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Transforming Therapeutic Relationships into Evidence-Based Practice

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img_1349This handout is an in-depth supplement to a web-based workshop I provided for the Chi Sigma Iota group at the University of the Cumberlands on January 13, 2019. Although it’s designed to go with the workshop, it’s also designed to be a standalone resource for learning more about how to integrate evidence-based relationship factors into counseling and psychotherapy practice.

The following principles, techniques, and strategies are listed in the order in which they were discussed in the workshop. More extensive information is included in the specific resources listed at the end of this handout, particularly, Clinical Interviewing (6th ed., Wiley 2017), Counseling and Psychotherapy Theories in Context and Practice (3rd ed., Wiley, 2018) and Tough Kids, Cool Counseling (2nd ed., 2007, ACA publications).

The 10 Evidence-Based Relationship Factors (EBRFs)

Beginning in the early 21st century, Norcross (2001; 2011) and others have put relational factors (e.g., Rogerian core conditions) on par with “empirically-supported techniques or procedures.” Norcross has done this by using the terminology: Evidence-Based or Empirically-Supported Relationships

What Norcross is talking about is the robust empirical support for specific and measurable relationship factors as contributors to positive counseling and psychotherapy outcomes. You can find the latest articles about empirically-supported relationships in a special issue of the journal Psychotherapy (Norcross & Lambert, 2018).

Here’s a list of the evidence-based relationship factors (EBRFs) that I covered in the workshop, followed by content and resources related to each factor.

  1. Congruence [Authenticity]
  2. Unconditional positive regard [Respect]
  3. Empathic understanding [Emotional attunement]
  4. Culture Humility and Sensitivity [Equity in worldview]
  5. Working Alliance 1: Emotional bond [Liking each other]
  6. Working Alliance 2: Goal consensus [Adler’s goal alignment]
  7. Working Alliance 3: Task collaboration [To reach client goals]
  8. Rupture and repair [Fixing relationship tension]
  9. Managing Countertransference [Self-awareness]
  10. Progress monitoring [Asking for feedback]

1. Congruence/Authenticity

There are many ways to show congruence or authenticity in counseling. Below, I’ve described some of the ways that are relatively easy to apply. Some of this content focuses on working with youth and other content focuses on working with adults, including parents.

Acknowledging Reality: Some young people, as well as older clients, may be initially suspicious and mistrustful of adults – especially sneaky, manipulative, authority figures like mental health professionals, school counselors or school psychologistsJ. To decrease distrust, it’s important to acknowledge reality about the reasons for meeting, about the fact that you don’t know each other, and to notice obvious differences between yourself and the client. Acknowledging reality is a form of transparency or congruence. Researchers consistently report that transparency, congruence, or genuineness is a predictor of positive counseling or psychotherapy outcomes (see Kolden, Klein, Wang, & Austin, 2011). Acknowledging reality includes a straightforward explanation of confidentiality and its limits.

Sharing Referral Information: To gracefully talk about referral information with students, you need to educate referral sources about how you’ll be using information they share with you. Teachers, administrators, probation officers, and parents should be coached to give you information that’s accurate and positive. If the referral information is especially negative, you should screen and interpret the information so it’s not overwhelming or off-putting to students. Simblett (1997) suggested that if therapists are planning to share referral information with clients, they should warn and prepare referral sources. If not, the referral sources may feel betrayed. Also, if you share negative referral information, it’s important to have empathy and side with the student’s feelings, while at the same time, not endorsing negative behaviors. For example, “I can see you’re really mad about your teacher telling me all this stuff about you. I don’t blame you for being mad. I’d be upset too. It’s hard to have people talking about you, even if they have good intentions.” Here’s a case example from Tough Kids, Cool Counseling (2007):

A female counselor is meeting for the first time with a 16-year-old female client. Immediately after introducing herself and offering a summary of the limits of confidentiality, she states, “I’m sure you know I talked with your parents and your probation officer before this meeting. So, instead of keeping you in the dark about what they said about you, I’d like to just go ahead and tell you everything I’ve been told. This sheet of paper has a summary of all that (counselor holds up sheet of paper). Is it okay if I just share all this with you?”

