Datasets:
introvoyz041
/
interviewing_and_change_strategies_for_helpers

Dataset card Data Studio Files Community
text
stringlengths
0
6.5k
source
stringclasses
1 value
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Sherry Cormier West Virginia University Paula S. Nuriu S University of Washington Cy Nthia J. o Sbor N Kent State University Interviewing and Change Strategies for Helpers 8e Australia ● Brazil ● Mexico ● Singapore ● United Kingdom ● United States Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
This is an electronic version of the print textbook. Due to electronic rights restrictions, some third party content may be suppressed. Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. The publisher reserves the right to remove content from this title at any time if subsequent rights restrictions require it. For valuable information on pricing, previous editions, changes to current editions, and alternate formats, please visit www. cengage. com/highered to search by ISBN#, author, title, or keyword for materials in your areas of interest. Important Notice: Media content referenced within the product description or the product text may not be available in the e Book version. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
© 2017, 2013, Cengage Learning ALL RIGHTS RESERVED. No part of this work covered by the copyright herein may be reproduced or distributed in any form or by any means, except as permitted by U. S. copyright law, without the prior written permission of the copyright owner. Library of Congress Control Number: 2015959070 Student Edition: ISBN: 978-1-305-27145-6 Loose-leaf Edition: ISBN: 978-1-305-86641-6 Cengage Learning 20 Channel Center Street Boston, MA 02210 USA Cengage Learning is a leading provider of customized learning solutions with employees residing in nearly 40 different countries and sales in more than 125 countries around the world.  Find your local representative at www. cengage. com Cengage Learning products are represented in Canada by Nelson Education, Ltd. To learn more about Cengage Learning Solutions, visit www. cengage. com Purchase any of our products at your local college store or at our preferred online store www. cengagebrain. com Interviewing and Change Strategies for Helpers, Eighth Edition Sherry Cormier, Paula S. Nurius, Cynthia J.  Osborn Product Director: Jon David Hague Product Manager: Julie Martinez Content Developer: Elizabeth Momb Product Assistant: Stephen Lagos Marketing Manager: Margaux Cameron Content Project Manager: Rita Jaramillo Art Director: Vernon Boes Manufacturing Planner: Judy Inouye Production Service: Charu Khanna at MPS Limited Text and Cover Designer: John Walker Cover Image: Garry Gay/Getty Images Compositor: MPS Limited For product information and technology assistance, contact us at Cengage Learning Customer & Sales Support, 1-800-354-9706 For permission to use material from this text or product, submit all requests online at www. cengage. com/permissions Further permissions questions can be e-mailed to permissionrequest@cengage. com Printed in the United States of America Print Number: 01 Print Year: 2016WCN: 02-300 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
In memory of Sherry's parents, Bill and Edith Keucher, Sherry's spouse, Jay H. Fast, Paula's mother, Gwyndolyn Medley Garner, and Cynthia's parents, Noel and Emma Ruth Osborn; and in honor of Dick Mitchell, Cynthia's spouse, and Bill Garner, Paula's brother, with grateful appreciation and affection. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
v Sherry Cormier is Professor Emerita in the Department of Counseling, Rehabilitation Counseling, and Counseling Psychology at West Virginia University in Morgantown, West Virginia. She is a licensed psychologist in the state of West Virginia. Her current research and practice interests are in counseling and psychology training and supervision models, health, wellness, stress management, and grief recovery. She is the mother of two 30-something daughters and the grandmother of a 10-year-old granddaughter. She enjoys yoga, walks on the beach, and kayaking in her Chesapeake Bay community. Paula S. Nurius is the Grace Beals Ferguson Scholar, Professor, and Associate Dean in the School of Social Work at the University of Washington in Seattle. Dr. Nurius is a mental health specialist with research, practice, and teaching addressing perception and responding under conditions of stress and trauma. She brings particular concern for vulnerable, marginalized populations and toward fostering prevention and resilience-enhancing interventions. Her current scholarship focuses on childhood and cumulative life course stress, including impacts of maltreatment, nonviolent adversity, and poverty on physical, mental, and behavioral health disparities. She enjoys the outdoor life of the Pacific Northwest with her husband, daughter, and schnoodle pooch. Cynthia J. Osborn is Professor of Counselor Education and Supervision at Kent State University in Kent, Ohio. She is a licensed professional clinical counselor and a licensed chemical dependency counselor in Ohio. Her research, clinical practice, and teaching have focused on addictive behaviors and counselor supervision from the perspectives of motivational interviewing and solution-focused therapy. Additional scholarship has addressed case conceptualization and treatment planning skills and stamina and resilience in behavioral health care. She enjoys reading character novels and practicing yoga, and she and her husband together enjoy exercising and the company of their Bichon Frisé dog, Jake. About the Authors Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
vii Contents Preface xi Chapter 1 Building Your Foundation as a Helper 1 Learning Outcomes 1 The Chambered Nautilus 1A Practice Nexus for the Helping Professions 2Four Stages of Helping 2Core Skills and Attributes 4Effectiveness and Accountability 15Evidence-Based Practice 16Concerns, Critiques, and Caveats of Evidence-Based Practice 20 Multiculturalism and Evidence-Based Practice 21Adapting and Adopting Evidence-Based Practices 24Innovations with Integrity 25Chapter Summary 28Knowledge and Skill Builder 29Knowledge and Skill Builder Feedback 33 Chapter 2 Critical Commitments 35 Learning Outcomes 35Toward Skillful Practice 35Growing Into Professional Competence 36Four Critical Commitments 37Diversity Issues 45Multicultural Counseling and Therapy 47Practicing Idiographically 48Beyond Multicultural Competencies to Cultural Attunement 54 Ethical Practice 55Ethical Decision-Making Models 70Chapter Summary 71Knowledge and Skill Builder 73Knowledge and Skill Builder Feedback 75 Chapter 3 Ingredients of an Effective Helping Relationship 76 Learning Outcomes 76 The Importance of the Helping Relationship 76Empirical Support for the Helping Relationship 77Cultural Variables in the Helping Relationship 78Facilitative Conditions 79The Working Alliance 90Transference and Countertransference 93Chapter Summary 101Knowledge and Skill Builder 102Knowledge and Skill Builder Feedback 104 Chapter 4 Listening 105 Learning Outcomes 105Three Steps of Listening 106Listening to Clients' Stories 107Listening to Clients' Nonverbal Behavior 107Four Listening Responses 112 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
