Book summary of Learning the art of helping - Young - 5th edition

What is a Personal Approach to Helping Others? - Chapter 1

Helping others professionally is both an internal and external journey. Externally, one needs to gain new knowledge and continue learning. Internally, one must commit to understanding oneself and one’s clients. It is natural to doubt one’s own abilities and experience frustration. It is important to keep one’s own prejudices and biases in mind in order to overcome hurdles and to help others.

One method to address issues that pose as roadblocks to helping others is called reflective practitioner. Reflective practitioners commit to being aware of their own biased or prejudicial reactions through reflection, keeping a journal, and discussions with one’s peers. This method also applies to one’s role as a student in this course. Everyone benefits from different learning techniques as not all students learn in the same ways. The key is to process knowledge and ask questions rather than to only absorb what one hears or reads. Additionally, not all rules are applicable in every situation. This makes it especially necessary to reevaluate paradigms and tailor them to individual clients and their specific situation. Through reflection, one can accommodate and incorporate information rather than reject it prematurely. This skill may be of particular benefit in cases where one does not share anything in common with the client. This difference can be cultural, socioeconomic, in terms of education, religion, etc. Through reflection one can distinguish personal prejudices and remain more objective and less judgmental. Reflection is also useful when processing information from others such as supervisors, peers, and clients. While it may be a natural reaction to act defensive in the face of criticism, a reflective practitioner will learn from the situation rather than blame their mistakes on others or make excuses.

A reflective practitioner can be proactive in several ways. The first method is to ask for supervision. A helper can discuss their client’s problems and successes with a supervisor. In such a conversation, the helper and supervisor can discuss potential courses of action, personal reactions, and ethical concerns. Regardless of the amount of experience a helper has, all helpers benefit from supervision as the reflective process is always important. Another method is to participate in a support group of helping peers. Meet regularly. Share information. Even therapists in private practice participate in support groups. Another method is to become a client. Over half of therapists also enter therapy and 90% of them consider the therapy helpful. Receiving therapy is one way to experience the client’s perspective. Additionally, one can reflect within the context of this book by reviewing one's attitudes through peer discussions and journaling.

Perry's Stages of Cognitive Development

It is common to feel both excited and anxious when taking on new challenges. This apprehension is normal in developing as a helper. In this section we will discuss Perry's stages of cognitive development. Through understanding these stages a developing helper can feel confident that he or she is on the correct path. The first stage is the dualistic stage. In this stage the helper believes that there is only one way to respond to their clients: the right way and the wrong way. This form of thinking leads to a strong feeling of internal pressure and an emphasis on performance. The desire to be right can interfere with one's ability to listen to the client. Helpers in this stage often ask for direct feedback on if their performance was right. The second stage is the multiplistic stage. In this stage a helper realizes that there is more than one correct response depending on the situation and the client. A helper in this stage may even feel like there are too many potentially correct responses to a given scenario and have difficulty choosing the best response. Additionally, helpers in this stage may feel defensive when they are corrected by their supervisor as they do not yet understand that there is a response system. The third and last stage is the relativistic stage. In this stage the helper is more skilled at choosing the most appropriate response out of many potential responses. For example, the helper is better able to use the information at hand to initiate a response that steers the session in the most beneficial direction. In this stage the helper has enough experience and knowledge to be confident in his or her effectiveness.

Hoffman's Guild Terminology

Developing as a helper can also be described as the development of expertise and the mastering of a set of skills. A master counselor or a master therapist does not result only from the proper education but from being mentored, through training, and possessing a passion for helping others. Robert Hoffman studied how expertise is gained and used guild terminology to define seven stages. The first stage is naivette where the student has no knowledge on helping or counseling. The second stage is novice where the student is a new trainee who has not yet been accepted. The third stage is initiate where the student has been accepted and is beginning training. The fourth stage is apprentice where the student is an assistant and begins the introduction stage. The fifth stage is journeyman where the student can now work a full day without supervision. In the counseling field this stage generally lasts two to three years between a student's graduation and a student becoming licensed. The sixth stage is expert where the journeyman is viewed as exceptional by his or her peers and can handle especially difficult cases. In this stage the journeyman may have a specific field of expertise. The seventh and final stage is master. The master is one of few experts who can teach others as their practice has become examples for others to follow.

Thus it becomes clear that it takes time to become a master helper. Additionally, it is also clear that a most helpers need supervision. Thirdly, people begin training to become helpers with different levels of experience. Many helpers are already journeymen when they register for training. They may feel they are wasting time reviewing information they already know. However, reviewing information one thinks one knows can also be helpful in reevaluating one's positions.

Potential Challenges

In their development as helpers, students are asked to practice scenarios and perform in front of others. Students should be open to constructive criticism and feedback to make the most of these sessions. Avoid comparing your performance with that of others. It is key that students take control of their education and continue to practice skills they need to fine tune. Do not be too embarrassed to ask questions or to ask for clarification. The skills you learn are necessary to effectively help your clients. Another challenge is to find a mentor. Having a good example is one key way to learn skills. A mentor can also give valuable feedback. However, finding a suitable mentor able to devote time to working with you may prove challenging. Another challenge is thinking that you will find a perfect technique. In reality you will need to learn many skills and have a collection of techniques at your disposal depending on the situation and on your client. It also natural to feel like you are in limbo in the beginning stages of training as you incorporate the skills you learn with your natural helping style. Often helpers go through a stage where they feel that their approach seems artificial and unnatural. It is important to not lose personal warmth and a sense of being genuine as helpers. Another challenge is learning to accept feedback. Your reactions to feedback will vary depending on your stage of training. Strive to openly share your work with others to gain constructive feedback. If you are a member of a minority group, are female, are the first in your family to attend college or if you are going through a stressful life event, you may experience heightened challenges.

Ethics

Helpers should abide by the Hippocratic guideline to first do no harm. In Latin this is primum non nocere. While this is the most basic challenge of those in the helping professions there are also other rules and regulations in the form of ethical guidelines. Some guidelines which should be adopted in your group training will now be discussed in further detail. The first ethical guideline is to not discuss what other group members say during the sessions. This helps encourage trust in the group. The second guideline is to avoid giving advice. Giving advice can slow client progress. Additionally, you may not be qualified to give advice. The third guideline is to not force your value system and beliefs on others. It is important to be sensitive to and respectful of differences. The fourth guideline is to only give feedback when asked. Your feedback should also be delivered in a sensitive way to be constructive and specific. The fifth guideline is to only use the techniques discussed in this book or suggested by your instructor. Using techniques you aren't familiar with could be harmful and have adverse effects. The sixth guideline is to tell a instructor right away if someone in the group is thinking about hurting themselves or others. Tell an authority figure regardless of if you think a violent act is likely to occur.

It is important to stress that a helper's development is a lifelong process. While there is not one specific set of qualities that all helpers have, Carl Rogers suggested three traits as essential to an effective helper. The first is congruence. Congruence is the ability to be sincere and reflect what you say in how you act. This helps to build a client's trust.

The second characteristic is positive regard. This means that while a helper may not approve of how a client behaves, he or she is still respectful. The third characteristic is empathy. Emotional empathy is the ability to understand how another person feels. Cognitive empathy is the ability to understand another person's values and motivations. Rather than judge or evaluate a client, a helper should strive to understand. Empathy encourages clients to resolve their own problems. In addition to the three characteristics described by Rogers, the helper must not rely on gaining the client's approval. The helper may need to anger the client and bring up sensitive topics. Other authors suggest additional characteristics as being beneficial to helpers. A helper should have a positive outlook, want to help others, and be accepting. A helper should have good self esteem and be mentally secure and healthy to aim for cooperation rather than control. Effective helpers tend to also be able to help themselves by dealing with stress and managing their time well. He or she is creative and of high intellect and is both curious and flexible as they may need to come up with innovative strategies. A helper also needs courage to listen to the pain of others and to take risks. Keep in mind that these mentioned characteristics can be developed through training and practice. Additionally, a person's skills can be beneficial to helping others when utilized properly.

What are the Basics of Helping? - Chapter 2

Helping is a term that includes all the things one does to assist others. Helping does not rely on a professional setting or a contract. It only requires one person willing to help, another person in need of help, and an appropriate setting. Even people outside of the helping profession can benefit from learning helping skills.

Interviewing is defined as a conversation between someone giving an interview and someone answering the questions posed. In this conversation, the person giving the interview poses questions in order to gather information and record information. The interview is one form of assessment. The aim of an interview is to gather data rather than to improve the client's situation. Interviews can be structured or non-structured depending on if there are predetermined questions. An interview can also help the person giving the interview make a decision regarding the person being interviewed. For example, employers interview job applicants and counselors conduct intake interviews. If an interview tests the interviewee in a real life situation, it is a situational interview. One type of situational interview is a stress interview where the person being interviewed is intentionally subjected to a stressful situation to gauge their reaction under pressure. Helpers conduct interviews for several reasons. They may interview to determine if someone is suited to counseling, to determine someone's skill level, or to confirm a diagnosis. The interviewing process can aid a helper in steering counseling in the right direction.

Counseling and psychology are professional forms of contracted helping aimed at helping clients realize their goals. Counselors and psychologists are trained to use certain techniques during regularly scheduled sessions which generally last one hour. Currently, the words counseling and psychotherapy mean the same thing. Historically, psychotherapy was intended for patients with mental disorders. Mental disorders are severe cognitive, emotional, or behavioral disturbances. Counseling was geared towards so called normal people and counselors avoided medical terminology. Additionally counseling focused on the relationship between the counselor and client rather than specific procedures or techniques. Now, counselors also work with people with mental disorders and are comfortable using medical terminology like treatment and diagnosis. Therapists nowadays also work with clients having marital problems and other issues not related to a mental disorder. While some people still do differentiate between counseling and psychotherapy, this summary will use the two terms interchangeably.

Coaching is a new practice where helpers do not aim to provide therapy but to be supportive and to encourage. Coaching is not regulated by licensing boards but in many other ways overlaps with the roles of counselors. Coaching does tend to be more encouragement based and goal specific.

Helping is different from friendship because the contract between participating individuals is different. Friendship is mutual helping where both individuals give and receive help. Professional helpers on the other hand give help in exchange for compensation. The focus is on the client. Additionally, a helper may ask very personal questions (regarding a traumatic childhood for example) that a friend would not breach. In the beginning stages of training it may be difficult to draw a distinction, but it is important to not treat clients as friends and friends as clients. It is also beneficial for counselors to clearly define what a client can expect from the helper/client relationship so there are no misunderstandings.

Expectations

It is common for beginning helpers to have unrealistic expectations regarding what can be achieved in the relationship with clients. On average, helpers have six to ten sessions with a client. Most clients do not expect long term relationships with helpers but rather seek out helpers for specific issues. Helpers should be realistic and not expect to solve all a client's problems or try to instigate more changes than the client wants.

Additionally a helper should not feel at fault for unmotivated clients. Almost one-third of clients are referred by courts, government agencies, etc. and participate not by choice. A helper can only offer an opportunity for change but the client must make the choice to change. Some clients do not want to change their behavior even if it is destructive. Other clients do want to change but need motivation or support. A helper should help a client visualize an alternate lifestyle and try to convince them that it is preferable to their current lifestyle. A helper can do this by stressing the negative effects of current choices such as alcohol abuse. A helper should also stress the positive results of making different choices such as sobriety.

Another unrealistic expectation is that caring about clients and having experience is enough. A helper must also learn skills and be well trained in continuing education. Additionally a helper may have the unrealistic view that if they are good at their jobs, the client will not need help in the future. In reality, a helper should feel successful if the client consults them again if they have a similar problem. A helper should not expect to be able to help every client as they may not be the best match. There can be several reasons for this. The helper may remind the client of a person they don't like or a client may prefer a helper from a similar background. Helpers should also accept that they will make mistakes. The key is to learn from the mistakes you make. Finally, there will be times where a helper feels incompetent or not knowledgable about a topic. This should be seen as motivation to keep learning. You can ask for help from a supervisor or refer the client to someone more knowledgable about the problem.

The Basics

Microskills are small units of basic skills. While this makes learning basic skills easier in someways, it also creates problems as students are not able to see the larger picture. Microskills bring about mega skills which are common curative factors. Common curative factors are viewed as the basic healing principles to effective theories and techniques in counseling. Jerome Frank conducted research to show how these factors where effective. He described six therapeutic factors. Factor one is to maintain a strong relationship with the client. Factor two is to increase the client's motivation and expectations of receiving help. Factor three is to encourage the client to be self-efficient. Factor four is to give the client new learning experiences. Factor five is to make the client more aware of his or her emotions as well as express emotions more. Factor six is to provide the client with chances to practice their new skills.

Therapeutic building blocks are essential to the helping interview and ad the fundamental skills used to change behavior. Factors can be combined into more complicated techniques. In this book we refer specifically to twenty-one therapeutic building blocks which are divided into six categories. We will address the categories ion more detail in future chapters. Table 1 below shows an overview:

The first category is invitational skills. These are the skills a helper uses to invite a client to participate in helper/client relationship. These skills can be verbal or nonverbal and invite the client to share their story. The second category is reflecting skills. This is the skill set a helper uses to communicate that they've heard the client's story. A helper can summarize in "snapshots" what the client has said. When a client feels they are being listened to and understood they are likely to disclose more. The third category is advanced reflecting skills. These skills go beyond reflecting and include reflecting meaning and summarizing. Rather than restating want the client has said, a helper gets closer to the root of the problem. For example losing a job is not simply a loss of income but may be viewed as a sign of failure. Using this skillset helps the client arrive at a deeper understanding of his or her self. The fourth category is challenging skills. These skills are used to draw attention to discrepancies in what a client says. They can be helpful in discovering a client's strengths and weaknesses. Challenging a client can cause stress to the therapeutic relationship but also help the client realize that the relationship differs from a friendship. This skill set includes giving feedback and confrontation. The fifth category is goal-setting skills. These skills focus the discussion on what the client identifies as key issues. Theses skills include focusing on the client and boiling down the problem. The sixth category of skills is change techniques. These techniques are used to help a client reach the goals they've set. These skills include giving advice, giving information, using alternative techniques, and brainstorming. The helper helps the client think about new possibilities as well as develop a course of action. Through practicing and repeating these building block skills, they become second nature and can be combined into complex and sophisticated techniques.

The Helping Process

The helping process typically occurs in five sequential steps: relationship building, assessment, goal setting, intervention and action, and evaluation and reflection. To progress to the subsequent stage, both the helper and client must contribute something. For example, in the relationship building stage the helper builds trust in nonverbal ways and the client discloses. The helper uses invitational skills to show understanding and to provide a safe environment where the client is comfortable sharing personal information.This therapeutic relationship is the foundation of the helping process.

In the assessment stage the helper collects information while the client gives information. This second stage cannot be readily separated from the first stage as helpers are always observing their clients. In later sessions, the helper will continue to collect information, but most of the data is disclosed in the first few sessions. Some agencies require a diagnosis be made in the first session and ask clients to fill out an intake form to gather psychological history. The pitfall of this approach is that a client may not feel a connection with a helper if the conversation is focused on completely the form. The client may choose to not return for another session. Additionally, an assessment tends to be more complete when a trust relationship already exists. Gathering client history is also beneficial in determining if the service being offered is suitable to the client's situation.

In the goal setting stage the helper and client work together to shape goals. This book's position is that goals should result from a collaboration between helper and client. The attainment of goals do not necessary need to be measured by behavior, but it is helpful to have an observable outcome so it is clear when a goal has been achieved.

In the intervention stage the helper uses his or her training to suggest techniques to help the client achieve goals. The client contributes by doing homework and practicing skills. In this stage, a helper uses more advanced skills to push clients to take action. The necessity of a trust relationship is evident in this stage as a client will only listen to a helper if that trust exists.

In the evaluation and reflection stage the helper asks the client to reflect on any progress. The helper and client determine if the helping relationship should be continued. Helpers can ask clients to evaluate how they are progressing towards their goals. Clients can do this verbally, in writing, or with the use of self-report tests.

What is a Helping Relationship? - Chapter 3

One challenge that helpers face is whether they should emphasize the relationship with the client or emphasize the techniques. There are now many standardized treatments for certain problems like anxiety, depression, or sexual abuse. These treatments are described in manuals. However, some people believe that too much focus is placed on helping techniques rather than the relationship between the helper and the client. Some research strongly suggests that the therapeutic relationship is essential. Lambert's study found that the helping relationship was accountable for the client's success twice as much as using techniques effectively. A strong working relationship is important to change behavior. Additionally, the achievement of goals is more likely in a good therapeutic relationship. The quality of the relationship is a bigger indicator of success than the helper's theoretical approach. The therapeutic relationship is also important since clients who do not like their helpers, or do not believe them to be capable of helping them, may drop out of therapy after a few sessions. It is necessary that the helper to be accepting and warm so that the client will be confident in the helper's abilities. The six common therapeutic factors discussed in chapter two all rely on a strong therapeutic relationship to be effective.

Characteristics of the Helping Relationship

Professional helping involves a client asking for help and a trained helper willing to assist. Professional helping is a specific therapeutic relationship. It is important to stress again that helping is different from befriending. We'll now discuss seven characteristics of the helping relationship. The first is that a mutual respect, or even mutual liking should exist. The helper should respect a client's autonomy just as a client should trust the helper’s knowledge and experience. While a client may still gain benefits without this component, any successes will be likely due to other curative factors. Second, the aim of the relationship is to resolve the client's problem. Thus the relationship is geared towards the client's interests and the focus is never on the helper's problems. Third, a sense of teamwork should exist. The helper and client work together to help the client achieve success. The helper should provide strength and encouragement. Fourth, a contract should be used to define what aspects of the sessions will be privileged information. This helps to clarify and build trust. Fifth, the client and helper agree on compensation. While some helpers are volunteers, most are paid for their services and this should be agreed upon in advance. Sixth, there is a defined boundary between helping sessions and personal lives. Generally, helpers schedule sessions with clients and have a procedure for emergencies. Helpers should not interact with clients in their personal time so that they may remain objective. The seventh and last characteristic that we'll discuss is that the therapeutic relationship is a contractual relationship and can be terminated by either client or helper. The relationship may end for several reasons: the client may achieve his or her goal, the client is making no progress, the agency may regulate the number of sessions, or the health insurance may only cover a limited number of sessions. Additionally, a helper may refer the client to a different helper who is more specifically able to help with certain issues that may arise.

The client's perspective on the therapeutic relationship is essential to his or her success in achieving goals. Bedi, Davis, and Williams conducted surveys in 2005 regarding the events that helped clients establish a strong relationship with their helpers. The clients mentioned several elements. The helper taught them techniques such as creating a list of their goals. The helper had good body language and made strong eye contact. The helper was a good listener. The helper shared if he or she had a similar experience. The helper encouraged the client by noticing their strengths. The helper respected the client as the decision maker. The helper used humor and was honest. The helper was recommended by others. Another study conducted by Lilliengren and Werbart in 2005 found that clients found labeling and sharing feelings, the relationship as being a nonjudgemental space, gaining self-awareness, answering questions, and discovering new ways to relate to others as the most helpful experiences.

Methods to Create a Therapeutic Relationship

Begin by reflecting on your natural abilities and what tends to attract people to ask you for help. Here are some suggestions for new behaviors to practice as well as behaviors to avoid when building a therapeutic relationship. Kanfer and Goldstein found that helping relationships are improved through certain relationship enhancers. Relationship enhancers lead to an environment conducive to emotional components of liking, trust, and respect. Trust results in relationship consequences where the client can share freely. In this way relationship enhancers pave the way for a trusting therapeutic relationship. Examples of relationship enhancers include non verbal communication in the form of physical closeness, posture, and warmth. These will be discussed in greater detail in the following chapter. For now, let's focus on two other relationship enhancers: empathy and disclosure.

Empathy is the ability to put yourself in another person's situation and understand their feelings, the facts, and the importance of their story. Sharing empathy also means that you can communicate your perceptions accurately to that person. Much has been written on empathy and its benefits to society. Daniel Goldman conducted a study which found that the ability to empathize is an important predictor of success, mental health, and happy relationships. Within the helper/client context, empathy includes the experiences of both parties. The helper must be able to communicate his or her understanding of the client's experience. Empathy also helps in relating to people from different backgrounds. Through empathy, we take a tutorial stance of learning rather than an authoritarian position. The tutorial stance of learning from clients helps us think beyond our own perspective and be tolerant of alternate perspectives. When a client senses that a helper empathizes they are less defensive as they understand that the help is not trying to convert the client to his or her perspective. While it is never truly possible to understand someone else's situation, it is important that the client recognizes the helper's effort.

