Tag Archives: Carl Rogers

Personal Reflections, Writing

Dear Karen: I have a professional and personal responsibility to speak out against Unacceptable behaviors

15 Comments

Last week I received a comment on this blog. Getting a comment is always very exciting, partly because I don’t get all that many and partly because the comments are usually positive and affirming. In this case the comment was neither positive nor affirming.

Although getting critical comments isn’t nearly as fun and ego-boosting as affirming comments, receiving criticism is important to self-examination and growth. The person who commented last Thursday was upset about my “politics.” As many of you know, I’ve occasionally written about Mr. Trump and lamented his behavior. Sometimes, I’ve felt nervous posting critiques of Mr. Trump, worrying that I may have been behaving in ways that were less that professional and worrying that perhaps I shouldn’t openly express my negative opinions about his behavior. However, in the end, I’ve often ended up deciding that my critiques of Mr. Trump aren’t really about politics anyway.

Digesting Thursday’s comment has helped me clarify my position on political commentary. Here’s a version of what I wrote back to my blog commenter.

********************************************

Dear Karen,

Thanks for your message.

Many years ago when I interviewed Natalie Rogers, I recall her telling me something very compelling about her father, Carl Rogers. She said, in her family, all feelings were accepted, but not all behaviors.

Although some of my judgments about Mr. Trump have political components, most of my judgments about him focus on his personality and behavior. Politics aside, I wouldn’t care if he was a democrat, an independent, a republican, a corporate mogul, a teacher, a coach, or a rock star. I find his behavior to be an unacceptable example for children. From my perspective it’s clear that Mr. Trump is much more focused on using and abusing power than he is on empowering others. To return to Carl Rogers: Rogers believed the best use of power was to empower others. My perception of Mr. Trump is that he’s invested in accumulating power, and not on empowering others.

I could make a list of video evidence of Mr. Trump mocking disabled people, calling women “fat pigs,” disrespecting war veterans (including John McCain, whom I’ve never written a negative judgmental word about, despite his politics), paying off prostitutes, saying positive and supportive things about dictators and racists, and his continuous flow of lies. If Mr. Trump was my neighbor or a colleague at my University, it would be wrong for me to let his behavior pass without making it clear that I find his behaviors to be a potentially destructive and negative influence on children in the neighborhood or the culture at the University. Not only do I have a responsibility to be non-judgmentally accepting in therapeutic contexts, I also have a responsibility to speak up and speak out against racism and the promotion of violence. I believe there’s ample evidence that Mr. Trump has promoted racism and incited violence. My rejection of those behaviors isn’t particularly political; I simply believe that it’s morally wrong to promote racism and foment violence.

I can see we have different views of Mr. Trump. You may not see the evidence that I see, or you may find his behaviors less offensive and less dangerous. Although it’s challenging for me to understand your perspective, I know you’re not alone, and I know you must have reasons for believing the ways you believe. I can accept that.

But to articulate my perspective further, here’s a therapy example. If I was working with a client who exhibited no empathy or said things to others that were likely to incite violence, as a psychotherapist, I would work toward a greater understanding of the client’s emotions. In addition, I would consider it my professional responsibility to question those behaviors . . . for both the good of the client and the good of people in the client’s world.

Again, thanks for your message. It’s important to hear other perspectives and to have a chance to question myself and my own motives. I appreciate you providing me with that opportunity.

Happy Sunday,

John SF

Counseling and Psychotherapy Theory and Practice

Person-Centered Spirituality

2 Comments

Rogerian Spirituality

Most of the distinct figures who developed major theories of psychotherapy also had distinct views about religion and spirituality. As you may recall, Freud was antagonistic toward religion. One of the interesting parts of exploring how each theoretical orientation deals with spirituality has involved learning a bit more about the religious and spiritual perspectives of people like Freud, Adler, and others.

In chapter 5 of Counseling and Psychotherapy Theories in Context and Practice, the focus is on Carl Rogers. Other than knowing that he was raised in a conservative Christian family, I didn’t know much about Rogers and his personal spirituality. Here’s a sampling of what I discovered.

Person-Centered Spirituality

On his journey to developing person-centered theory and therapy, Carl Rogers renounced traditional Christianity. Given that all religions, including Christianity, can be viewed as directly imposing judgmental conditions of worth, Rogers’s renouncing Christianity as antithetical to his beliefs is not surprising. In particular, Rogers may have been especially reactive to religious dogma because of his childhood experiences in an extremely conservative Christian family. Thorne (1990) proposed that Rogers broke from Christianity, at least in part, over the doctrine of original sin.

Although he died an agnostic, toward the end of his life, Rogers began speaking about transcendental or mystical experiences (Thorne, 1992). These spiritual statements were mostly made in the context of interpersonal mutuality and human connection, derived from person-centered or I-Thou experiences. Within the person-centered world, his statements about spirituality have been viewed as controversial (Fruehwirth, 2013). In an interview with Elizabeth Sheerer, one of Rogers’s early colleagues at the University of Chicago Counseling Center, Sheerer was asked about why Rogers never formally addressed spirituality. Her response included:

That’s Carl. This was an area of difficulty for Carl. We learned early in the game not to talk about religion with Carl … it was uncomfortable for him …. But, of course, his work is so profoundly influenced by his background in Christianity. I don’t think he could have developed without that background. (Barrineau, 1990, pp. 423–424)

There have been contemporary efforts to build a bridge between spirituality and PCT. One example is Fruehwirth’s (2013) work connecting PCT and Christian contemplation. He proposed that if wordless contemplation can be regarded as “the heart of the Christian spiritual tradition” (p. 370), then parallels can be drawn to wordless contemplation and the PCT experience. Similarly, a case can be made connecting the acceptance doctrine of Christian, Buddhist, and other religious viewpoints with the PCT process.