After receiving the client’s assent, the counselor moves her chair alongside the client, taking care to respect client boundaries while symbolically moving to a position where they can read the referral information together. She then reviews the information, which includes both positive information (the client is reportedly likeable, intelligent, and has many friends) and information about the legal and behavioral problems the adolescent has recently experienced. After sharing each bit of information, she checks in with the client by saying, “It says here that you’ve been caught shoplifting three times, is that correct?” or “Do you want to add anything to what your mom said about how you will all of a sudden get really, really angry?” When positive information is covered, the counselor says thing like, “So it looks like your teachers think you’re very intelligent and say that you’re well-liked at school . . . do you think that’s true . . . are you intelligent and well-liked?” If referral information from teachers, parents, or probation officers is especially negative, the counselor should screen and interpret the information so it is not overwhelming or off-putting to young clients. (from Sommers-Flanagan and Sommers-Flanagan, 2007, p. 32) 

Authentic Purpose Statements: One technical manifestation of congruence or transparency is the use of an authentic purpose statement. This requires you to be clear about your own “why” of being in the room and then concisely sharing that with your student or client. Examples include: “My job is to help you be successful here” or “Your goals are my goals, as long as they’re legal and healthy.” Authentic purpose statements can also serve, in part, as an initial role induction.

Responding to Client or Student Questions: Authenticity may be the most robust factor linked to positive treatment outcomes. How you handle client or student questions is one way to display congruence or authenticity. The following model can be helpful.

  1. Answer directly or explain why you’re not answering directly – “I think you’re asking a good question, but before I answer, I want to dive a little deeper into what’s under your question. That’s the sort of thing we do in counseling.”
  2. Use a reflection/paraphrase – “It sounds like you’re not sure I can be of any help.”
  3. Validate the underlying message/curiosity – “I don’t blame you for thinking that. Lots of people aren’t sure if counseling can work for them. I’d probably feel the same way as you.”
  4. Use psychoeducation, then answer after exploring – “Before answering, I’d like to ask you a few questions that might be important. First, if I say, ‘Yes’ I’ve done some drugs, I wonder how you would react? Second, if I say ‘No’ I haven’t done drugs, I wonder how you would react to that?”
  5. Use psychoeducation to explain not answering – Most of the time I’m happy to answer your questions. But this one feels like it’s too much about me . . . and of course the focus in counseling is supposed to be more on you than it is on me.”
  6. Use interpretation or confrontation – “It’s not unusual in counseling for clients to want to avoid talking about their personal situation and feelings. One way to avoid that is to ask me lots of questions. I’m wondering if that might be one of the reasons why you seem like you want to keep the focus on me.”
  7. Articulate a dilemma (Yalom) – “I have a dilemma. One part of me really wants to answer your question. But another part of me is worried it will move the focus of counseling away from you and onto me.”

Self-Disclosure: Although authenticity is important, it’s quite possible to be too open or to have too much self-disclosure. To prevent excessive self-disclosure, consider the following guidelines.

When to Self-Disclose

  • When you’re asked a direct question and it makes good sense to answer directly and briefly.
  • When a disclosure is likely to increase interpersonal connection (“I enjoy meeting with you”).
  • When disclosure is likely to facilitate transparency and therefore make it less likely for clients to “wonder” if you’re judging them (“my theoretical foundation is person-centered. That means I want to listen to you talk about your life, your experiences, and your emotions. That means I’ll probably listen more than I talk”).
  • When it’s helpful for psychoeducation purposes (mindfulness takes lots of discipline; I struggle with it too.” If you’re interested, I can share with you a couple tips that really helped me”)

When NOT to Self-Disclose

  • When you’re talking too much about yourself and muddying the focus.
  • When you’re trying to slip in advice (e.g., “being assertive in that sort of situation worked for me”). This is especially a bad idea with minority clients because we shouldn’t assume they have our values or that what worked for us will work for them.
  • When it takes away from any of the EBRFs.
  • When it’s more about you and for you and less about the client (“I’m really proud of my children’s work ethic”).

2. Unconditional Positive Regard

Unconditional positive regard involves accepting clients and showing them immense respect. As Rogers said long ago, when clients feel accepted, then they become free to explore their insecure “nooks and crannies.”

For all of the person-centered core conditions, it’s not good to express them directly. That means you want to avoid saying “I accept you fully as you are.” There are many reasons for not expressing the core conditions directly (which we talk about in the book, Clinical Interviewing). The following counselor/psychotherapist behaviors are ways to show respect and positive regard indirectly. I’ve elaborated on a few of these.