It should be clarified that empathy in helping is not the same as supporting a client's decisions or agreeing with them. Many helpers may be reluctant to empathize because they think they will be taking sides. However, the helper can communicate that he or she understands the client's circumstances without supporting how the client chooses to deal with the circumstances. Additionally, empathy is not pretending to understand as it is ineffective if it is not sincere. In the beginning, a helper should try to be patient and invest time in listening carefully to the client before claiming to understand. Empathy is also not making the client's problems your own. Of course one may be affected by the pain of others, but it is necessary to separate it from your personal life and not be overwhelmed. Empathy is also different from sympathy. Sympathy means pity for someone and suggests that person is inferior to you. It is important to maintain a relationship without hierarchy. Finally, empathy is important throughout the therapeutic relationship and especially essential in the beginning relationship building stage.

Another key relationship enhancer is self-disclosure. However, it must be used with caution and must be appropriate. Some suggest that beginning helpers avoid self-disclosure entirely. When used properly, self-disclosure is associated with positive client outcomes and increased trust. Additionally, it makes the helper more attractive, and leads to more disclosure from the client. Moderate self-disclosure is preferable to mildly personal or highly personal disclosures. Self-disclosing statements are not the same as self-involving statements. The former relates facts about oneself while the latter relates thoughts and feelings. While research tends to encourage self-involving statements, self-disclosing statements are not as widely encouraged. This is likely due to their success being dependent on the client's response and preference. Every client is different regarding what they deem to be too much personal information from the helper which may cause the helper to appear unprofessional. It is important that the client does not feel sessions are too focused on the helper. Additionally, the helper should be sensitive. A client with low self-esteem may feel insecure hearing about the helper's successes. Too much self-disclosure can also threaten the helper's authority in the eyes of the client. A client may also become bored after hearing the same story several times. Helpers should avoid making self-disclosures that are too deep, timed poorly, or irrelevant to the client's situation. The aim of self-disclosure is to build a relationship, help the client feel less alone, help the client see a different perspective, or to help the client understand that his or her experience is normal. A helper must be aware when a client needs to focus on his or her issues rather than shift focus to someone else. It is a good idea to shift the focus back to the client after making a self-disclosure.

Other factors can also put stress on the helping relationship. The environment where sessions take place also has an effect. A helper's office should be comfortable, have good lighting, and be quiet. Soft lighting is preferable to bright fluorescent lights. The decor should be comfortable instead of cold and clinical. However, the office should not appear to be the helper's living room either. It should still be professional. Ideally, there should be no obstructions such as a desk between the helper and the client. The room should be properly insulated for sound to give the client privacy.

It should be stated that these are the ideal conditions. Many helpers give sessions via phone or Internet. Others who work for schools may not have their own office to meet with students. Still other helpers work in a cubicle setting without much privacy. In these cases, the helper will need to instigate creative solutions (a traveling kit with a clock and a box of tissues, for example).

Distractions such as outside noise can interfere with a session. A sign saying, "quiet please" or, "session in progress" should be placed on the outside of the door. A white noise machine or other sound canceling device may also be necessary. Others disruptions such as phone calls or knocks on the door should be avoided so it is clear to clients that they are the top priority during the session.

A helper should appear credible to the client. This may seem challenging when a helper is in the beginning stages of his or her training. A helper can reassure him or herself by remembering and using the skills they do know. A helper should not exaggerate his or her experience nor diminish it. Do not tell the client of your fears of inadequacy. Do not try to maintain professionalism by creating emotional distance through being too formal. You will appear more credible if you appear organized, confident, and interested. Strive to communicate this through nonverbal ways such as body language.

Twelve Roadblocks to Communication

Thomas Gordon describes twelve therapeutic faux-pas. In French, faux-pas means false steps or wrong turns. They should not be viewed as mistakes, but rather as detours that can be corrected later. They are roadblocks to communication. Gordon felt that these twelve roadblocks suggest that the client cannot solve his or her own problems and needs someone else to do it for them. This disempowers the client and transfers their responsibility to the helper. The first is to order, direct, or command. Examples include language such as: "you must,” "you cannot," "stop it," "I expect you to." The second faux pas is to warn, admonish, or threaten. Examples include: "if you don't do this, then..." and "do this or else..." The third faux pas is to moralize, preach, or implore.

Examples include: "it is your responsibility to do this," and "I wish you would do this." The fourth faux pas is to advise, give suggestions, or solutions. Examples include "let me suggest," and "it is in your best interest to..." as well as "the best solution is..." The fifth faux pas is to persuade through logic, lecturing, or arguing. Examples include: "the right thing to do is..." and "the facts suggest you should..." The sixth faux pas is to judge, criticize, disagree or blame. Examples include: "you aren't thinking clearly" and "you are wrong". The seventh faux pas is to praise, agree, or butter up. For example: "you usually have good judgement." "You have so much potential." The eighth faux pas is to call names, to ridicule, or to shame. For example: "you really messed up this time," "you are a sloppy worker," "you're thinking like a lawyer." The ninth faux pas is to interpret, analyze, or diagnose. For example: "you are jealous," "you are paranoid." "What you need is..." The tenth faux pas is to reassure, sympathize, console, or support. For example: "you'll see it differently tomorrow," "It's not so bad," or "don't over think it" the eleventh faux pas is to probe, question, or interrogate.

Examples include: "why did you do that?" "When did you realize you felt this way?" The twelfth faux pas is to distract, to divert, or to joke. For example: "look on the bright side..." and "that reminds me of..." or "Wait tell you hear what happened to..."

Wolberg found other responses as also disruptive. These include an exclamation of surprise such as, "oh no! That's terrible," being punitive, falsely reassuring the client, overusing psychological terminology (also known as psychobabble), or coming to premature interpretations before enough information has been gathered. Finally, probing traumatic issues when a client is clearly resistant can also be detrimental to communication.

Transference and Countertransference

As the therapeutic relationship grows stronger, openness, respect, trust and liking will also grow. These feelings are generally encouraged as they promote positive change and increases the client's involvement with treatment as well as increases the likelihood that they will follow the treatment. Other strong feelings may also develop. Psychoanalysts use the terms transference and countertransference to describe these feelings. Transference occurs when a client bonds with a helper and the client feels the same feelings of self-doubt, fear being abandoned, and feel other feelings left over from romantic or parental relationships. Countertransference occurs when the helper associates the client with a past or present relationship or feels strong feelings for the client. When strong feelings interfere and disrupt the therapeutic relationship, the helper should consult his or her supervisor to address the issues. Feelings can be positive or negative. Negative transference may be the reason some treatments fail. In other situations, transference does not disrupt the relationship and can even be reflected upon and examined in relationship to the client's other relationships.

If a helper experiences countertransference and it affects the therapeutic sessions, a supervisor should be consulted. Negative emotional reactions towards a client may cause the helper to behave differently and be less effective. Some clients may illicit a strong negative reaction such as anger from helpers. While a helper may be tempted to simply share their feelings with the client, this is ill-advised if the aim is to relieve the helper's own anxiety. Disclosures should only be made if they are to the benefit of the client. See figure 3.

The way a client reacts to a helper can be due to transference or it can be a reaction to the helper's behavior. Regardless of the reason, the helper should help the client be more aware of the feelings and explore the source of those feelings. Here are some steps if a client expresses anger. First, communicate that you accept what the client is saying and do not be defensive or retaliate. The second step is to explore the client's feelings. After expressing anger, a client may withdraw because he or she fears punishment and abandonment. Encourage the client to explore his or her anger and get to the source. The third step is to use self-involving statements to share your thoughts and feelings about the client and his or her behavior. The fourth step is to make use of the client's expression of anger and relate it to other interpersonal relationships. Only do this if you can avoid shaming, blaming, or embarrassing the client.

Some psychoanalysts like Freud believe that transference results from unresolved issues in previous relationships and must be dealt with to address underlying emotional issues with parents or siblings. An alternate view of transference describes it as a series of cognitive distortions due to a pattern of thinking. Both these viewpoints stress the client as being focused on external (the helper's characteristics) rather than internal issues (self-awareness).

How to Deal with Difference? - Chapter 4

When approaching a client, keep in mind that understanding his or her needs is more effective than the technique you chose to use. This is particularly essential when working with a client from a background that differs from your own. It is for this reason that this book focuses on how to build relationships rather than specific techniques. For a technical intervention to be useful, a client must cooperate. This requires a good relationship between client and helper. Sometimes a client may be reluctant to participate in a particular exercise that is unfamiliar in his or her culture. At such moments, it is important for the helper to communicate understanding, acceptance, and sensitivity. When a client and helper come from different ethnic, gender, cultural, language, religious, economic, or family backgrounds, it can be additionally challenging to form a bond.

The likelihood of success in a therapeutic relationship increases when the helper and client are well matched. This can be referred to as having chemistry. A helper and client who are poorly matched face challenges to a successful relationship. One difference that may lead to a poor fit is if the helper and client are in different life stages. Some clients prefer helpers that are older and potentially wiser. Other clients prefer helpers closer to their own age. An older client may feel that a younger helper is too inexperienced. A client may want to discuss a topic the helper does not understand. Groups of people who share common experiences are called special populations. Examples of special populations include war veterans, homeless people, alcoholics, gay or lesbian people, people of the same regions belief, etc. Other differences that may pose a challenge are if people hold racial or ethnic stereotypes; if people have personality differences; gender differences, and if people have differences in religion or life philosophy. In other instances, differences can benefit a helper and client relationship. For example, a very shy and reserved helper may benefit from helper who is comfortable in social situations and see him or her as a role model. Since it is not possible within this book to discuss in detail all potential differences between a helper and client, we will focus on two: cultural differences and gender differences. We will relate theses differences to learning categories of skills, knowledge, and attitude.

Cultural Differences and the Challenges They Pose

Culture is defined as a set of shared beliefs, values, behaviors, traditions, and taboos that a group of people pass on to future generations. Passing on of culture tends to occur through families, and institutions such as churches and cultural organizations. Members of a group differ in how acculturated, or soaked in their culture they are. The culture of minority groups may be lessened through the influence of the dominant culture. Each person is culturally unique and even two people raised in the same house may differ to what extent they absorb their culture. A helper should be aware of these unique differences and avoid holding cultural stereotypes. One example of how these differences may manifest is in what a person thinks is within his or her power to change. In the United States, it is a widely held belief anyone can improve their lives if they work hard. This may not be the belief in countries with different politics or a different economy. A client and a helper may differ in how they view control and responsibility. Some studies show that a client is more likely to continue therapy and be more satisfied with their treatment when they have a helper of the same cultural background in terms of ethnicity and language. Variability in cultural attitudes can be studied in relation to Rotter's concept of internal versus external locus of control. This refers to the degree that an individual feels his or her behavior is due to personal effort versus outside influences such as luck or other people. Cultures differ in the trait of inner-directedness.

When a helper is first challenged to help someone of a different culture, he or she may find it difficult to stay nonjudgmental and non-biased and may see the client's viewpoint as distorted. What follows are suggestions of how to remain neutral. They can be categorized as knowledge, skills, and attitudes.

Knowledge

There are three ways to learn and gain knowledge about a client. The first is through a cultural study. This requires the helper gather some facts about the culture. Helpers should be weary of stereotyping from basic facts. However, this exercise can encourage a helper to recognize diversity. Every helper in the United States should at least study the history and culture of Asian Americans, Hispanic Americans, Native Americans, and African Americans. A helper benefits from being trained in two or more languages. Additionally, different cultures have differences in nonverbal communication as well as language that may be considered offensive. We will discuss these in further detail in a following chapter. For now, understand that while a helper may not be aware of all the differences that may exist, he or she should be open to discussing them and be aware when they interfere with communication. Helpers should also be aware of the different roles that family plays in different cultures. For example, in the United Stated, becoming independent of your family is a sign of maturity. However in Asian and Latino cultures, this is not the case.

The second way to learn about a client's cultural background is through experiencing the culture. This immersive experience can occur through traveling abroad, through having a diverse group of friends, or through visiting different cultural events. All of these experiences offer a more nuanced experience of a culture different from your own and serves to breakdown stereotypes.

Thirdly, a helper can let a client teach him or her about their culture. The helper should remain open minded and try to not judge based on the the perspective of the dominate culture. This third approach is beneficial when one considers the scope of the differences that exist between cultures. Studying every difference is unrealistic. The tutorial approach addresses this concern.

Skills

There are several skills a helper should practice. The first is to listen. In the beginning of building a relationship, a helper should focus on listening rather than giving advice. This helps the helper gather the necessary information and make an informed advisement. The second skill is to learn to work with existing support systems within the culture. For example, some cultures may place great importance on the role of a priest or minister and are more likely to be influenced by them than on outside helper. The third skill is to achieve credibility. Sue and Zane describe credibility as essential in therapeutic relationships where the helper and client are of different cultural backgrounds.

They identify two types of credibility. The first is ascribed credibility which is the status a client gives a helper based on age, gender, experience, and the existence of shared experiences or culture. The second type of credibility is achieved credibility which are the helper's skills and demonstrated abilities. This means that if a helper is not ascribed credibility by the client due to differences in backgrounds he or she can still gain credibility over time through demonstrating their knowledge or skills. A helper can gain credibility by framing problems in a way that is in line with a client's beliefs and values. For example, framing a problem as being a medical problem rather than a psychological problem may be more acceptable to a Hispanic client. Other cultures may prefer to focus on practical or educational approaches than discussing their feelings. However, a helper should not devise a strategy by prejudging a client based on his or her cultural background. It is necessary to determine the best approach in light of each person's unique traits. Not taking this into account will actually make a helper appear less credible. When a helper does not have credibility in the eyes of the client, the client may not return for future sessions. A helper can try to achieve credibility by trying to help the client as soon as possible in a tangible way. Secondly, a helper can ask other members of the client's community such as traditional healers or clergy for support. Finally, the helper must use a treatment that the helper believes to be credible. A client's background also influences the theories and techniques they are inclined to accept. A helper should strive to tailor the treatment to the client. This means a helper should be comfortable with a wide range of skills and methods to connect with a client. Additionally, a helper should always be aware of the context and tailor their treatment accordingly.

Culturally competent helpers are those that have the knowledge and skills mentioned above and have an open and accepting attitude. Additionally, they have an attitude of empathy, understand their own value systems and appreciate the views of others, and understand that cultures are shaped by economics and politics. They also try to avoid being culturally encapsulated which is defined as a refusal to accept that the views and values of other cultures are as valid as our own. Helpers also have the attitude of collaboration when setting goals with clients.

Gender Differences and the Challenges They Pose

Sex refers to the physiological differences between men and women while gender refers to the roles each sex is taught. Different cultures have different expectations for boys and girls. In the United States, men have generally been portrayed as more credible, powerful, and influential than women. Until recently, both men and women preferred male helpers. Nowadays, both prefer helpers of the same sex. Helpers also prefer clients of the same sex. Helpers benefit from consciousness-raising activities to reflect on their preconceived ideas regarding culture and gender.

In terms of knowledge, it is clear that a person's gender is fundamental to his or her identity. However, it is also important to examine the extent to which someone has been trained as traditionally male or traditionally female. Male and female clients may communicate in different ways. They also talk about different topics or frame a topic in different ways. It is important to not make assumptions based on someone's sex but to gain knowledge about a client and understand their unique characteristics.

In terms of skills, a helper should possess the skills of the reflective practitioner we discussed in chapter one. In reflecting, a helper identifies concerns and considers it from different angles. We all hold some assumptions about gender that may lead to misunderstandings. It is helpful to keep a journal, have a group discussion, and seek a supervisor to gain other perspectives. Additionally, a helper can follow some guidelines. First, address gender in the assessment process. Second, be proactive in discussing any issues of gender or misunderstandings that occur in therapeutic sessions. Third, ask a supervisor's perspective on if your attitude about a client is due to your own gender assumptions. Fourth, be conscious of how gender influences family roles and family violence.

In terms of attitude, gender stereotypes should be avoided. Stereotyping someone by gender may influence how we diagnose them. The differences between female and male can be described in terms of attitude and perception rather than differences in behavior. Research has not found any evidence that women and men express emotions or react differently from each other. However, people often feel that women are more emotional than men are. What should be considered, is that men and women have been socialized in different ways.

It is important to be aware of some common expectations as they can be be problematic in relationships. A male helper working with a female client should keep the following tips in mind. Avoid androcentrism which is a belief that the male experience is the normal and common. Be aware that a woman may have experienced sexual abuse and may feel fear or a lack of trust. Be aware of the pressures on women to carry out many roles (mother, wife, employee). Be aware if you are expecting her to follow your lead and therefore carry out traditional gender role norms. Be aware if you are treating the client as fragile. Be aware that you don't treat a client differently who is a lesbian.

As a female helper working with a male client, keep the following in mind: be aware of the concept of toxic masculinity where a man feels less masculine if he asks for help. Be aware that some male clients choose female therapists because they feel they can feel more free to share their weaknesses while other men feel that they can influence a female therapist. Be aware that you do not judge a man negatively who is not highly motivated or driven. Be aware that a male client's respect for a female helper may become romantic feelings. Be aware of your level of comfort when a man expresses his feeling or cries. Be aware that you do not treat a gay client differently than a straight client.

How to utilise Invitational Skills: Nonverbal and opening? - Chapter 5

Humans have a need to communicate and be understood. This can be seen in practices like keeping a journal, religious confession, prayer, and having confidants. The therapeutic relationship also can serve this function. James Pennebaker studied how people benefit from self-disclosure. He found that college students who regularly kept diaries had stronger immune systems and better health than those who did not. When a client visits a therapist he or she wants to explain themselves to a listener who will not judge them. This chapter focuses on the first set of skills known as invitational skills that a helper should utilize. Invitational skills are divided into nonverbal skills and opening skills. Nonverbal skills are also called body language. Nonverbal skills communicates information in addition to the words being said.

Nonverbal Communication

There are seven main ways to communicate nonverbally. Direct eye contact with some breaks for the comfort of the client is the first and most important nonverbal skill since it indicates listening. In western cultures, people who maintain strong eye contact are seen as more honest and reliable. Keep in mind that people of some cultures are offended by direct eye contact. If this is of concern, a helper can discuss the issue with the client. If a direct discussion does not seem appropriate, the helper can try to mirror the client's eye contact. Eye contact is more useful in some situations than others. When the client is addressing a difficult issue, strong direct eye contact may be uncomfortable.

The next important way to communicate nonverbally is through body position. The helper should face the client squarely and have an open body position (no crossed arms or legs). When the helper has an open body position the client will be more relaxed and open up more. The helper should maintain a relaxed but assertive posture. To communicate that you are listening, you should lean forward slightly.

Third, the helper should use silence well to let the client fill in gaps in conversation. It is a social norm to fill awkward silences. When used well, silences encourage a client to continue speaking. It also allows the client time to reflect. However, silence tends to be used by more experienced helpers because if it is used too often or too early, a client may feel unsupported.

Fourth, the tone of voice should be of the right volume and be warm and supportive. A client may be emotionally distraught and visit a therapist as a result. A helper who communicates empathy through his or her tone if voice can help stabilize the client.

Fifth, a helper should use facial expressions and gestures such as head nodding to encourage the client to talk. The basic facial expressions for feelings of sadness, joy, anger, fear, surprise, and disgust are the same regardless of culture. Of the 5000 other discernible facial expressions, some are culturally specific. A helper should pay attention to a client's facial expressions. If it does not match what the client is saying, it may be a sign of dishonesty or conflict.

Gestures also provide important clues. Someone who does not gesture at all appears aloof whereas moving a lot may be a sign of anxiety. A helper should use moderately reactive gestures. Another way to communicate nonverbally is thorough physical distance. What is considered an individual's bubble or personal space differs between cultures. For example Americans feel comfortable when there is a distance of 1 to 4 feet between them while Italians still feel comfortable even when they are only a few inches apart. In a western setting, 5 feet is ideal. Additionally, physical barriers such as desks should be removed for a less formal setting.