viii Contents The Clarification Response: Listening for Accuracy 113 Paraphrase and Reflection: Listening for Facts and Feelings 114 Summarization: Listening for Patterns and Themes 126Listening to Diverse Groups of Clients 128Distractions and Distractability: Listening to Yourself 131Chapter Summary 133Knowledge and Skill Builder 136Knowledge and Skill Builder Feedback 138 Chapter 5 Influencing Responses 139 Learning Outcomes 139Social Influence In Helping 139Influencing Responses and Timing 140What Does Influencing Require of Helpers? 140Six Influencing Responses 141Sequencing of Influencing Responses In Interviews 141Questions 143Information Giving 146Self-Disclosure 149Immediacy 156Interpretations and Additive/Advanced Empathy 159Confrontation/Challenge 163Skill Integration: Putting it all Together! 170Chapter Summary 170Knowledge and Skill Builder 171Knowledge and Skill Builder Feedback 176 Chapter 6 Assessing and Conceptualizing Client Problems and Contexts 177 Learning Outcomes 177 Client Statements 177What Is Clinical Assessment? 177Our Assumptions About Clinical Assessment 178Functional Assessment: The ABC Model and Chain Analysis 186 Diagnostic Classification of Client Issues 193Limitations of Diagnosis: Categories, Labels, and Gender/Multicultural Biases 196 Mental Status Examination 197Diagnostic Interviewing 198Sensitive Subjects and Risk Assessment in Diagnostic Interviewing 199 Intake Interviews and History 201Cultural Issues in Intake and Assessment Interviews 205Putting it all Together: Evidence-Based Assessment and Conceptualization 207 Model Case: Conceptualizing 207Chapter Summary 212Knowledge and Skill Builder 213Knowledge and Skill Builder Feedback 214 Chapter 7 Conducting an Interview Assessment with Clients 215 Learning Outcomes 215 Assessment Interviewing 215Eleven Categories for Assessing Clients 216Limitations of Interview Leads in Assessment 232Model Dialogue: Interview Assessment 234Chapter Summary 242Knowledge and Skill Builder 243Knowledge and Skill Builder Feedback 250 Chapter 8 Constructing, Contextualizing, and Evaluating Treatment Goals 251 Learning Outcomes 251 Personal Reflection Activity 251Where Are We Headed? 251Beginning With The End in Mind 252Purposes of Treatment Goals 252Characteristics of Well-Constructed Treatment Goals 254Support for Goal Characteristics 258Cultural Considerations 258The Process of Change 261Collaborative Construction of Treatment Goals 267 Model Dialogue: Goal Formulation 269Contextualizing Treatment Goals 273First Things First: Prioritizing and Sequencing Goals 276 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Contents ix Working With Resistance, Reactance, Reluctance, and Ambivalence 346 Solution-Focused Therapy 347 Model Dialogue: Deconstructing Solutions 355Motivational Interviewing 357Model Dialogue: Affirming, Emphasizing Autonomy, and Advising only with Permission 368 Applications of SFT and MI with Diverse Groups 370Chapter Summary 372Knowledge and Skill Builder 374Knowledge and Skill Builder Feedback 377 Chapter 11 Cognitive Change Strategies 379 Learning Outcomes 379 An Overview of the Theoretical Framework 380Reframing 382Reframing Components 383Reframing with Diverse Clients 386Cognitive Modeling Components 386Model Dialogue: Cognitive Modeling 389Cognitive Restructuring 392Cognitive Restructuring Components 392Some Caveats 406Cognitive Change Strategies with Diverse Clients 406 Model Dialogue: Cognitive Restructuring 409Integrative Interventions: Linkages of ACT and DBT with Cognitive Change Strategies 412 Chapter Summary 414Knowledge and Skill Builder 416Knowledge and Skill Builder Feedback 423 Chapter 12 Cognitive Approaches to Stress Management 425 Learning Outcomes 425 Stress and Coping 425Cultural, Socioeconomic, and Discrimination Variations in Stress 430 Spirituality Considerations 431Problem-Solving Therapy 432Problem-Solving Therapy Components 433Running Interference by Addressing Obstacles 278 Identifying Resources to Facilitate Goal Achievement 279 Evaluating Treatment Process and Outcomes 279What to Evaluate 280How to Evaluate 282When to Evaluate 285Treatment Evaluation Pointers 288Model Dialogue: Evaluating Progress 288Chapter Summary 293Knowledge and Skill Builder 295Knowledge and Skill Builder Feedback 301 Chapter 9 Clinical Decision-Making and Treatment Planning 302 Learning Outcomes 302 Treatment Planning Purpose and Benefits 302Common Factors and Specific Ingredients of Treatment 303 Factors Affecting Treatment Selection 304Evidence-Based Practice and Treatment Planning 311Models of Treatment-Client Matching 312Planning for Type, Duration, and Mode of Treatment 314 Cultural Issues in Treatment Planning and Selection 317Intentional Integration of Cultural Interventions 319The Process of Treatment Planning 325Model Dialogue: Exploring Treatment Strategies 329Chapter Summary 332Knowledge and Skill Builder 333Knowledge and Skill Builder Feedback 335 Chapter 10 Models for Working with Resistance 336 Learning Outcomes 336 Partnering with Client Experience 336Resistance, Reactance, Reluctance, and Ambivalence 336 Two Models for Working with Resistance 341Research on Solution-Focused Therapy (SFT) and Motivational Interviewing (MI) 342 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
x Contents Research with Diverse and Vulnerable Groups 519 Virtual Reality 522Pharmacotherapy to Enhance Exposure 522Model Dialogue for Exposure Therapy 523Chapter Summary 525Knowledge and Skill Builder 526Knowledge and Skill Builder Feedback 527 Chapter 15 Self-Management Strategies 528 Learning Outcomes 528Terminology and Areas of Focus 528Steps in Developing Self-Management Programs 529Characteristics of Effective Self-Management Programs 531 Self-Monitoring Overview 532Components of Self-Monitoring 535Model Example: Self-Monitoring 540Stimulus Control Components 541Model Example: Stimulus Control 544Self-Reward Overview 545Self-Reward Components 546Caveats with Applying Self-Reward Strategies 550Model Example: Self-Reward 550Self-Efficacy Overview 550Sources of Self-Efficacy 551Summary 555Model Example: Self-Efficacy 556Applications of Self-Management with Diverse Groups and Types of Problems 557 Guidelines for Using Self-Management with Diverse Groups of Clients 559 Self-Management as a Professional Aide for Helpers 560Chapter Summary 561Knowledge and Skill Builder 562Knowledge and Skill Builder Feedback 563 References 565 Name index 621Subject index 641Problem-Solving with Diverse Clients 440 Model Example: Problem-Solving Therapy 441Stress Inoculation Training: An Integrative Clinical Approach 443 Stress Inoculation Training Components 443Model Dialogue: Stress Inoculation 450Chapter Summary 452Knowledge and Skill Builder 453Knowledge and Skill Builder Feedback 459 Chapter 13 Self-Calming Approaches to Stress Management 460 Learning Outcomes 460 The Physiology of Breathing and Stress 460A Focus on Diaphragmatic Breathing 461Caveats with Diaphragmatic Breathing 463Muscle Relaxation 464Muscle Relaxation Procedure 465Caveats with Muscle Relaxation 471Model Dialogue: Muscle Relaxation 471Meditation: Processes and Uses 472Mindfulness Meditation Procedure 475Caveats with Meditation 479Model Example of Mindfulness Meditation 481Applications of Meditation for Diverse Issues and with Diverse Clients 483 Chapter Summary 484Knowledge and Skill Builder 485Knowledge and Skill Builder Feedback 490 Chapter 14 Exposure Therapy for Anxiety, Fear, and Trauma 491 Learning Outcomes 491 What Is Exposure? 492Theoretical Background for Exposure 494Components and Processes of Exposure Therapy 497Gradual Exposure 505Intensive Exposure 512Collaborative Considerations in Conducting Exposure 514 Caveats about Exposure 517 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
xi Preface The eighth edition of Interviewing and Change Strategies for Helpers reflects a number of changes. The new edi-tion represents a blending of our collective expertise in counseling, psychology, social work, and health and hu-man services. Our partnership in these interdisciplinary areas augments the book's responsiveness to the unique perspectives of each discipline while also working at the interface or nexus, addressing cross-cutting issues and commitments. This book is intended to be used by helpers who are trained in a variety of health and helping-oriented disciplines, including counseling, social work, psychol-ogy, human services, and related professions. We recog-nize that terminology varies across settings. You will see the term helper as well as practitioner, clinician, therapist, and service provider used throughout the book. One of the fundamental changes we have made in this edition is in response to continued requests for a streamlined book that can be used with relative ease in the parameters of several quarters or a given semester. Our Conceptual Foundation Our conceptual foundation, which we describe in Chapters 1 and 2, reflects four critical areas for helpers from various disciplines: (1) core skills and attributes; (2) effectiveness and evidence-based practice; (3) diversity issues; and (4) critical commitments and ethical practice. The core skills that we present cut across all helping disciplines and in this edition we present them in Chapters 3, 4, and 5. Diversity issues and ecological models are presented in Chapters 2, 6, and 7, and