  • Being on time
  • Non-directive listening
  • Asking clients what is important to them
  • Remembering client details
  • Asking permission
  • Second session first question
  • Using interactive summaries

Asking Permission: Asking permission is a basic technique that clearly expresses your respect for your client. When using any technique, it’s useful to (a) ask permission to describe the technique (“Is it okay if we take a few minutes for me to describe this thing called progressive muscle relaxation?”); (b) describe the technique; and then (c) check in on your client’s reaction or thoughts about the technique. I even like to ask permission to self-disclose or give feedback (“Is it okay with you to share something I’ve noticed?”).

Second Session First Question: The time between session #1 and session #2 can include many different experiences. It’s tempting to start the second session with a social question like, “How was your week?” My opinion is that social openings tend to defocus counseling and mostly aren’t appropriate (unless you’re modeling social skills and/or have an anxious client who is uncomfortable with a more formal opening. The second session first question is: “What did you find memorable or important to you from our meeting last week?”

 3. Empathic Understanding

Most counselors and counseling students are well-versed in how to use empathy. One situation that can challenge your empathic responding occurs when you’re working with a client who is depressed and suicidal. The following is an adapted excerpt from an article published in the Journal of Health Service Psychology:

Many or most suicidal patients are probably experiencing depression and/or hopelessness. If this is the case, they will be predisposed to discussing what makes them more suicidal; it may be more difficult for them to identify factors linked to feeling less suicidal. States of depression and hopelessness drive patients toward negative rumination and act as fogging agents when it comes to exploring or considering positives.

Exploring and Addressing Hopelessness

Hopelessness is a common feature linked to clinical depression and suicidality. Although hopelessness can manifest in different ways, having a general strategy for assessing and working through hopelessness can be helpful. Specifically, Beck (Wenzel, Brown, & Beck, 2009) has emphasized that treatment of suicidal patients must address hopelessness. Here are two examples of how to empathically explore and work with hopelessness.

Exploring intent, addressing hopelessness, and initiating problem-solving in the context of getting help. Once you have information about active suicide ideation or a previous attempt or attempts, you have a responsibility to acknowledge and explore suicidality. One common strength-based tool is a solution-focused question.

“You’ve tried suicide before, but you’re here with me now . . . what has helped?”

Unfortunately, if you’re working with a patient who is severely depressed, it is not unusual for your solution focused question to elicit a response like this:

“Nothing helped. Nothing ever helps.”

In response, one error clinicians often make is to venture into a yes-no questioning process about what might help or what might have helped in the past. However, if you are working with a patient who is extremely depressed and experiencing mental constriction, your patient will discount every idea you come up with and insist that nothing ever has helped and that nothing ever will help. This process can increase hopelessness and consequently a different assessment approach is required. Even the most severely depressed patients can, when given the right frame, acknowledge that every attempt to address depression and suicidality isn’t equally bad. Using a continuum where severely depressed and mentally constricted patients can rank interventions strategies (instead of a series of yes-no questions) is a better approach:

Counselor: It sounds like you’ve tried many different things to help with your depressed feelings and suicidal thoughts. Let’s look at all them. I’m guessing some of them are worse than others. For example, I know you’ve tried physical exercise, you’ve tried talking to your brother and sister and one friend, and you’ve tried different medications. Let’s list these out and see which has been worse and which has been less bad.

Client: The meds were the worst. They made me feel like I was already dead inside.

Counselor: Okay. Let’s put meds down as the worst option you’ve experienced so far. Which one was a little less worse than the meds?

You’ll notice the counselor emphasized that some efforts at dealing with depression/suicide were worse than others. Focusing on “worse” resonates with the patient’s negative emotional state. It will be easier to begin with the most worthless strategy of all and build up to strategies that are “a little less bad.” Building a unique continuum of helpfulness for your patient is the goal. Then, you can add new ideas that you suggest or that the patient suggests and put them in their appropriate place on the continuum. If this approach works well, you will have collaboratively generated several ideas (some new and some old) that are worth experimenting with in the future.

Addressing hopelessness and initiating problem-solving in the context of social disconnection. As you explore Susan’s social relationships, you ask, “Who is in your life that might provide you with support during this difficult time?” She answers, “I just don’t get on with people. No one understands. There’s no point talking to anyone.” With this disclosure, Susan has revealed interpersonal disconnection, along with hopelessness about being socially disconnected forever. At this point, it’s easy for clinicians to fall into an unproductive problem-solving pursuit in an effort to identify someone in Susan’s environment who would show her kindness and compassion (e.g., “How about your mother?”). Instead, because Susan is experiencing depressive symptoms, one way in which she might display problem-solving impairment is by denying that anyone in her world could be helpful. Consequently, the problem-solving process should begin with the counselor resonating with Susan’s hopelessness, and then move forward. Here’s an illustration:

Counselor: It feels like there’s no one to turn to. Nobody really gets what you’re going through.