Overall, it seems reasonable that, for some therapists and clients, the deep interpersonal acceptance inherent in the PCT experience might have religious, spiritual, or mystical components. Spiritual-based acceptance is probably the main place where an integration of PCT and religion/spirituality can occur. In contrast, wherever and whenever judgment flows from religious doctrine, religion and PCT are incompatible.

 

Counseling and Psychotherapy Theory and Practice

Evidence-Based Relationship Factors in Counseling and Psychotherapy

Leave a comment

The medical model of psychotherapy . . . has led us to accept a view of clients as inert and passive objects on whom we operate and whom we medicate. Gene V. Glass, in The Great Psychotherapy Debate, 2001, p. ix

John and Max Seattle

In a 1957 publication in the Journal of Consulting Psychology, Carl Rogers boldly declared:

  1. No psychotherapy techniques or methods are needed to achieve psychotherapeutic change.
  2. Diagnostic knowledge is “for the most part, a colossal waste of time” (1957, p. 102).

Let’s pause for a moment and reflect on what Rogers was saying.

**PAUSE HERE FOR SERIOUS REFLECTION**

If diagnosis is a waste of time and therapy techniques are unnecessary, then what can counselors or therapists do to produce positive outcomes? Here’s what Rogers said:

All that is necessary and sufficient for change to occur in psychotherapy is a certain type of relationship between psychotherapist and client.

Rogers’s revolutionary statements refocused counseling and psychotherapy. Until Rogers, therapy was primarily about theoretically based methods, techniques, and interventions. After Rogers, writers and practitioners began debating whether the relationship between client and therapist—not the methods and techniques employed—might be producing positive therapy outcomes.

This debate continues today. Wampold (2001) has called it “the great psychotherapy debate.” This debate has been boiled down to a dichotomy captured by the question: “Do treatments cure disorders or do relationships heal people?” (Norcross & Lambert, p. 3).

Keep in mind that like lots of things on planet Earth, the techniques vs. relationship debate promotes a false dichotomy. IMHO, most “rational” professionals understand that therapy relationships and techniques are BOTH important to positive outcomes. Seriously, how could it be otherwise?

But there is a positive outcome from this debate. Various researchers around the world started focusing on how to define specific relationship factors that contribute to counseling outcomes. Previously, these relationship factors were lumped into a category called “common factors.” Common factors were viewed as the main reason why all therapy approaches tend to produce approximately equal positive outcomes.

Flowing from research on common factors, one of the most fascinating and important movements in counseling and psychotherapy is now called, “Evidence-based relationships” (Norcross, 2011). As it turns out, there’s a large body of existing and accumulating research to help us clearly identify what’s relationally therapeutic.

In the attached link, you’ll find the powerpoint slides that Kim Parrow and I developed for a supervisor training yesterday, at the University of Montana. Our goal was to describe, demonstrate, and discuss 10 specific and observable relationship factors that contribute to positive counseling outcomes. We call them Evidence-Based Relationship Factors (EBRFs). They include:

  1. Congruence
  2. Unconditional positive regard
  3. Empathic understanding
  4. WA1: Emotional bond
  5. WA2: Goal consensus – Focus on strengths
  6. WA3: Task collaboration
  7. Rupture and repair
  8. Countertransference (management)
  9. Progress monitoring (feedback)
  10. Culture and Cultural Humility

The link at the bottom of this post will take you to our powerpoint slides. Also, for more information, you can always check out various theories textbooks, including Counseling and Psychotherapy Theories in Context and Practice (from which this blog was adapted). https://www.amazon.com/Counseling-Psychotherapy-Theories-Practice-Resource/dp/1119084202/ref=sr_1_1?ie=UTF8&qid=1504292029&sr=8-1&keywords=counseling+and+psychotherapy+theories+in+context+and+practice

EBRFs for Supervisors 2017 FIN

Counseling and Psychotherapy Theory and Practice

On Becoming a Counselor: What’s a Rogerian, Anyway? by Lauren Leslie

3 Comments

carl-rogers

IMHO, more people should read Carl Rogers. But I understand, sometimes there just isn’t enough time in the day to fit in your Yoga class, mindfulness meditation practice, cardio workout, meal prep, work and family-life, and other responsibilities. So here’s an option: Below you’ll find a review of a classic Carl Rogers work: On Becoming a Person. It was written by Lauren Leslie to fulfill an assignment I give in our Counseling Theories class. It’s a fun read and gives you an abbreviated glimpse of the amazing Carl Rogers from the perspective of a first-year graduate student in clinical mental health counseling.

On Becoming a Counselor: What’s a Rogerian, Anyway?

Lauren Leslie
University of Montana

            Carl Rogers’ On Becoming a Person is a collection of essays and edited speeches written between 1951 and 1961, while client-centered humanistic therapy was being simultaneously embraced and challenged by the establishment. Rogers states he intends to write to professional psychologists, members of the counseling profession, and informed laymen, different populations who nonetheless have at least one thing in common:

. . .while the group to which this book speaks meaningfully will…have many wide-ranging interests, a common thread may well be their concern about the person and his  becoming, in a modern world which appears intent upon ignoring or diminishing him. (Rogers, 2012, “To the Reader” para. 8)

Throughout the text, Rogers offers a picture of himself as a person and a therapist. He provides insights into the growth of his theoretical framework as well as therapy transcripts to flesh out central elements of client-centered practice. Ultimately, the text crystallizes the effectiveness of empathy, congruence, and unconditional positive regard within a therapeutic relationship, and it is difficult to argue against Rogers’ persuasive and clear writing. Critics insist Rogers’ model is incomplete or insufficient, but the core tenets remain central to the practice of contemporary psychotherapy.

