Therapy Skills: Counselling
Skills to be trained
The Four Corners of Counselling
First Corner – Clarify & accessing Information
Intention 1- To clarify and to gather information for your own benefit.
Use: Reflection of content/paraphrasing to clarify. Use opening and closing questions and summarizations to gather more information. Use minimal prompts, encouragers and reflection of feeling.
Second Corner- Rapport & Understanding
Intention 2 - To offer empathy and understanding to the client and build rapport, relationship and trust. To encourage emotional release when appropriate.
Use: Reflection of feeling, meaning, warmth, respect, genuiness and congruence.
Third Corner- Deepen Understanding & take action
Intention 3- to encourage deeper connections in the client's view of themselves and their world. To see themselves as part of the bigger picture. To encourage them in taking responsibility and finally action.
Use: Advanced empathy, empathic summarizations, meaning and values clarification, immediacy, self-disclosure and goal setting. (Also known as challenging skills.)
Fourth Corner- The doorway! Using specific therapies
Intention 4- to encourage opening of defenses and use of other therapeutic regimes and skills. To encourage deeper healing, understanding and emotional release and resolution, especially past psychological defenses.
Use: "First 3 corner skills" with specific therapies in mind to target specific thoughts, emotions, body experiences and unconscious parts (IMT's).
Skills: Reflection of Feeling and Content/ Responding
To reflect or respond means to relay to the client in your words an understanding of their world. Ideally it elicits the meaning between their literal words. It should be more specific and concrete than the clients' language, serving to grasp the essential meaning in one or two coherent phrases.
To say "I understand" does nothing to add to reality of them feeling understood you need to convey this back to them. A practice concept is the "you feel because" format. You may not say it that way but reflection of feeling and content is effectively empathy in words. The feeling statement picks up the emotional experience they are struggling to express or have and the content part is the reason or meaning behind the feeling and this covers the intellectual component. You need to convey both where possible.
It is possible of course to just relay the feeling (reflection of feeling). "You feel exhausted". This is appropriate at times. Similarly it is natural at times to relay the content. "Your week has been very full".
Hence we now have in effect 3 microskills:
Reflection of content, Reflection of feeling and Reflection of feeling and content
Attitude of skills: Empathy, respect, genuineness, warmth, and positive regard.
Offer a "climate of regard" to create good rapport. The best single word to convey rapport is empathy: Offering understanding for the others experience as if you could picture yourself climbing into their world and experiencing their life. That is the precise way to do it.
- Imagine or picture yourself in their life situation
- Try to imagine how you would feel or an approximation to the circumstance
- Compare that with what they are saying
- Convey that; respond back with your best understanding of what they experience
Carl Rogers (1961), virtually the father of modern day counselling and one of the best exponents of the approach said:
If I can create a relationship characterized on my part:
By a genuiness and transparency, in which I am my real feelings;
By a warm acceptance of and prizing of the other person as a separate individual;
By a sensitive ability to see his world and himself as he sees them;
Then the other individual in the relationship:
Will experience and understand aspects of himself, which previously he has repressed;
Will find himself becoming better integrated, more able to function effectively;
Will become more similar to the person he would like to be;
Will be more self-directing and self-confident
Will become more of a person, more unique and more self-expressive;
Will be more understanding, more acceptant of others;
Will be able to cope with the problems of life more adequately and more comfortably.
Skills: Opening and closing questions: "What's your intention?"
In this course we take departure from the notion of closed and open questions. A closed question e.g. "do you like chocolates?" can lead to a yes-no answer. Alternatively it could lead to a factual answer e.g. "what is your weight?"
An open-ended question leads to a gathering of information with a wider range of responses e.g. "how are you feeling" or "what sort of a life have you had?"
However what of the question, "can you tell me a little more about yourself?" Surely this is a closed question- they could answer yes. The point is that this remains somehow a very good question. Alternatively, the question "is there a way of describing that pain in another phrase", is a closed question. What is 'ok' about these questions, even though a technocrat may dispense with them as 'bad' closed questions?
The answer is that they have an opening effect. They have a dynamic impact, which encourages the client to go in the direction of the desired intention. No one is likely to say yes or no to the two questions because it is obvious what is required. However "are you unhappy?" does not have an opening effect. The person could easily say yes and stop.
The point is that we seek an opening or closing effect depending on our intention.
Typical opening questions start with "how, what, when, where, can and could". "How did that happen? What were the things that went though your mind? Where did you feel that in your body? Could/can you tell me more about your experience?"
