Tag Archives: evidence-based relationships

Building Better Counselors

JSF Dance Party

This is a link to a hot off the presses article in Counseling Today. The focus is all about how professional counselors (and all psychotherapists) can be BOTH evidence-based AND relationally oriented. My co-author, Kindle Lewis, is one of our fantastic doctoral students in the Department of Counselor Education at the University of Montana. And . . . by the way. . . the University of Montana is NOW the NEW best college destination on the planet. Ask me why:).

Here’s the link: http://ct.counseling.org/2017/11/building-better-counselors/

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

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).

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 .


An Intake Interview Outline and Activity

Aloha from Honolulu. This week Rita and I have been working from Honolulu, Hawaii as we attend and present at the annual convention of the American Counseling Association. Yesterday we presented on how counselors can integrate evidence-based relationships into the first interview. This is mostly based on John Norcross’s excellent work on evidence-based relationships. After the presentation one attendee asked if I could send him a copy of an intake interview outline. . . and so I’m posting a brief intake interview outline and an associated classroom activity below.

More on Highlights from Honolulu soon. But here’s an intake outline for now. This is from the Clinical Interviewing text, but you should keep in mind that the Clinical Interviewing text also includes a more extensive outline. See: http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=la_B0030LK6NM_1_1?s=books&ie=UTF8&qid=1396163487&sr=1-1

A Brief Intake Checklist

When necessary, the following topics may be covered quickly and efficiently within a time-limited model.
______  1. Obtain presession or registration information from the client in a sensitive manner. Specifically, explain: “This background information will help us provide you with services more efficiently.”
______  2. Inform clients of session time limits at the beginning of their session. This information can also be provided on the registration materials. All policy information, as well as informed consent forms, should be provided to clients prior to meeting with their therapist.
______  3. Allow clients a brief time period (not more than 10 minutes) to introduce themselves and their problems to you. Begin asking specific diagnostic questions toward the 10-minute mark, if not before.
______  4. Summarize clients’ major problem (and sometimes a secondary problem) back to them. Obtain agreement from them that they would like to work on their primary problem area.
______  5. Help clients reframe their primary problem into a realistic long-term goal.
______  6. Briefly identify how long clients have had their particular problem. Also, ask for a review of how they have tried to remediate their problem (e.g., what approaches have been used previously).
______  7. Identify problem antecedents and consequences, but also ask clients about problem exceptions. For example: “Tell me about times when your problem isn’t occurring. What happens that helps you eliminate the problem at those times?”
______  8. Tell clients that their personal history is important to you, but that there is obviously not time available to explore their past. Instead, ask them to tell you two or three critical events that they believe you should know about them. Also, ask them about (a) sexual abuse, (b) physical abuse, (c) traumatic experiences, (d) suicide attempts, (e) episodes of violent behavior or loss of personal control, (f) brain injuries or pertinent medical problems, and (g) current suicidal or homicidal impulses.
______  9. If you will be conducting ongoing counseling, you may ask clients to write a brief (two- to three-page) autobiography.
______ 10. Emphasize goals and solutions rather than problems and causes.
______ 11. Give clients a homework assignment to be completed before they return for another session. This may include behavioral or cognitive self-monitoring or a solution-oriented exception assignment.
______ 12. After the initial session, write up a treatment plan that clients can sign at the beginning of the second session.

Prompting Clients to Stick With Essential Information

Using the limited-session intake-interviewing checklist provided in Table 7.2, work with a partner from class to streamline your intake interviewing skills. Therapists working in a managed care environment must stay focused and goal-directed throughout the intake interview. To maintain this crucial focus, it may be helpful to:
1. Inform your client in advance that you have only a limited amount of time and therefore must stick to essential issues or key factors.
2. If your client drifts into some less-essential area, gently redirect him or her by saying something such as:
“You know, I’d like to hear more about what your mother thinks about global warming (or whatever issue is being discussed), but because our time is limited, I’m going to ask you a different set of questions. Between this meeting and our next meeting, I want you to write me an autobiography—maybe a couple of pages about your personal history and experiences that have shaped your life. If you want, you can include some information about your mom in your autobiography and get it to me before our next session.”
Often, clients are willing to talk about particular issues at great length, but when asked to write about those issues, they’re much more succinct.
Overall, the key point is to politely prompt clients to only discuss essential and highly relevant information about themselves. Either before or after practicing this activity with your partner, see how many gentle prompts you can develop to facilitate managed care intake interviewing procedures.