On Becoming a Person collects texts of varying genres into a sort of holistic catalog of Rogerian thought. Due to this variety of genre, Rogers’ tone and subject matter shifts; he addresses his own personality and life, includes transcripts of counseling sessions, and tries to systematize examples of his practice into stages of client development to analyze effectiveness of treatment. Rogers philosophizes on the human condition and therapeutic practice, Kierkegaard and Buber, and scientific research and personal change. It is a sweeping book which attempts meaningful understanding and data-driven conclusions. At one point, Rogers claims “There is no general agreement as to what constitutes ‘success’ [in psychotherapy]…. The concept of ‘cure’ is entirely inappropriate, since … we are dealing with learned behavior, not with a disease” (Rogers, 2012, p. 227). He consistently moves in opposition to the kind of concrete, experimental thinking favored in certain parts of the psychological community and comes off far more as a philosopher studying existential questions than as a data-driven scientist.

In considering himself, Rogers (2012) states, a client “discovers how much of his life is guided by what he thinks he should be, not by what he is. Often he discovers that he exists only in response to the demands of others…” (p. 109). In the same passage, he muses on the insight of Kierkegaard on this point: “He points out that…the deepest form of despair is to choose ‘to be another than himself.’ On the other hand, ‘…to be that self which one truly is, is indeed the opposite of despair,’” (p. 109). If this isn’t existential philosophy, the reader must ask, what is? In his own practice, Rogers (2012) characterizes a fundamental shift from “How can I treat, or cure, or change this person?” (p. 32) to his later, fuller question “How can I provide a relationship which this person may use for his own personal growth?” (p. 32). From his training in psychology, Rogers claims to have followed his own instincts into client-centered therapy. His writing overtly embraces that exploration.

Despite his philosophical bent, in large sections of his writing, Rogers draws on established scientific structures or language. He writes a whole chapter which tries to formulate a “general law of interpersonal relationships,” then launches into a lengthy and example-laden consideration of the firmness of knowledge and conclusions within the behavioral sciences at the time. His cognitive resting place seems to be that the behavioral sciences are in their infancy, and while practitioners may rely on a lot of interesting information now being discovered, exploration, philosophy, and instinct still hold places of honor within the field. More than fifty years after the book’s first publication, the situation seems to have changed very little, though there is more data in certain areas. Though Rogers seems to have viewed psychotherapy as a scientific practice, his person-centered view showed him countless variables with which to contend. Perhaps in an environment without controls, philosophy and instinct present better-formed or more immediate solutions than experimentation can.

Rogers seems to boil complex situations down to essentials wherever he can: relationship is his central theme, and empathy, congruence, and unconditional positive regard are the three relationship components. This pursuit of simplicity may be attentiveness to the broad audience of On Becoming a Person or may be indicative of Rogers’ own worldview. Whatever its source, it leaves Rogers open to criticism from those who see things as unsimplifiable. In a similar way, the individual variation and client focus implicit in Rogers’ therapy leave him open to criticism from those who see him acting only as a clarifying mirror for clients, not as a truly congruent party to change-spurring relationships. In one example of a common critique, Ralph H. Quinn (1993) contends that “[a] fully person-centered therapist…would feel compelled to stay with the client’s lead…[and] trust that the client knows best” (p. 20) rather than confronting the client in a moment of genuine human response.

Genuineness in psychotherapy…does not mean simply the willingness to confront a client…. More than anything it means that the therapist must strive to be fully present with the client, to bring all of himself or herself to the therapeutic relationship. As therapists, we must be willing to risk as much as we ask our clients to risk, to be as transparent and courageous as they must be, if the therapy is to produce real life change. (Quinn, 1993, p. 20-21)

This section includes the assertion that bold congruence and full presence are not already parts of person-centered therapy, and Rogers was remiss in not addressing them. Quinn (1993) later implies a fully person-centered approach can easily be seen as practicing “Pollyannish optimism and therapeutic passivity” (p. 21). Such criticism is valid enough, and points out elements of Rogers’ work that may be over-simplified. However, the complexity with which Rogers addresses each essay, idea, and client interaction suggests he did not see humanity or psychotherapy as simple, and did not approach them passively. Rogers may not have dwelled enough in his writing on the practice of congruence; perhaps it was an element that seemed also to contain infinite variables and defy simple definition. I tend to think this criticism stems from a misinterpretation of Rogers’ intentions and practices. In the final analysis, even critic Quinn (1993) only suggests practicing more (riskier?) congruence on the part of the therapist, not abandoning Rogers’ principles.

In terms of my own use of this book, its variety in tone and subject matter makes it a uniquely useful text. Each section and each essay can be read independently, and dipping into Rogers’ world is a clarifying and centering experience that could bring me back to the core of therapeutic practice in times of questioning and uncertainty. Reading this book now gave me a window into the complexities inherent in a model that can be seen as very simple (by Rogers’ design, admittedly). Considering this approach in my own attempts to define or grasp client “distress” has been helpful in placing myself in the wide world of this human-helping profession, and has helped me frame my own conception of what I am doing here and what a client might want or need from me in this role. This reading has been one new way of incorporating personal change into myself: deliberately approaching the self I am discovering myself to be.

 

References

Quinn, R.H. (1993). Confronting Carl Rogers: A developmental-interactional approach to

person-centered therapy. Journal of Humanistic Psychology, 33(1), 6-23. doi:

10.1177/0022167893331002

Rogers, C. (2012). On Becoming a Person. [Kindle Voyage version]. Retrieved from

Amazon.com

Counseling and Psychotherapy Theory and Practice

An Interview with Natalie Rogers (Daughter of Carl Rogers) about Person-Centered Therapy

6 Comments

Of all the counseling and psychotherapy approaches out there, person-centered therapy might be the most quickly dismissed of them all. I’ve had therapists watch or listen to a PCT demonstration and then make dismissive comments like: “Oh yeah. That was just basic listening skills. I know all about that.”

It’s usually hard for me to figure out how to best respond to that sort of statement. What makes it hard to take is that typically, when someone says something like, “I already know all that Rogerian stuff,” it’s a surefire sign that they really don’t get person-centered therapy.

