The helper may feel uncertain that the client will be able to function independently.3. The helper may believe that he or she was not effective.4. The helper may feel that his or her professional identity is challenged by the client’s

premature termination.5. The termination may represent a loss of continued learning for the helper, who was

looking forward to gaining experience from the client’s peculiar problem.6. The helper may miss the vicarious excitement of the client’s exploits.7. The termination may uncover historical events associated with loss in the helper’s

life.8. A helper’s feelings of loss at termination may also be due to a reliance on helping

relationships to meet a need for intimacy (friendship) as well as a conscious or un-conscious sexual attraction.

Krantz and Lund (1979) feel that trainees may have special difficulty with termination. Beginning helpers may keep clients too long because they like the client or because they hope that the client will accomplish even greater goals. They may also be unprepared for their own feelings or for the powerful loss experienced by the client, no matter how much they are intellectually informed. A supportive super-visory relationship is the best way to help trainees through difficult terminations (Sciscoe, 1990).

HOW TO MAINTAIN THERAPEUTIC GAINS AND PREVENT RELAPSE FOLLOWING TERMINATION

Relapse prevention is another name for client and helper activities that anticipate situa-tions that are likely to lead to a return to former behaviors and practice alternative responses. Relapse prevention has been studied extensively in relation to addiction (Daley & Maccarelli, 2014; Marlatt & Donovan, 2005) but relapse is a threat for all sorts of behavior and mental symptoms. For example, lifetime relapse for depression has been estimated to be as high as 60% or 70% (Clarke, Mayo-Wilson, Kenny, & Pilling, 2015). A general technique to deal with relapse is to normalize it. Expect relapse and prepare the client immediately for setbacks, making sure that the therapeutic relationship is open enough to allow the client to be honest when relapses occur. This section covers a num-ber of other techniques designed to help maintain therapeutic gains and avoid relapse (Cavanagh, 1982; Perry & Paquin, 1987).

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Follow-Up

The term follow-up refers to a brief contact the helper makes a few weeks or months following termination. The purpose of the contact, which might be a phone call or an e-mail, is to determine how the client is progressing and to remind the client that the door is open if help is needed in the future (Wolberg, 1977).

Booster Sessions

Another way to maintain treatment gains is to schedule follow-up sessions with longer and longer intervals spaced over 12 months. The client can be informed of the follow-up system during the final sessions. For example, a helper can make brief contact with the client at 6 weeks, 6 months, and after a year. In other cases, it may be useful to actually have the client return for a single session at each of these times. When clients are learning specific skills, such as assertiveness training, stress management, and communication, these follow-ups can be called booster sessions, or “refreshers,” with the stated aim of reviewing learning and dealing with any problems (see Donovan et al., 2015). One ben-efit of planning for refreshers is that the client need not later feel a sense of failure if a return appointment is needed. These planned sessions are particularly useful with chil-dren and adolescents because they may benefit most from reminders and may see them as a sign of the helper’s continuing interest.

Engaging Paraprofessionals

Some agencies provide follow-up services with a paraprofessional for clients on a free or inexpensive basis. Mental health clinics, for example, may provide home visits by case-workers to monitor medication and identify areas of continuing need in those suffering from severe mental disorders.

Self-Help Groups

Self-help groups, if improperly conducted, can be a case of the blind leading the blind, but they can also be extremely powerful supports for clients following treatment. The quality of such groups is variable, and so the helper must be familiar with groups in the client’s vicin-ity before making a recommendation. Because clients are sometimes reluctant to attend self-help groups, helpers must strongly encourage clients to become involved. Sometimes clients do not want to attend self-help groups because it forces them to admit they have a problem. For example, college students who have alcohol problems rarely attend Alcoholics Anony-mous because they do not see themselves as alcoholics and do not want to be different from their peers. It is crucial that the helper support attendance at support groups in these cases and encourage the client to attend a few sessions (perhaps three times) before giving up.