also are integrated throughout the book. Evidence-based assessment and its implementation in the interviewing process are described in Chapters 6 and 7. Effectiveness and evidence-based practice is introduced in Chapter 1 and presented again in Chapters 8 and 9. Chapters 10 through 15 give special attention to research supporting the application of change strategies to diverse groups and the importance of culture and context in applying these and other helping strategies. Recognizing the enormous influence of evidence-based expectations on contem-porary practice, we have incorporated current findings into each of our chapters on various change strategies (Chapters 10 through 15). Layered across all of this is the fourth area of our con-ceptual model: critical thinking and ethical judgment. We focus on this area specifically in Chapters 1 and 2 and explore these topics again throughout the remainder of the book because they permeate all of the decisions that helpers face at each phase of the helping process, from establishing the helping relationship, to assessing client problems, setting treatment goals, and selecting, using, and evaluating change intervention strategies. Many users of the text have indicated that combining major stages of the helping process with specific change strategies facili-tates integration within and across courses that aim for this bigger picture and is also beneficial for students. Built-In and Supplemental Instructional Guides: Features of the Book We have retained the specific features of the text that we have learned through feedback make it invaluable as a resource guide—and we have taken this emphasis a step further. We have worked to distinguish this teaching text by providing a rich array of built-in exercises, exem-plars, and tools to promote and evaluate student com-prehension. The book balances attention to conceptual and empirical foundations with an emphasis on real-life factors in practice settings and ample use of examples and how-to guidelines. In addition, consistent with the out-come emphasis of accreditation standards of counseling, Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
xii Preface 2. The longstanding commitment of this book to valu-ing human diversity is commensurate with its estab-lished commitment to consulting and incorporating scientific research. In many ways, this edition reflects a healthy dialectic or tension between science and in-novation, empiricism, and improvisation. And it is this both/and approach, this practice of living and work-ing in between polarities, that has spawned integrative therapies such as dialectical behavior therapy (DBT), an evidence-based practice that we draw from through-out the chapters. 3. Chapter 1 showcases the symbolism of the cham-bered nautilus featured on the cover of the book and introduces readers to the practice nexus featured on the inside cover of the book. In the first half of the chapter, the first component of the practice nexus is discussed. Specifically, four core skills and attributes (self-awareness and self-reflection, mindfulness, self-care, and self-compassion) are presented and discussed as a means of promoting helper stamina and resilience. In the second half of the chapter, the second compo-nent of the practice nexus, effectiveness, is highlighted. In this section extensive discussion is devoted to evi-dence-based practice (EBP). This discussion includes criticisms of EBP as well as continued efforts to adapt EBP to culturally diverse populations. A listing of culturally adaptive interventions to EBP is provided, along with examples of such adaptation. 4. The third and fourth components of the practice nexus are the focus of Chapter 2: critical commitments (including ethical practice) and diversity issues. We dis-cuss four critical commitments professional helpers are encouraged to make to grow into clinical competence: commitment to lifelong learning; commitment to col-laboration; commitment to values-based practice; and commitment to beneficence. The section on diversity issues includes prominent and newer frameworks for working with culturally diverse populations, such as the more idiosyncratic focus on the intersection of multiple identities proposed by feminist multicultural scholars. The ethical issues section includes updates from profes-sional codes of ethics and a new section on telepractice, with a corresponding new learning activity. 5. Consideration of the therapeutic relationship has been expanded (Chapter 3) to include the ever-expanding empirical basis for various relationship conditions toward increasing effectiveness. New additions to this chapter include the additional evidence base for helper empathy, the working alliance, and relation-ship ruptures, as well as an expanded discussion of microaggressions and the therapeutic relationship and invalidating environments. psychology, social work, and human services, chapters are guided by learning outcomes and opportunities to practice with numerous learning activities and guided feedback. Model cases and dialogues are given in each chapter, as well as end-of-chapter evaluations (referred to as “Knowledge and Skill Builders”) with feedback de-signed to help assess chapter competencies. In addition, we have developed a range of supplemen-tary materials to enrich the teaching experience. These include an instructor's manual, a bank of test questions (which can be used by instructors for course exams or by students in later preparing for accrediting exams), and Power Point slides for each chapter. Brand new to this edition, Mind Tap® is the digital learning solution that helps instructors engage and trans-form today's students into critical thinkers. Through paths of dynamic assignments and applications that you can personalize, real-time course analytics, and an acces-sible reader, Mind Tap helps you turn your students into higher-level thinkers. Your students become practitioners of their own learning as they master practical skills and build professional confidence. Students will be engaged in a scaffolded learning experience designed to move their thinking skills from lower-order to higher-order by rein-forcing learned skills and concepts through demonstrated application. New to the Eighth Edition With sensitivity to the value of using a book within a semes-ter or two-quarter framework, we have worked for a more streamlined book in this edition. We have retained the same organizing structure and skill-building components that adopters have long valued, and provide some integrated and distilled content to provide an up-to-date compendium of interviewing and change practices applicable across a range of settings and clientele. Throughout, we aim to build on recent clinical evidence and to point to emerging develop-ments relevant to instruction in clinical services. 1. In this edition we increased this book's enduring commitment to working with diverse groups. This includes further attention to working with youth, older adults, and sexual minorities, in addition to diversity implications related to gender, race/ethnicity, religion, immigration, and disability. Although this book is focused predominantly on individual change (e. g., strengthening problem-solving, adaptive coping, self-efficacy, management of long-term problems or conditions), we have aimed to strengthen attention to the importance of context and the frequent role of environmental sources of stress and injustices. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Preface xiii amplify the discussion of the multiple levels of processes involved in the development and operation of schemas involved in psychological disorders. This material il-lustrates ways that biological factors such as genetics, brain functioning, and physiology are systematically linked with cognitive and emotional factors, which then interplay with interpersonal, environmental, and behavioral factors in both the development of and in-tervention with psychological problems. Here we also update information about schema development and schema therapy, about new intervention findings for cognitive change strategies with diverse populations, and about developments of cognitive strategies with acceptance and commitment therapy (ACT) and DBT. 14. Stress is among the universally shared struggles of clients. Therefore, we have emphasized stress as a criti-cal set of factors in the development of problems and in understanding ways that change strategies must address stress. In Chapter 12 we describe cultural, socioeconomic, and life course implications of stress. We update findings regarding neurophysiological pathways through which stress becomes embodied, leading to physical and mental health impairment. We update interventions applied with diverse groups, including attention to minority stress. We update de-velopment in stress inoculation and problem-solving therapies including incorporation of emotional mind-fulness techniques. 