The last nonverbal way of communicating we will discuss is touching and warmth. Touch has a long history in helping. It can show caring and support. Some writers feel that not using touch can hinder therapy. Holroyd and Brodsky view touch as especially helpful when working with socially immature clients or with clients who are depressed or experiencing grief. They also suggest using touch to emphasize a point and during greeting or termination of a session. Goldman and Fordyce state that by touching another person, we increase our ability to influence them. It should be noted that while touch has healing properties, there are taboos that should be respected. Touch can led to sexual and transference reactions from a client. A client who has been sexually abused may also respond negatively to touch. Some writers suggest a helper should only use touch when he or she knows the client well. Additionally, in some situations it may be best to restrict touch to communicate encouragement or concern. Fisher, Rytting, and Heslin give three guidelines to determine when to use touch. First of all, it should be appropriate to the specific context. Secondly, touch should not force a level of intimacy on the client that he or she is not comfortable with. Third, touch should not be used to communicate a negative message. Due to the risks of using touch, beginning helpers are advised to not use touch, but to communicate warmth.

It is estimated that only 7 percent of emotion is communicated in words, while 38 percent is communicated by a person's voice and 55 percent by his or her face. The importance of body language can be seen in how important decisions still tend to be handled in person rather than via email. The art of persuasion also works best face to face. A helper also must persuade a client to open up. However it should be noted that body language can be ambiguous at times. For example, a person who folds their arms in front of them is not necessarily closed off to what the helper is saying. He or she may simply feel cold. There are also cultural differences in how people express and interpret body language.

Opening Skills

The second category, opening skills, act to encourage conversation. They ask the client to open up without being too invasive. They also help show the client that the helper is listening and understanding his or her story. Opening skills can include encouraging statements and open and closed questions. When used together, these two categories of skills help encourage the client to open up and show the helper is listening. Encouragement is the words a helper uses to get a client to have the courage to confide. Encouragement can be divided into two categories: door openers and minimal encouragers.

Encouragement: Door Openers and Minimal Encouragers

A door opener is a non-coercive invitation to talk. It is used by the helper to shows openness to discussion. Judgmental or evaluative responses on the other hand are door closers. It is important that the helper use door openers which are positive and non judgmental. It can include observations the helper has made. For example, "You look down today, would you like to talk about it?" Other door openers include "What's on your mind?", "Can you tell me more about that?", and "Tell me about that." Door openers are used by helpers to encourage a client to expand or elaborate on their story, to begin a conversation, and to gain more time for the helper to consider a response.

Minimal encouragers are short statements that show the helper is listening to and understanding the client. They are not invasive and allow the client to dictate the direction of the conversation. Examples include: "I see." "I hear you." "Mm-hmm." etc. Of course minimal encouragers will not solve a client's problems but if they are not used a client may feel unsupported. The essential function of minimal encouragers is to signal that the helper is present. They should not interrupt the flow of the story.

Questions

The second opening skill we will discuss is questions. This is also the most easily abused opening skill. If a helper asks too many questions he may signal to the client that he is not listening. Additionally, a client may feel evaluated or like he or she is being interrogated. Questions may also change the course of a client's story or interrupt their train of thought. In a helping session, the client should be learning how to express him or herself rather than learning to answer questions. Examples of unhelpful questions include: "How are you doing?" "How have things been?" and "How do you feel about that?" Of course, a helper will need to ask questions to gather important information. A few guidelines can help a helper determine when questions are appropriate. Questions should be specific and relate to facts. They are useful when an essential part of the story is unclear or to encourage a client to open up.

Questions to Avoid: Why Questions and Leading Questions

Common questions to avoid include why questions and leading questions. When people ask why, they assume that the other person knows why and that knowing why will help the client to solve the problem. This encourages people to over rationalize when responding. In most instances, the answer to a why question is "It seemed like the a good idea at the time." Helpers may revert to asking questions when listening to an angry or silent client becomes difficult. The better approach is to use attentive silence and encouragers. Another type of question to avoid is the leading question. This question suggests that the helper has the answer and if the client follows the helper's line of thinking he or she will discover the answer. A leading question is often a way to give advice or argue. Leading questions are often used with children or adolescents. Research shows that leading questions tend to shut down conversations.

Closed and Open Questions

Other questions include closed questions and open questions. Closed questions ask for information that is factual. Some closed questions or yes or no questions. Another example of a closed questions is to ask someone their age. Closed questions are important for gathering factual information and prove especially useful in emergencies or in complicated stories. As with other questions, asking too many closed questions, like a person's address, may lead a client to feel the helping relationship is based upon answering questions. As a result, the client may take a passive role and wait for questions. In these moments it is important to emphasize the collaborative nature of the helping relationship.

Open questions do not ask for specific information but encourages the client to disclose. Open questions allow to client to express him or herself more and are viewed as more helpful. Examples include: "Can you tell me about the types of problems you've been having?" "You say you have low-self esteem, what do you mean?" The difference between closed and open questions are similar to the difference between multiple choice exams and essay exams. While multiple choice exams test an understanding of the facts, essay responses all the respondent to show a more in depth and nuanced understanding. Responses to open questions tend to give more information than responses to closed questions. A helper who wants to ask a closed question should try to change it into an open question when possible.

A helper should strive to listen actively. Some feel that the act of listening fully can in itself be healing. To listen actively, one must give the speaker his or her full attention and communicate understanding without interrupting the speaker. There are several challenges to active listening. The first is our urge to help and listener the clients pain. Friends may give quick advice due to an urge to help and instigate a change. However, in a professional situation, a helper should let a client fully tell their story. When a person tells their story, they are expressing how they view the world. A helper who listens actively can better tailor an intervention unique to the specific client. All clients tell their narrative differently. Some will delve into their story during the first session, others have to be encouraged bit by bit.

How to utilise Reflecting Skills, part 1: Paraphrasing & reflected thoughts? - Chapter 6

While the invitational skills described in the last chapter show that the helper is present and listening, they do not show that the helper understands what the client is saying. Reflecting skills are interventions a helper uses to encourage a deeper exploration of feelings, meanings, and facts that may coexist in the way a client presents his or her problems. A client's telling of his or her story has three key aspects. The first is the client's understanding of his or her thoughts and the facts. This occurs on a cognitive level. Second is the underlying feelings of client. This is the emotional level. Third is the hidden meanings, or the existential level. In order to understand the whole story, all three aspects must be explored. This chapter focuses on the first aspect, the cognitive level. In order to reflect facts and the client's thinking, a helper must learn the skill of paraphrasing. We begin with a skill of responding to facts and thoughts because people tend to be more comfortable beginning a conversation by discussing facts than emotions. The level of comfort in discussing feelings differs from culture to culture and between genders. In helping relationships facts and feelings are both important and later chapters will focus on reflecting feeling and reflecting meaning.

Reflecting means repeating what the client has said in a condensed way and using different words. The tone should be nonjudgemental. Reflecting has four purposes. First, through reflecting we show empathy in a verbal way. Not only does the helper hear the facts, he or she hears the deep meaning and tries to share the experience. Second, reflecting is way to mirror to the client what he or she is communicating and give him or her the opportunity to correct the impression given. A beginning helper should not worry that every reflection is perfectly accurate. Be aware that you a client can correct your word choice and clarify the meaning. Third, reflecting encourages to client to explore the experience further. The client may delve into more personal details and discuss deeper feelings. Fourth, reflecting brings to light hidden messages that may otherwise stay hidden. A client may be uncomfortable disclosing feelings of fear or worry at the beginning of the helping relationship. Through reflecting, a helper can bring these feelings to the forefront.

Rather than asking questions to clarify a part of a story, a helper use paraphrasing to determine if he or she understood. Paraphrasing is not a word for word repetition of what the client said. It is a condensed version using different words and stated in a nonjudgemental way. It should be short and to the point so as not to distract the client from telling the story. In paraphrasing, the helper makes the client aware of his or her perceptions of an experience. This is one way where the therapeutic relationship differs from a friendship. The therapist is not just providing support but asks the client to reflect on his or her own perceptions.

Two Steps of Paraphrasing

Paraphrasing occurs in two steps. The first step is to listen carefully. The second step is to condense and reword. To carry out the second step, the helper must find the most important information in what the client has said. If the helper focuses too much on a less crucial detail, the client may become sidetracked. The helper should strive to subtly highlight a key issue in the client's statements.

Paraphrasing can be used as soon as the helper has a grasp of the facts or wants to make the facts more clear. As the session continues, paraphrasing is helpful in reflecting aspects beyond the facts such as how the client's thoughts and perceptions. It should be used after opening skills and invitational skills. A common order is invitational skills, opening, skills, encouragers, open questions, then paraphrasing. It is not necessary, and may even be counterproductive, to paraphrase every statement. Let the client speak for a while before paraphrasing.

Topics

The specific subject of discussion is referred to as a topic. In the early stages of a helping relationship, a client may discuss many topics during an hour long session. The early sessions tend to be assessment oriented so this is to be expected. Later sessions will focus on certain subjects closely related to the client's key problems, exploring each topic fully before moving on to the next. While a beginning helper may want to rush through topics, one should strive to ask open questions and paraphrase to be certain the topic has been explored and understood. After understanding the surface issues, the helper should delve deeper using reflecting feelings. To understand a topic, it is helpful to follow the typical sequence of skills using encouragers, then open questions, then paraphrasing. Again, the paraphrase acts as a summary of the client's statement (not only of the facts but of the client's feelings in that situation. All clients have depth and layers. Following the suggested sequence beginning at opening skills, going on to invitational skills, to paraphrasing, to reflecting feelings, to reflecting meaning is advised because you begin with the least invasive actions. Each client is different and will respond in different degrees to each skill-set. While some clients may be quite open about their feelings others may find it challenging.

Depth Scale

It can be helpful to consider a depth scale for paraphrasing. Accurately paraphrasing a client's statement is given a 0 on the scale. If the helper's paraphrase moves the client to a more superficial level where the topic is less important, it is assigned a -1. If the helper is able to grasp a deeper meaning the client implied but did not state directly, the paraphrase can be assigned a +1.

Common Pitfalls of Paraphrasing

One mistake when paraphrasing is to only restate the facts. It is important that the helper try to grasp the client's thoughts and perceptions. Another problem may arise if there are too many distractions. These can be distractions in the surrounding environment. Most of the time, these distractions are mental noise or the helper's own thoughts which interfere with his or her focus on what the client is saying. This may happen if the client says something that brings up personal memories or something that evokes an emotional reaction. If this happens, the helper should ask the client to repeat the part of the story that the helper did not follow. The helper should then paraphrase the client's statement. It is important to learn to manage internal noise. One way is to identify triggers early and write about them in a journal. Another issue may be worrying about how to respond. This becomes less of an issue with practice. It helps to focus intently on the client and keep in mind that you need only respond to the last thing the client said. This will be a more natural flow of conversation and you will explore topics in more depth rather than jump to something new. Another challenge is that beginners may feel inclined to side with the client and assume others are at fault. It is important that a helper not paraphrase a judgmental statement. The last common pitfall is when a helper is judgmental of the client. This may be due to the helper seeing a behavior that she or he feels should be corrected. The helper should try to respond in a nonjudgemental way.

How to utilise Reflecting Skills, part 2: Feelings reflected? - Chapter 7

Now we move on to reflecting feelings. In order to reflect the feelings of others, it is essential to have emotional intelligence. Emotional intelligence is the ability to monitor your own feelings and the feelings of others and to use that awareness for guidance. Reflecting the feelings of a client requires recognizing their feelings and reflecting them back verbally. Through reflecting a client's feelings, helpers communicate to the client the recognition that a client's problems affect the client. The techniques of reflecting feelings is basically the same as paraphrasing. From the client's perspective, when their feelings are reflected they become more aware of their emotional responses to their problems. For example, if the helper reflects to the client, "I can see that this makes you very angry," the client may then recognize that emotion, "yeah, I guess I am angry." The reflection should be given without judgement to show that feelings that the client may be unaware of or feel guilty about having are understood. The most important reason the reflect a client's feelings is to help the client reach a deeper level of self-disclosure by focusing them on being more aware of their feelings and verbalizing them. Techniques that can help clients self disclose help them to express their feelings which is in itself therapeutic. Reflecting feelings also deepens the helper client relationship. Trust is built when the client knows he or she can express feelings and not be judged. This technique originates from Carl Rogers who was very client centered. It is now widely used. Helpers who are skilled at reflecting feelings accurately can support and counsel a client even if they lack other skills. Lastly, a client feels relief after expressing feelings and hearing them reflected. Clients can experience an emotional roller coaster through the course of one session. Thorough reflecting feelings, these feels are labeled and untangled. For example, a helper who responds, “you feel betrayed, but still have a strong connection," can help a client understand the coexistence of opposing feelings. In this way, a client can gain a sense of control.

Steps in Reflecting Feelings

Similarly to paraphrasing, reflecting feelings also occurs in two steps. Step one is to recognize the client's feelings. Step two is to articulate the feelings that are not being directly expressed but can be detected in what the client says and how he or she says it. One way to approach step one is to imagine yourself as the client. With the facts you know, your knowledge of the client's history, and your understanding of the client's personality, try to become the client (not think how you would feel in the client's situation).

The table above is useful in categorizing feelings into basic emotions. The primary emotions of joy, sadness, anger, guilt or shame, fear, disgust, surprise, and interest can be identified by people from all cultural backgrounds. Other categories of feelings include feelings of strength, feelings of weakness, and feelings of distress. Feelings range in intensity form mild, to moderate, to strong. In addition to correctly identifying a client's feelings, it is important to be aware of to what degree the client is experiencing the feeling. Words like a little, some, and a lot, should be used. Also keep in mind the client's own vocabulary when choosing how to label a feeling. Don't use words the client may not understand.

In step two, the helper makes a statement to mirror how the client feels. This may require identifying feelings that the client has not clearly expressed. This step is challenging in that one must try to verbalize these feelings correctly. Identifying feelings and reflecting them may be skills that are learned separately. Once you practice identifying feelings it will be easier to reflect them and verbalize them. Generally speaking, there are two basic formulas for statements used to reflect feelings. One formula is "You feel _____." In the following example, consider how reflecting feelings affects the client and the helper client relationship.

Client: "You can imagine how I felt when he got married so soon after he divorced my mom."

Helper: "It must have been a shock."

The second, more complex formula connects feelings and content. "You feel _________ because _______." As in the previous formula, the first blank is the reflection of the client's feelings. The second blank gives a reason for the feeling through paraphrasing the content of the client's statements. As the client and helper continue the session in the example above, the second formula is used.

Client: "I was completely taken off guard. I thought they had the ideal relationship."

Helper: "You feel disappointed because he didn't live up to your image."

Not every reflection must include a paraphrase. Some helpers feel it sounds fake to say, "You feel ____ because______. This is the basic formula which can be changed to feel more natural.

Challenges to Reflecting Feelings

The ability to clearly reflect feelings is one of the most important skills a helper needs to have. However, it is a difficult skill to learn. The analyst, Theodore Reik, said that helpers must listen with the "third ear" to hear what was left unsaid by the client as the client may not even be aware of those feelings. Different cultures have different norms regarding the expression of feelings. Some cultures may view it as rude or a weakness to state feelings openly. When a client is reluctant to show feelings, the helper may find it a frustrating and challenging experience to reflect the client's feelings. It may take more time and effort. Additionally, gender also has an effect. Men may find it hard to express their feelings because they may have been raised to see the showing of feeling as a sign of weakness or lack of control. Women tend to be encouraged to express their feelings but may be expected to hide certain feelings like anger which are perceived as not feminine.

Through practice beginning helpers can hone their skills reflecting feelings. If you have trouble reflecting feelings or find that a whole practice session goes by without reflecting a feeling, discuss your challenges with other students and teachers and ask for feedback during the practice sessions.

We will now discuss a few of the common hurdles in reflecting feelings. One common problem is when the helper asks the client "How did you feel?" when the helper is unable to reflect feeling. This is a closed question and does not build empathy. The client may also be unable to label the exact feeling. It is better for the helper to use open questions and door openers to encourage the client to disclose more. As the client continues to talk, you may be able to reflect their feelings.

Another common problem is to wait too long to reflect. At the beginning of a session, the helper should use invitational skills to get the client to start talking. However, try to reflect feelings early on. A helper should avoid waiting ten to fifteen minutes before reflecting feelings. It is preferable to reflect feelings inaccurately rather than not at all. To speed up your reflecting skills, it is helpful to practice identifying feelings. One way to practice is to review the conversations in this summary and try to identify the client's feelings. Another way is to watch television shows such as soap operas and other dramas and practice reflecting the feelings of the characters.

Another common mistake when reflecting feelings is to frame your reflection as a question instead of a statement. When the feeling is reflected as a question, the client only has to agree or disagree with the reflection rather than disclose more and expand on his or her statements. When a helper uses a statement rather than a question, it shows more confidence and also communicates understanding better. Some statements may sound like questions if they are stated by raising your voice at the end of the sentence. Practice with your fellow students to be aware if you do this and try to correct it.

Do not combine a reflection and a question. This is called a compound response. Give the client time to respond to the reflection before asking the question. Clients tend to respond to the last thing that was said. When you immediately follow a reflection with a question, the client will only answer the question. If you tend to give compound responses, practice not asking questions and only reflecting feelings.

One key aim of reflecting feelings is to make a client more aware of his or her emotional responses. One common error is to focus on someone else. A client may spend much time talking about people in their lives and delve into tangential stories. When a helper reflects the client's feelings about people in their lives, it is important to focus the reflection on the client's feelings rather than the other person. Focusing on the other person leads to judgmental statements and may be unfair or inaccurate as you have not spoken with the other person and heard their story. For example, if a client says, "My best friend doesn't try to spend time with me. She always cancels our plans, sometimes it seems like she only makes plans out of a sense of obligation," it is preferable to respond, "You miss your friendship," rather than, "Your friend is neglecting you."

Avoid letting the client speak too long without responding. Beginner helpers may feel awkward interrupting a client. However, it is important to paraphrase and reflect so the client recognizes you understand. Very talkative or anxious clients may not pause for the helpers to interject. It is important to discuss key issues in detail and not only superficially. The solution to this problem is to interrupt the client when necessary and be aware that the client can benefit by a more structured conversation with paraphrasing and reflections. You can use phrases such as,"Let me stop you for a second to make sure I understand," or "Sorry to interrupt, but let me tell you what I'm hearing." Also keep in mind that both parties should participate to build a trusting helping relationship.

Another mistake is to use the word "feel" instead of the word "think." Both the helper and the client make this mistake. A helper should not accept a client is feeling an emotion because they state it as such. It is important for the helper to identify and reflect the feelings that the client does not explicitly state. A client may say, "I feel like I am finally getting somewhere." It would be a mistake for the helper to reflect, "You feel you are making progress." This is not a reflection of feeling but is an incorrect paraphrase. A helper may also misuse the word "feel" for the word "think." A helper may say, "You feel your parents should respect your privacy more." This is not a reflection of a feeling as a helper should say, "You think your parents should respect your privacy more." When the word "feel" can be replaced with the word "think" in a statement without changing the meaning, this is not a reflection of a feeling but an inaccurate paraphrase. To reflect feeling a helper may say, "You feel hurt and angry because you think your parents should respect your privacy."

Undershooting and overshooting should also be avoided. They deal with the intensity of the feelings the helper reflects. When a helper reflects a feeling that is more intense than what the client expresses, this is overshooting. When a helper reflects a feeling that is less intense than what the client expresses, this is undershooting. These mistakes are often corrected as the helper expands their feeling vocabulary.

When a helper has a limited feeling vocabulary, they may be more likely to make another mistake, parroting. Parroting occurs when the helper restates what the client says, possibly in a more concise way. Essentially, rather than reflecting a feeling, you paraphrase. Parroting may happen when the client states directly how they feel. A helper may be at a loss to reflect a new feeling. The goal should be to delve into underlying feelings that the client has not stated clearly. The helper can also consider if the client's labeling of the feeling is accurate. There may be another more specific feeling the client has not recognized.

The final common error we will discuss is not using concise reflecting statements. In the beginning, a helper may try to reflect everything the client says in hopes that they will be correct at least some of the time. It is advisable to focus your reflections on key topics or phrases.