Susan: That’s the way it has always been.

Counselor: This might sound weird, but I’m wondering who is the worst person for you to talk with? Who would really not get it and just make you feel worse?

Susan: That’s easy. My dad doesn’t get me. He would tell me I need a kick in the ass to get myself going.

Counselor: And that would feel really not helpful. Not helpful at all.

Susan: That’s never helpful to me.

Counselor: How about someone who’s not quite as bad as your dad? Who would be a little better than him, but still not especially good to talk with?

You can also use a visual version of this approach. To do so, you draw a circle in the middle of the page and write your patient’s name in the circle. Then, you say you want to get a visual sense of who, in the patient’s universe of social contacts, is most and least likely to be responsive and show support. In Susan’s case, you would place her father as a very distant circle in orbit around Susan. Then as you generate additional names, you would follow Susan’s guidance and place the circles closer or further away from the circle representing Susan. In the end, you will have a map of who—in Susan’s social universe—is closest (and furthest) and most (and least) supportive.

With patients who are depressed and experiencing problem-solving deficits, a good general strategy is to show empathy for the hopelessness and social disconnection, but then build a continuum from the bottom toward people who are “less bad” to talk with.

This method: (a) provides empathy; (b) addresses hopelessness; (c) addresses problem-solving deficits through the identification of alternative social support people; and (d) initiates problem-solving (by building a continuum that moves upward toward the best or “least bad” people for social connection).

4. Culture and Cultural Humility

Competent counselors and psychotherapists are able to reach across cultural divides with respect and sensitivity. In preliminary research, cultural humility has been linked with positive therapeutic outcomes.

Here’s a short excerpt on cultural humility from the Clinical Interviewing textbook:

Over the past decade researchers and writers have begun making distinctions between cultural competence and cultural humility. Cultural humility is viewed as an overarching multicultural orientation or perspective that mental health providers may or may not hold. It springs from the idea that individuals from dominant cultures—or any culture—often have a natural tendency to view their cultural perspective as right and good and sometimes as superior. This tendency implies that attaining multicultural competence isn’t enough for clinicians to be effective with culturally diverse clients. Clinicians need to be able to let go of their own cultural perspective and value the different perspective of their clients (Hook, Davis, Owen, Worthington, & Utsey, 2013).

Three interpersonal dimensions of multicultural humility have been identified:

  1. An other-orientation instead of a self-orientation
  2. Respect for others and their values/ways of being
  3. An attitude that includes a lack of superiority

Cultural humility is closely aligned with, but not the same thing as multicultural competence. It’s generally presented as a supplement to multicultural competence. It has its own research base and appears to independently contribute to clinician effectiveness. In a recent research study, when clients viewed therapists as having higher levels of cultural humility, they also (a) endorsed higher ratings of the working alliance and (b) perceived themselves as having better outcomes (Hook et al, 2013).

The Working Alliance

Clinical research on the working alliance is immense. The section below is another excerpt from Clinical Interviewing.

The idea that therapist and client collaborate in ways that support positive outcomes originated with Freud (1912/1958). Later, psychoanalytic theorists introduced the terms therapeutic alliance and working alliance (Greenson, 1965; Zetzel, 1956). Greenson (1965, 1967) distinguished between the two, viewing the working alliance as the client’s ability to cooperate with the analyst on psychoanalytic tasks and the therapeutic alliance as the bond between client and analyst. Eventually, Bordin (1979; 1994) introduced a pantheoretical model that he referred to as the working alliance. Bordin’s model includes three dimensions:

  1. Goal consensus or agreement
  2. Collaborative engagement in mutual tasks
  3. Development of a relational bond

 5. Goal Consensus (Mutual Goal-Setting)

Goal-Setting with Young Clients: I use the following procedure for setting mutual goals with young clients. This technique is used to help students or young clients begin to articulate their own goals (and not goals that have been defined FOR THEM by adults).

Working with adolescents is different from working with adults. In this excerpt from a 2013 article, we briefly focus on how the opening interaction with an adolescent client might look different than an opening interaction with an adult client (from: Sommers-Flanagan, J., & Bequette, T. (2013). The initial interview with adolescents. Journal of Contemporary Psychotherapy, 43(1), 13-22.)