Although this is mostly just my opinion, it’s also the opinion of Natalie Rogers (daughter of Carl Rogers, the person who originally developed person-centered therapy). The following is an edited excerpt of two telephone interviews I did with her way back in 2003. This excerpt is included in our theories textbook: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/0470617934/ref=cm_cr_pr_product_top?ie=UTF8

Additional interview material is in an article published in the Journal of Counseling and Development in 2007: http://onlinelibrary.wiley.com/doi/10.1002/j.1556-6678.2007.tb00454.x/abstract

And even more interview material is resting on the hard-drive of my computer.

Other fun and interesting content about person-centered therapy is in our Student Guide: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/0470904372/ref=sr_1_fkmr1_1?s=books&ie=UTF8&qid=1438700878&sr=1-1-fkmr1&keywords=sommers-flanagan+student+guide

Here’s what Natalie had to say about the status of Person-Centered Therapy in the U.S.

Why Is the Person-Centered Approach Undervalued in the United States?

In the following excerpt from two telephone interviews, Natalie Rogers discusses why person-centered approaches tend to be undervalued or overlooked in the United States.

John Sommers-Flanagan (JSF): Other than the managed-care focus and an emphasis on quick fixes, can you think of any reasons why more American therapists aren’t practicing PCT?

Natalie Rogers (NR): That’s a good question. Most psychology students I know only get a chapter or two in the academic world, and they don’t really understand in any depth what the person-centered approach is about. And, most importantly, I think they haven’t experienced it. They’ve read [about] it and they’ve talked about it and they’ve analyzed it, but my own belief is that it really takes in-depth experiencing of the client-centered approach to know the healing power of empathy and congruence and unconditional positive regard.

JSF: So it’s almost like students get more of an intellectual understanding, but you’re just not seeing them get the experiential part.

NR: Even the intellectual understanding is very superficial, because they read maybe a chapter and watch the old Gloria film (Rogers, 1965). The fact that there have been 16 books written on client-centered therapy and a lot of other books now that Carl’s passed away and the research that he did is so profound . . . the in-depth research on what actually helps clients go deeper into their feelings and thoughts.

JSF: Right.

NR: You know, [how therapists can help clients go deeper into their feelings and thoughts] is hardly ever mentioned in academia as far as I know.

JSF: And what I remember from our last conversation was that you said you thought it didn’t happen in the U.S. at all and maybe a little bit in Europe?

NR: I think it does happen a lot more in Europe, and most particularly in the United Kingdom, Scotland and England. They have really excellent training programs in the client-centered approach, and the books that are coming out are coming out from there. You know in Germany they have a several-year, very extensive training program that’s also linked in, I believe, to becoming accredited or licensed as a therapist. Things are going that particular route in Europe, but none of that is here in the States.

JSF: That seems to reflect our own emphasis on the surface or the quick fix as well in that people just really haven’t gone deeper and experienced the power of PCT.

NR: Right. And then again I think the other point is that the ego needs of the therapists [appear] to be strong here. Therapists in this country seem to need to have the attitude that “I have the answers” or at least that “I know more,” and it’s . . . the old medical model that we still hold onto in this country a lot. The doctor knows what he needs to diagnose and treat, knows what’s wrong and that there are ten steps to fix it.

JSF: Right, which seems to be the opposite of the person-centered therapy of “trust the individual, trust the person.”

NR: Not just seems to be, it is the opposite. So, to actually believe, to have faith in the individual, to have faith that each person has the answers within himself or herself if given the proper conditions, and that’s a big if. That philosophy takes a great deal of humility on the part of the therapist.

JSF: For us to realize that we don’t have all the answers for another person.

NR: Right. I kind of like the gardener metaphor. That I’m the gardener and I help till the soil and I help water the plants and fertilize the plants, and care for them. And I need to understand what the plant needs, what conditions that plant needs for it to actually grow and become its full potential. That’s very different. That’s what I see as one metaphor for being a therapist. I don’t know all the answers, but I’m a person who creates the conditions for the person to grow.

JSF: Kind of the fertile field metaphor. So . . . what would you tell beginning therapists that would help them see the tremendous value of following person-centered principles?

NR: Well, I always ask my students to examine their own beliefs about psychotherapy and about what it is that creates psychological feelings and growth. I think it’s a philosophical, spiritual belief system that we’re looking at. People are using the words “methods” and “techniques,” which always puts me off, because although there certainly are methods that we use, it’s much bigger than that. It’s a belief system about the connection between mind, body, and emotional spirit. And so I ask them what do they believe creates personal growth, and what have they experienced themselves that creates growth, and we get them to think and talk about their religious experiences, their psychotherapy experiences, their experiences in nature, and their experiences in relationships. I think they’re all profound. And then when we focus in on relationships, which is what psychotherapy is about, then I want them to experience . . . from me or my colleagues in hour-long demonstrations what it means to be client-centered. So then they experience it as witnesses and they can experience it as a client.

JSF: So more students need to directly experience, or at least witness, client-centered therapy.

NR: Let me give an example. I was talking to a colleague once who had some of my training and who said that he was now using brief therapy, brief psychotherapy, and I admitted I didn’t really know what that was. We decided that he’d have to give me some ideas on what that’s like. So I listened to him describe the theory and practice for quite a while and questioned him about it. And as he was describing it, I was wondering, how would I feel if I were in the client’s chair and this was what was being done to me. And so then I felt pretty uncomfortable, and thought, “I guess I wouldn’t like it.” So I asked him, “Have you ever been a client in this kind of brief therapy yourself?” And he said “No,” and I thought that was inexcusable. To practice something on somebody else that you haven’t experienced in-depth yourself. I think it is inexcusable. So that illustrates in a kind of negative way the point that I wanted to make. You really need to have in-depth experience of that which you are going to have other people do.