Of course, closing or closed questions are not 'bad'! If we want to gain information about the knot in the diaphragm of the person we don't want to say, "What sorts of feelings have you had? We want to close down the range of responses to: "Can you tell me how else you could describe that knot feeling. For example does it have a shape? What other feelings go with the knotted sensation?" Sometimes you may want to get a yes or no answer. "Do you love your husband?" or "What do you do?" These are closed down deliberately or intentionally.
Hence before asking the question ask your self "what area do I want to open up here, how broadly and how much do I want to close this down, specifically"?" The question will follow according to your intention and you will be more effective.
General principle here is to avoid why questions. Why?! Well they may lead to a defensive remark e.g. why are you upset? The person may feel they have to justify the feelings. Instead of a why question we could simply respond: "you feel upset, its really making you suffer".
Furthermore, 'why' questions lead to a 'head oriented' or intellectual answer, 'why' seeks the reason. As a general principle we should seek an emotional experience in the body rather than a reason or rationalization in the head. (A defense process commonly used to avoid the more painful emotion.) So when we ask why we collude with them to stay immobilized.
Limit questions in general
Too many questions lead to a style of interviewing rather than counselling. They block the experiencing process, make the counsellor do all the work and suggest to the client that this is a doctor type interview, "they ask the questions I answer them". A counselling process encourages exploration of feeling and experience.
The 5-Minute Exercise
This is suitable for clients who have lots of trouble being aware of their feelings and body states. It is very suitable for highly verbal, intellectual or "high" sounding clients.
- Explain to them you are going to do the 5-minute exercise and that all they will have to do is express their feelings for 5 minutes.
- It is insufficient to say this only. You need to make it clear that they will use "one word feeling statements and not worry about the whys and wherefores". In addition they should only report feelings they are having now.
- Commence and see if they have understood. If a person resorts to "head or data statements", interrupt and say: "No, you need to only mention feeling words like nervous, self conscious and irritated."
- Some clients don't realize how simple it is, and when they do they usually haven't realized how threatening and 'naked' an experience it is.
- Some trainees, want to rescue the client and engage in dialogue or feel concerned if someone says they feel annoyed about the exercise, or it seems pointless, simply refer back and say "how does that feel or what feeling does that bring up for you now."
- Don't gather themes or interpret until the 5 minutes are up and then thank them for doing it and ask how it was for them. Mention that it is a difficult and strange thing to do so they've done well.
- Notice how they did it, there are no rights or wrongs but everyone does it in a 'signature' manner and tells you something about their way of reporting feelings and their relationship with their body.
Follow-up themes that have emerged which are usually vital. You may use something here as a 'portal' to investigate a deeper state or feeling.
Self Disclosure & Advanced Empathy
Self-Disclosure is a simple skill that is easy for the counsellor to perform. You simply discuss with the client some aspect of your experience that is pertinent to theirs.
- Let client know you are mentioning this to help them, not to talk about yourself.
- Make sure your responses are relevant to their situation-a metaphor of their situation.
- Be careful with the timing, sensitivity is crucial. (Be careful its not your issue!)
- Keep disclosures simple and focussed towards the topic at hand.
- Don't disclose too much and don't overburden the client with material that is too heavy or leads them to conclude, "so the situation is hopeless or too hard"!
Counsellor: "When I was first learning about self-disclosure at Lifeline I was surprised how easy it was to use. I thought I would have to practice it a great deal like all the other skills. Maybe it will be like that for you?" Simple as that!!
Advanced Accurate Empathy
Advanced accurate empathy (adv. Empathy), is like a composite skill but very elegant and satisfying to use. The intention is to read between the lines. It is a slightly interpretive skill. Egan (2002, pp199-205), offers these sub-skill terms:
- Helping to make the implied- explicit
- Identifying themes in their stories
- Making connections that maybe missing at the surface level
- Sharing educative hunches based on empathic understanding
- Connecting Islands
- Drawing conclusions from premises
(The latter two are from Egan (1986), they are re-included because they add intuitive weight to what Adv. Empathy is about).
Adv. Empathy is not about making clever guesses or projecting onto the client of course. It should be received readily by the client as interesting and highly plausible, evocative as if you are unveiling a truth close to the surface yet not too advanced for them. Steps to take are:
- Apply your normal corner 1 and 2 skills and then occasionally ask yourself "so what are they trying to say here? What is between the lines, what's hinted at but not spelled out?"
- Gather together a statement, which is empathic in effect and not too cerebral. You may for example look to 'identify themes', (like stringing beads, 'this goes with that').