How to utilise Reflecting Skills Part 3: Reflecting Meaning? - Chapter 8

This chapter focuses on the skill of reflecting meaning and summarizing. It is essential to be aware that every individual's perceptions and interpretations are unique as every individual has a different history, needs, beliefs, and values. The same event can be perceived differently by each witness. What an event means to a person can only be understood through a deeper understanding of that person. In order for a helper to have a deeper understanding of a client, he or she must see past facts to the significance and meaning events have for the client. Additionally, our expectations affect our perception, what we focus on, and our memory. In this way, it is even more important to understand how a client interprets what happened than to understand the event itself. This concept adheres to constructivism which states people are active in constructing their experience of reality in concert with others. When applied to the helping profession, it suggests that people can only be understood when their unique perspective is taken into account. Through using advanced reflective skills such as reframing and countering a helper can recognize the meaning underlying a client's story.

Meaning is a series of generalizations that is helpful for navigating our environments and the world. Leontiev describes experiences as "alloyed with firm beliefs, fuzzy ideas, and unconscious schemes and prejudices. Often a client's problems are due to an incompatibility between a new experience and the client's worldview. Worldview can be defined as a collection of personal meanings. Worldview is influenced by language, gender, race, socioeconomic status, age, religion, trauma, etc. Personal values and what a person views as important also factors into meaning. Views of self include statements such as "I always land on my feet," or "Nothing I do works out." Such statements are a general expression of how a person views him or herself and are not specific to actual abilities such as being good a guitar, or having a good sense of direction. View of other statements include, "All men are the same, or "people will take advantage." View of the world or the environment statements include, "if it is meant to be it will happen," or,"this is God's punishment." Value statements include, "Men should be the breadwinners." And "you should always do your best."

Reflecting meaning is essential as it gets at the heart of a client's individual outlook. Reflecting meaning goes beyond paraphrasing and reflecting feeling to discuss the underlying reasons. Reflecting meaning tries to answer the question, "Why are we talking about this topic?"

The figure above illustrates the layers all clients have. Levels of disclosure can be compared to peeling an onion with the inner layers revealed later. Also visible in this figure is that it is to be expected that conversations may become superficial again occasionally. The helper can focus the client on deeper issues and provide a safe space for disclosure to gain a full meaning of the story.

Not only does reflecting meaning help to build trust and shows the helper's understanding, is necessary to reflect meaning in order to draw awareness to meaning. A client may tell a story while being unable to identify the meaning and significance. The client may take the issues they encounter regularly for granted and will benefit from the helper pointing it out. In this way, a helper acts as a mirror to reflect the client's image. However this image is not physical appearance but the client's unique perception of others, the self, and the world at large.When a client can view him or herself from the perspective of someone else, the client can start to make changes. Additionally, reflecting meaning leads to deeper discussions and increased disclosure and a more thorough exploration of the topic. When a helper is unable to reflect meaning, discussions may remain superficial. Of course each client is different. A helper should recognize that encouraging statements do not invite the client to delve deeper into an issue. It is necessary to reflect feeling and meaning.

Clients may be unaware that their story has additional meanings and deeper layers. A helper challenges a client to delve into the inner layers. Arnold Lazarus founded multimodal therapy and describes the inner circle strategy.

In the inner circle strategy, the helper draws a series of concentric circles. Ring E, the outermost ring encompasses the most superficial information that may be shared upon a first meeting or introduction. Examples include a client's occupation, age, or marital status. The innermost circle A includes very personal topics such as sexual problems, anger, negative self-image, and secrets the client views as immoral. The rings in between rings E and A encompass the range between public and very personal. After identifying each ring, a helper can ask the client to write the names of people who have access to each ring. This method is useful to challenge a client when the conversations are too superficial.

Since meaning is constructed differently by each client, a helper must be able to understand what is meaningful without the client stating it directly. Studies on stress show that it is difficult to pinpoint stressful events. What is more important is not the number of stressful events that occurs but the significance each event has. Most people would describe going through a divorce as causing stress. However, in stressful marriages, a divorce may be necessary to reduce stress. Meaning is even more difficult to recognize than feelings as they occur even further beneath the surface. A helper may need to use their intuition to arrive at the meaning. The better a helper knows the client, the more likely their intuition will be correct.

Ways to Arrive at the Meaning

In general, helpers use two different basic strategies to arrive at the meaning. The first is to pose open questions which ask the client to focus on why an incident was significant for them. The second strategy is to reflect meaning thorough careful listening. The standard format for reflecting meaning follows that of reflecting feeling. The first blank of "you feel _____ because________ should be filled in with an accurate reflection of feeling. However, rather than the second blank being filled by a paraphrase as it would be when reflecting feeling, fill the blank with a reflection of meaning. Sometimes it is necessary to reflect feeling, paraphrase, and then reflect meaning. For example: "You were excited (feeling) when you moved out of your parent's house (paraphrase) because it meant you were becoming an independent adult (meaning)." Reflect as deeply as your intuition and understanding of the client's situation allows. If you can reflect feeling and paraphrase but can't reflect meaning yet, use your invitational skills and reflecting skills to encourage the client to continue their story. Open questions are useful for uncovering meaning. An example can be see in the following exchange.

• Client: My family is really mad at me because I was late picking up my sister from school. I know I shouldn't be late, but I was really busy. I don't see why they got so mad.

• Helper: You feel confused by their reaction. (Reflecting feeling)

• Client: Yes, but I am also really angry.

• Helper: What is it about what happened that makes you feel angry? (Asking an open question)

• Client: My parents don't take my obligations seriously. Everything is about my sister. Everyone's time is important except for mine.

The Ultimate Feeling Technique

A helpful technique is the Ultimate Feeling Technique developed by Leontiev. It involves asking a series of questions beginning with "why do people..." followed by other why questions. For example, "Why do people travel?"

• Response: To see a new place.

• Question: Why see new things?

• Response: To see different ways to do things.

• Question: Why see different ways of doing things?

• Response: To be inspired to new methods.

• Question: Why use new methods?

• Response: To stay ahead of of the competition and make a better product.

From this simple technique, one can see that the respondent is competitive and values innovation.

Summarizing

How to Summarize

The last reflecting skill to learn is how to summarize. It is an easier technique to learn than reflecting meaning. However, we are discussing it last as it is not possible to summarize without first paraphrasing, reflecting feeling, and reflecting meaning. The aim of summarizing is to give the client a concise report of the session thus far. It helps the client give structure to the feelings and thoughts he or she has expressed. A summary can include content, feelings, meanings of key issues, and future plans. Summarizing can be use throughout a session depending on the type of summary. The main types are: focusing summaries, signal summaries, thematic summaries, and planning summaries.

Focusing summaries can be used at the beginning of the session to focus the discussion on major issues, highlight the client's responsibility for a problem, and state the goals. A focusing statement may start, "In the last few sessions, we seem to have been dealing with two main issues. The first being _______. The second issue being ________." Focusing summaries can also be used in the first session with a new client. A helper may start, "Let's review what I know thus far ______. Is this correct?" Through a focusing summary, a client immediately gets on track and starts to talk about key topics in reacting to the summary.

Signal summaries are used in the middle of a session to show that a helper has processed the information given about a certain topic and that the client can begin talking about a new topic. Without a signal summary, a client may feel it necessary to circle back to the same issues. A good time to deliver a signal summary is when the client is at the end of the story and pauses. A client may say, "So that's about it." A helper may start the signal summary by saying, "Before we move on, let's summarize what we've discussed thus far."

Thematic summaries do not signal a transition to a new topic, instead it delves more deeply into an issue that keeps coming up. A theme is a pattern of content, feelings, or meanings that a client returns to over and over. A helper makes thematic summary after connecting the content, feelings, and meanings the client has expressed. The client may be unaware that the same issues are reappearing across different sessions. See the following example.

• Helper: There seem to be a key issue that keeps coming up; you feel anger in several of your close relationships.

• Helper: from what you've said thus far, I seem to notice a pattern that I'd like to check out. You seem to want to end a relationship when you reach a moment where the initial romance and excitement is gone.

• Helper: From our last few sessions, one major issue seems to be that you seem reluctant to commit to a career or a relationship because you are afraid of letting your parents down if you fail.

Thematic themes are challenging to practice because they require getting to know a client well enough and having had enough sessions for issues to reappear. Keep in mind that thematic summaries result from the helper's noticing a pattern and his or her intuition. Be careful in making a thematic summary because if you are incorrect the client may feel analyzed. It is best to propose the theme tentatively.

Planning Summaries review the progress of sessions, plans, and any agreements made during the session. A planning summary gives a session a sense of closure and ends it on a positive note. Examples include:

• Helper: It seems like we've identified a few issues we should pursue. The first issue being _____. The second issue being _________. With this in mind, we thought about you entering group counseling. Additionally, you want to identify some goals for your career. We can start to do that right away. We can set up an assessment plan and discuss your goals in the next few sessions. How does all this sound?

• Helper: Let's review what we've discussed this session. You are happy with where you are professionally, but not with your relationship with your family. You have said this is because you are not assertive. It sounds like we should discuss this aspect in more detail the next time we meet. What do you think?

Timing

It is difficult to state the exact order in which to use each skill as each client tells their story at a different pace and have different personalities. Generally speaking, helping sessions tend to follow a similar path called the nonjudgemental listening cycle (NLC). It is called nonjudgemental because having positive regard is essential to developing trust with the client. Sometimes it may be difficult as in cases where the client may have acted violently or done something we feel is immoral. However, the helper must communicate respect to the client and interest in his or her life by responding in an accepting way. This listening cycle repeats with each key topic the client expresses.

As seen in the figure above. Each topic creates a circle from starting with an open question to ending with a summary. This figure should be viewed as a map of the average session though not every session will follow this exact sequence. This figure represents a session that is more typical after a few sessions when the helper and client have spent some time together.

The figure above shows a questioning cycle rather than a listening cycle. This type of cycle can be seen as more typical of early training sessions. In this example, a beginning helper is unable to reflect and falls back on a closed question to keep the conversation going. The helper may be tempted to give advice because they learn many facts. However, the conversation does not get deeper. One way to get past this is to respond to the last thing the client said with a paraphrase or an open question. This will keep the conversation going as you try to figure out a reflection. When you ask closed questions, the client responds with short answers, not giving you extra time to consider your reflection.

How to utilise Challenging Skills: Feedback and Confrontation? - Chapter 9

In contrast to invitational skills and reflecting skills which are supportive, challenging skills are more confrontational and are a big step for helpers. Every person responds to a situation or event with more than one perspective and more than one feeling. A client may have several stories to tell on one event or issue. Consider a client who was abused as a child, he or she may describe their childhood as loving. The client is focusing on voicing one feeling. However, there are other voices that the client is aware of that tells a different story. A helper may need to give feedback and confront the client with discrepancies in their stories. In doing so, a helper may shatter fantasies that have protected the client. This shift may lead to resentment or discomfort as other ways to view the story are discussed.

The figure above was adapted from research into managerial styles within different organizations and depicts the ratio of confrontation to support. Depending on the ratio, a helper may be viewed as critical, apathetic, helpful, or a friend. A helper should find a balance between being supportive and being challenging. This ratio affects how willing a client is to explore his or her thoughts, feelings, actions, and motivations. This ratio also influences the level of trust a client has for the helper and likelihood of the client discussing deep versus superficial topics. When a helper does not challenge the client, the client does not examine his or herself. When a helper overly challenges a client, the client trusts the helper less. When trust is low, a client does not want to disclose or self examine. According to this figure, the worst situation for a helper client relationship is high confrontation and low support.

When To Use Challenging Skills

Once a helper begins to challenge the client, a shift occurs from relationship building to goals. This shift also makes it clear that the helping relationship is not a friendship. At the beginning of the helping relationship, the helper aims to encourage the client to disclose through use of the nonjudgemental listening cycle. As the helper goes through the cycle several times, certain discrepancies and gaps appear. A helper then uses challenging skills to help the client gain more self-awareness and function with a clear and unclouded self image. This allows the client to be empowered to reach goals through exploring his or her own thoughts, feelings, and actions.

Clients need to be challenged in several scenarios. One scenario is if the client has incorrect information about his or herself. For example, if a client thinks he or she is not intelligent when there is information which shows the contrary. Another scenario is when the client has irrational beliefs or ideas. A third scenario is when a client misreads the behavior of other people. For example, if a client acts on an assumption without first confirming the assumption. A statement that illustrates this is, "I could tell by his actions that he was not interested in me anymore." Another scenario is when a client blames someone else instead of looking at his or her own behavior. Additionally, a client should be challenged when there are inconsistencies between his or her thoughts, feelings, actions, and values. An example would be a client who speaks about the importance of honesty while hiding an affair from her husband. A client should also be challenged if they are not working in the direction of their goals. Helpers can use two basic skills to challenge the client. The first skill is to give your honest reaction in the form of feedback. The second skill is to use confrontation to draw attention to inconsistencies in the client's story.

Feedback and Confrontation

Feedback is essential to personal growth. It is important to be able to give feedback and to receive feedback. Studies show that individuals who can be more transparent with others have increased mental health. Often people seek help because they have problems in their interpersonal relationships. They may get confusing messages about themselves from others. Close friends and family are often reluctant to give honest feedback because they are worried about the negative affects for the relationship. The lack of willingness to give negative or critical feedback is called the "mum" effect. As a result, people often operate with an unclear idea of how we are viewed by others.

The figure above is the Johari window. It shows that information about the self is a combination of what we perceive about ourselves and the feedback we get from others. The Johari window shows that thorough self-disclosure and feedback we learn about ourselves. The helping relationship seeks to lesson the unknown area. The window shows that self-disclosure shrinks the hidden area, and widens the public area. Individuals with a wider public area are able to disclose more, have better relationships, and can give the helper more information about his or her issues. The size of the window in relation to the three other windows will differ based on the client's personality and how open and transparent he or she is. Sometimes the public area can be too large. This can be seen in clients who talk too much about themselves and drive people away. Feedback shrinks the blindspot. Helping can also increase the unknown area by helping a client learn new things about him or herself. Techniques like using imagery, free association, and using creativity can help a client discover new things about themselves. The Johari window is useful when introducing clients to group therapy. The client can be asked to draw his or her own Johari window and label items in the public area and the hidden area. The client and helper can use the window to discuss what are appropriate disclosures. Additionally, the helper can discuss how giving and receiving feedback in a group setting can decrease blind spots.

Ways to Give Feedback

To give feedback means to give the client information on what you see, feel, or suspect about them. If the feedback is specific to the client and constructive it will help the client grow. Helpers give feedback for three main reasons. The first reason is to show the client how his or her behavior affects the helper. For example: "You say you want to be more confident, however I do not experience this when you do not make eye contact." The second reason a helper gives feedback is to evaluate how a client is progressing towards his or her goals. For example: "You have taken a big step in your fear of commitment by moving in with your boyfriend." The third reason to give feedback is to communicate to the client a helper's observations. For example: "I notice you never talk about your younger sister."

A client may reject feedback because it is too painful to see the truth, because the client thinks the feedback is not true, or because the feedback is too harsh. In his book PET: Parental Effectiveness Training, Thomas Gordon suggests using "I messages" to give feedback. Statements that begin with “I” show that the helper is expressing his or her take on the situation. This helps the client to feel less defensive. Several other suggestions on how to give feedback may be helpful as well. Try to not give feedback regarding a client's personality traits as it is difficult to change these traits and therefore easy for clients to reject the feedback. An example can be seen in the professional world of poor feedback if a boss says, "You procrastinate too much." Good feedback would be, "The second deadline has passed, and I do not have your report." Also, try to be nonjudgemental, concrete, and specific in the feedback you give. Poor feedback: "You are really annoying me." Good feedback: "I find it annoying when you talk so loudly while I'm reading." Ask permission before giving feedback. For example, "I've noticed something and would like to give you some feedback. Is that alright with you?" Additionally, some feedback may be especially difficult for the client to hear. These should be approached tentatively. For example, poor feedback: "During the last session you talked about feeling guilty for not spending enough time with your mother before she died. Now you don't seem to want to talk about it." Good feedback: "during our last conversation, I got the feeling that talking about your mother's death is very difficult for you. Maybe it is because you feel guilty, am I right?" Another good piece of advice is to give no more than one or two pieces of feedback at a time. When you give too much feedback at once, a client is likely to become defensive and not hear what you are saying. Also, remember to give positive feedback as well. It is good to point out a client's strengths as well. It helps a client to know what is working well and be reminded of the resources they have. The last piece of advice is to ask an open question to see how the client is responding to your feedback. For example, "I just gave you some feedback regarding_____, what is your reaction to what I said?"

Confrontation: Discrepancies and Cognitive Dissonance

Confrontation is a type of intervention that draws a client’s attention to a discrepancy (defined as an inconsistency or conflict in a client’s thoughts, feelings, or behavior). When confronted with a discrepancy in his or her beliefs, behaviors, words, or nonverbal messages, a client becomes aware of the discrepancy and hopefully will also become motivated to resolve the discrepancy. Discrepancies can be seen in all of a client’s problems. For example, a client who says he loves his job but constantly complains about it, or a highly intelligent client who feels inferior. According to some theorists such as Ivey and Simek-Downing, resolving discrepancies is the main goal of therapy. Therapists from Fritz Perls to Albert Ellis have used confrontation to varying degrees. Studies show that a consistently moderately confrontational style is more effective than a consistently highly confrontational style. Beginning helpers may be tempted to follow highly confrontational styles like that of Ellis. However, it is important to draw a client’s attention to an inconsistency without alienating the client. Confrontation should be used after skills like invitational skills and reflecting skills have been practiced. Research shows that more experienced helpers use confrontation more and speak less while still being able to provide support.

Cognitive dissonance theory posits that individuals are motivated to keep values, beliefs, and attitudes consistent. When an individual has some sort of inconsistency between their values, beliefs, actions, and thoughts, they experience tension and want to lessen the tension. As a result, the individual may say that the inconsistency doesn’t matter or even distort reality to reduce tension. This is a defense mechanism used by people to reduce dissonance and anxiety instead of move ahead by making choices through planning and thinking. While confrontation of a client’s discrepancies will cause tension, it will also make the client aware of the choices they have. Kiesler and Pallak researched studies on cognitive dissonance and discovered a connection between dissonance and physiological arousal. Ernst Beier refers to “beneficial uncertainty” which is a client becoming open to change or to a shift as he or she is made aware of two incompatibilities. While confrontation may be beneficial, a helper should keep in mind that the client does not find the experience enjoyable. If the helper is too confrontational, the client may reject the message as well as become less willing to trust the helper and disclose other feelings. For these reasons, helpers tend to use confrontation in small doses while giving the client a great deal of support.

Six Common Discrepancies

Keep in mind the following six common discrepancies.

1) The first common discrepancy is between verbal and nonverbal messages.

• Client: The situation is so awful it is almost funny (laughs). Sometimes he hates me, next he loves me.

• Helper: Your laughing implies that this isn't serious, but I can tell but what you a saying that this is a painful situation for you. (Confrontation)

2) The second common discrepancy is between experiences and beliefs.

• Client: I've been dating the same two guys these last two months. I do the best I can, though I'm not very good looking.

• Helper: I hear you say you don't feel attractive but you tell me you date a lot. (Confrontation)

3) A third discrepancy is between how a client behaves and their values.

• Client: My wife is the most important person to me, but I haven't been able to spend much time with her. If I want to get a promotion, I have to put in a lot of extra hours at work.

• Helper: If I understand you right, you say that your relationship with your wife is important to you, but you've let your career get in the way. (Confrontation)

4) A fourth discrepancy is between how a client behaves and what the client says.

• Client: I've been going to counseling for my alcoholism but it isn't helping. Whenever I see my old friends, we always end up at the bar.

• Helper: I'm a bit confused. You say you want to stop drinking, yet you continue to see your old drinking buddies. (Confrontation)

5) A fifth discrepancy is between plans and experiences.

• Client: Yes, my girlfriend and I have been arguing a lot lately, but I think if we go ahead and move in together then things will get better.

• Helper: From what I've heard thus far, you and your girlfriend tend to fight more when you spend a lot of time together. How will living together and spending more time together help improve the relationship? (Confrontation)

6) The sixth discrepancy is between two verbal messages.

• Client: I doesn't bother me that my wife makes a lot more money than I do. Though I do feel like she judges me for it. I've been thinking about switching careers.