Counseling and Psychotherapy Theory and Practice, Tough Kids Cool Counseling

A Relationally-Oriented Evidence-Based Practice Model for Mental Health Counselors

3 Comments

This paper is an adapted summary and extension of an article recently published in the Journal of Mental Health Counseling (April, 2015, pp. 95-108). The original article was titled: Evidence-Based Relationship Practice: Enhancing Counselor Competence. This abbreviation and adaptation is primarily designed to summarize the content, but also to focus more directly on the implications of developing an evidence-based model especially for mental health counselors. This paper ends with an “Appendix” outlining specific parameters of an evidence-based mental health counseling model. The Appendix material isn’t in the original article. If you’re a member of the American Mental Health Counseling Association, you can find the original article here: https://amhca.site-ym.com/?JMHCv37n2

Foundations

There are two domains that serve as a foundation for all competent mental health practice. These are:

1. Ethical practice
2. Multicultural sensitivity.

Professional counselors must practice ethically. At minimum, this means abiding by the ACA (2014) and American Mental Health Counselors Association (AMHCA; 2010) ethical codes. Ponton and Duba (2009) referred to this commitment as a covenant professional counselors have with and for their clients.

Traditional theoretical perspectives must be modified or expanded to address cultural diversity (J. Sommers-Flanagan, Hays, Gallardo, Poyralzi, Sue, & Sommers-Flanagan, 2009). Clients should not be expected to adapt to their counselor’s theory; rather, counselors should adapt their theory or approach to fit clients (Gallardo, 2013). Although multicultural competence is an ethical mandate, the need to embrace multicultural awareness, knowledge, and skills is also a practical reality. [The original article lists six evidence-based ways in which mental health counselors can adapt their counseling services to be more multiculturally sensitive.]

Evidence-Based Counselor Competence

Given the nature of professional counseling and counselor identity, it seems obvious that mental health counselors should embrace a model for counseling competence and EBP that emphasizes therapeutic relationships. That is why the model I propose considers both theoretically and empirically supported relationship factors and specific interventions (procedures). . . .

The reality is that relational acts and treatment methods are so closely interwoven that in counseling sometimes it is difficult to discern which is operating at a given moment (Lambert & Ogles, 2014). Consequently, the following Relationship-Oriented Evidence-Based Practice (ROEBP) behavioral descriptions incorporate both relational and technical components. The ROEBP behavior list primarily focuses on evidence-based relationship factors, although these relational factors are nearly always teamed with technical procedures.

Evidence-Based Relationship Factors

Each mental health counselor will inevitably display therapeutic relational factors in unique ways that may be difficult for other practitioners to replicate, because anything relational or interpersonal is alive, automatically unique, and therefore resists sterile descriptive language. Nevertheless, counselors can implement the following core relational attitudes and behaviors in their own unique manner and still adhere to EBP principles.

Congruence and Genuineness

In mental health counseling, the counselor is the instrument through which treatment is provided. This is probably why Rogers’s original core condition of congruence (1957) is still central to counseling efficacy. However, because Natalie Rogers (Sommers-Flanagan, 2007) once told me that she believed very few mental health professionals in the U.S. really understand her father’s work, let me make four brief points about congruence [You can read the original article to get the details on this].

The Working Alliance

In 1979, Bordin described the working alliance as a three-dimensional and pan-theoretical therapeutic factor. The three dimensions were (a) forming an emotional bond; (b) counselor-client goal-consensus or agreement; and (c) task collaboration. Researchers have affirmed that these working alliance dimensions contribute to positive treatment outcomes (Horvath, Re, Flückiger, and Symonds, 2011). [Practical ways in which mental health counselors can apply these three dimensions in their work are described in the article.]

Unconditional Positive Regard or Radical Acceptance

Originally, Rogers (1957) described unconditional positive regard as the counselor “experiencing a warm acceptance of each aspect of the client’s experience” (p. 98). This is, of course, often impossible. Though unconditional positive regard is easy and natural when counselor and client values are aligned, the competent counselor recognizes that there will be many discrepancies, small or large, between what the counselor thinks is right and what the client thinks is right. I recall a Pakistani Muslim supervisee who reported that hearing people talk about being gay or lesbian made her feel physically nauseated. To her credit, she worked through this (over a period of two years) and was able to embrace an accepting attitude. . . .

In addition to Rogers’s work, I’ve found Marsha Linehan’s dialectical behavior therapy concept of radical acceptance (1993) very helpful. As someone who has logged many counseling hours with clients who display challenging behaviors, remembering radical acceptance helps me greet even the most extreme and disagreeable (to me) client statements with a genuine accepting response (usually something like, “Thanks so much for sharing that with me and being so honest about what you think”).

Empathic Understanding

You should already be thoroughly familiar with Rogers’s ideas about empathy and the robust empirical support for empathy as a contributor to positive counseling outcomes. However, one important caveat about empathy is that the personal feelings of counselors and ratings of their own empathy are relatively unimportant. What matters is whether and how much clients experience their counselors as empathic. This is a crucial distinction. It is all too easy for all humans—including counselors—to focus on their side of interpersonal experiences. When it comes to whether empathy is a facilitative therapy condition, it is the client’s judgment of whether the counselor was empathic that predicts positive outcomes. . . .

Rupture and Repair

Getting it wrong is a natural part of life and counseling. There will always be empathic misses, poorly timed disclosures, and intermittent disengagement. These should be viewed as inevitable problems in the working alliance. As in many other areas of life, tension in the counselor-client relationship offers both danger and opportunity.

The danger is that counselors will ignore, overlook, or be unaware of relationship tensions or ruptures, in which case clients will be more likely to drop out of counseling and outcomes will be adversely affected. But the chance to correct our missteps is an unparalleled therapeutic opportunity. It involves the powerful process of self-correction and refocusing on the client and the counselor-client relationship. . . .

Although there are many ways to repair or work through relationship rupture, the original article discusses two overarching approaches.

Managing Countertransference

Thirty years ago Steve de Shazer (1984) not only reported that “resistance” had died as a therapeutic concept, he held a funeral for it in his backyard. Similarly, some counselors and psychotherapists might like to bury the whole idea of countertransference, putting it out of sight and out of mind. However, renaming or ignoring constructs will not make them go away.