Continue Self-Monitoring Activities

Self-monitoring means that the client is asked to keep records of progress on the treat-ment goals. These reports can be reviewed at the follow-up sessions. Earlier we discussed how collecting data is important for recognizing success during the process of the helping relationship. Through smartphone apps or simply using a journal, clients can continue to record progress (Bauer, de Niet, Timman, & Kordy, 2010).

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Role-Playing for Relapse Prevention

The technique of role-playing was described in detail in a previous chapter. Role-playing can allow the client to face risky situations more realistically. If the client is in an indi-vidual setting, the helper can assist the client in constructing a scene that the client feels is somewhat challenging. The client is then coached as he or she plays various parts. For example, a client who is trying to quit smoking role-plays sitting at a bar when a friend offers her a cigarette. The helper may need to play the part of the client if she needs assistance in finding the language to refuse. The goal is to have the client discover a sat-isfactory way of dealing with a situation that could trigger a relapse.

Letter Writing

Letter writing by the helper is an underutilized but powerful way to spark the client’s motivation to continue working on goals as well as to remind the client that the helper is concerned and available (Kress, Hinkle, & Protivnak, 2011). Narrative therapists have been the main champions of letter writing (Andrews, Clark, & Baird, 1997). Through let-ters, a helper can reinforce the client’s new life story and help the client continue to see the new perspective developed in therapy (White, 2000). Young and Rosen (1985) describe a group therapy activity in which clients write a letter to themselves during the last group session before termination. In their letters, clients remind themselves of their goals and also excuses they may use to try to avoid achieving their goals. The group facilitator mails the letters to clients about a month after the completion of group therapy.

SummaryThis chapter advocates that helpers stay current with outcome research or evidence that the client is chang-ing. Using outcome measures such as tests, SUDS scales, and goal-attainment scaling, assures us that cli-ents are working toward their goals. We also recom-mend using practice-based evidence or clinical data like progress notes to evaluate clients’ progress. The chapter also deals with termination or the ending of the helping relationship. A major problem is determin-ing when a client has reached the maximum benefit or

whether the client is terminating prematurely. We sug-gest ways to assist helpers in reducing the probability of early termination and to develop a positive end to the relationship. When clients reach their goals, help-ers should first prepare them for termination and then deal with the clients’ feelings of loss (and their own) that might accompany the ending. Even after the help-ing relationship is over, helpers can build in some means of maintaining the client’s progress while leav-ing the door open for booster sessions.

Exercises

GROUP EXERCISES

Exercise 1: Develop a Goal-Attainment Scale

The purpose of this exercise is to allow students to fill out the goal-attainment scale worksheet (Table 11.1). In pairs, students each take a turn as helper and client identifying a real or fictional issue that they could im-agine trying to change. Complete the worksheet, using

the six steps contained in the “Use Goal-Attainment Measures” section. When you have both had the op-portunity to fill out the worksheet with your client, dis-cuss how useful it was to analyze the goal in this way.

Exercise 2: Role-Play a Termination Session

In a small group, two members role-play client and helper discussing termination, which is to take place

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in a week’s time. The client and helper agree that most goals have been met, but the client feels that there are still some unresolved issues. In this scenario, the other members of the small group act as observers and give the helper feedback on the following:

• Did the helper review the history of the helping relationship with the client?

• Did the helper help the client celebrate success in attaining the goals?

• How did the helper handle unresolved issues?• Did the helper leave the door open and, at the

same time, express confidence in the client’s readiness to terminate?

SMALL GROUP DISCUSSIONS

Discussion 1: Justifying Your Job

Today, helpers of all kinds are asked to prove that what they are doing really works. For example, a school counselor provides stress workshops to sophomores and collects data that show improved test scores as a result of the intervention. When you are working in a helping profession, do you think you should be con-cerned about client success? Does this growing con-cern with numbers seem like a good idea or just an additional burden?

Discussion 2: Sample Case

Discuss the following case with a small group. Your client is a 17-year-old high school senior who has been discussing suicidal thou