What I’m Writing Today: CI5 Chapter 5

With a February 1 deadline looming, I’m in all out writing and editing mode. Today’s topic: Congruence. Below is an excerpt from the draft of the upcoming 5th edition of Clinical Interviewing. I gotta say, Congruence and Carl Rogers—good stuff—way better than any NFL playoff games:). I know, Empathy would be a little better, but you can’t always get what you want.

Here’s a glimpse of the opening of chapter 5: Evidence-Based Relationships in the Clinical Interview

In 1957, Carl Rogers made a bold declaration that has profoundly shaped research and practice in counseling and psychotherapy. He hypothesized in a Journal of Consulting Psychology article that no techniques or methods were needed, that diagnostic knowledge was “for the most part, a colossal waste of time” (1957, p. 102), and that all that was necessary and sufficient for therapeutic change to occur was a certain type of relationship between therapist and client.

Although we could go back further in time and note that Freud (of course) had originally discussed the potential value of therapeutic relationships, Rogers’s revolutionary statements refocused the profession. Until Rogers, therapy was primarily about theoretically-based methods, techniques, and interventions. After Rogers {{365 Rogers 1961; 690 Rogers 1957; 363 Rogers 1942;}}, we began thinking and talking about the possibility that it might be the relationship between client and therapist—not necessarily the methods and techniques employed—that produced therapeutic change.

For years, a great debate has fulminated within the counseling and psychotherapy disciplines {{499 Wampold 2001;}}. Norcross and Lambert (2011) refer to this debate as “The culture wars in psychotherapy” (p. 3). They describe it as a polarization or dichotomy captured by the question: “Do treatments cure disorders or do relationships heal people?” (p. 3). As academics and professional organizations have engaged in this debate, typically there has been little room for moderation and common sense. There have been assertions about the “rape” of psychotherapy as well as strong criticisms of practitioners who blithely ignore important empirical research {{4453 Baker,Timothy B. 2008; 5969 Fox, Ronald E. 1995;}}. The heat of this controversy continues, in part, because we live in a world with limited health care dollars . . . and the fight to determine which forms of therapy are included as “valid” and therefore reimbursable will likely continue.

But the focus of this chapter is about a part of the controversy that’s really no longer a controversy at all. In the past two decades excellent research and research reviews have settled at least one dimension of the argument. Evidence now overwhelming shows that therapy relationships do contribute to positive outcomes across all forms of therapy and setting {{2241 Goldfried 2007; 285 Sommers-Flanagan 2007; 4074 Norcross 2011;}}. The question is no longer a matter of whether the relationship in counseling and psychotherapy matters, but how much it matters.

This chapter focuses on what has come to be known as “evidence-based therapy relationships” {{5958 Norcross 2011;}}. Although organized around specific theories and supporting research, the chapter also provides clinical examples for how the theories and evidence translate into specific evidence-based relationship facilitating behaviors that occur in the clinical interview.

Carl Rogers’s Core Conditions

Carl Rogers (1942) believed that the necessary and sufficient therapeutic relationship consisted of three core conditions: (a) congruence, (b) unconditional positive regard, and (c) empathic understanding. In his words:

Thus, the relationship which I have found helpful is characterized by a sort of transparency on my part, in which my real feelings are evident; by an acceptance of this other person as a separate person with value in his own right; and by a deep empathic understanding which enables me to see his private world through his eyes. When these conditions are achieved, I become a companion to my client, accompanying him in the frightening search for himself, which he now feels free to undertake. (Rogers, 1961, p. 34)


Congruence means that a person’s thoughts, feelings, and behaviors match. Based on person-centered theory and therapy, congruence is less a skill and more an experience. Congruent therapists are described as genuine, authentic, and comfortable with themselves. Congruence includes spontaneity and honesty; it’s usually associated with the clinical skill of immediacy and involves some degree of self-disclosure (see Chapter 4).