Counselors are more effective when they are aware of and deal with their own unresolved emotional and behavioral reactions (Hayes, Gelso, & Hummel, 2011). Personal counseling or psychotherapy, clinical supervision, participation in peer supervision groups—such practices can help counselors become aware of and gracefully work through their countertransference reactions.

Implementing In- and Out-of-Session Procedures

Proponents of ESTs and EBP emphasize the importance of employing specific psychological or behavioral procedures with clients. Among the procedures that have empirical support are relaxation, exposure, behavioral activation, and problem-solving (Sommers-Flanagan & Sommers-Flanagan, 2012). In addition, some procedures, such as eye movement desensitization reprocessing (EMDR), have significant empirical support even though it is not clear whether the eye movements themselves or other parts of the tightly controlled EMDR protocol are the “active” ingredients. To be consistent with an evidence-based mental health counseling model, professional counselors should implement empirically supported procedures, but should do so using a collaborative interpersonal process. . . .

Progress Monitoring

Progress monitoring (PM) is a relatively new phenomenon on the evidence-based scene. PM is robustly related to positive outcomes and relatively easy to apply (Meier, 2015). Although not covered by many professional counseling publications, all practicing counselors should integrate some form of PM into their practice.

PM simply means that, formally or informally, counselors consistently check with clients about “how things are going.” Data from empirical studies consistently show, however, that practitioners who use formal progress monitoring rating scales tend to have both more favorable outcomes and fewer negative outcomes or treatment failures (Meier, , 2015). . . .

Concluding Comments

Mental health counselors can and should integrate evidence-based approaches into their practice. Although it might be useful for counselors to seek training in ESTs, embracing and applying evidence-based relationships as a core component of counselor competency is more consistent with professional counselor identity. The purpose of making this distinction and providing the information in this article is to advocate for an alternative evidence-based identity—one that counselors can more wholeheartedly embrace.

In this article I focused on nine relational factors that are empirically linked to positive counseling outcomes. This is only a beginning. Research will continue, and for space reasons I neglected several dimensions of counselor-client relational interactions that are consistent with professional counselor identity. For example, other than a brief discussion of PM, I did not address the potential merits and problems of formal assessment. In the future I would hope for a more distinct assessment model that specifies how counselors interact with clients, emphasizing transparency and collaboration. But that discussion must wait for another day. Until then, I wish you all the best as you incorporate relationally-oriented evidence-based counseling principles into the exceptionally important services you provide.

References are included in the original article

Appendix

[This is added material]

A General Practice Model for Evidence-Based Mental Health Counseling

Different professional groups use different terminology for describing their usual and customary standards for clinical practice. In psychology “empirically-supported” is often, but not always used as a means for identifying an approach that meets scientifically-based standards. Physicians and psychiatrists establish “practice parameters” for treating specific disorders. For example, the American Academy of Child and Adolescent Psychiatry (AACAP) has a Committee on Quality Issues that has generated practice parameters for depressive disorders, obsessive-compulsive disorders, multicultural competency, and many other areas of child and adolescent psychiatric clinical practice.

Given that psychology and medicine have their own language for referring to evidence-based standards, it might be useful for professional counseling to come up with its own terminology. This would be terminology that reflects an emphasis on achieving wellness (rather than the medical model) as well as the relational emphasis consistent with counseling. In the Journal of Mental Health Counseling article I referred to this as: Relationship-Oriented Evidence-Based Practice (ROEBP). This isn’t bad, but I’m guessing someone might be able to do better at capturing counselor identity within an evidence-based practice.

Here’s a first try at outlining an ROEBP for mental health counseling. I recognize that this is mostly a rough outline, but also believe that any practice guidelines that are established for professional mental health counselors should be broad so as to include many different and unique styles that exist among individual counselors.

1. All mental health counselors embrace their professional ethical guidelines and use multicultural sensitivity and appropriate multicultural adaptations when working with individual clients. These foundational competencies and commitments must be present for a professional counselor to claim he or she is practicing evidence-based mental health counseling.

2. Mental health counseling is initiated using a collaborative informed consent process. This process should include both written informed consent (consistent with HIPAA), but also verbal interactions to help make every specific counselors approach and style explicit to prospective clients.

3. When referral information is available to mental health counselors, at least some of this information is shared directly with clients using a positive and strength-based format and interaction.

4. Mental health counselors intentionally employ empirically-supported relationship factors throughout counseling. These include, but may not be limited to:

a. Having an office-setting and interpersonal demeanor that contributes to the development of a positive emotional bond between client and counselor

b. Developing a list of mutually agreed upon problems or goals that constitute the main focus of counseling. This involves a collaborative and empathic process.

c. Working with clients on in-session tasks or procedures that are explicitly linked to the mutually agreed upon counseling problems or goals.

d. Congruence and Genuineness

e. Unconditional Positive Regard or Radical Acceptance

f. Empathic Understanding

g. Managing Ruptures and Engaging in Repair

h. Managing Countertransference

5. Recognizing that clients are sometimes drawn toward and benefit from the application of specific therapeutic procedures, mental health counselors seek permission to use these procedures with clients if they are appropriate for the remediation of a particular problem and/or for client personal growth. The procedures employed should be empirically supported. If they are not empirically-supported (e.g., procedures from energy psychology) clients should be informed that the procedure may be promising, but is not a standard and accepted counseling procedure.

6. Mental health counselors use either a formal or informal progress monitoring procedure to consistently check with clients regarding the client’s perception of counseling progress.

Feel free to email me at john.sf@mso.umt.edu with comments about this article summary and ideas about evidence-based mental health counseling practice.