• Helper: So I hear you say that it doesn't bother you, but on the other hand you are affected enough to consider a big change like switching careers. (Confrontation)

Note that there are also ethical considerations when using confrontation. While ethical codes do not specifically address confrontation, codes do discuss using emotionally arousing techniques. For example, it is unethical to use a technique that you are not experienced in without supervision. Confrontation should be discussed with a supervisor before it is used. You should also be sensitive to a client's religious and cultural background before using a technique like confrontation. It is also unethical to use confrontation as a way to vent your own frustration. The client's needs should be considered before that of the helper.

Forms of Confrontation

Confrontation statements tend to follow the following forms.

• Verbal versus nonverbal: you said _____ but your body language says_______.

• Negative beliefs about self versus strengths: you believe _____ but you possess _______.

• Values versus actions: you value _____ but you act ______.

• Plans or beliefs versus experiences: you plan to do _____but your experiences tell you ____.

• Verbal versus verbal: you said_____but you also say______.

• It is helpful to keep in mind the statement, "On the one hand ________, yet on the other hand_______." Try not to overuse this statement but this formula is a good reminder for identifying discrepancies.

Four Steps in Confrontation

The first step in confrontation is to build a relationship prior to confronting. Trust can be built through using the nonjudgemental listening cycle. Take the time to listen to the client and fully understand the story before using confrontation techniques. It is important to time the confrontation well as it will put stress on a a relationship. Be sure that you have built enough of a rapport with the client to use confrontation techniques. The second step is to deliver the confrontation in the way the client will most likely accept it. A helper may need to ease into the confrontation to reduce the anxiety a client may feel when confronted. The third step is to observe how the client reacts to the confrontation. If you notice that the client does not accept the confrontation, you may need to repeat it in a different way. Step four is to follow up the confrontation in the form of further exploration, clarification, or another confrontation. The route will depend on how the client reacts to the confrontation.

Other Methods

Helpers can also help a client gain awareness of a discrepancy through other methods. These other methods include relationship immediacy, challenging irrational beliefs, and through using humor. Relationship immediacy is a technique whereby helpers give clients immediate feedback on how the client affects the helper. The helper comments on how he or she feels or what he or she thinks regarding what's taking place in the relationship. These statements should follow three key guidelines. The first guideline is that the statement should have the word "I" to make it clear that the statement is the helper's perspective. The second guideline is that the helper should talk about the client's behavior or the relationship in a nonjudgemental way. The third guideline is that the helper should communicate his or her thoughts or feelings without overloading the client. Refer to the following statement where each guideline is illustrated and labeled in parentheses. " (1) I notice that (2) when I make a suggestion, we seem to end up in a struggle until we drop the topic. (3) I am worried about this." It is useful to use the relationship immediacy technique because the relationship a client has with a helper may be indicative of other key relationships in the client's life.

Additionally, this technique involves a situation that is happening currently and is therefore more effective since it will be more powerful and memorable to the client. This technique asks the client to reflect on his or her relationship with the helper by processing the helper's feedback. This technique should be used when the relationship between the helper and client can be seen as a microcosm of other relationships the client has or if there is stress in the helping relationship that should be resolved. A helper should use this technique carefully and not use it as an excuse to vent his or her own frustration. A helper should consider if a statement he or she plans to make is for the helper's benefit or for the client's benefit. Again, the client's needs should take precedence over the helper's.

Another method to draw attention to a discrepancy is through challenging irrational beliefs. This involves making a client aware that a belief is irrational and teaching the client how to combat the irrational beliefs when they occur. While the helper draws attention to what beliefs are irrational, it is the client's role to confront the beliefs. This technique can also strain the helping relationship has beliefs are very personal and people may become defensive when their beliefs are questioned. See the following examples. The first example is shouldn't and musting: "I should have memorized the answers by now, I must get a perfect grade in the exam." A helper can respond with a more rational challenge, "Have you ever tried to say you would like to get a good grade rather than you must. I think using words like should and must lead to negative feelings if you don't achieve a perfect score." The second example is awfulizing. A client may say, "If it doesn't happen, it will be the end of the world, a tragedy. It will be awful." A helper can use a rational challenge, "Isn't it more accurate to say it will be a a letdown if it doesn't happen?" The next example is low frustration tolerance: "It's like I can't stand waiting, I must spend my paycheck right away even if I should save some of it." A helper can challenge, "It sounds to me like you are saying it is uncomfortable to wait, but is it really impossible?" Another example is rating and blaming: "It's their fault for not trying to help me apply to school." A helper can challenge, "I wonder about this responsibility you feel they had to help you apply to school when you never asked for their help." The fifth example is overgeneralizing or having an always or never attitude, "I tried going to the meeting, but it never helps, everyone just hangs out and smokes. The organization is useless." A helper may respond, "I'm not so sure that going to one meeting gives you enough of an experience to generalize. Did you really not get anything out of the meeting?"

Another method is to use humor. Humor in the form of exaggeration or storytelling can be a way to get around a client's defensiveness. A client may accept a funny story because humor is not typically viewed as mean or judgmental. But it is still important to have developed a relationship with the client so he or she does not interpret the humor as you making fun of them.

How to Evaluate A Client's Reaction To Confrontation

The first scale we'll discuss is the Helper Confrontation Scale (HCS). This three-point scale rates how effective a helper is in confronting the client. The lowest score is 1. At this level, the helper overlooks or does not recognize discrepancies or uses a style that is too harsh or negative. Helpers at this level also may deliver badly timed confrontations or confront too early in the relationship. At level 2, a helper recognizes and highlights inconsistencies. The timing of the confrontation is also correct. The style is appropriate. At level 3, a helper uses direct confrontation and will challenge a client to change his or her behavior while still protecting the client's self-esteem through being nonjudgemental and approaching the topic gently.

The second scale we will discuss is the Client Acceptance Scale (CAS). This is a training tool which helps beginning helpers evaluate how a client responds to confrontation. It is not used in normal practice but is helpful while a helper is learning confrontation techniques. This is also a three-point scale with ratings being given based on the extent to which the client recognizes the inconsistency highlighted. Level 1 of client acceptance occurs when a client denies the discrepancy. The client may try to change the topic, discredit the helper, look for support somewhere else, or falsely agree to the discrepancy. Level 2 of client acceptance occurs when the client accepts one aspect or one part of the discrepancy as being true but rejects another part of the confrontation. A helper should then focus on the areas of agreement and clarify the other aspects of disagreement to make sure the story is being understood. Level 3 occurs when the client fully accepts the confrontation, recognizes the discrepancy and agrees to resolve the discrepancy or attempt to change his or her behavior.

Another approach to confrontation is to encourage self-confrontation on the part of the client. In this way, the client directs the confrontation instead of the helper drawing attention to discrepancies. It is good for a client to develop the skill of self-confrontation since they will continue to benefit from it once the helping relationship ends. Motivational interviewing is a method to encourage self confrontation. In this method a helper asks the client a series of questions. The client experiences confrontation through being aware that they continue negative behavior patterns. While self-confrontation can be seen as a complex assessment and research tool, it can also be seen as a way for a client to conduct research on him or herself with the helper's support. A client can be asked to write down all the issues they think is a problem in their life. He or she can respond to questions like, "What are the things I really don't want to do?", "In what ways am I lying to myself?", "What are some possibilities in my life that I'm not aware of?", or "What conclusions am I coming to about my life that is not supported by evidence?" The helper can assist the client by guiding discussions and explorations of these topics. The helper and client collaborate to try to identify themes and discuss a plan to resolve discrepancies.

How to Interview and Assess? - Chapter 10

The term assessment refers to gathering information about a client and a client's problems. This can happen in various ways and starts on initial contact with the client in the form of listening to the client's story and observing the client's behavior. Testing, questionnaires, and forms are used in formal assessments. Observation and listening are used in informal assessments. While formal assessments will take place at a certain time during the helping relationship, informal assessments take place throughout the relationship. There is no formula for how long to spend on each stage of the helping process due to the differences between clients. Generally speaking, a helper should spend the first session on building the therapeutic relationship and spend the next one or two sessions on more in depth assessments. Later, the helper and client move on the goal setting which may involve testings, then move on to intervention and action, then to evaluation and reflection. This process can be viewed as a road map to the helping process. The assessment stage generally takes about ten percent of the full number of sessions.

It is common for a formal assessment to be conducted by someone else before the client meets the helper. This is usually done to save time and money, but it also helps determine if the services the helper offers a suitable for the needs of the client. Additionally, this allows another person besides the helper to conduct the formal assessment which may interfere with the helping relationship. Since the first impression between helper and client is important, a helper should focus on building a relationship first and ask questions later. A client who is given the opportunity to tell their story rather than fill out a form will provide more information during later assessments. Of course certain essential information will need to be gathered. To avoid interfering with the session itself, a helper can ask a client to come in early or stay later to fill out forms. Assessments should be a planned part of the helping relationship but the helper should also expect to conduct assessments throughout the relationship and for assessments to overlap with later stages as information must be collected during each stage. It is necessary to collect information so that appropriate goals can be set, appropriate techniques can be used, and success can be recognized.

Assessment should be seen as a continuous process throughout the helping relationship. Helpers may forget to ask an important question. A client may not be forthcoming with necessary information or be truthful. A helper should try to find out as much about a client as possible. Some people see collecting too much background information as less important than the client's current situation. However, it is important to know something of the client's history as it may be essential to the client's current problems. It is necessary to assess key issues like serious mental disorders, substance abuse, or dangerous thoughts to self or others in a systematic way.

Testing

Testing has varied in popularity in the history of helping professions. It was encouraged after World War II. In the 1960's, testing was criticized after some pitfalls were discovered. For example, many tests were found to be culturally biased. Carl Rogers's approach of focusing on the uniqueness of each client became popular. This approach and others like it moved the helping professions away from formal testing. Nowadays, there is a more balanced approach towards testing. It is used as a tool but is not the only way to get at the truth. When used correctly, testing can help uncover topics that should be discussed and offer insight into areas that the helper did not consider. Testing can also waste time that would have been better spent in conversation with the client. Testing should only be used when the cultural background of the client is taken into account to avoid cultural bias.

The Importance of Assessment

There are several reasons why helpers should allot some time to assessment. The first reason is that assessment helps the helper find out if the client would benefit from the services he or she offers. Some clients may benefit more from other forms of therapy more than "talk therapy." The second reason assessment is important is because it helps in setting realistic and useful goals. In gathering information, questions should be broad enough to catch any key issues and deep enough to delve into specific topics. Third, assessment can help a client realize when other events are connected with his or her problem. Fourth, assessment helps gather information that tells us the impact a client's environment has. For example, through assessment a helper may find out that a client lives with a foster family, belongs to a religious minority, or is bullied in school. Fifth, thorough using systematic assessment, we move past the stereotypes we may hold when we ask clients about their cultural or family backgrounds. A sixth reason that assessment is important is because it is useful in identifying people who are at risk for violence. A history of harming others or harming his or herself may indicate that client may be at risk.

Assessment is also useful in showing historical information as seen in the figure above. This assessment tool is called a timeline. A client is asked to note important events in the order that they happened. Thorough this device, a helper can better understand a client's worldview thorough what they deem to be important. An eight reason that assessment is important is that it can be used to focus on a client's strengths. An example of a strength based assessment device is the Behavioral and Emotional Rating Schedule. This type of tool is useful in promoting a client's self-esteem. Other strength based assessment devices focus on studying a client's emotional, physical, social, occupational, spiritual, and cognitive well being. Through emphasizing strengths, helpers can strategize to capitalize on a client's existing skills and coping abilities. Assessment also helps a client to become aware of key problems. Finally, assessment is useful in ruling out problems like medical conditions. It can help to more quickly pinpoint areas of concern and thereby save valuable time.

Some forms of assessment such as personality tests and or diagnoses can result in overgeneralizing and not accounting for individual differences. For example, once a child has been diagnosed with ADHD (Attention Deficit Disorder), his or her actions a likely to be viewed as a symptom of the disorder. It is important to remember that most people do not fit into a specific category and to recognize the uniqueness of each person. Rather than rely on one test or form, one should listen to the client's story carefully to get as much of the whole picture as possible. This is the best way to make a plan for treatment that suits the client's needs.

Diagnosis

Diagnosis can be viewed as a simplifying process of organizing the information collected about a client's problem. There are seven key sources for this information: formal testing, the helper's observations, information given be friends and family of the client, information given by the client, medical history, other agencies, and the legal system. As beginning helpers, you will take courses on evaluation and assessments. Keep in mind that these tools are a way to simply the process by placing clients in increasingly specific categories.

The figure above illustrates the funneling that happens with the information collected from different sources. The figure also shows how key issues (for example low-self esteem, marital problems, etc.) become the focus of discussions after being identified and prioritized. The helper than determines which methods or techniques to use for each problem thorough discussion with the client.

Methods for Beginning Assessment

The Mental Status Examination is one method to organize an assessment. This method generally includes recording the client's responses to questions as well as recording the helper's observations during the first interview. The Mental Status Examination can be viewed as a picture of the client's current mental functioning. It usually does not delve into the client's history. This method has been criticized for several reasons. One reason is that it may pose irrelevant questions to the client. It does not directly help in diagnosing using DSM. Additionally, it has been seen as too culturally specific. For example, asking questions about past US presidents to gauge intelligence. Despite these pitfalls, The Mental Status Examination is still used by many helpers as an initial screening. This examination method is mentioned as one example of an assessment technique. Other beginning methods of assessment are observation, questioning, genograms, as well as interviews conducted with a short intake form.

First Method: Observation

The first method we will discuss is observation. It is not a passive process but requires focused effort. With experience, a helper can notice patterns from a few clues from a client's appearance or even his or her way if speaking. Sigmund Freud emphasized the importance of observation and deduction. He posited that unconscious motivations could be observed in the client's daily activities in the form of unconscious actions or verbal slips. These slips of the tongue are called parapraxes. Through observing these unconscious acts, Freud tried to deduce the client's problems. Nowadays, helpers understand that human behavior is too complex to be understood with only a few observations. For this reason, helpers use several methods to confirm or disprove their hypothesis. While it is necessary to make observations, a helper should refrain from jumping to conclusions. A helper should be aware that our expectations and experiences affect what we see and remember. This tendency can be seen in a study conducted by Rosenhan where individuals faked symptoms in order to be admitted into a mental hospital. After they were admitted, all of their subsequent behavior was viewed as abnormal. For example, a man writing in his journal was viewed as obsessive. Through our experience and our training, we view the world through a certain lens. While it is unavoidable to have some form of bias, a helper should be aware of the existence of the bias. Through supervision and reflection helpers can review their observations and recognize areas where their lens may be distorted. It is also advisable for helpers to interact with people of different cultures to better understand behavior and avoid stereotyping.

When observing helpers should keep several categories of what to observe. The first is speech. Be aware of all aspects of how a client speaks including the tone of voice, if the client has an accent, if the voice reflects substance abuse, if the speech is relaxed or anxious, if the client speaks without listening, etc. The second category is the client's clothing. Does the client wear expensive, old, stylish, seductive, or out of fashion clothes? Is there something unusual or inappropriate about how the client is dressed? A third category of things to observe is the client's grooming. This refers to the client's personal hygiene and their level of interest in cleanliness and an organized appearance. The fourth category is the client's posture, build, and gait. Posture refers to how the client holds his or her body. Does the client sit straight up or slouch? Does the client's posture show his or her current emotional state or is it indicative of a general attitude? Build refers to the client's physical being. Is she or he attractive physically, is the client thin, obese, have acne, or have any physical disabilities? Gait refers to how the client walks. Does it reflect depression, anxiety, confidence, etc? Another category to observe is the client's facial expressions. Does the client show his or her feelings or have a blank expression? Does the client maintain eye contact, laugh, or smile? Additionally, observe a client's other body movements such as hand gestures.

A helper should also note his or her general impression of the client. There may be a general feeling of hostility (for example) that is not addressed through observations in the others categories. Keep in mind that more holistic impressions may be a symptom of stereotypes as they may not be related to a direct observation. Finally, a helper should pay attention his or her own interpersonal reflexes or instinctive reactions. For example, people tend to react more positively to someone who is physically attractive. Our interpersonal reflexes triggers how the other person responds. These instinctive reaction should be noted by the helper's as it is possible that other people who interact with the client respond in a similar way. A helper should try to be detached when considering how other people may respond to the client.

Method Two: Questioning

Another method of assessment is through questioning. As we've mentioned, asking too many questions may lead a client to feel examined or judged and strain the relationship. However, questions are necessary for taking personal and sexual histories, organizing genograms, stimulating action, focusing the client on a topic which should be explored further, and to get important information on goals. In a sense, questioning is an art and can be therapeutic when used well. Examples of questions often asked by helpers to focus on a client's problems include the following. "How can I help you?" "Where would you like to start?" "What do you want to stop doing or do less of?" "What is it that you want to start doing or do more of?" "How do you think your life would change if the problem were resolved?"

Method Three: Genograms

Genograms are a third method. Genograms are pictorial representations of the client's family tree. It is useful in quickly communicating a client's family history.

(See figure 10)

The figure above shows genogram symbols used to depict relationships.

(See figure 11)

The figure above is an example of a genogram. This is an example of a fairly traditional family. Most genograms which include divorces, step families, or unmarried people living together are more complex. When a client has a large family or many step relations, a genogram is can help the helper identify relations without needing to repeatedly question the client. Creating the genogram can also be therapeutic if a client's key problem involves his or her family. A genogram is also useful in an exploration of how family has influenced aspects of the client's life such as career choice, abuse, or substance/alcohol abuse. A genogram can also show cultural influences on the client. It can show strengths and weaknesses in relationships within the family. It can be useful in uncovering gender role expectations, the effects of birth order, the existence of sibling rivalry. A genogram is also useful in tracing patterns of behavior and documenting historical traumas such as suicides.

Method Four: Short Intake Form

Another method is conducting an interview using a short intake form. In this method, a helper notes impressions of the client in a systemic way by recording them in a form. A form is helpful in that it reminds the helper to check for key problems. An example of an intake form is a prototype form which asks the helper to observe the client on three key categories (A,B,C).

• Category A refers to affective or emotional issues and status. Clients seek help when they experience overwhelming or confusing feelings. They may look for help with anxiety, grief, anger, or depression. A helper should gauge the intensity, duration, and frequency of negative feelings. A helper should also help the client identify positive feelings and when they occur.

• Category B refers to behavior deficits, strengths, and excesses. Many clients look for help to stop or lessen behaviors that are excessive such as addictions. Other clients seek help for behaviors they want to learn such as time management skills or social skills. A helper should also identify positive behaviors such as exercise or meditation.

• Category C refers to cognitions. This includes the client's thoughts, images, and the client's worldview. The helper should also note any intellectual deficits or strengths, any head injuries, and any learning problems such as dyslexia.

Additionally, the helper should find out about the client's level of development, family history, cultural or religious background, and physical challenges and strengths. In order to assess developmental issues, a helper needs to have a basic understanding of human development. This includes the theories of major theorists. A helper can then tailor their techniques to account for differences in the life stages of the client. In this section of the form, people tend to be grouped into common age-related categories: children, adolescents, college students, and older people.

There are many assessment and helping techniques that have been developed to help children. How a child functions in school can be seen as a general indicator of the level of the child's adjustment. It is advisable to interview a child's teachers, parents, siblings, and grandparents. In adolescent, issues of trust, autonomy, dangerous behaviors, and anger may appear. In assessing adolescents, a helper should remember to delve in to drug use, alcohol consumption, sexual behavior, and relationships with immediate family members. When assessing college students, it is necessary to discuss issues of self-esteem, separation from family, eating disorders, substance abuse, pregnancy, sexual behavior, and a need for more intimate relationships. When assessing older people, helpers will need to understand the time when the client was growing up. Helpers should discuss issues of loss, health, the death if a spouse, family relationships, and fears due to loneliness.

When assessing family history helpers should gather information about the client's family history of depression, suicide, depression, anxiety, substance abuse, and sexual abuse. A person's ideas about gender roles, parental roles, and what is normal tend to come out of their family experience. Learning about a client's family history can give important information regarding the client's worldview.