Congruence is complex and has been described as “abstract and elusive” {{5961 Kolden, Gregory G. 2011;}} (p. 187). The ability to be congruent includes an internal dimension that involves clients being in touch with their inner feelings or real self plus an external or expressive dimension that involves therapists’ being able to articulate their internal experiences in ways that clients can understand. The following excerpt from Rogers’s work illustrates these internal and external dimensions of experiencing and expressing congruence:

We tend to express the outer edges of our feelings. That leaves us protected and makes the other person unsafe. We say, “This and this (which you did) hurt me.” We do not say, “This and this weakness of mine made me be hurt when you did this and this.”

To find this inward edge of my feelings, I need only ask myself, “Why?” When I find myself bored, angry, tense, hurt, at a loss, or worried, I ask myself, “Why?” Then, instead of “You bore me,” or “this makes me mad,” I find the “why” in me which makes it so. That is always more personal and positive, and much safer to express. Instead of “You bore me,” I find, “I want to hear more personally from you,” or, “You tell me what happened, but I want to hear also what it all meant to you.” (pp. 390-391)

Rogers also emphasized that congruent expression is important even if it consists of attitudes, thoughts, or feelings that don’t, on the surface, appear conducive to a good relationship. He’s suggesting that it’s acceptable—and even good—to speak about things that are difficult to talk about. However, as you can see from the preceding example, Rogers expected therapists to look inward and transform their negative feelings into more positive external expressions of congruence.

Guidelines for Using Congruence

When discussing congruence, students often wonder how this concept is manifest. Common questions include:

  • Does congruence mean I say what I’m really thinking in the session?
  • If I feel sexually attracted to a client, should I be “congruent” and share my feelings?
  • If I feel like touching a client, should I go ahead and touch?
  • What if I don’t like something a client does? Am I being incongruent if I don’t express my dislike?

These are important questions. Watson, Greenberg, & Lietaer {{4387 Greenberg,Leslie S. 1998;}} provided one way for determining the appropriateness of therapist transparency or congruence. They wrote: “. . . it is not necessary to share every aspect of [your] experience but only those that [you] feel would be facilitative of [your] clients’ work” (p. 9). This is a good initial guideline: Would the disclosure be facilitative? In fact, sometimes, too much self-disclosure—even in the service of congruence or authenticity—can muddy the assessment or therapeutic focus. Perhaps the key point is to maintain balance; the old psychoanalytic model of therapist as a blank screen can foster distrust, reluctance, and resistance, while too much self-disclosure can distort and degrade the therapeutic focus {{2454 Farber 2006;}}.

Rogers also suggested limits on congruence. He directly stated that therapy wasn’t a time for clinicians to talk about their own feelings:

Certainly the aim is not for the therapist to express or talk about his own feelings, but primarily that he should not be deceiving the client as to himself. At times he may need to talk about some of his own feelings (either to the client, or to a colleague or superior) if they are standing in the way. (pp. 133–134) {{760 Rogers 1958;}}

Let’s say you’re working with a client and you feel the impulse to congruently self-disclose in the moment. If you’re not sure your comment will be facilitative or whether it will keep the focus on the client (where the therapy focus belongs), then you shouldn’t disclose. Additionally, you should discuss ongoing struggles with self-disclosure with your peers or supervisors because by so doing, you’ll deepen your learning about how best to be congruent with clients.

Since the 1960s, feminist therapists have strongly advocated congruence or authenticity in interviewer-client relations. Brody {{331 Brody 1984;}} described the range of responses that an authentic therapist might use:

To be involved, to use myself as a variable in the process, entails using, from time to time, mimicry, provocation, joking, annoyance, analogies, or brief lectures. It also means utilizing my own and others’ physical behavior, sensations, emotional states, and reactions to me and others, and sharing a variety of intuitive responses. This is being authentic. (p. 17)

Brody is advocating many sophisticated and advanced therapeutic strategies; but keep in mind that she’s an experienced clinician. Authentic or congruent approaches to interviewing are best if combined with good clinical judgment, which is obtained, in part, through clinical experience.