(From Egan) Trainee: " I didn't get there at all… you know, I think I see probes, (skilled questions) as challenges… The thread through all this is playing it safe, … because I don't want to damage the client. But now its clear I'm afraid to push." (Instance of client using adv. Empathy from insight into themselves.)
Immediacy & Confrontation
Egan, (2002, pp209-213) clarifies Immediacy as Direct Mutual Talk, originally termed by Carkhuff (1979). It is also called you-me talk. In essence it is about using the 'immediate' situation between you and your client to help them learn from the relationship you share together. They can then take this 'safe-zone' exploration to generalize to other relationship situations. Egan emphasizes it is an important tool for managing the working alliance.
There are 3 types of Immediacy:
- Overall relationship Immediacy:
Counsellor: "We seem to have developed a good relationship here. I feel we respect each other. I have been able to make demands on you, and you have made demands on me. There has been a great deal of give-and-take in our relationship. You've gotten angry with me, and I've gotten impatient with you at times, but we've worked it out. I'm wondering what our relationship has that is missing in your relationship with your supervisor." (From Egan)
- Event Focussed Immediacy i.e. an immediate event that has occurred
"Counsellor: Well, our conversation today started out quite lively, and now it seems rather subdued. I've noticed that the muscles in my shoulders have become tense. I sometimes tense up that way when I feel that I might have said something wrong. It could be just me, but I sense that things are a bit strained between us right now". (Egan)
- Self-Involving statements
Counsellor: "I feel really good when you spell out your exact feeling, its like a confirmation for me but also says you feel comfortable to correct me and that's more accurate therapy for you then."
As you can see these are very similar in effect and it's not important to worry too much about learning all three. In earlier texts, Egan pointed out quite helpfully that Immediacy involved three skills: a partial self-disclosure advanced empathy and an impact of confrontation.
Egan(2002) is not as clear on this topic, however confrontation is done in the following manner:
- It is in the interests of the client's development not our own frustration.
- It is done in relativity with the underlying strength of the relationship you share.
- It is done in the 'spirit of advanced accurate empathy'.
Hence it is still helpful to use Ivey's (1999) application of the term. He uses the analogy of "on one hand you feel you don't think you can master advanced accurate empathy skills, yet on the other hand you were surprised recently that you felt the same way about immediacy and did really well. I wonder if this is an anxiety you often go through before you triumph and surprise yourself?"
So Ivey's idea is to use the "on one hand, but on the other hand" technique to compare discrepancies in the client's story, yet 'on the other hand' use it to their advantage!
Egan (1986, pp219-228) states that there are 'potpourri areas' (akin to adv. Empathy) that one may consider here: We can challenge discrepancies, distortions, self-defeating internal experiences, behaviours, games, smoke screens and excuses.
Definition of skill- Goal setting (Outcome analysis and Action plans)
Outcome analysis is about helping clients to form a structured picture of a solution, it is a solution-focussed skill. Amazingly, when you ask most clients to visualize a goal they are very poor at anything concrete whatsoever. They have been problem focussed only. If you have severe anxiety, sure you will say you want to be relaxed, happy, back to normal and so forth but most people will actually be preoccupied with their anxiety- the problem only.
It is very hard for the mind to concentrate on or gather impetus to a goal achievement unless there is a clear picture of what's required.
You want to clean up the backyard but what does that mean? What tools will you require, how long will it take, what's realistic today? What overall time commitment is necessary, would it be better to pay someone to do it instead? What are the costs what are the benefits? This is solution-focused thinking but we still don't have a plan or a conviction of what we will do. More likely than not we are problem focused "I must clean up the backyard, one day" but we are only visualizing the mess not the stepping-stones in the solution path.
Facilitative Steps to an Action Plan
- Use corner one skills to enquire about the clients' broad goals.
- If they fail to articulate clear outcome oriented statements, explain the need for the mind to have clear images in order to make the steps to a solution.
- Ask them to imagine they awaken the next morning and a miracle has occurred. "In this miracle what if all your dreams had come true. Ask them what would be different?"
- To assist them use the following checklist to stimulate their thoughts.
Miraculous changes Checklist:
What changes would be apparent amongst?
- Behaviours e.g. diet, drug taking, eating, social activities, exercise, courses undertaken, dress, grooming, sexuality
- General or specific life skills
- Communication with others
- Relationships with others
- Values that are effected or change
- Meanings that are shifted
- Place of living, e.g. structural changes, lifestyle changes
Sketching the Action Plan
- Write down the points that they can visualize changing often clients find this difficult and may not have many. Use your second and third corner skills to assist with patterns and meanings as they emerge. Flesh out any goal that emerges.