15. In Chapter 13 we have expanded attention to the growing evidence support for stress management, par-ticularly mindfulness-based practices. Here we provide an illustration of recent applications across a range of child and adult populations as well as settings (e. g., workplace) and contexts of helping. We also update ways that mindfulness constructs and meditation are being incorporated across a range of interventions, including mindfulness-based stress reduction, mind-fulness-based cognitive therapy, DBT, and ACT. 16. In Chapter 14 we provide updates on extension learn-ing and increased focus on prolonged exposure ther-apy, including applications with military veterans and cultural minority groups. This chapter also provides updates on virtual reality exposure therapies as well as additional coverage of clinical issues related to safety behaviors, return of fear, dropout, and fear tolerance. 17. In Chapter 15 we describe new uses of the Inter-net and technological devices to support longer-term self-management interventions, which are particularly valuable for clients with special needs, when people are more distant from services or support communities, or when access to immediate help is needed. This chapter includes numerous literature updates on each of the 6. Chapter 4 includes an expanded discussion of the processes of listening as well as updated evidence-based literature on the listening responses, particularly reflec-tion of feeling. 7. Chapter 5, Influencing Responses, includes an up-dated evidence base for the influencing responses, particularly self-disclosure. It also includes a new dis-cussion of the effects of self-disclosure and environ-mental settings, technology, and information giving, and a new section integrated into the chapter and the Knowledge and Skill Builder on Skill Integration. 8. Chapter 6 focuses more broadly now on both clinical and evidence-based assessment. The material on the person-in-environment model has been updated and the functional assessment model has been expanded and includes new examples and new content regard-ing chain analysis, which is a component of dialecti-cal behavior therapy. An entirely new section on the DSM-5 is also described in Chapter 6. This chapter also includes expanded coverage of conducting risk assessment in diagnostic interviewing and expanded coverage of mental status interviewing. 9. Chapter 7 describes the implementation of evidence-based assessment in the interviewing process. This chapter includes expanded coverage of clients' indi-vidual and environmental strengths and resources as well as functional analyses assessment queries. Case examples have been changed to reflect current DSM-5 diagnoses. 10. The purpose and process of developing treatment goals are described in Chapter 8, as are characteristics of well-constructed goals. Stage models (e. g., stages of change model) are introduced to assist with the se-quential and collaborative task of treatment planning. The process of further refining—or contextualizing—treatment goals is likened to preparing for a journey and includes references to easy-to-use and evidence-based client assessment measures. 11. Chapter 9 is devoted to clinical decision-making and treatment planning. Updates include an expansion of client and helper factors contributing to client change, references to the newest addition of The ASAM Crite-ria used to match clients to levels of care, and resources for intentionally integrating cultural interventions. 12. Strategies of working through various forms of re-sistance, as well as client ambivalence, are found in Chapter 10. These strategies are informed by solution-focused therapy and motivational interviewing, two approaches whose respective research base has been expanded in this edition. 13. The science underlying cognitive therapies is dem-onstrating increasing complexity. In Chapter 11 we Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
xiv Preface categories of self-management, illustrating the rapid growth in populations and problem foci to which they are applied, including helping professionals managing complex and stressful work environments. The instructor's manual is authored by Penny Minor, a Ph D degree candidate in Counselor Education and Su-pervision at Kent State University and a licensed profes-sional clinical counselor in Ohio. She also developed the test bank of questions for each chapter and the assessment that is available in Mind Tap. We also offer a resource that can be used for in-class or online teaching formats: a compendium of Power Point slides covering major points within each chapter. (These supplements are available to qualified adopters through the instructor section of the Cengage Learning website. Please consult your local sales representative for details. ) This edition also features Cengage Helper Studio training videos in helping skills which Sherry Cormier and Cynthia Osborn developed and produced as a part of Mind Tap. People We Acknowledge Over the years, we have been asked, “What is it like to put together a book like this?” Our first response is always, “We require a lot of help. ” For this edition we are indebted to a number of people for their wonderful help: to Penny Minor, Kent State University Ph D degree candidate in Counselor Education and Supervision, for preparation of the instructor's manual, test bank, and Power Point slide resources; Kelly Martin-Vegue (University of Washington MSW student) for her invaluable insights, recommenda-tions, and contributions from a consumer perspective; and to Dr. Daniel Mc Neil and Dr. Brandon Kyle for their col-laborative authoring of Chapter 14 on exposure therapy. We are very grateful to the staff at Cengage Learning, particularly to our current editor, Julie Martinez, for her commitment, enthusiasm, and wisdom. The final form of this book as you, the reader, now see it would not have been possible without the superb efforts of the entire Cengage Learning team, especially our content develop-ers: Mary Noel, Stefanie Chase, and Elizabeth Momb. We also acknowledge with gratitude the contribution of our manuscript reviewers, who include the following: Akira Otani, Ed. D, Spectrum Behavioral Health Center Edward Keane, Ph. D., Housatonic Community College Susan Adams, Ph. D., Texas Woman's University Jacqueline Persons, Ph. D., University of California, Berkeley Daniel W. Mc Neil, Ph. D., West Virginia University Brandon N. Kyle, Ph. D., East Carolina University To all of you: Many thanks! We could not have done this without your careful and detailed comments and suggestions. Sherry Cormier, Paula S. Nurius, and Cynthia J. Osborn Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