In addition to noting a client's religious affiliation, ethnicity, and class, it is necessary to understand the client's acculturation or the degree to which he or she identifies with the cultural affiliation. Additionally, it is helpful to find out if seeking therapy is viewed as positive or negative in terms of his or her culture and if the client is proud or ashamed of his or her culture.

The helper should also collect information about a client's physical changes and their strengths. Physical changes refers to physical limitations or disabilities (this includes conditions that are not visible such as diabetes or heart conditions. A helper should also find out if a client's problems may stem from a medical diagnoses. For example instead of stress causing headaches, a brain tumor may be the culprit. Helpers should identify substance abuse and treat it first as it will undermine progress on other issues. In this section a help should also note a client's physical assets and abilities.

Trigger questions

Within each of the sections in the prototype intake form are trigger questions. This questions remind the helper to ask a supervisor for help when a client responds in certain ways. These trigger questions are as follows. The first question is if a client meets the criteria for anxiety or depression and other major emotional disorders. The client may need of be referred for special treatment or need medication. The second question is if the client exhibits signs of having suicidal thoughts, has a history of harming his or herself, or has thoughts of or a history of harming other people. The third question is if the client has abnormal thought processes, hallucinations, delusions, or other thought disorders. The fourth question is if the therapeutic relationship is on the right path. Have issues of background differences or trust been addressed? The fifth question is if any medical problems be causing the client's problems. The sixth question is if the client needs treatment for substance abuse.

Referrals

Sometimes a helper may be able to give necessary tests. Other times, it may be necessary to refer the client to an expert for the necessary testing. It is advisable to refer the client in the following circumstances: when responses to trigger questions indicate violence, mental disorder or substance abuse, when the client is unreliable or does not want to answer questions (the client may need to be tested for personality disorders or antisocial behavior), when the client has a medical condition that may be causing the problem, when a client has memory problems (this may be a sign of anxiety or neurological problems), when the client has trouble reading or writing (this may be a sign of ADHD, dyslexia, or another learning disorder), when the client functions poorly but can't give enough information, when you question previous diagnosis.

How to set Constructive Goals? - Chapter 11

Each helping session should focus on a client's goals. After a beginning helper has empathized with the client through the nonjudgemental listening cycle, he or she may wonder what comes next. This is a good time to set goals. When goals are set, a client can think about and work on goals between sessions. This also helps to make the helper's techniques make sense to the client. When goals are set through discussion and mutual participation with the client, he or she feels empowered to achieve the goal and feels like a partner in the helping process. Another reason it is important to set goals is that helps to determine when the helping relationship will end (when the goal is reached). Some helpers use a time-limit approach to determine when the helping relationship will end. Setting a limited number of sessions, usually between six and twelve, helps emphasize the importance of each session and maximize focus during each session. However, in this approach the therapeutic relationship may end before regardless of if the goal is reached.

It is important not to set goals too early. It is necessary for the helper to establish a trust relationship with the client and complete a thorough assessment. It is important to first use invitational skills, reflecting skills, and challenging skills to gain information about the client and his or her problems. If this knowledge is not gathered, the goals may be ineffective or not relevant.

In the goal setting stage, a helper will need to narrow down the information to specific tasks and aims. While earlier stages tend to involve a wide range of topics, the goal setting stage focuses the discussion to a few key topics. Rather than continue to introduce new areas for discussion, in this stage the helper needs to identify the most important issues to be discussed in subsequent helping sessions.

Setting constructive goals

The goals that a helper and client set should be constructive. This means the goal should be specific, stated positively, simple, important to the client, and realistic. The first criteria for a constructive goal is that the goal should be specific. Before identifying a goal, a helper should ask the client what issues she or he wants to work on. This may result in a vague response from the client. It is important to arrive at a specific goal. When someone has a clear and specific goal, he or she makes more progress towards achieving the goal. When a goal is specific and not fuzzy, the direction of progress is more apparent to the client. The client is more able to begin to take steps in towards achieving the goal and work on the goal between helping sessions. Helpers may also have trouble or lack interest in setting goals as many helpers prefer to focus on the process of helping and deal with issues that arise during sessions. However, it is advisable to set some benchmarks and goals in order to make better use of time in helping sessions. Research shows that when a helper has goals in mind, helping sessions tend to be more focused on the needs of the client. The awareness of goals also helps the helper be aware if he or she possesses the necessary skill sets or if a referral should be made.

Positively stated goals have the benefit of focusing the client's resources and increasing feelings of hope when the client can imagine specific positive outcomes. Stating a goal also helps in selecting treatment technique and communicating the motivations for choosing a technique to third parties, agents, and supervisors. A helper who sets specific goals is better able to gauge if helping sessions have been successful. Goals also help a client gauge how they are progressing. When the therapeutic relationship ends, a helper can evaluate the client's achievements in a realistic way. The following helper statements illustrate how a helper can intervene to help the client be more specific. "I understand that you want to be more happy, but what would you be doing to be happy that you are not doing now?" "What things are you talking about when you say things aren't going as well as you'd hoped?" "I hear you say that you want things to improve in your relationship with your father, want specific things would you want to improve?" "You say that you want to stop living in the past, where do you want to live?"

Another criteria for a goal to be constructive is that a goal should be stated in a positive way. Often a client will phrase a goal as something they want to stop doing or a behavior they would like to reduce. These are examples of negatively stated goals. They are less able to motivate us than positively stated goals. A helper should aim to rephrase problems as goals. The following helper questions encourage clients to restate problems as goals. "If a miracle happened tonight and all of your problems went away, what are the first differences that you would notice that would make it clear that your problems vanished?" "You say that you and your parents fight all the time, if you all weren't fighting what would you want to be doing instead?" "If you imagine that I gave you a job that provided all the resources, money, and benefits that you need, where would it be and what would your position be?"

A third criteria for a constructive goal is that the goal should be simple. A simple goal is especially important when a client feels discouraged. Start with small goals so the client can feel encouraged when he or she achieves the goal. The client will be more likely to want to move on to achieving more challenging goals. Many agencies ask helpers to set behavioral goals that can be measured and are observable. The helper begins with the baseline which is the client's current behavior and set target behaviors. Behavioral goals can be developed by asking the client to state the baseline which is the current level of behavior, describe the goal, and specify target behaviors in terms if duration, intensity, and frequency. For example, let's say a client has a goal of becoming more comfortable and less anxious in social settings. His baseline behavior is that he can only stay at a gathering for fifteen minutes, can have a short conversation with male coworkers, but rarely attempts to converse with female coworkers. His target behavior is to attend a social event and talk to coworkers (frequency), at least one conversation should be with a female coworker, stay for half an hour (duration), and keep a subjective stress level or SUD of 3 (intensity). It is helpful to set behavioral goals because it is then very clear to the client what should be achieved. Many agencies ask helpers to set behavioral goals since success can then be measured. Other agencies determine if goals have been achieved through other methods such as client feedback forms, and helper and client assessments. The following helper questions encourage a client to simplify her goal of decreasing stress in her life. "What activities will help you lessen stress?" "How frequenting would you like to engage in the stress reducing activity?" "How long would you like to meditate?" "If your stress level is a 10 now, what level would you see like see as an improvement?"

The fourth criteria of a constructive goal is that it should be important to the client. While it is clear that a client will work hard towards a goal that matters a lot to them, many clients are referred by family, friends, courts, schools etc. to resolve issue the client has little interest in resolving. This proves a challenge to successful goal achievement. Additionally a client may have a goal that the helper finds morally objectionable. In these cases, a helper should tell the client early in the helping relationship so the relationship does not develop too far before giving a referral. The following questions are used be helpers to determine how important a goal is to the client. "How likely are you to follow through with this goal?" "How important is this goal to you?" "If you achieve this goal, what changes will happen in your life?" "Is this a goal you've set for yourself or a goal that other people in your life want you to achieve?"

The fifth criteria of a constructive goal is that it should be realistic. A helper can help a client recognize when a goal is unrealistic or if a client has two goals that are in opposition to each other. For example, a client may want to improve his relationship with his wife and children but is willing to make any changes to his job commitments which requires him to travel frequently. A helper can deal with unrealistic goals by highlighting the discrepancy or by encouraging the client to explore if a goal is realistic or not.

If a helper has a hard time identifying a goal, he or she can utilize several tools. Personal Project Analysis is a system for exploring and identifying goals using a template. See www.brianrlittle.com for more information on Personal Project Analysis. The Self-Development Project List and other measure to elicit positive future goals and plans is useful for identifying and measuring positive life goals. Other measures help in finding and monitoring goals for counseling and psychotherapy such as the Simplified Target Complaints Measure and the Bern Inventory of Treatment Goals.

How to Focus on the Client

Thomas Gordon gives the advice that helpers should ask themselves the questions, "who owns the problem?" when helping clients set goals. This question is most often answered by identifying the person most affected emotionally. For example, the man who complains about his boss owns the problem and will need to decide if he should look for other jobs. A couple who seeks help for their marriage problem both own the problem. It is important to ask this question so that a helper does not get distracted by problems that are owned by someone other than the client. Before a helper and client set goals for changes in the client's behavior, both should be aware of what behaviors are in the client's control and therefore able to be changed. In the technique of focusing on the client, the helper asks the client to take responsibility for his or her problems instead of trying to reform others around the client. This method shifts the focus from others and the client's environment to the issues the client owns.

When a client focuses too much on others, he or she feels a lack of power and is not self aware. If the helper does not shift the focus to the client, the helper communicates to the client that he or she agrees the client's problems are due to external factors. When the helper refocuses on the client, the helper empowers the client and stops the client from blaming others or outside forces for his or her problems. A helper uses skills such as reflecting feeling, asking questions, and reflecting meaning to focus on the client. A helper should paraphrase a client's statement which blames someone else to focus on the client. When reflecting feeling, a helper can choose words carefully. For example, rather than reflect "you are trapped," a helper can say, "you feel trapped" to focus on the client's feelings. It is important that a helper acknowledge when there are external forces affecting the client but emphasize the client's role in making choices and implementing changes. By focusing the discussion on the client rather than other people, the client's environment, or outside forces, sessions can be more productive and more positive. The client will be more likely to feel a sense of empowerment and practice self-examination.

How to Boil Down the Problem

In most cases, a client enters therapy with a tangle of stories rather than clear or specific goals. At some point, a helper shifts from listening to new stories or new issues to focusing on key areas. Boiling down the problem is a metaphor for this process. The first step in boiling down the problem is to summarize and list the issues. In this step the helper uses summarizing skills, reflecting skills, and paraphrasing to determine if he or she has understood the content of what the client has said. The second step is to use at least one closed question to ask the client narrow down the issues to the ones he or he deems a priority. The third step is to choose a problem to focus on. The helper should consider the criteria for establishing a constructive goal when narrowing down problems. The fourth step is to reframe the problem as a goal. In this step, the helper should motivate the client to imagine what will happen if the problem is solved. The fifth step is to double-check that the client and helper are on the same page and have reached an agreement. The helper should summarize the goals that both parties have agreed to. The helper can also ask the client to state the goals in his or he own words or write down the goals. A helper should provide encouragement that the goal is attainable.

After boiling down the problem, it may be beneficial (and sometimes required by agencies) to set measurable goals. Measurable goals can also benefit the client as step by step progress towards the attainment of the goal is more clear. When developing measurable goals consider what the desired outcome is, how it will be measured, how you will know when it is achieved successfully, and the general timeframe.

It may also be helpful to break-down a long term goal into a series of short-term goals. Short term goals may seem insignificant when taken separately, but when combined with other goals they can help a client successfully achieve a long term goal.

Change Techniques: When to use Intervention and Action? - Chapter 12

This chapter will focus on another set of skills called change techniques which are useful in helping a client address his or her problem. After setting goals, the focus shifts to intervention and action. Interventions encourage the client to think of new options, step outside their comfort one, and leave old habits behind. The basic change techniques are giving advice, giving information, brainstorming, and alternate interpretation.

Giving Advice

Giving advice is a complex subject. It can be a crutch that beginning helpers overly rely on. For this reason, many teachers ban advice giving for beginning helpers. Helpers should avoid giving advice for several reasons. First of all, people constantly receive advice from friends and family. A helper's role is different. Additionally, people giving advice is ineffective as people rarely follow the advice they are given. Even in medical situations, about half of all the medication a doctor prescribes is not taken. A helper's role is challenging because it requires getting people to solve their own problems. While advice may sometimes encourage a client's thinking, it is more often ignored. If a client does follow a helper's advice, he or she does not feel empowered and responsible for the change. It is important that a client feel motivated and empowered to solve his or her own problems once the helping relationship ends. Some helpers may unknowingly give lectures or sermons disguised as advice. The helper may then speak too generally rather than focus on the specific client. This may also harm the helping relationship. There may also be extreme consequences to giving the wrong advice which may endanger or harm the client. Finally, a helper may give advice that is insensitive to the culture, background, or religious views of the client. This may also have a negative impact on the relationship.

Before giving advice a helper should consider the following. Is the helper trained in the specific issue the client is having and have special knowledge on the topic? Has the helper experienced the same issue or worked with many other clients who have experienced the issue? Is the helper aware that his or her experiences differ from the client's? Does the helper possess the ability to give advice in a way that will outline both the potential positive and the potential negative outcomes? Does the helper have a thorough understanding of the client's history and background? Does the helper recognize that advice is a two way interaction which should include the client?

If advice is given, it should be concrete. It should be presented as one optional course of action among many other potential solutions which the client suggests. Advice is appropriate if a client is in physical danger that a helper's advice can prevent. Advice is inappropriate if the client seems to depend on others to make decisions for him or her, if the client has not listened to previous advice, when the client wants to be assured on topics that are unpredictable, when the client seeks advice in order to influence someone else, when the client can solve the problem without external advice, or when the advice is in conflict with a client's background, or basic values. From these examples, it should be seen that there are times where advice can help a client. However, it is rare and therefore advice should be used sparsely. If you recognize that you have a natural tendency to give advice, try to avoid giving advice at all until you learn to not rely on it.

Giving Information

Another changing skill is giving information. This means giving the client data or facts to help him or her reach the goal. Examples of data or facts include referrals to community resources, pointing out incorrect ideas regarding drugs, stereotypes, sexuality, or parenting. Helpers should not give too much information so as not to overwhelm the client. It is important that a helper follow up later with the client to see if the information such as a referral was put to use and had an influence.

Brainstorming

Helpers can use brainstorming to help a client find creative solutions to problems. Brainstorming was first developed as a technique to come up with new ideas for advertising. The atmosphere is relaxed and playful with all ideas being recorded. All members of the group participate and no one should dominate. The ideas that are generated are not evaluated as the aim is for creativity. Practicality or the feasibility of an idea is of no importance as playfulness and creativity are encouraged. The goal is for a large quantity of ideas not a few good quality ideas. People are encouraged to build on each other's ideas and combine ideas. Research suggests that when two people brainstorm together they generate fewer ideas than if they made separate lists. This may be due to production blocking which happens when people are reluctant to interrupt and as a result some ideas are not recorded. It may be beneficial for the client and helper to make separate lists as the client may be reluctant to interrupt the helper or if the client puts a lot of importance on the helper's opinion. It is important that after brainstorming, a client and helper are clear on the next steps. Brainstorming in a helping relationship also differs from other types of brainstorming in that in the beginning more time will be devoted to identifying assumptions and challenging them.

There are three basic steps to brainstorming. The first step is to challenge assumptions and ask the right questions. This is an important step because it helps focus the discussion on the current problem rather than past solutions. Closed questions such as "what do you want to achieve thorough solving this problem?" and "Want is the most important thing you want to achieve?" are useful to identify key topics. The next step is to generate ideas. Since the focus is on generating as many ideas as possible rather than generating good ideas, a helper may set a minimum number of ideas that should be generated. The third step is to evaluate the ideas and choose which idea to pursue further. The helper and client can go through the lists and discuss the potential solutions before identifying one solution. Through brainstorming, a client feels motivated and empowered and learn an important problem solving skill.

Alternate Interpretation

The last changing skill we will discuss in this chapter is alternate interpretation. It is used to show clients that a problem can be seen from many different angles. A helper may choose to use alternate interpretation if a client begins to catastrophize about an event. This means that the client expects the event to be devastating without knowing what the actual outcomes will be. In alternate interpretation, the helper asks the client to stop thinking about the worst case scenario and explore the building up to that conclusion. The first step is for the helper to listen to the clients problem and explain the method of alternate interpretation which is to identify other possible outcomes. The next step is for the helper to make a list of three to four other outcomes or interpretations which fit the facts as well as or better than the catastrophic conclusion. The third step is for the helper to give the client a homework assignment to practice alternate conclusion when met with an upsetting event between sessions.

How to make an Evaluation and Outcome Assessment? - Chapter 13

In deciding when the helping relationship should end, consider if goals have been meet and evaluate if more work needs to be done or if more goals should be made. In the roadmap of the helping process, we have arrived at the evaluation and reflection phase.

Due to a growing volume of inappropriate medical treatment, researchers and insurance companies request clinicians to show that their work is scientific and has helped the client. As a result there is now growing interest in outcome assessment in the helping professions. The term outcome research refers to studies that explore if the client was helped. While some studies that have been conducted show that helpers can be trained in helping skills and some methods are more effective than others, but few studies explore how the client reacts. Some theorists suggest that only treatment methods that have been backed up with research should be used. This is research as a prescription for the helper's practice. However, this may be too rigid an approach. Just as two patients who are prescribed the same medicine may react differently, a helping technique may help one client but not work for another. Treatment should be adjusted to fit the individual client. In this way, research can be viewed as a reflective tool not a prescription for practice. Additionally, you can use practice-based evidence and monitor a client's progress and make necessary changes. Outcome evaluation can also contribute to the helper's level of self confidence. In the beginning stages of helping, progress may be difficult to detect and a helper may feel ineffective. Gathering evidence and tracking outcomes may be helpful.

Methods to Evaluate Outcomes

There are many fairly nonintrusive ways to track progress such as using progress notes, global measures, specific symptom measures, client satisfaction forms, and goal attainment measures. When helpers work in an academic setting or a clinical setting they will be asked to use progress reports. There are several types of progress reports including SOAP which stands for subjective, objective, assessment, plan, and computer based programs such as Athena and TheraScribe. It is best to use a format that adheres to the goals that the helper and client agree on. Notes function to do five main things. Notes should restate the goals. Notes should describe the progress towards the goal that is made during the week outside of the helping sessions as well as the results of any given homework assignments. Notes should indicate new information and relevant events from the week. Notes should include any goal relevant discussions during the session. Lastly, notes should include any plans for the following week which relate to the goals. Generally speaking, notes keep the helper focused on the goals and help the sessions stay on track. As these reports are goal specific, do not include your personal reflections or reactions. Those can be kept in a separate journal. Also exclude any irrelevant or embarrassing information.

Another method to assess outcome is to use a global method in order to detect overall progress. Several measure psychological distress and psychopathology which can be sued to gauge if the client is improving overall. There is also the Brief Symptom Inventory (BSI) and the OQ-45. These tests a done with paper and pencil and take only a few minutes. It is beneficial to do periodic assessments using a global method to make sure the helper notices positive and negative changes.

Another method to assess outcomes is through specific measures such as the Beck Depression Inventory II. Specific measures are helpful in detecting specific changes (such as depression). Helpers may use the 21 point Beck assessment every week to detect fluctuations in mood in depressed patients.

Still another method is to use subjective scaling and self-report in assessing improvement. The Subjective Units of Discomfort Scale (SUDS) asks clients to rate on a scale of 1 to 10 or 1 to 100 their level of discomfort at that moment. The client can be given SUDS regularly with the results noted in progress reports. This way changes in mood can be noted and clients can be informed of improvement. The client can also be asked to note the frequency, intensity, and duration of a behavior. Using self report methods encourage the client to track his or her own progress and recognize what works and what doesn't.

In many situations, someone in the client's environment may be better able to recognize change than the client. For this reason, helpers can ask other people such as a friend of the client to monitor change. The friend can give the client feedback when he or she sees a change in behavior. The client should be the one to chose to use this method or not. There are pitfalls as the other person may take too much responsibility. The other person many not respect the confidentiality of the client or put his or her needs before the client's. However, in some situations having another person monitor change can be useful in motivating the client.

Client satisfaction scales which ask clients to rate their overall satisfaction with the services provided can also be used to assess outcome if a few key statements such as "I was able to achieve my goal" or "my relationship with my counselor was instrumental in my improvement."