- Sketch out on paper or white board, the concrete steps that would be necessary to reach such a goal.
- Write down the gaps in skill or capacity that would become obstacles to a positive outcome. (E.g. "I would need to communicate better but I'm too shy"- Implicit sub-goal is a need to develop better communication skills).
The therapeutic alliance (TA), or the relationship formed when the professional and the client are working together cooperatively in the best interest of the client, has been shown in a number studies to be an important part of the therapy process. This relationship begins from the moment the client and the therapist first make contact and is less concerned with the skill of the therapist than with the attitudes and the relationship between the therapist and the client. This relationship comes out of the creation of a safe environment conducive to communication and trust.
The actual effect of the TA is unclear. It may have a direct effect, where the solid relationship and unconditional positive regard has, in and of itself, corrective interpersonal therapeutic effect. Alternatively, it may have an indirect effect and mediates the efficacy of interventions. It has also been suggested that a successful intervention results in a good TA, rather than the other way around. Clearly though, the cultivation of a strong TA with clients can only be conducive to successful therapy.
Bergin & Garfield's Handbook of Psychotherapy and Behaviour Change identified a number of predictive aspects of a good TA.
- Personal Role Investment
- The level of personal engagement shown by both the therapist and the client in their typical interactions
- The level of motivation and the credibility (genuineness) of their role enactment
- The patient's motivation to change
- Interactive Coordination
- The level to which the relationship is a collaboration between the two parties including;
- The consultation with the client on the therapy, as opposed to the direction by the therapist
- The degree to which the client collaborates as opposed to attempt to control the process
- Agreement between the therapist on client on both goals and the tasks presented
- Expressive Attunement
- The level of personal rapport between the therapist and the client – therapist empathic understanding
- The ability of the client to express themselves clearly, leading to higher quality of communication
- Patient empathic understanding and agreement with therapist's techniques
- The level of communication between the two parties
- Affective Attitude
- Level of therapist's affirmation of client, as opposed to negation
- Level of patient's affirmation of therapist, as opposed to negation
- Experiential Congruence
The extent to which the client and therapist are not only in agreement on tasks and goals, but the extent to which they have similar experiences of the therapy and related tasks.
- Patient characteristics
- Ability to experience therapy
- Acceptance of feeling
- Felt Autonomy
- Defense maturity
- Modelled self-care
- Therapist characteristics
- Ability to self-evaluate critically
The process of trajectory of therapy can also impact on the therapeutic alliance in a number of ways. For example, if a client feels that therapy is progressing too quickly, they are likely to become threatened by this, resulting in a breakdown of the alliance. Alternatively, if a client feels that nothing is happening in the session and they are not progressing, they are likely to lose faith in the process, and thus lose faith in their therapist.
One Model of the process has been divided up into the following stages.
- Orientation phase – where client and therapist meet and connections are formed.
- Rapport and trust are established
- The relationship and connection are paramount
- Client helps to identify the problem and goals and become a collaborative member in the process
- Identification phase
- Clarifying goals and expectations in and for the relationship
- Further getting to know and understand each other
- Working phase – both parties are committed to the relationship and client is involved in own self-help
- Client must know and believe that therapist is on their side, supportive and caring when dealing with difficult issues
- Care must be taken not to enter working phase before relationship is established as painful and difficult issues may arise
- Resolution Phase – Client has gained all that is needed and is ready to leave
- Met stated goals and resolved crises
- Be aware of fears of abandonment or need for closure
How to Work on Establishing a Strong Therapeutic Alliance
Fostering a strong connection with the client in the early stages of counselling is vital to establishing a strong TA. There are a number of ways that this can be done
- Creating a therapeutic climate
- A therapeutic climate arises from firstly, unconditional positive regard from the therapist
- Making the expectations of both therapy, and from the client themselves, clear from the outset
- Talking to the client about confidentiality, and the trust that they can feel confident in having in you
- Working collaboratively with the client on their goals and ensuring their satisfaction with the path ahead
- Considering the client's world
- The therapist must be able to consider the client's world as if it were their own, walk in their shoes, if you like.
- This includes the client's gender, age, socio-economic background, cultural beliefs, religious beliefs and the family context from which they come.
- Ensuring the client's needs are paramount
- Too often, therapist's have their own ideas of where a problem is coming from, or what is happening with the client. Whether or not these assumptions are correct is redundant if the client has not yet made these connections
- The client's views and concerns must always be the issues dealt with, whether the therapist agrees with these or not.