Counseling and Psychotherapy Theory and Practice

Check Out the April 2015 Issue of the Journal of Mental Health Counseling for an Article on Evidence-Based Relationship Practice

4 Comments

This is an excerpt of the first portion of an article I had the honor to publish in the Journal of Mental Health Counseling. My thanks go to Rich Ponton, the JMHC editor for both his patience and for making this article possible. The first 835 words of the article follow. For the whole thing, you can go to the JMHC website: http://www.amhca.org/?page=jmhc

Competence in mental health counseling is inevitably complex and multidimensional. Ironically, the complexity can become overwhelming when well-intended professionals work together to identify the knowledge and skills counselors need to be considered competent. A good example of this is the standards defined in 2009 by the Council for Accreditation of Counseling and Related Educational Program (CACREP, 2009). To establish competence in mental health counseling, the standards require that counselor training programs integrate into their curricula eight core knowledge-based standards and six specialty standards. The eight core standards are splintered into 67 learning objectives and the six specialty standards into 61 critical knowledge and skill components that must be measured as student learning outcomes (Minton & Gibson, 2012). To further elaborate the complexity, the American Mental Health Counseling Association (AMHCA, 2010) has its own Standards for the Practice of Mental Health Counseling.

The myriad standards mean that counselor educators and counseling students must determine exactly how the 128 CACREP competencies (many of which are clearly unrelated to actually doing counseling) and the AMHCA clinical and training standards together translate into mental health counselor competence. Although meeting this challenge can be intellectually exhilarating, moving from the standards to how mental health counselors should act in the room with clients is far from intuitive.

This article represents an effort to gather evidence-based practice (EBP) principles and describe them in terms of practical behaviors or approaches that contribute to counselor competence and positive client outcomes. Although considering the standards conceptually is necessary and sometimes helpful, the purpose of this article is to present a straightforward EBP model that can be tailored to fit different theoretical orientations and individual counselor styles.

What Is Evidence-Based Mental Health Counseling Practice?
Historically, the counseling profession has not had a strong science or research emphasis (Sexton, 2000; Yates, 2013). In fact, a PsycINFO title search of the top five professional counseling journals revealed only 12 articles over the past 15 years that had “evidence-based” or “empirically-supported” in their titles (the journals were Counselor Education and Supervision, Counseling Outcome Research and Evaluation; Journal of Counseling and Development; Journal of Mental Health Counseling; and Journal of Multicultural Counseling and Development). In a systematic review, Ray and colleagues (2011) reported that only 1.9% of articles in counseling journals are concerned with outcomes research. No wonder, as Yates (2013) wrote in Counseling Outcome Research and Evaluation, “Despite the recommendations for infusing outcome research and evidence-based practices (EBPs) into the counseling profession, there still exists uncertainty and confusion from educators and students about what EBP is” (p. 41).

In some ways it is right and good that professional counselors have a less scientific orientation than related disciplines. After all, mental health counseling evolved, in part, as an alternative to treatments provided by psychologists and psychiatrists (Gladding, 2012). This less rigorously scientific approach may partly explain why the public usually views professional counselors as more “helpful, caring, friendly . . . , and understanding” than psychologists and psychiatrists (Warner & Bradley, 1991, p. 139). The purpose of this article is certainly not to make a case for professional counselors to become more rigidly scientific but rather to help counselors embrace practical and relevant scientific research while maintaining a friendly interpersonal style and a wellness-oriented professional identity (Mellin, Hunt, & Nichols, 2011).

Terminology
Like all words, the terms used to describe evidence-based counseling and psychotherapy are linguistic inventions designed to communicate important information. Unfortunately, evidence-based terminology has by now evolved into what might best be described as Babel-esque. Therefore, before outlining an evidence-based mental health counseling model, I look briefly into the politics, history, and usage of evidence-based terminology.

Evidence-based terminology originated in medicine, spilled over into psychology, and from there made its way to professional counseling, education, social work, prevention, business, and nearly every other corner of the first world. Recently I was at a conference where the keynote speaker described not including purple on Powerpoint slides as a best practice. Although no doubt the speaker’s comments were based on something, I was not convinced that the something had anything to do with scientific research.

In mental health treatment, at least some of the confusion about EBP originated in 1986, when Gerald Klerman, then head of the National Institute for Mental Health (NIMH), remarked in a speech to the Society for Psychotherapy Research (perhaps with irony) that “We must come to view psychotherapy as we do aspirin” (quoted in Beutler, 2009, p. 308). Klerman was promoting the medicalization of psychotherapy as a means to compete for limited health care dollars. He was advocating scientific analysis and application of psychotherapy for specific ailments. The use of aspirin as his medical analogy was ironic because, although the active ingredient in aspirin is well-known (acetyl salicylic acid), until the early 1980s little was known about how and why aspirin worked—and even today there remain mysteries about aspirin’s mechanism of action and range of application. However, like aspirin Klerman’s comments had a specific effect but also triggered gastrointestinal side effects in some professionals .

Bowling

Counseling and Psychotherapy Theory and Practice, Personal Reflections

Listening as Meditation on Psychotherapy.net

1 Comment

Listening in psychotherapy and counseling is partly art and partly science. This week I have the good fortune of having a blog piece I wrote on Listening as Meditation published at psychotherapy.net. You can access this blog piece — and other excellent psychotherapy.net blog pieces — at: http://www.psychotherapy.net/blog

Have an excellent and mindful Wednesday.

John SF

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Why Therapists Should Never Say, “I know how you feel”

1 Comment

The following excerpt is adapted from the fifth edition of the text, Clinical Interviewing (John Wiley & Sons, 6th edition forthcoming in October).

**********************************************************************

Many writers have tried operationalizing Carl Rogers’s core conditions. However, efforts to transform person-centered therapy core conditions into specific behavioral skills always seem to fall short. As Natalie Rogers (J. Sommers-Flanagan, 2007) emphasized, trying to translate the core conditions into concrete behaviors is usually a sign that the writer or therapist simply doesn’t understand person-centered principles.

This lack of understanding occurs principally because core Rogerian attitudes are attitudes, not behaviors. This is a basic conceptual principle that has proven difficult to understand—perhaps especially for behaviorists. The point Rogers was making then (in the 1950s), and that still holds today, is that therapists should enter the consulting room with (a) deep belief in the potential of the client; (b) sincere desire to be open, honest, and authentic; (c) palpable respect for the individual self of the client; and (d) a gentle focus on the client’s inner thoughts, feelings, and perceptions. Further complicating this process is the fact that the therapist must rely primarily on indirectly communicating these attitudes because efforts to directly communicate trust, congruence, unconditional positive regard, and empathic understanding is nearly always contradictory to each of the attitudes.