When working with adults, therapists often open with a variation of, “What brings you for counseling” or “How can I be of help” (J. Sommers-Flanagan & Sommers-Flanagan, 2012). These openings are ill-fitted for psychotherapy with adolescents because they assume the presence of insight, motivation, and a desire for help—which may or may not be correct.

Based on clinical experience, we recommend opening statements or questions that are invitations to work together. Adolescent clients may or may not reject the invitation, but because adolescent clients typically did not select their psychotherapist, offering an invitation is a reasonable opening. We recommend invitations that emphasize disclosure, collaboration, and interest and that initiates a process of exploring client goals. For example,

I’d like to start by telling you how I like to work with teenagers. I’m interested in helping you be successful. That’s my goal, to help you be successful in here or out in the world. My goal is to help you accomplish your goals. But there’s a limit on that. My goals are your goals just as long as your goals are legal and healthy.

The messages imbedded in that sample opening include: (a) this is what I am about; (b) I want to work with you; (c) I am interested in you and your success; (d) there are limits regarding what I will help you with. It is very possible for adolescent clients to oppose this opening in one way or another, but no matter how they respond, a message that includes disclosure, collaboration, interest, and limits is a good beginning.

Some adolescent clients will respond to an opening like the preceding with a clear goal statement. We’ve had clients state: “I want to be happier.” Although “I want to be happier” is somewhat general, it is a good beginning for parsing out more specific goals with clients.    Other clients will be less clear or less cooperative in response to the invitation to collaborate. When asked to identify goals, some may say, “I don’t know” while others communicate “I don’t care.”

Concession and redirection are potentially helpful with clients who say they don’t care about therapy or about goal-setting. A concession and redirection response might look like this: “That’s okay. You don’t have to care. How about we just talk for a while about whatever you like to do. I’d be interested in hearing about the things you enjoy if you’re okay telling me.” Again, after conceding that the client does not have to care, the preceding response is an invitation to talk about something less threatening. If adolescent clients are willing to talk about something less threatening, psychotherapists then have a chance to listen well, express empathy, and build the positive emotional bond that A. Freud (1946, p. 31) considered a “prerequisite” to effective therapy with young clients.

Some adolescents may be unclear about limits to which psychotherapists influence and control others outside therapy. They may imbue therapists with greater power and authority than reality confers. Some adolescents may envision their therapist as a savior ready to provide rescue from antagonistic peers or oppressive administrators. Clarification is important:

Before starting, I want to make sure you understand my role. In therapy you and I work together to understand some of the things that might be bugging you and come up with solutions or ideas to try. But, even though I like to think I know everything and can solve any problem, there are limits to my power. For example, let’s say you’re having a conflict with peers. I would work with you to resolve these conflicts, but I’m not the police, and I can’t get them sent to jail or shipped to military school. I can’t get anyone fired, and I can’t help you break any laws. Does that make sense? Do you have any questions for me?

A clear explanation of the therapist’s role and an explanation about counseling process can allay uncertainties and fears about therapy. Inviting questions and allowing time for discussion helps empower adolescent clients, build rapport, and lower resistance.

Wishes and Goals: Wishes and goals is a specific mutual goal-setting procedure that I’ve used with youth. It’s described in the Tough Kids, Cool Counseling book. You can watch a youtube video demonstration of the procedure being used as part of a session opening with a 12-year-old client named Claire. Here’s the link: https://www.youtube.com/watch?v=rHHrMC8t6vY&feature=youtu.be

 6. Collaborative Therapeutic Tasks (aka task collaboration)

In psychotherapy, tasks and techniques are also referred to as procedures. Even if counselors are employing a highly relational approach, it is still crucial to engage clients in specific tasks, activities, or procedures that are conceptually linked to solving their problems and achieving their goals. This may be a more implicit process, as when a solution-focused counselor helps clients identify and elaborate on exceptions, or more explicit, as when counselors teach clients how to make decisions using a four-step problem-solving process.

Though engaging clients in therapeutic tasks involves applying specific techniques, it quickly becomes relational. From the evidence-based relationship perspective, which specific procedures to apply is far less important than how they are applied. They must be applied collaboratively:

  1. The procedure—such as progressive muscle relaxation, Socratic questioning, or eye movements—must be explained clearly and linked to client goals (a psychoeducation process).
  2. Before the procedure is employed in the session, the client gives explicit permission or informed consent (e.g., “Is it okay with you if we try out this progressive muscle relaxation technique?”). This permission-seeking interaction is sometimes referred to as an invitation for collaboration.
  3. This part of the relational piece is crucial: after implementing the task or procedure, evidence-based counselors intermittently check in with clients (e.g., “What was your reaction to the role play we just tried?”). This requires sensitivity, empathic listening skills, and reassurance. Again, it makes no difference whether the specific task or procedure is free association (psychoanalytic theory), active listening and encouragement of the emergence of the self (as in person-centered counseling), reflecting as-if (Adlerian counseling), mindfulness meditation (cognitive-based mindfulness therapy), or another option. The point is that the relational activity of working together on a task contributes to positive outcomes (the preceding is from Sommers-Flanagan, 2015).