1 Building Your Foundation as a Helper The Chambered Nautilus The story of the sea snail or mollusk that makes its home in the spiral-shaped nautilus shell is fascinating and compelling. It captures well the primary message of this book—change and growth. An inside and lateral, or “sliced,” view of three empty nautilus shells is showcased on the cover of the book. We ask that you pause now to look at the designs of all three. Spend a few moments in-specting their shapes. Notice first the spiral formation of each shell, which has its beginning at the center. Also no-tice that the shell comprises successively larger compart-ments or chambers. Each chamber was where the mollusk lived at one time. As it grew, it created a new, larger living space. It is because of these chambers that this sea creature is often referred to as the chambered nautilus. The chambered nautilus is in the family of cephalopods that also includes the octopus and squid. Unlike some of its close relatives, however, the nautilus does not discard an outgrown shell in search of a larger one. Rather, it retains its shell throughout its adult life. As the mollusk grows, it forms a new and larger chamber to accommo-date its size. In other words, it builds on its foundation. In so doing, it seals off the last chamber. Its entire life is therefore dominated by the production of one new living chamber after another, each new chamber connected to earlier ones and a part of an ever-enlarging and stronger shell. How this is done remains a mystery. Nixon and Young (2003) state, “This process of forward movement is not understood but does involve the repositioning of the muscles that attach the animal to its shell” (p. 36). In other words, the growth and development of the cham-bered nautilus is ongoing and requires a firm foundation, strength, determination, perseverance, and flexibility. The mollusk lives in only one chamber at a time—in the largest and last chamber of the shell. It firmly anchors itself to the shell by a pair of powerful muscles. It moves around the ocean depths entirely by jet propulsion and uses the empty chambers it once called home for buoyancy. Despite this buoyancy that allows it to move laterally with the ocean currents, the nautilus is able to travel vertical distances of up to 2,000 feet per day. This is made possible by the mollusk using the muscles in its body and tentacles to draw in and expel seawater. It is quite the strong, resilient, and versatile animal! This is one of the reasons the nautilus has been referred to as the “survivor” (Boyle & Rodhouse, 2005, p. 50). We encourage you to spend some time viewing some amazing videos on www. You T ube. com of living nautiluses. Simply search by using the key words “chambered nautilus. ” Learning Outcomes After completing this chapter, you will be able to 1. Recognize, in writing, using dialogue from a counseling supervision session, one example each of the need for developing the core helper skills of: (a) self-awareness and self-reflection; (b) mindfulness; and (c) self-care and self-compassion. You also will be able to identify one specific activity for developing each of these three skills to promote stamina and resilience as a professional helper. 2. Define evidence-based practice (EBP) from a list of descriptors provided (what it is and what it is not), identify two of its in-tended benefits and at least two of its criticisms, and identify at least six methods for adapting EBPs for culturally diverse populations. chapter 1 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
2 Chapter 1 nautilus and its spiral-shaped shell can inspire helpers and clients alike in the process of change and growth. A Practice Nexus for the Helping Professions During the approximately 35-year history of this book, we have learned quite a bit from our readers and from the changing fields of practice, and our approach has evolved as a result. In Figure 1. 1 we illustrate the unique nature of this text in terms of today's practice nexus—the interrela-tion, connections, and interfaces of our field. These might be likened to the interrelationships among the chambers of the nautilus shell. The figure depicts the relatedness and connection among the four major components of practice knowledge: (1) core skills and attributes; (2) effectiveness and accountability; (3) critical commit-ments; and (4) diversity. The components come together to define the central core of what you need for today's practice. So we focus on the interface—the area of over-lap among the components of practice knowledge—to provide a coherent and unifying foundation. As the figure shows, each component contains specialized content that you will pursue to greater or lesser degrees, depending on the need. And as you specialize, you will certainly find other components of practice that you will need to master. The totality of it all will develop over years of practice, ongoing training, receiving feedback from clients and col-leagues, and self-reflection. To begin, however, you need core content, an understanding of the interrelations, and practical as well as conceptual understanding. Four Stages of Helping The four components of today's practice nexus are ad-dressed in the 15 chapters of this book and are part of four primary stages of helping: 1. Establishing an effective therapeutic relationship2. Assessment and goal setting3. Strategy selection and implementation4. Evaluation and termination The first stage of the helping process, establishing an effective therapeutic relationship with the client, is based primarily on client-centered or person-centered therapy (Rogers, 1951). We present skills for this stage in Chapters 3-5. The potential value of a sound relationship As we have learned more about the chambered nautilus, we cannot help but make some comparisons to helping professionals, and to our helping professions. We believe skilled and effective helpers are part of a professional community yet are also one of a kind. Each helper is his or her own person, not a replica of a supervisor or some-one working intently to be just like Carl Rogers, Aaron Beck, or Marsha Linehan. In addition, helpers make use of their buoyancy to “go with the flow” as needed, for example, by cooperating with clients and supervisors and by implementing a recently learned evidence-based prac-tice (EBP). At the same time, however, skilled helpers also know when to “go against the current. ” This means that they stretch themselves by doing something uncustom-ary and perhaps uncomfortable at first, such as sitting in silence with a client or interrupting a client when needed. Like the chambered nautilus, the professional helper's vertical travel also suggests the deliberate use of clinically trained muscles in search of new ideas and better alternatives for clients, all the while remaining immersed in the necessity of ethical practice. An example of this is modifying an EBP to accommodate the cultural values, traditions, and needs of a particular client or client popu-lation, a practice consistent with the culturally affirmative services we discuss in Chapter 2. Just as the chambered nautilus retains its shell and builds on its former living compartments, effective helpers use their life experiences and graduate training to build a strong foundation on which to grow and fashion a level of expertise in their work. In so doing, they remain resource-ful and inventive. This parallels the forward movement of the nautilus, which involves the flexing and repositioning of its muscles to adapt to new living and work environ-ments. Professional helpers can be like the strong and resilient nautilus by concentrating on the present moment and the current living environment while leaning into and preparing for the next stage of growth. This means that retreating to previous chambers is not possible—they no longer fit. Likewise, sticking to (or remaining stuck in) customary practice and “same-old, same-old” ways of thinking results in a stifling work environment, in addi-tion to ethical vulnerability, burnout, and ineffective care. Just like the nautilus, we have no choice but to move on because change and growth are constant. The spiral shape of the nautilus shell suggests that the mollusk can keep growing forever. This also is true for professional helpers! We hope the skills, strategies, and interventions described in this book will assist professional helpers to guide their clients step by step in the construction of new, more ac-commodating, and healthier living spaces using existing re-sources and strengths. Perhaps the maturing and determined Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 3 relationship part of therapy is necessary but not sufficient to help them with the kinds of choices and changes they seek to make. These clients need additional kinds of ac-tion or intervention strategies. The second stage of helping, assessment and goal setting, often begins with or soon after establishing a therapeutic relationship. In these first two stages, the practitioner is interested mainly in helping clients explore their concerns and wishes. Assessment is designed as a collaborative endeavor, a joint undertaking intended to help the clinician and client obtain a better picture, idea, or grasp of what is happening with the client and what prompted the client to seek the services of a helper at this base cannot be overlooked. Research has consistently noted that the therapeutic relationship accounts for a substantial amount of client change, approximately 30% (Lambert, 1992). This is understandable given that the relationship is the specific part of the process that conveys the helper's interest in and acceptance of the client as a unique and worthwhile person. It is the foundation for—or the container of—all subsequent therapeutic work. The helper's validation of the client can be empowering, generating hope the client may not have experienced in a very long time. For some clients, working with a profes-sional helper who stays primarily in this stage of help-ing may be useful and sufficient. For other clients, the relevance applicability practice practice vulnera ble, and underser ved populations environment Multiprofessional Multiproblem Evidence-based Collaborative Oppressed, Person in Ethics in practice Critical thinking Interviewing and Change Strategies fo r Helpers Critical Commitments Diversity Effectiveness and Accountability Core Skills and Attributes Figure 1. 