There are some behaviours that can be engaged in to help with the initial development of a therapeutic alliance
- Actively listening and understanding clients
- Suspension of critical judgement
- Expressing appropriate warmth and acceptance
- Communicating that you understand their world as they experience it
- Providing a combination of support and challenge
- Assisting clients in cultivating their inner resources for change
- Helping clients take the specific steps needed to bring about change
The therapeutic alliance is a construct that many researchers have begun to address, and consequently, definitions are abundant. For the most part however, there are four core components to this.
- Communication/Rapport – the affective relationship or bond between the therapist and their client. From this, the client can develop trust, respect and faith in therapy, without which therapy will not be successful. Important concepts included in this are confidentiality, consistency and boundary setting
- Unconditional positive regard – Many clients are not able to feel respect or dignity, or unconditional positive regard in other areas of their life. In order to feel safe enough in therapy to work, they must feel confident that they are not being judged whatever their actions may be. Genuineness is a vital aspect of this component
- Empathy and understanding – A client must feel that they are being understood and that their perceptions are being reflected by the therapist to further help them understand.
- The Patient/Therapist collaboration – For a good alliance to develop, the client must feel that they are indeed part of the decision making process and that they have some control over their therapeutic path.
As a new therapist, it is important to remember that often it is not WHAT you do, but HOW you do it that is going to make all the difference to your clients. To be a good therapist, the best starting point is to be present, to attend, to understand and to provide that unconditional positive regard. With that as a starting point, your client's will have faith in the process, and in you, and be more likely to succeed in the therapy and techniques you provide them with.
Ref: Bergin and Garfield's Handbook of Psychotherapy and Behaviour Change, Lambert, MJ editor, 2004, Wiley and Sons NY
(Paper prepared by Alex Foster as clinical placement project work at FPU Highbury, 2006)
Focus Condition: Suicidality
Suicidality: An assessment procedure (from Mhapkit©).
Management and Assessment of Suicidal Persons Guidelines and Essentials
- Counsel and use appropriate therapy to acknowledge the feelings and thoughts that the person is having. Remember that empathy is therapeutic.
- A common mistake is to not hear that many of the statements (eg I want to end it or what's the point of going on, are feelings of despair, hopelessness, meaninglessness or worthlessness. So reflect these.)
- Spend considerable time 'being with' your client and allow that they may be at the bottom of a trough and if you hang in with them they may rise to the surface emotionally. This does not feel comfortable on the way through!
- Try paradoxically agreeing with them that indeed feeling the way they do must feel sensible to want it to end but "I wonder whether you have the feelings mixed up with your life here? Perhaps you want to kill the lifestyle and not the life?"
- From here you could ask what things about their life they most want to change even if it seems impossible right now to them.
- Check the status of suicidality at the end of your therapy session.
- Is this person still thinking of a plan to commit suicide? A clear plan is a bad sign. However, suicidal ideation alone is not so bad. The most reassuring statement here is "I feel that way but I would never do anything about it."
- If there is a plan, what level of specificity is there? The clearer the plan the more dangerous the reality.
- Have they tried suicide before especially in the last month or so?
- Are they going home to an empty house?
- Are there other social supports?
- Would it be useful to diminish the time before next appointment? Provide contact numbers that they can use in emergency?
- What worldly contacts keep them from suicide e.g. children, spouse etc?
- Would it be useful to engage them in a no-suicide contract verbal or written? How convincing were they if they agreed?
- Are you still unhappy that they are at risk? Certainly a clear plan with poor social supports is not worth the risk. They may well take their own life.
- Ring ACIS (Assessment and Crisis Intervention Service) 131-465 and discuss situation. They can assess with a view to hospitalization. ACIS is the Government 24 hr Mental Health Service, staffed by professionals specializing in this service.
Counselling Checklist –Summary
- Listen and reflect- remember the person and not the problem (It is a process not a question answer routine)
- Summarize External problem to make it clear you have the right direction (gather as a 'nut shell' statement from the client)
- Emphasize feelings and move to the Inside Problem-Negative Problem Focus
- Leave space and time for your client to process ideas and feelings (try to 'be' with the client, be aware of their body language and less of your own skills!)
- Use your questions sparingly and with intention to keep focus
- After you have some idea of the Inside problem, gain an indication of the Positive-Solution focus axis to gain a sense of what is ideal
- Use challenging skills for the deeper Inside Problem
- Guide your process to emphasise collaboration and working together (Working Alliance factors)
- Finish with a positive clear plan for next weeks session
- Try to remain hopeful and optimistic (Hope is important in therapy but so also is genuiness)
Crucial pervasive therapeutic "common factors" (To all therapies) are:
Unconditional positive regard