A counselor educator friend of ours, Kurt Kraus, articulated why trying to directly communicate understanding is problematic. He wrote:

When a supervisee errantly says, “I know how you feel” in response to a client’s disclosure, I twitch and contort. I believe that one of the great gifts of multicultural awareness is for me accepting the limitations to the felt-experience of empathy. I can only imagine how another feels, and sometimes the reach of my experience is so short as to only approximate what another feels. This is a good thing to learn. I’ll upright myself in my chair and say, “I used to think that I knew how others felt too. May I teach you a lesson that has served me well?” (J. Sommers-Flanagan & Sommers-Flanagan, 2012) (p. 146)

Kraus’s lesson is an excellent one for all of us. The phrases, “I know how you feel” and “I understand” should be stricken from the vocabulary of counselors and psychotherapists.

Uncategorized

Exploring Empathy: Part II

Leave a comment

Misguided Empathic Attempts

It’s surprisingly easy to try too hard to express empathy, to completely miss your client’s emotional point, or otherwise stumble in your efforts to be empathic. Classic statements that beginning therapists often use, but should avoid, include {{34 Sommers-Flanagan,John 1989;}}:

1.  “I know how you feel” or “I understand.”

In response to such a statement, clients may retort: “No. You don’t understand how I feel” and would be absolutely correct. “I understand” is a condescending response that should be avoided. However, saying “I want to understand” or “I’m trying to understand” is perfectly acceptable.

2.  “I’ve been through the same type of thing.”

Clients may respond with skepticism or ask you to elaborate on your experience. Suddenly the roles are reversed: The interviewer is being interviewed.

3.  “Oh my God, that must have been terrible.”

Clients who have experienced trauma sometimes are uncertain about how traumatic their experiences really were. Therefore, to hear a professional exclaim that what they lived through and coped with was “terrible” can be too negative. The important point here is whether you are leading or tracking the client’s emotional experience. If the client is giving you a clear indication that he or she senses the “terribleness” of his or her experiences, reflecting that the experiences “must have been terrible” is empathic. However, a better empathic response would remove the judgment of “must have” and get rid of the “Oh my God” (i.e., “Sounds like you felt terrible about what happened.”).

The Evidence Base for Empathy

There’s a substantial body of empirical research addressing the relationship between empathy and treatment process and outcomes. This research strongly supports the central role of empathy in facilitating positive treatment outcomes.

In a meta-analysis of 47 studies including over 3,000 clients, Greenberg and colleagues (2001) reported a correlation of .32 between empathy and treatment outcome. Although this is not a large correlation, they noted, “empathy . . . accounted for almost 10% of outcome variance” and “Overall, empathy accounts for as much and probably more outcome variance than does specific intervention” (p. 381).

Elliot and colleagues (2011) also conducted a more recent meta-analysis. This sample included: “224 separate tests of the empathy-outcome association” (p. 139) from 57 studies including 3,599 clients. They concluded (based on a weighted r of 0.30) that empathy accounts for about 9% of therapy outcomes variance.

Based on their 2001 meta-analysis and an analysis of various theoretical propositions, Greenberg et al., identified four ways in which empathy contributes to positive treatment outcomes.

  1. Empathy improves the therapeutic relationship. When clients feel understood, they’re more likely to stay in therapy and be satisfied with their therapist.
  2. Empathy contributes to a corrective emotional experience. A corrective emotional experience occurs when the client expects more of the same pain-causing interactions with others, but instead, experiences acceptance and understanding. Empathic understanding tends to foster deeper and more trusting interactions and disclosures.
  3. Empathy facilitates client verbal, emotional, and intellectual self-exploration and insight. Rogers (1961) emphasized this: “It is only as I see them (your feelings and thoughts) as you see them, and accept them and you, that you feel really free to explore all the hidden nooks and frightening crannies of your inner and often buried experience” (p. 34).
  4. Empathy moves clients in the direction of self-healing. This allows clients to take the lead in their own personal change—based on a deeper understanding of their own motivations.

Although it’s always difficult to prove causal relationships in psychotherapy research, it appears that empathy contributes to positive treatment outcomes {{705 Duan 2002; 4508 Elliot 2011; 1047 Greenberg 2001;}}. In fact, some authors suggest that empathy is the basis for all effective therapeutic interventions: “Because empathy is the basis for understanding, one can conclude that there is no effective intervention without empathy and all effective interventions have to be empathic” (Duan et al., 2002, p. 209).

Concluding Thoughts on Empathy

Empathy is a vastly important, powerful, and complex interpersonal phenomenon. People express themselves on multiple levels, and due to natural human ambivalence, can simultaneously express conflicting meanings and emotions. Greenberg and associates (2001) captured the challenges of being empathic with individual clients when they wrote:

Certain fragile clients may find expressions of empathy too intrusive, while highly resistant clients may find empathy too directive; still other clients may find an empathic focus on feelings too foreign. Therapists therefore need to know when—and when not—to respond empathetically. Therapists need to continually engage in process diagnoses to determine when and how to communicate empathic understanding and at what level to focus their empathic responses from one moment to the next. (p. 383)

The preceding description of how it’s necessary to constantly attune your empathic responding to your individual client probably sounds daunting . . . and it should. When we add cultural diversity to the empathic mix, the task becomes doubly daunting. Nevertheless, we encourage you to embrace the challenge with hope, optimism, and patience. It’s only by sitting with people as they struggle to express their emotional pain and suffering that we can further refine our empathic way of being. Like everything, empathic responding takes practice, something Rogers (1961) recommended over 50 years ago.

 Even though that last section was titled, Concluding Thoughts, Part III is coming soon:)