1 A Practice Nexus for Today's Helping Professional Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
4 Chapter 1 time. Think of this stage as the client and helper locating the horizon for the client's journey of change and also determining the compass to be used to indicate progress toward reaching the client's preferred destination. The in-formation gleaned from assessment is extremely valuable in planning strategies. It provides clarity and direction. It also can be used to manage resistance or occasions when client and helper do not agree or encounter an impasse. We describe assessment skills and strategies in Chapters 6 and 7. As the problems and issues are identified and de-fined, the practitioner and client also work through the process of developing outcome goals. The skill of treat-ment goal formulation is described in Chapter 8. Strategy selection and implementation is the third stage of helping. The clinician's task at this point is to help with client understanding and related action. Insight can be useful, but insight alone is far less useful than insight accompanied by a supporting plan that helps the client translate new or different understandings into observable and specific actions or behaviors. Insight also is a Western and individualistic concept that may not apply or be use-ful to many culturally diverse clients. Think of this stage of helping as the skill-building phase when clients, like the chambered nautilus, are learning about and using new or reconfigured muscles to sustain a healthier living environment or to construct a new one. Toward this end, the helper and client select and sequence a plan of action: intervention strategies that are based on the assessment data and are designed to help the client achieve the des-ignated goals. In developing action plans, it is important to select plans that relate to the identified concerns and goals and that are not in conflict with the client's primary beliefs and values (see Chapters 9-15). The last stage of helping, evaluation and termina-tion, involves assessing the effectiveness of interventions used—as well as the therapist's style in facilitating the process of change—and the progress the client has made toward the desired goals (see Chapters 8-10). This kind of evaluation assists you in knowing when to terminate the process or to revamp your initial action plans. Also, clients can easily become discouraged during the change process, realizing that transferring the skills learned in counseling to various aspects of their lives is a challenge. Social supports may not be in place, necessitating the development of new and healthier relationships. Clients often find observable and concrete signs of progress to be quite reinforcing. Our listing of evaluation as the last stage of helping can inadvertently suggest that gauging effectiveness comes near the end of counseling. This is far from the truth. If we are not making effective progress in developing a col-laborative, therapeutic relationship or in understanding the perspective of a client early on in our work, then we need to be aware of this right away. In reality, we need to be intentionally evaluating effectiveness throughout the helping process, sharing our observations with clients, soliciting their feedback, and negotiating a plan of care. These four stages of helping are not discrete. Actually, there is quite a bit of flow and interrelationship among the four stages. In other words, elements of these stages are present throughout the helping process, with varying degrees of emphasis. Change rarely follows a predict-able path. Clients encounter challenges and setbacks as they implement new behaviors. Symptoms may not abate quickly or respond well to preliminary interventions. A revision of the initial plan of care is not uncommon. The foci and tasks of each stage of helping thus are not confined to that stage. This also is true of the four com-ponents of the practice nexus. Their interrelationship is a constant throughout our work with clients. We ask now that you return your gaze to Figure 1. 1. T wo components of the practice nexus—core skills and attributes and effectiveness and accountability—are the focus of this first chapter. The remaining two compo-nents—critical commitments (including ethical practice) and diversity—are addressed in Chapter 2. All four com-ponents, however, are woven throughout the book. To be more precise, the nexus of these components throughout the four stages of helping is the foundation of the book. Core Skills and Attributes Think back to when you knew you wanted to become a professional helper. More than likely it was at a time when others had been telling you how good a listener you were. Even some might have said you offered helpful advice. It was not necessarily that you went out looking for people to help—they just seemed to migrate to you, asking if you could spare a moment, or, for others, not bothering to ask, but proceeding to divulge personal information and then waiting for your response. Your desire to become a professional helper also may have been propelled by witnessing the aftermath of tragedy in your school or hometown, or even experiencing first-hand debilitating fear, trauma, and injustices. Because of insuf-ficient care provided to those in need or, by contrast, the helping hand you received that allowed you to breathe again and learn how to persist and be resilient, you vowed to be a part of a solution rather than to perpetuate a problem. “Never again,” you may have said. “I want to help... and to do it right. ” Maybe you cannot remember a specific time or event that crystallized your decision to become a professional LO1 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 5 helper. Perhaps it had to do with looking back over your life and realizing that some kind of change was in order, that remaining on the same life path did not portend much excitement or even any hope. “It's now or never,” you may have said. “Something has to change... for the better. ” Regardless of the circumstances that brought you to the entrance of your graduate training program, you're ready for something different. Although questioning how this may all work out for you (in terms of time, finances, and extent of community involvement), you are eager to get started and venture into this professional realm. You want to be a part of change—for others and for yourself. And you are ready to begin learning and to continue learning what it takes to be a change agent. “Bring it on,” you may say. “Just give me the tools so that I can build my toolbox and get out there to help people. ” The analogy of the toolbox is one we hear often from our graduate students. It brings to mind the work of a car-penter or an electrician, the professional who is equipped with various instruments to build something new or fix something that is broken. Although students and new professionals may take comfort in having a figurative toolbox that they can carry with them to each encounter with a client, we caution them to not allow this anal-ogy to persist and remain