 7. Forming an Emotional Bond

A good example of a positive emotional bond occurs when counselors and clients experience mutual liking and mutual positive anticipation of counseling sessions. The following excerpt is from Sommers-Flanagan (2015).

The formation of a positive emotional bond begins with informed consent, continues in the waiting room and during first impressions, includes creation of a pleasant and comfortable counseling space, and involves specific counselor responses throughout each session, such as empathic reflections, positive strength-based feedback, and validating feelings. It also involves letting clients talk about their problems and the past as they wish—even when the counselor is operating from an approach that typically does not place much value on gathering historical information, such as CBT or solution-focused counseling. For example, Judith Beck (2011) emphasized that cognitive-behavior therapists should talk freely with clients about the past either when the client is stuck or when clients want to talk about the past. This is one of the ways in which relational and technical aspects of counseling merge. For all theoretical perspectives—from existential to reality therapy to CBT—counselors take special care to bond with clients, and part of that bonding involves letting them talk about what they want to talk about.

Recommendations for Developing a Positive Working Alliance

Again, from Clinical Interviewing.

Therapists who want to develop a positive working alliance (and that should include everyone) will employ alliance-building strategies beginning with first contact. Using Bordin’s (1979) model, alliance-building strategies focus on (a) collaborative goal setting; (b) engaging clients in mutual therapy-related tasks; and (c) development of a positive emotional bond. Progress monitoring is also recommended. The following list includes alliance-building concepts and illustrations:

Initial interviews and early sessions are especially important to alliance-building. Many clients will be naïve about psychotherapy. This makes role inductions essential. Here’s a cognitive-behavioral therapy (CBT) example:

For the rest of today’s session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we “cover all of our bases.” We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of. (Ledley, Marx, & Heimberg, 2010, p. 36)

Asking clients direct questions about what they want from counseling and then integrating that information into your treatment plan helps build the alliance. In CBT this includes making a problem list (J. Beck, 2011).

Clinician:     What brings you to counseling and how can I be of help?

Client:          I’ve just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.

Clinician:     Then we definitely want to put that on our list of goals. Can I write that down? [Client nods assent] How about for now we say, “Find ways to help you start feeling more up?”

Client:          Sounds good to me.

Engaging in collaborative goal-setting to achieve goal consensus is central to alliance-building. In CBT this involves transforming the “problem list” into a set of mutual treatment goals.

Clinician:     So far I’ve got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?

Client:          Totally. It would be amazing to tackle those successfully.

Problem lists and goals are a good start, but clients engage with clinicians better when they know the treatment plan (TP) for moving from problems to goals. The TP includes specific tasks that will happen in therapy and may begin in the first clinical interview. Here’s an example of a “Devil’s Advocacy” technique where the clinician takes on the client’s negative thoughts and then has the client respond (Newman, 2013). You’ll notice that collaboratively engaging in mutual tasks offers spontaneous opportunities for deeper connection and clinician-client bonding:

Clinician:     You said you want a romantic relationship, but then you start thinking it’s too painful and pointless. Let’s try a technique where I take on your negative thinking and you respond with a reasonable counter argument. Would you try this with me?

Client:          Sure. I can try.

Clinician:     Excellent. Here we go: “It’s pointless to pursue a romantic relationship because they always come to a painful end.”

Client:          That’s possible, but it’s also possible to have some good times along the way toward the painful end.

Clinician:     [Smiles, breaks from role, and says] . . . That’s the best come-back ever.

Soliciting feedback from clients from the first session on to monitor the quality and direction of the working alliance contributes to the alliance. Although you can use an instrument for this, you can also ask directly:

We’ve been talking for 20 minutes and so I want to check in with you on how you’re feeling about our time together so far. How are you doing with this process?

Making sure you’re able to respond to client anger without becoming defensive or counterattacking is essential to positive working relationships. We usually apply radical acceptance (Linehan, 1993). Here’s an excerpt from an initial session with an 18-year-old male where the clinician accepted the client’s aggressive message and transformed it into a relational issue:

Clinician:     I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.