Graphic methods such as goal attainment scaling can also be used to evaluate progress.

One example is a goal attainment guide. Each goal is given a short description in the goal statement section. Specific indications of success are listed underneath the goal. For example, if the goal is to keep social support for becoming sober, a specific indicator may be to attend support meetings regularly. The range between least favorable and best outcome is then described. In relation to the previous example, the least favorable outcome may be to go to one meeting a month while the best outcome is to attend one meeting a week. The client's current level of functioning is recorded underneath. The helper and client should agree on an initial level of functioning to act as a baseline to measure improvement against. Additional notes can be made to the scale periodically to show progress. In addition to monitoring progress, this method is also helpful during the termination process. Rather than look at the outcomes of individual clients, helpers can also use program evaluation to assess the overall effectiveness of the practice.

Termination: Ending the Helper Client Relationship

Termination refers to the time in which a client and helper negotiate the end of the helping relationship. Nowadays, helpers may have an approach where the client can revisit periodically and helping relationships tend to be shorter now than they use to be. For these reasons, termination may be less disruptive now than in the past. There are still practical concerns such as when to bring up the topic, how to not terminate the relationship too soon, and how to handle the emotional reactions of helper and client.

When the helping relationship ends before any real progress is made, this is called premature termination. A meta-analysis of studies on psychotherapy showed that the average drop out rate was 49 percent. There is no characteristic that can predict a client dropping out. However, it seems that dropouts are a result of stress on the helping relationship. Other studies show that even one session can be helpful to a client and that clients generally expect the relationship to be shorter than the helper does. However, it is important to understand why a client may chose to not return for additional sessions. There a several reasons a client may not return. The client may have had to wait too long for an appointment. The client may have had to go through several channels and feel that the helping relationship is too impersonal as a result. If a setting or situation increases the chances that a client will drop out, a helper can ask the client to agree to a set number of sessions. Helpers can give clients information about their qualifications and about therapy so that expectations are realistic. Helpers can remind the client about their next session. If a client terminates early, the helper should contact them to ask why. If a client leaves therapy before their goal is reached, the helper should communicate that the client is welcome to return later.

When is Termination Necessary?

The helping relationship should end if clients reach their goals, if clients have not made progress after many sessions, or if they can solve their own issues but have become dependent on the helper. If the client is terminated because he or she is not making progress, they should be referred to other venues for help. It can be difficult to determine if helping sessions have been successful. Sciscoe describes five questions a helper should consider while trying to determine if a client should be terminated. The first question is to consider if the problem is under control. The second question to consider is if the client is less distressed now and more able to cope. The third question is if the client is more self aware and has better relationships now. The fourth question is if the client is enjoying life and work more. The fifth question is if the client feels capable of living without the therapeutic relationship.

Preparing a Client for the End of the Helping Relationship

The helping relationship should not be ended suddenly. It is recommended to bring up the topic at least three sessions before the termination. Others recommend seven sessions notice. Still others says one-sixth of sessions should be devoted to discussing termination. Opinions differ as to the exact amount of time helpers need to prepare clients for termination. It is important to use your best judgment as preparing for termination will be different depending on the length and quality of the helping relationship. When preparing a client for termination, the helper and client should discuss the counseling process and any progress that that been made. The helper should highlight the client's strengths and end the relationship in a positive way.

A client often will feel a sense of loss when the helping relationship is ending. Helpers should ask clients to recognize the positive and the negative feelings they have when a relationship ends. It is advisable to bring up the topic of termination well in advance. Encourage the client to view termination as the next stage where they practice their new skills. Be specific as to the number of sessions early on so the termination will not be unexpected. Fade out the termination by spacing out appointments so the client meets the helper less and less. Communicate to the client that he or she was responsible for the progress made and they can be responsible in the future. Use reflective listening and let the client express his or her loss.

Helpers may also feel conflicted at the end of helping relationship for several reasons. The helper may view the relationship as being very important. The helper may not be confident that the client will be able to function without help. A helper may worry that he or she was ineffective or feel insecure professionally if a client ends the relationship prematurely. The helper may have been looking forward to gaining experience about a client's specific problem. The helper may miss the excitement of the client's stories. The helper may associate the loss with another loss in his or her life. The helper may have been sexually attracted to the client or felt friendship. Termination may be especially difficult for beginning helpers.

Maintaining Progress and Preventing Relapse

Helpers use techniques of relapse prevention to anticipate and prepare for situations where a client may fall back on old behaviors. One technique is through follow-ups or brief contact where a helper gets in touch with a client a few weeks after termination. During this contact, the helper determines how the client is progressing and reminds the client that he or she can return if help is needed later. Another technique is fading. This occurs when a helper schedules increasingly infrequent follow-up appointments with the client for a year. These sessions can be booster sessions or refreshers for skills they are practicing. This method is especially useful for children and adolescents. Some agencies offer clients the services of paraprofessionals. Self-help groups can also be a useful resource. The quality of groups differs greatly and it is important to find a group that fits the needs of the client. Clients may be reluctant to attend a group since it means admitting he or she has a problem (such as alcoholism in the case of Alcoholics Anonymous). For this reason, helpers will need to encourage attendance of a minimum of three sessions. The client can be asked to keep records as to their progress in the form of self-monitoring. The reports can be reviewed with the helper during follow-up sessions. A less formal method is to ask the client to keep a personal journal. A helper can also encourage a client to use self management skills where the client rewards him or herself for certain positive behaviors. During follow-up sessions the helper and client and discuss new strategies and reward systems. Relapse is common after termination and clients should be advised that progress may feel slow. A client can use role playing as a technique to deal with situations that could lead to relapse. Role playing will be discussed in further detail in a following chapter. Another strategy is letter writing where a helper uses the format of letter writing to encourage and motivate the client.

What are the REPLAN Model and Curative Factors? - Chapter 14

Helpers may feel inclined to learn and use as many techniques as possible in the hopes of finding one that will work of most client or a currently challenging client. It is important to remember to respect the uniqueness if each client's situation. The aim should be to move in the direction of a client's goals and chose techniques that suit the goals.

A curative factor is defined as a common element which explains why several different therapies appear to work. Curative factors helps us organize techniques and understand the aim of certain chosen techniques. The full range of helping techniques and skills can be connected to one or more factors. There are six in total which form the acronym REPLAN.

The R in REPLAN represents relationship as maintaining a strong helper and client relationship is essential. E stands for enhancing efficacy and self-esteem. Most helpers agree that improving a client's self-esteem is beneficial. However, changing long held beliefs is difficult. P is for practicing new behaviors. Later in the chapter we will discuss techniques for encouraging clients to practice new behaviors. L stands for lowering and raising emotional arousal. The next chapter will discuss methods for lowering emotions such as quieting techniques for relaxation as well as methods for raising emotions to encourage the client to be aware of suppressed feelings. A is for activating client expectations, hope, and motivation. The next chapter will also ways helpers can encourage and motivate a client. N stands for new learning experiences. Helpers can provide such experiences in many ways. These methods will also be discussed in the next chapter.

Treatment Planning

The commonly known medical method for assessment and diagnosis is called the diagnostic treatment planning method. In this method the diagnosis determines the treatment plan. Many different methods for planning a treatment exist. Many clinicians also create a treatment plan which follows the theory they subscribe to (Gestalt, Adlerian, behavioral theories or psychodynamic theories). REPLAN can help in creating a general treatment plan. REPLAN focuses on goals and does not conflict with theoretically based models or arriving at a DSM-IV diagnosis. REPLAN does maintain that even clients with the same diagnosis needs treatments planned specifically for the individual. Unlike other types of treatment planning, REPLAN uses strategies related to one or two curative factors to focus on a few goals. It is useful in focusing a client on a few goals at one time. It can still be used with long term therapy and occur frequently.

The steps in REPLAN

The REPLAN model has three steps. The first step is to identify treatment goals that both the helper and the client agree to. These goals should be filtered down to be manageable and then prioritized. The second step is to use some of the six curative factors to come up with potential strategies or techniques to attain the goals. At this point the helper should consider which curative factors are most likely to help the client attain his or her goals. The helper should also consider which techniques or strategies the client will be likely to accept. The third step is to revisit the treatment and replan it regularly and to focus on new problems as goals are attained.

1) Curative Factors and Advanced Techniques

2) Curative Factor: Enhancing Efficiency and Self-Esteem

The first curative factor will we will discuss further is enhancing efficiency and self-esteem. Most people agree that increasing a client's self-esteem should be one aim of helping. Humanist theorists see the helper's role as aiding in a client's "can-ness" or sense of his or her own ability to achieve goals. Carl Rogers aimed to decrease the gap between the ideal self and the perceived self. Adler described having faith in oneself as a sign of mental health. Studies identify low-self esteem as contributing to disorders such as anxiety and depression. Some people view the concept of self-esteem as too nonspecific.

It is less problematic when we divide self-esteem into efficacy (which means competence) and self-worth. Efficacy is the expectation that an individual can carry out a task. One example is that an experienced pilot is confident that he or she can carry out the task of flying a plane. Efficacy can be modified through experience. For example, the pilot who crashes a plane may feel less confident. A client may be reluctant to take on a goal due to negative past experiences or failures. A helper can help improve the client's self-esteem by focusing on strengths and skills the client does have as well as by highlighting talents the client may not recognize. Unlike efficacy, self-worth is not task specific. It is a global feeling that an individual has the right to exist and has a life worth living. Self-worth can be seen as self-approval. An individual can feel a sense of efficacy in several tasks and still experience low self-worth. There are many potential reasons a client may experience low self-esteem. Two key reasons are irrational beliefs and body image.

Irrational beliefs are destructive ideas about one’s self that cause low self esteem. They are difficult to challenge and get rid of because they are firmly held though they cause emotional pain. Albert Ellis viewed low self-esteem as a result of such beliefs and described seven main categories of irrational beliefs. The first category that irrational beliefs can fall into is the idea that an adult should be approved of and loved by all the important people in his or her life. The second is the idea that a person is only worthwhile if he or she is competent and adequate in everything. The third idea is that certain people are bad or evil and should be punished severely. The fourth idea is that it is a catastrophe when things are not how we want them to be. The fifth idea says that a person's unhappiness is due to outside factors and the person cannot control it. The sixth idea is that it is easier to avoid challenges than to face them. The seventh idea is that our present is determined by our past and that the things that strongly affected us in the past will always strongly affect us.

Body image is another cause of low self-esteem. Being attractive is a seen by most as socially important. People who feel unattractive may develop low self-esteem. While women use to have more body image issues than men, society now also has ideals of male attractiveness that may encourage negative body image in men. It should be noted that negative body image is more common for adolescent girls due to the weight gain associated with entering puberty. As helpers are also affected by society's ideals of beauty and the images of mass media, a helper should be aware of how we treat clients we do not find attractive. Beginning helpers may have difficulty with clients who refuse to lose weight or who dress in an unattractive way. Helpers should remember that a negative body image may be a sign of serious issues such as eating disorders.

The Technique of Countering: one key way to increase a client's self-esteem is through the technique of countering. This is a method to lessen the negative inner voice that focusing on failure and impedes performance. The word countering refers to producing a self-statement that is not compatible with a critical thought. Assertiveness training and other methods used to decrease external voices may be helpful in the future, but one should begin by silencing the inner negative voice. Through countering one learns to argue with disapproval. The negative inner critic may have developed through irrational beliefs we learn from our families. Often these negative thoughts happen automatically. For example, before giving a speech one might say, "I know I’m going to forget the words." This negative thought then leads to lowered expectations of self and feelings of anger and depression.

Steps in Countering

1. The first step in countering is to briefly assess how frequent negative thoughts are and how they affect the client. A client should be asked to self assess or self-monitor the frequency of the negative thoughts or behavior. A client can do this by writing down the self-criticism verbatim and writing the negative feelings it brings up. The negative thoughts are discussed in the next session and are helpful in giving more information to both the client and the helper, as well as letting the helper know which feelings are associated with which comments. This exercise can also show the client that what he or she thought were valid arguments in fact bring up negative feelings.

2. The second step in countering is to identify the core beliefs and the negative patterns of thought. After a minimum of one week's worth of self monitoring, the client's core beliefs and negative thought patterns may be identifiable. The helper and client should discuss the patterns and identify a few to work on. In this exercise, several core beliefs may come up such as "I lack focus" or "I have no discipline."

3. The third step in countering is to identify the counters that work. A counter can be sentence or only one word such as "nonsense." The best counters are inline with a client's values and help the client talk back to the self-critic. The helper and client work together to find several counters that the client can test to find what works best.

4. The fourth step is to test and revise counters to see which counters are effective. It generally takes longer than a week for the counter to lessen negative thoughts as negative thoughts are ingrained and automatic. A helper can try to test a counter with a client by having the client read a negative criticism and rate his or her emotional reaction on the SUDS, then read a counter and again rate his or her emotional reaction on the SUDS. If the rating decreases, the counter can be seen as effective.

5. The fifth step is for the client to practice the counter and report the results in follow-up sessions.

Tips For Countering: the helper should explain to the client that some counters are more effective than others and that ineffective counters should be identified and discarded. A less effective counter may be modified to be more potent. A helper can suggest words that make a counter more effective. For example, adding the word "clearly" before the counter may increase its potency. Counters should be specific to the negative criticism as well as realistic. Shorter counters tend to be more useful than longer counters. McMullin felt that counters should be in the same form as the negative criticism, for example, a positive visual image for a negative visual image.

Thought stopping is a variation of countering and is useful in stopping negative thoughts before they grow beyond our ability to cope with them which leads to anxiety. Thought stopping has been useful in treating recurring thoughts, for example, obsessive compulsive disorder and to help people quit smoking. The helper can teach the client the method during a session and the client can practice it as needed. The first step is to state the negative thought. The second step is to create a jarring interruption such as "stop!" The third step is to replace the negative thought with another thought.

3) Curative Factor: Practicing New Behaviors

The second curative factor we will discuss is practicing new behaviors. The psychoeducational approach emphasizes the need for practicing new skills and behaviors as the approach posits that many of a client's problems are due to a lack of certain skills. Clients should be shown models of behaviors that they can then practice. Examples of skills that a client may need to see include good parenting skills, better communication skills, and how to face as situation one fears. It is necessary that a client go beyond recognizing their problem to stop a negative behavior. A client should overcome their old habits and develop a new behavioral pattern. This new behavioral pattern can be established through practice.

Steps for educating a client about a skill are as follows: first the theory should be explained to the client, second the helper or group member correctly demonstrates the theory to the client in the form of a model, third the learner demonstrates the behavior in a simulated or real situation in class, fourth the learner practices the new behavior in homework assignments.

Role-Playing method

Roleplaying is a common technique that helpers use to encourage clients to face situations they want to avoid and to train a client in social skills. In roleplaying, a client can practice the new behavior in a simulated situation where the helper takes the role as someone the client is interacting with (as an auxiliary) or as an observer. Roleplaying can also be in a group setting where group members interact with each other and provide feedback. It was pioneered by the Viennese psychiatrist J. L. Moreno. Moreno also developed the psychodramatic method. He believed that people should learn new skills in their natural environment. Since this is not always feasible, the psychodramatic method aims to recreate behavior on a psychodramatic stage. Rather than telling about problems, clients are encouraged to show.

Roleplaying can be practiced without a full understanding of the psychodramatic method. One person can play all the characters or many people can roleplay together. This is one of the most effective ways to practice a new behavior. Clients benefit from receiving immediate feedback. The method also helps clients become more aware of their feelings and their relationships with important figures in their lives.

Role-playing occurs in three main phases. The first phase is the warm-up phase. A warm-up is any activity that helps a client emotionally engage with the experience he or she wants to address. Warming helps in lessening stage fright and encourages the protagonist to get involved in the process and prepare. A helper may ask the client to discuss the situation to warm up or to engage in a physical action such as pacing. A helper also ask the client to pretend to be the other person. This is called role reversal. This is one of the most effective ways to engage a client in roleplay. Role reversal also makes the situation more realistic as the client must construct potential responses of the other person as well as cope with the responses. It is helpful to keep in mind the phrase "moving from the periphery to the center" in relation to the warm up phase of Roleplaying as the helper should shift towards more significant issues. This means building up the scenarios to the more potentially challenging scenes. Through warming up, a client can move beyond stage fright and be emotionally in tune with the situation.

The second phases of roleplay is action. After the warm up, the helper instructs the client to take on the role and enact the situation. The helper sets the scene by asking the client to set the stage to resemble the actual scene. The client can use any props that are available. The helper aids the client by defining the stage, describing the time and date, describing the situation, and identifying the key people.

The third phase is sharing and analysis. In group therapy, this phase allows the protagonist to reenter the group and step out of the spotlight. The other group members can relate the scene to their own personal experiences. Later, group members give the client feedback and discuss the roleplay. In one on one sessions, the helper can immediately give the client feedback. Feedback should be simple, specific, and recognize the positive aspects of the behavior.

After the third phase, the client may be asked to reenact or practice again the behavior until he or she is confident in the behavior. The client can be given homework and asked to report on the results in the following session. More Roleplaying may take place in the following session and once the helper feels the client is ready, he or she can ask the client to practice the behavior in a real life situation.

Challenges in Roleplaying: the most common challenge in roleplaying is stage fright. This can be decreased with a longer warm-up, more preparation time, and boosting the client's confidence and reassuring the client. As the technique is powerful, strong emotions may come out. While this is unlikely to happen when practicing a new behavior, beginning helpers should avoid reenacting traumatic scenes from the client's past. Finally, the helper should think in dramatic terms of showing and action rather than thoughts and feelings. Through the dramatic situation, the helper can gain much insight about the context of behavior and more specific information about the behavior rather than the client's description of the behavior.

Homework method

The second method we will now discuss is homework. Homework includes in assignment or task the client is instructed by the helper to complete between sessions. Some tasks are used for assessment while other tasks are used to encourage the client to become more aware of his or her behavior. Homework assignments can also be used as independent practice sessions. We will focus on homework that is used to practice new behaviors. As mentioned previously, these new behaviors are modeled during the session, practiced in the session, then assigned as homework. The next session then begins by reviewing homework. A key benefit to homework is that it gives follow-up treatment and continues the treatment between sessions. Homework assignments also reframe insights and awareness as tangible behaviors. Thus it is helpful to transfer training into real life situations as soon as possible. In practicing homework, the client becomes more empowered in achieving his or her goals.

Examples of Homework

• Bibliotherapy is when clients are assigned readings. There is an abundance of self-help books available, though some are over-simplified and anecdotal. A helper should always read the book before assigning it to a client to be sure the book is relevant to the client's situation and if the book will help the client attain his or her goals. Important points in the book can be discussed during sessions. Additionally, examples in books can model behaviors for the client and the client may identity with figures within the book.

• Another homework example is aides. Aides are a client's spouse, friend, or family member who can be asked to give feedback or support. The helper generally will meet the aide at a session and identify them as being in a feedback role or the support role. The downside in working with aides is that the helper should supervise them. Another problem may be an aide who is too enthusiastic and takes too much responsibility from the client.

• The third example is journaling and record keeping. Journaling is a daily writing assignment. It can be used in an open ended approach to encourage the client to reflect on his or her feelings and thoughts. It can also be used to record practice sessions. The table and figure below provide an example of Anna.

Challenges In Homework: it is important to choose the homework assignments that have a high probability for success. This is important for encouraging the client to be hopeful as well as to show that change occurs gradually. Homework assignments should also be specific to and tailored to each client. Homework assignments should not be standard and impersonal. Consider activities the client enjoys. If the client enjoys reading, a reading assignment may be more acceptable than a writing assignment. Regular practice should also be emphasized. For example, several shorter practice sessions throughout the week is preferable to one long session. Homework should not be too complicated. It should fit easily into the client's life. As the client makes progress, the difficult of the homework can increase.

Curative Factors Continued? - Chapter 15

Curative Factor: Lowering and Raising Emotional Arousal

In some cases a client's emotions such as anger, fear, or stress may need to be reduced. This can be done with the help of quieting techniques such as relaxation training or meditation. These tend to be safe techniques to practice and can lead to positive client experiences. In other situations, a client may benefit from heightened emotions which can lead to change and learning to express their feelings. Clients who have not dealt with painful experiences, tend to use defense mechanisms, or are under expressive may benefit from emotional arousal. However, arousing emotions comes with many risks and should not be attempted without a long period of training as well as without proper supervision.