prominent in their career. For one thing, a toolbox brings to mind something that is external to you, something like an appendage that is not you, that can be inauthentic. This is not to say that the “tools of the trade”—the strategies, interventions, guide-lines, and practice principles of the profession—are not important. They are! They are critical! But when they are not understood and are not incorporated into the helper's overall practice style, their potential for misuse increases. This is when they are applied out of context, when the helper is faithfully implementing an assess-ment protocol, for example, but is not mindful of how some of the standard questions have offended a particular client. The open-ended question, “How do you feel?” is considered an important tool, as is the “miracle question” in solution-focused therapy. But when they are asked without understanding their purpose for a particular cli-ent at a particular time, they may be interpreted by the client as disrespectful and intrusive and may result in the client's early departure. Tools, therefore, are not intended to be used in a mechanical fashion, only applied because the instruction manual says so. Because of this, we do not want to encourage helpers to continue to rely on tech-niques they do not understand, have not yet practiced and received feedback on, and have not incorporated into their overall style. Doing so over the course of one's career would be disingenuous and inauthentic. The analogy of a toolbox also suggests there is some-thing that needs to be fixed or corrected and that it is the helper who must fix, correct, or straighten out what is wrong in clients. This is not a helpful perspective. Reference to tools also implies that it is the tools, the instruments themselves, that are responsible for client improvement. It is as if the tools are imbued with some kind of power to effect change and, regardless of the client or the therapist, each kind of tool will work in a particu-lar way to fix what is broken. This is another example of using a tool out of context. Again, we do not find this comparison helpful. Thinking this way negates the con-tributions of the helper and the client! Our fourth and final reason for not encouraging the toolbox analogy is that it can prevent a discussion of helper skills. Although some may liken tools or counseling tech-niques to helper skills, they are not quite the same. Tools and techniques are often regarded as external to the helper (especially when learning to use a new tool), whereas skills comprise the helper's qualities, traits, and learned behav-iors. To speak of tools is to speak of something other than the helper; to speak of skills is to talk about the helper. The focus of the former is impersonal; the focus of the latter is the person of the helper and how he or she has learned to embody and demonstrate certain skills for the benefit of a client. A prime example of this distinction is found in what are referred to in person-centered therapy as the core conditions of the therapeutic environment: genuine-ness or congruence, unconditional positive regard, and empathic understanding. These are discussed in greater detail in Chapter 3. Notice that these are not impersonal “things” or tools—they are the qualities or attributes and skills of the helper, how he or she relates to another person to create the conditions for client change. It may be more accurate, therefore, to talk about the skilled helper (Egan, 2014) or the helper who prac-tices what is referred to in dialectical behavior therapy as skillful means (Linehan, 2015). Skills refer to and describe the way a helper practices and reflect how the helper has learned, made sense of, and integrated certain theories and techniques (or tools) of helping. In other words, skills reflect the person of the helper. A skilled and skillful helper is a professional, not a technician or what Skovholt and Jennings (2004) referred to as a “tech-nique wizard” (p. 140). Whereas learning a technique can take only a few hours, becoming a skilled professional and a wise person takes many years (see Rønnestad & Skovholt, 2013). Our focus on core skills and attributes throughout this book is in effect a focus on you as the helping professional—your qualities, traits, and learned behaviors—so that clients derive maximum benefit from services provided. It is a learning and growth process: Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
6 Chapter 1 from a mechanical and disjointed use of tools in the tool-box to practicing with skillful means. Like the way the chambered nautilus grows, this process can take place over many years, but its foundation begins now, with careful attention to matters of context and environment. We dedicate the remainder of this section to a discus-sion of three core skills and attributes that are essential throughout the stages of helping: (1) self-awareness and self-reflection; (2) mindfulness; and (3) self-care and self-compassion. These make possible the promotion of stam-ina and resilience, concepts that also are addressed in this chapter. Think of these as core skills and attributes from which to start your journey of growth and change as a professional helper. Just as the chambered nautilus began its development at the core or center of the spiral shell, we believe these skills and attributes are the foundation of your own development as a professional helper. Self-Awareness and Self-Reflection Being drawn to uncertainty is one precondition for thera-pist development. According to Jennings, Skovholt, Goh, and Lian (2013), helpers who “thrive... are comfortable in the seemingly paradoxical reality of searching for clarity while enjoying the ambiguity and confusion of the human condition” (p. 239). This means that the terrain of help-ing is not clear and the journey cannot be predicted. It also means that there is no one-size-fits-all “answer book” to consult so that you know what to do with clients each step of the way. Rather than getting clearer as you move through your graduate studies, it may be that this work of professional helping seems to be getting murkier as you go along. T wo of the 20 “hazards” of practicing as a profes-sional helper that Skovholt and T rotter-Mathison (2011) listed illustrate this murkiness: lack of concrete results and closure in our work with clients, and not knowing how to measure improvement or even effectiveness. What does uncertainty have to do with the core skills of self-awareness and self-reflection? Quite a bit! For one, it means that these skills are essential because there is no absolute “how to” manual out there for you to consult. In session with your clients, you are the one facilitating the conversation, establishing a connection with the cli-ent, assessing the case, and making decisions about client care. More often than not, no other professional is in the session to assume those responsibilities. You are the sole professional in the moment with clients. Understood in another way, you are the only active ingredient in that therapeutic encounter that you can control. More than likely other factors are beyond your control, such as cli-ent characteristics and the immediate treatment setting. Although you may be guided by a specific theoretical orientation or operating from an evidence-based treat-ment manual, that theory and those treatment protocols were not developed expressly for the client with whom you are working. Rather, you are the one in the imme-diacy of the moment to determine, adapt, and deliver services to each client. This is what it means to move beyond rote use of tools in a toolbox to developing skillful means. The tools are no longer disconnected from you; they now have become part of your routine functioning so that quality client care is maintained. This also is part of the professional development process, the forward move-ment similar to that of the growing chambered nautilus— developing from mere technician to a skilled and respon-sive professional. The instruction manual remains; its purpose is now understood. Just as the chambered nautilus must navigate through the murky waters of the deep sea, so must practitioners make their way through the ambiguous terrain of clinical practice. The skills of self-awareness and self-reflection