Client:          You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response) (J. Sommers-Flanagan & Bequette, 2013, p. 15).

Clinician:     Thanks for telling me that. I’d never want to have the kind of relationship with you where you felt like hitting me. And so if I ever say anything that offensive, I hope you’ll just tell me, and I’ll stop.

 8. Rupture and Repair

In many counseling situations there are inevitable strains, impasses, resistance, and intermittent weakening of the therapeutic relationship. These things happen naturally and both client and the counselor contribute to these therapeutic ruptures. As counselors, sooner or later, we all  “fail” to get it right; we might miss with our paraphrases, let out a little judgment, or recommend a therapeutic task that the client finds aversive.

There are two basic signs of therapeutic rupture. These include (a) when clients withdraw and (b) when clients behave in an aggressive or confrontational manner.

If/when you notice there may be a rupture, you have several options. These include:

  • Apologizing
  • Repeating the therapeutic rationale
  • Changing tasks or goals
  • Clarifying misunderstandings at a surface level
  • Exploring relational themes and taking responsibility for the rupture (this might include cultural misunderstandings)

Of course, repair doesn’t happen instantly, but over time, you can regain trust and deepen the relationship.

Noticing Process and Making Corrections (Rupture and Repair): When there’s a clear pattern that begins to manifest itself in the counseling session, it’s best to acknowledge that pattern. In one session I had with a Black 19-year-old male, I offered a half-dozen paraphrases and most of them were rejected. The client said things like, “Nah” and “Not exactly.” Eventually, after several paraphrases “misses” I managed to notice the pattern and share with the client, “I noticed that I’m trying to listen to you and understand what you’re saying, but I keep getting it wrong and you keep correcting me. I’m sorry for this and I appreciate you letting me know when I don’t quite get things right. If it’s okay with you, I’ll keep trying and you can keep correcting me when I get things wrong.” In situations like this one, it’s recommended that the counselor acknowledge the process reality in the session. Because, as Yalom has so articulately noted, commenting on process can be intense, it can be better to begin process commentary by noticing your own less-than-optimal patterns.

 9. Managing Countertransference

Research suggests that our countertransference reactions can teach us about ourselves, our underlying conflicts, and our clients (Betan, Heim, Conklin, & Westen, 2005; Mohr, Gelso, & Hill, 2005). For example, based on a survey of 181 psychiatrists and clinical Counselors, Betan et al., reported “patients not only elicit idiosyncratic responses from particular clinicians (based on the clinician’s history and the interaction of the patient’s and the clinician’s dynamics) but also elicit what we might call average expectable countertransference responses, which likely resemble responses by other significant people in the patient’s life” (p. 895). Countertransference is now widely considered a natural phenomenon and useful source of information that can contribute to counseling process and outcome (Luborsky, 2006). In fact, clinicians from various theoretical orientations have historically acknowledged the reality of countertransference.

Speaking from a behavioral perspective, Goldfried and Davison (1976), the authors of Clinical Behavior Therapy, offered the following advice: “The therapist should continually observe his own behavior and emotional reactions, and question what the client may have done to bring about such reactions” (p. 58). Similarly, Beitman (1983) suggested that even technique-oriented counselors may fall prey to countertransference. He believes that “any technique may be used in the service of avoidance of countertransference awareness” (p. 83). In other words, clinicians may repetitively apply a particular therapeutic technique to their clients (e.g., progressive muscle relaxation, mental imagery, or thought stopping) without realizing they are applying the techniques to address their own needs, rather than the needs of their clients. There are many moments to reflect on how countertransference dynamics might affect the counseling process during the workshop. More recent research affirms that identifying and working through countertransference is associated with positive counseling and psychotherapy outcomes (see: Norcross, 2011).

To deal effectively with countertransference requires the following possibilities:

  • The counselor is aware of the possibility
  • The counselor seeks supervision
  • The counselor gets counseling
  • The counselor owns his/her/their countertransference reaction in the session and makes a commitment to dealing with it effectively

 10. Progress Monitoring

Progress monitoring occurs when counselors routinely and formally check in with clients regarding the clients’ progress. This “checking in” can focus on the counseling relationship/alliance or on symptom improvement. At a very basic level, counselors can check in informally, like Carl Rogers often did (e.g., “Am I getting that right?”

More formal progress monitoring can involve use of formal scales like the session rating Scale and the Outcomes Rating Scale. You can find these instruments online.