Lessening Emotional Arousal

While emotions like anxiety and fear are occasionally necessary and even beneficial, in excess they can cause stress and interfere with an individual's relationships as well as his or her job performance. In primitive times, the emotions associated with the "fight or flight" response played an important role in survival. However, nowadays stress can have adverse health effects. For these reasons helpers show clients how they can learn skills such as time management skills, and take better care of themselves (exercise and nutrition) as a way to lessen stress. Helpers can also teach clients quietening techniques in order to reduce stress. Common techniques include: muscle relaxation, systematic desensitization, biofeedback training, applied relaxation, guided imagery, social support, and meditation.

Muscle Relaxation technique

Muscle relaxation training is a fundamental way a client can reduce emotional arousal. Positive feelings due to lowered muscle tension can result immediately. Edmund Jacobson developed a relaxation technique in 1938. If done correctly, a client can use the technique to identify and relax all major muscle groups. The full training method can take many months to learn, but less thorough methods can also be successful. The following method is a simplified version from Witmer which can be learned in three to four sessions of twenty minutes. All the sessions are the same and goes through tensing and relaxing all the muscle groups of the body. The six major groups are as follows: 1. hands and arms, 2. head, face, and throat, 3. neck and shoulders, 4. chest, shoulders, and upper back, 5. Lower back, stomach, and hips, 6. Hips, legs, and feet. Keep in mind that relaxation techniques are more effective when combined with cognitive methods of controlling stressful thoughts.

Five Steps to Deep Muscle Relaxation

1. The first step is preparation. In this step, the helper should ask the client to find a comfortable position, either laying down or sitting. It is important that the head is supported and that legs and arms are not crossed. There should be as few distractions as possible. The client should not move unless it is in order to get more comfortable. Instruct the client to raise one finger to show that the instruction is understood and completed.

2. The next step is the tightening and relaxing of progressive muscle groups. The client should try to hold each muscle tense for 6 to 7 seconds or until they feel the muscle is fully tightened. Avoid holding muscles tight for too long as cramps or spasms can occur. While the muscle group is tense, the client should focus on that muscle group and relax other muscle groups as well as hold his or her breath.

3. The third step is to fully relax and to breathe. After tensing a muscle group, the client should relax fully and exhale. Relaxation should be followed by slow, deep diaphragmatic breathing for about twenty seconds. This is defined as inhaling and exhaling below the ribs instead of in the upper body. Clients can practice by placing a hand on their chest and a hand on their stomach. The hand on the stomach should move up and down with each breath while the hand on the chest should not move. The client should then repeat tensing and relaxing the same muscle group. Then move on to the next muscle group.

4. Step four is the body scan. In this step the client is asked to focus on specific areas of the body and relax them. In this step the helper can customize the method so the client focuses further on areas they experience more difficultly with. Clients can also use this step on its own throughout the day to check body tension.

5. Step five is to give a practice assignment to the client. The client should be given either an audio copy of their first relaxation technique training or be given a copy of a standard commercial version. The client should practice the technique two times a day, usually when waking up and before going to sleep. The client should also pay attention to which muscle areas they experience the most tension in and communicate this during the next session.

Meditation technique

Another quieting technique is meditation. It is highly effective for reducing panic, anger, and anxiety. Additionally, meditation can lead to positive benefits of happiness, becoming more alert, increased focus, optimism, and feelings of well-being. Meditation has been useful in treating substance abuse and used with prayer in the twelve steps of Alcoholics Anonymous. Mediation can immediately stop mental images and noise that leads to anxiety. While relaxation produces physical rest, meditation leads to mental quietude. It is thus a good replacement for tranquilizers. Meditation should be practiced daily for at least fifteen minutes to produce results. After results are noticed, meditation should be practiced for at least thirty minutes everyday. It is helpful to practice with a teacher. It has been seen that using a mental device, or mantra, is helpful in focusing the mind. A phrase should be slowly repeated mentally at regular intervals. This helps occupy the mind while the practitioner concentrates. Both spiritual and nondenominational forms of meditation exist.

Increasing Emotional Arousal

Cathartic methods go as far back as Ancient Greek drama. The word katharsis refers to the purging or purification felt after emotions are expressed. Cathartic methods can be seen in the confession of sins, rituals of mourning, and religious rituals. In the book Studies on Hysteria, Breuer and Freud discuss their findings by provoking clients to relive past traumatic experience, healing could occur through the release of negative emotions stored in the unconscious. While most helping professionals no longer subscribe to Freud's principles, many still use the arousing of emotions as a helping technique. Emotions have been aroused through hypnosis and drugs, psychodramatic methods, guided imagery, reflective listening, confrontation, free association, the empty chair used in Gestalt therapy, play therapy and more.

Catharsis includes two key aspects or parts. The first is to simulate the emotions of the client. The second is to encourage the client to express these emotions. The aim of part one is to encourage and motivate change. The aim of part two is allow the client to fully experience their emotions and communicate these emotions. To maximize effectiveness, emotional arousal should be used with cognitive shifts. Evidence shows that underexpressive individuals can especially benefit from these techniques. It is however important to keep in mind that use of these techniques can be traumatic for and even potentially harmful to clients. Less confrontational arousal techniques may be to encourage a client to express his or her feelings. Highly confrontational arousal techniques may lead a client to feel out of control when very powerful and strong emotions are evoked. We will focus on moderate techniques which encourage clients to focus on feelings but without pressure. Only very experienced helpers should use highly confrontational techniques as while there may be rewards there are big risks as well. Goleman identified a ventilation fallacy where expressing anger may feel so good that an individual may become more likely to feel angry later.

Stimulus and Creative Arts techniques

Stimulus techniques where a helper exposes a client to music, film, art, or books to bring out strong reactions. For example, a client may identify with the hero of a film. The helper and client can then discuss what feelings and thoughts were evoked. It is important that these clients are carefully chosen and not alone and able to discuss their feelings after the session. Helpers can use the creative arts in encouraging clients to express themselves through artmaking. Clients are not passive as in the previous example, but are active in making the work. Mediums for the expression of an inner state include dance, poetry, collages, paintings, and work with puppets or dolls.

Curative Factor: Activating Client Expectations, Hope, and Motivation

A helper should be aware that when first entering the helping relationship, the client is likely to feel discouraged, unmotivated, and not confident. Before a client can tackle their problems, they must stop feeling like their situation is hopeless. Jerome Frank describes demoralization as a state of mind which is characterized by one or more states: lower self-esteem, feeling of incompetence, feeling hopeless, feeling helpless, or feeling alienated. Seligman describes learned helplessness as being similar to depression. He found that people become so discouraged after failing to solve unsolvable problems that their later performance on solvable problems was negatively affected. Frank felt that depression, lowered self-esteem and anxiety mostly resulted from being demoralized. Frank went on to propose that symptoms become worse when people feel discouraged, leading to a cycle.

Client Expectation

The placebo effect has been credited with dramatic client improvement early in the helping process. This reference to a medical analogy suggests that the helper is tricking the client with an ineffective treatment. The placebo effect, which can also be called the expectancy effect, actually makes use of factors of social influence when a client trusts the helper and believes that he or she can be helped. In this sense, the expectation of help is in itself healing.

Encouragement

Encouragement can be seen as the opposite of demoralization. It is a technique and idea that is closely related to the theory of individual psychology developed by Alfred Adler. However, helpers who do not subscribe to Adler's approach still use the technique of encouragement. Studies show that is the second most commonly used technique and is used by 90% of helpers. These results suggest that encouragement is an essential and important technique in helping.

It is necessary to differentiate encouragement from praise. Praise can have negative effects as it suggests that the helper is in the role of judge and is expressing approval of the client who is in the role of the child. Encouragement is motivation for a client to develop faith in him or herself. In encouraging the client, a helper pushes the client to have a more positive outlook. Additionally encouragement focuses on inner goals and directions while praise or reinforcement emphasizes outcomes and outer directions. Encouragement also attempts to help the client balance thoughts, feelings, and action while praise focuses more on action. Praise can be viewed as a reward for a specific action. Encourage to also promotes independence while praise or reinforcement promotes an association between a behavior and a specific reinforcer. In this way, praise does not generalize to other situations as encouragement does.

Individuals who suffer from depression, dependence, alienation, or low self-esteem respond best to encouragement. It is also helpful for individuals who need a lot of attention, have a need to be in control, are perfectionists, or who have a tendency to be close-minded. Essentially, encouragement is suited for people who have lost faith in other people and are weary of giving up control.

Encouraging Responses

Theorists and writers have noted fourteen main types of encouraging responses. The first is to recognize and acknowledge the client's effort and any improvements. The second response is to focus on the client's present abilities and possibilities and not focus on past failures. The third is to focus on a client's strengths. The fifth response is to express interest in the client's well-being and progress. The sixth response is to focus on topics that the clients interested in. A seventh response is to ask the client to self-evaluate instead of comparing the client with a norm. The eighth response is to respect the client's individuality. The ninth response is to use honest self-disclosure and connect with the client. The tenth response is to treat the client as an equal partner and offer your help. The eleventh response is to use humor. The twelfth response is to give accurate feedback on actions and behavior and not on personality. The thirteenth encouraging response is to confront discouraging behavior. The fourteenth response is to ask the client to commit to goals and be enthusiastic.

The above responses may appear to be oversimplified but they are useful to keep in mind and to give general direction to beginning helpers. These fourteen encouraging responses can be generally grouped into three groups.

1. The first general aim is to focus on what is positive and what can be changed. The first four encouraging responses fall into this group. They aim to refocus the clients attention on what is positive rather than what is lacking. The helper should highlight positive aspects and the client's strengths and show faith that the client can succeed. Additionally, the client should be encouraged to focus on the present instead of the past. Keep in mind that the client should not be told to avoid or ignore stressful or negative situations. Instead, the client should develop a more balanced view. The client should also be encouraged to focus on what he or she can change rather than situations they cannot control. Optimism is viewing he world as friendly and supportive. While not everyone is optimistic, it can be learned. Studies have shown that optimism has health benefits, good mental health and less stress while pessimism is associated with depression, health problems, and lowered achievement.

2. The second general aim is to emphasize the uniqueness of the client and the equality of the helping relationship. The fifth through the tenth encouraging responses can be grouped into this category. The helper can use self-disclosure to communicate the equality of the relationship and bond with the client. A helper should also show the client that they should evaluate themselves by their own internal standards and not by external standards.

3. The third general aim is to push the client through enthusiasm. The eleventh through the fourteenth encouraging responses fit into this category. Encouragement is not only showing support. It also involves challenging the client to act and motivate change. The helper can do this through giving feedback, using humor, and confronting the client's logic.

Steps in Encouragement

The first step is for the helper to use the nonjudgemental listening cycle to build trust it the client and to understand the client's problem. If the problem is not properly understood, encouraging responses may be irrelevant and ineffective. The nonjudgemental listening cycle is also encouraging since it emphasizes an equal and respectful helper client relationship. In the second step, the helper should offer to be an ally to the client and suggest working together to solve the problem. The third step is for the helper to bring attention to positives and what efforts the client has made no matter how small. In the fourth step, the helper gives feedback or confrontation and asks the client to commit to taking steps towards achieving his or her goal. The fifth step is for the helper to continue showing enthusiasm for the client's feelings and progress and for the client's goals.

Different Levels of motivation

Clients are different in how ready they are for change. Two groups of writers have started classifying clients according to their level of motivation. The first model we will discuss is Prochaska and DiClemente's Stages of change. This is called the transtheoretical model which proposes six stages. Like some other models, this models focuses on motivational interviewing and is thus very useful for dealing with addiction. The model is also useful because a helper can choose effective interventions and techniques based on the client's level of motivation.

1. The first stage in the model is the precontemplation stage. In this stage, the client I not aware of a need to change and has no desire to change. He or she may be surprised when friends or family suggest a change. Clients at this stage are often referred by a court or important figures in the client's life. The best treatment at this level is to educate the client and invite the client to think more. The helper should avoid moralizing.

2. The second stage is the contemplation stage. A person enters this stage when he or she becomes aware that a problem exists. While, the individual may admit to the problem he or she will not admit that the problem is severe or that they need professional help. The helper should encourage the client to consider the pros and cons of change and think about the positive aspects of change. The helper can aim to increase the client expectation.

3. The third stage is the preparation stage. At this stage a client may take small steps towards change but still go back and forth. A helper can help the client by identifying skills that the client needs to develop before embarking on change. The helper can also assist the client in identifying sources of support.

4. The fourth stage is action or determination. In this stage, the client is ready to change his or her behavior and look for outside help. The shift to this phase may be sudden or gradual. Often this shift happens when a client reaches "rock bottom" and feels they have no options but the enact change. A helper can assist a client in this stage through directives, treatment programs, and assigning homework. The helper can highlight when the client is successfully avoiding obstacles and identify triggers of relapse behavior.

5. The fifth stage is the maintenance stage which occurs after a client receives help and the problem is under control. The client may need to change his or her life to accommodate change and new behaviors. The helper and the client's family and friends should continue to give support. Helpers can also help the client develop a rewards system when they maintain the changed behavior.

6. A potential sixth stage is the relapse stage. It is common to relapse and return to old habits. The helper can help the client become motivated again. The helper should not focus on the loss and instead help the client find better methods to cope with triggers of old behavior.

De Shazer's model describes three categories: visitors, complainants, and customers. Visitors are people who do not have a complaint but are referred by someone else who does have a complaint. Visitors should be given information and given suggestions for educational programs by helpers. The helper can try to convince the client that a problem is present, but if the client is resistant, he or she can be given information about where they can receive help in the future. Complainants are clients who are uncomfortable and are looking for help. They want to think about change but may not be ready to take the first steps. Helpers should try to encourage complainants to shift closer towards change. Customers are clients who are willing, able, and ready to take action towards change. It is important that a helper not confuse a complainant with a customer. Only customers should be given action based directives and homework.

Curative Factor: Providing New Learning Experiences

This therapeutic factor has been referred as changing the worldview, developing insights, cognitive restructuring, and perception transformation among many others. Research shows that developing new outlook skills is one of the most often mentioned insights that clients gain through therapy. A new outlook can be motivated through instruction, modeling, humor, metaphors, interpretation, reframing, and through stories. There are two basic techniques involved in providing new learning experiences. The first technique is to offer a client new information and skills. The second technique is to help clients alter any inappropriate beliefs or perceptions.

Several of the problems a client may experience are due to a lack of knowledge or training. Through training, individuals can learn stress coping skills, learn about alternatives to addictive behavior, and learn better interpersonal, communication, and parenting skills (among many other skill sets). When a client takes on a new perspective, he or she can change their thinking regarding painful past experiences and become more open to experiences they may have been afraid of before. However, before the change resulting from new information can alter a client’s perspective for the better, it is first unsettling and challenging. Not only may a client be resistant to change, other individuals close to the client may also resist change or try to slow the change.

Methods

There are several methods that are useful for helpers in providing a client with new learning experiences.

1. One method is interpretation. Interpretation involves encouraging the client to view the problem from the point of view theoretical perspectives. The reasoning is that once a helper explains the problem from a perspective such as the psychodynamic perspective, the client gains insight and is more able to change. An example may be that a female client’s reaction to her husband is a result of lifelong issues she’s had with her father. When this reaction is interpreted and confronted the client can begin to recognize her own unconscious motivations. Once she gains insight, the learning may be applicable to other scenarios, for example male figures in general. Interpretation is an advanced technique and should be learned in extended training. Nowadays, it is also a controversial technique as it suggests the helper is in expert which contradicts the aim of helper client collaboration.

2. A second method is through modeling. Bandura noted that we learn by copying the behavior of other people. Modeling has been popular in teaching children prosocial behavior, to teach parents, to help clients confront situations they are afraid of, and to teach helpers (among many other examples). In the context of group therapy, group members may copy the helper or other group members who are functioning better. Modeling can be both intentional or a beneficial by-product. Role-playing is an example of intentional modeling. Essentially, a client is able to see a skill preformed successfully in modeling. He or she can then try to reproduce the skill and the helper can provide feedback.

3. A third method is to use metaphors, stories, parables, or other tales. Helpers can use metaphors and stories to get the attention and interest of the listener by using imagery, humor, and suspense. The client may not even be aware that there is a message to the story or that he or she is having a learning experience. A story can get around a client’s resistance to new learning. Stories can be more effective than advice giving because it allows the client to determine the next course of action. It is important to use stories that fit the client’s background and worldview so that the client can connect with the story.

4. A fourth method is to expose the client to stimuli he or she wants to avoid. Many cleints seek help because they are afraid of social situations or have other fears. They relieve their anxiety by avoiding these things or situations even when the behavior is ineffective or superstitious. A helper can teach the client that the things and situations they avoid will not hurt them. Exposure is a technique where clients gradually face their fears. Helpers can determine a hierarchy of fears and slowly help clients face more and more challenging situations.

5. A fifth method is humor. Humor is helpful in a similar way as using metaphors or storytelling. A joke can also contain a message, interpretation, or shift. Keep in mind that humor differs with cultures. It is important that the client does not think the helper does not take his or her problem seriously or that the helper is making fun of him or her. However, humor tends to be spontaneous and is difficult to plan. A helper can try to lessen the repercussions of an ineffective joke by building a strong trusting relationship with the client.

6. A sixth method is the use of linguistic changes. These are suggestions by the helper that a client discusses his or her problem using different words. An example to to ask a client to use certain words to reinforce the idea that the client is in charge of his or her life. Instead of saying, “I can’t manage to be on time to meetings,” a client can change the language to say, “I won’t go to meetings on time.”

7. A seventh method is to use change questions or strategic questions. Thus far, we have discouraged asking questions because they can may the client feel judged and become defensive. However, some questions can be helpful. Three examples of useful change questions are scaling questions, the miracle question, and embedded questions. Scaling questions encourage action and motivate change. A helper can ask a client to choose a number on a scale in relation to their specific problem. The client and helper can then discuss what actions would need to occur to change the number in a positive direction. The miracle question is also intended to motivate clients towards goals. The question usually surprises the client and can make it easier to discuss potential changes. For example, “I have a question that is a bit unusual. You can think it over before you respond. Imagine that when you go to bed tonight and after you wake up tomorrow, the problem that brought you here is resolved. Now, it is important to know that you were asleep when the problem was solved, so you didn’t know that the miracle happened. What would be the first thing that you notice that makes you realize the miracle happened and your problem is solved?” The miracle question can put the client in a new line of thinking about possibilities by encouraging them to focus on a scenario where their problem is gone. This helps the client be more hopeful and able to discuss changing their behavior. Another question is the embedded question. These questions have a hidden suggestion. They are focused on the future and are optimistic. They suggest that the client is expected to change and that he or she will change. Examples include, “When the problem is resolved, what will you be doing that you are not doing now?” or “When you confront your father, what will change in your family?”

8. An eighth method is through direct instruction. This is a highly useful method which includes lectures, discussion groups, models, and using films and other example to educate clients. It can happen in the helper’s office.

Reframing

The common question of seeing a glass as half full or as half empty shows that any situation can be seen in terms of the positive and the negative aspects. When a helper asks a client to see a problem in a more positive and solvable way, this is a way of reframing. In reframing, a helper assists a client in shifting from blaming to taking responsibility. Reframing involves developing a new definition of a problem and a more constructive definition which is more specific and just as accurate as the previous definition. To do this, a helper must understand a client's current worldview and replace it with an alternative that the client will find acceptable.

There are three suggested steps in reframing. The first step is to use the nonjudgemental listening cycle to understand the client’s problem. The helper should reflect meaning before reframing. The next step is to build a bridge from the client's current viewpoint to the more positive viewpoint. It is key to recognize some aspects of the client’s current view but reframe it to be solvable and suggest another way of seeing the situation. The third step is to reinforce the bridge. Changes in outlook tend to happen slowly. A helper can assign homework to emphasize and sustain the shift.

It is important that the client can connect the important aspects of the new frame to the old frame. This encourages a successful transition. Of course, it may not be feasible to recognize every aspect that is important to the client. However, the helper should make an effort to try to touch on the aspects that may be key. Reframing must also be timed well. Reframing should be specific to the client’s problems, worldview, and situation, as well as specific to where the client is emotionally.