The most important part of progress monitoring may be as simple as you, the counselor, showing interest in the client.

A Bonus Technique

As a method for deepening your understanding of the EBRFs, I recommend that you watch some counseling sessions with the intent to “see” the EBRFs in action. To give you an opportunity for that, I’m offering this bonus technique and an accompanying video clip.

The Three-Step Emotional Change Trick: Emotions are complex. Young people need strategies for dealing with negative affect. The three-step emotional change trick is one method for providing emotional education. For details, and a video demonstration, see: https://johnsommersflanagan.com/2017/03/12/revisiting-the-3-step-emotional-change-trick-including-a-video-example/

John S-F Resources

The main resources from which this handout is drawn are below, starting with my own publications and then continuing to additional citations.

Sommers-Flanagan, J. (2018). Conversations about suicide: Strategies for detecting and assessing suicide risk. Journal of Health Service Psychology, 44, 33-45.

Sommers-Flanagan, J., & Shaw, S. L. (2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48, 98-106.

Sommers-Flanagan, J. (2015). Evidence-based relationship practice: Enhancing counselor competence. Journal of Mental Health Counseling, 37, 95-108.

Sommers-Flanagan, J. (2018). Suicide assessment and intervention with suicidal clients [Video]. 7.5 hour training video for mental health professionals.  Mill Valley, CA: Psychotherapy.net.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (3rd ed.). Hoboken, NJ: Wiley.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Clinical Interviewing (6th ed.). Hoboken, NJ: Wiley.

Sommers-Flanagan, J. (2016). Assessment strategies. In M. Englar-Carlson (Ed.). The skills of counseling [Video]. Alexandria, VA: Alexander Street Press.

Sommers-Flanagan, J. (2015). Evidence-based relationship practice: Enhancing counselor competence. Journal of Mental Health Counseling, 37, 95-108.

Sommers-Flanagan, J., & Bequette, T. (2013). The initial psychotherapy interview with adolescent clients. Journal of Contemporary Psychotherapy, 43(1), 13-22.

Sommers-Flanagan, J., Richardson, B.G., & Sommers-Flanagan, R. (2011). A multi-theoretical, developmental, and evidence-based approach for understanding and managing adolescent resistance to psychotherapy. Journal of Contemporary Psychotherapy, 41, 69-80.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2007). Tough kids, cool counseling: User-friendly approaches with challenging youth (2nd ed.). Alexandria, VA: American Counseling Association.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Clinical interviewing (6th ed.). Hoboken, NJ: John Wiley & Sons.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (3rd ed.). Hoboken, NJ: Wiley.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2004). The challenge of counseling teens: Counselor behaviors that reduce resistance and facilitate connection. [Videotape]. North Amherst, MA: Microtraining Associates.

Selected References

Betan, E., Heim, A.K., Conklin, C. Z., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry, 162 (5), 890 – 898.

Castro-Blanco, D., & Karver, M. S. (2010). Elusive alliance: Treatment engagement strategies with high-risk adolescents. Washington, DC: American Psychological Association.

de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton.

Feindler, E. (1986). Adolescent anger control. New York: Pergamon Press.

Kolden, G. G., Klein, M. H., Wang, C., & Austin, S. B. (2011). Congruence/genuineness. Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.) (pp. 187–202). New York, NY: Oxford University Press.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Preparing people for change (3rd ed.). New York: Guilford Press.

Norcross, J. C. (Ed.). (2011). Evidence-based therapy relationships. Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.). New York, NY: Oxford University Press.

Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303-315.

Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.

Shirk, S. R., Karver, M. S., & Brown, R. (2011). The alliance in child and adolescent psychotherapy. Psychotherapy, 48, 17-24.

Villalba, J. A., Jr. (2007). Culture-specific assets to consider when counseling Latina/o children and adolescents. Journal of Multicultural Counseling and Development, 35(1), 15-25.

Watkins, J. G. (1971). The affect bridge: A hypnoanalytic technique. International Journal of Clinical and Experimental Hypnosis, 19, 21-27.

Weisz, J., & Kazdin, A. E. (2010). Evidence-based psychotherapies for children and adolescents (2nd ed.). New York: Guilford.

If you have questions about this handout, or are interested in having John SF conduct a workshop or keynote for your organization, contact John at: john.sf@mso.umt.edu. You may reproduce this handout if you like, but please provide an appropriate citation. For additional free materials related to this workshop and other topics, go to John’s Blog at: johnsommersflanagan.com

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