make this possible. These are practices intended to keep the practitioner in check and also to monitor the quality of services extended to his or her clients. High self-awareness and in-depth self-reflection are primary characteristics of highly skilled, effective, or “master” therapists in the United States and four other countries (Jennings et al., 2013). Self-awareness is being highly observant of one-self, and self-reflection is a form of self-monitoring or self-regulation. Rather than being self-absorbed in a nar-cissistic manner, self-awareness and self-reflection are skills of introspection that consider yourself from differ-ent dimensions (e. g., verbal expression, demeanor, values) as you learn new skills and are exposed to professional guidelines. It might be helpful to think of self-awareness and self-reflection as consultation skills—that is, the ability to consult your inner compass as part of the clinical decision-making process. Your inner compass continues to be shaped as you learn more about theory, research, and professional standards. It could be said that your in-ner compass is what sits on the practitioner's stool, a stool Skovholt and Starkey (2010) described as having the three legs of practitioner experience, personal life, and academic research. These three legs are sources of knowledge for you to consult throughout your career. This must be done deliberately, such as setting aside time to read a self-help book and journal about what you have read, obtaining ad-ditional supervision, or attending an experiential profes-sional growth workshop. Your compass requires routine calibration, just as your stool needs to be balanced and leveled. Self-awareness and self-reflection are the skills you use to calibrate your inner compass by consulting theory, research-informed practices, supervisory directives, and Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 7 ethical and other professional guidelines. These skills also are used to maintain balance as you operate from your practitioner's stool. Before reading further, we invite you to pause and participate in Learning Activity 1. 1. This activity is in-tended to heighten your self-awareness and make use of your self-reflection skills. Specifically, this activity is designed to help you explore your reasons for entering the helping profession, as well as what you hope to gain from your work as a helping professional. Because this is demanding work that involves substantial personal com-mitment, routine self-reflection is essential to effective practice. Mindfulness Related to self-awareness and self-reflection is the core skill of mindfulness. Think of it as a specialized and dis-ciplined form of self-awareness and self-reflection. It is an intentional practice that is central to dialectical behavior therapy (DBT; Linehan, 2015) and to acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012). Mindfulness also is a core skill in at least four other approaches. Jon Kabat-Zinn's (1990) mindfulness-based stress reduction (MBSR) initially was developed for persons with chronic pain and is now intended for persons with a variety of psychological and medical issues. It is group-based training conducted in 2. 5-hour weekly sessions for 8 weeks, with an additional 1-day meditation retreat. Mindfulness-based cognitive therapy (MBCT) for depression (Segal, Williams, & Teasdale, 2002) and mindfulness-based relapse prevention (MBRP) for addictive behaviors (Bowen, Chawla, & Marlatt, 2011) are designed based on the work of Kabat-Zinn. A newer approach is mindful self-compassion (MSC; Germer & Neff, 2013) that teaches self-compassion skills to the gen-eral public and is fashioned according to MBSR's format. Inspired by Eastern spiritual practices of meditation, namely Buddhism and Zen, mindfulness is understood as practicing focused attention, specifically, remaining aware of and deliberately attuned to the present moment. Although often confused with meditation, it is not. Rather than “zoning out” or retreating from the present moment, mindfulness is “a way of living awake, with your eyes wide open” (Dimidjian & Linehan, 2009, p. 425). This means that it is an attentional skill or a way of paying attention on purpose. It therefore is not “mindlessness. ” It is a heightened state of consciousness wherein the focus of attention is on in-the-moment perceptual experience, making use of as many senses as possible (e. g., sight, sound, smell)—and also attending to visceral functioning (e. g., breathing)—to be fully immersed in the textured detail of the concentrated now. In this way, mindfulness Learning Activity 1. 1 Survey of Helper Motives and Goals This activity is designed to help you explore areas of your-self that in some fashion will affect your helping. Take some time to consider these questions at different points in your development as a helper. We offer no feedback for this ac-tivity, because the responses are yours and yours alone. You may wish to discuss your responses with a peer, a supervi-sor, or your own therapist. 1. What is it about the helping profession (e. g., social work, counseling, psychology) that is attractive to you or enticing for you? 2. What do you look forward to learning and doing over the next 5 years? 3. What is anxiety-provoking to you about the work or lifestyle of a professional helper? 4. What are you cautious or hesitant about as you con-tinue in the profession? 5. If you had to select one event in your life or one per-sonal experience that contributed to your decision to pursue the helping profession you are now in, what would that event or experience be? 6. What have you learned about yourself by having expe-rienced tragedy, trauma, or types of personal pain and injustices at some point in your life? What more do you still have to learn about yourself as a result of such pain? 7. Which of your personal qualities do you believe will serve you well as a helping professional? Why do you believe this? 8. What aspects of yourself (e. g., being “rough around the edges”) do you still need to work on for you to be a helpful practitioner? How do you see yourself address-ing these traits? 9. How do you handle being in conflict? Being con-fronted? Being evaluated? What defenses do you use in these situations? 10. How would someone who knows you well describe your style of helping or caring? 11. What client populations or client issues do you enjoy working with or look forward to working with? For what reasons? 12. What client populations or client issues are difficult for you to work with or do you foresee as being difficult for you to work with? For what reasons? 13. What are three primary factors that contribute to being an effective helper? 14. How will you know when you have been an effective helper? Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
8 Chapter 1 is like stepping outside yourself, taking a meta-perspective on your own experience, so that you can consider your perception of the present moment with greater objectivity (Neff & Pommier, 2013). Mindfulness is the means by which an individual makes direct contact to immediate experience, not to abstrac-tions or concepts. Persons who practice mindfulness are able to control or focus their attention on the present moment. They do not control what is being attended to, such as deliberately trying to change their breathing or rid their mind of thoughts; rather, they control how they attend to what is happening in and around them in the here and now. In this way, mindfulness is unlike certain forms of prayer and is not to be confused with prayer. It is not a form of communicating with or connecting to a transcendent being. Furthermore, mindfulness does not seek to make something happen, such as relaxation or preventing certain kinds of behavior (e. g., fighting). Dimidjian and Linehan (2009) state, “Mindfulness has as its goal only mindfulness” (p. 425). Mindfulness is the polar opposite of multitasking. It does not mean, however, doing nothing or being nonpro-ductive. It does mean intently focusing on one thing at a time and doing so in the present moment. This requires effort! Although not intended to make something hap-pen or to control that which is the focus of attention, research suggests that persons who consistently practice mindfulness experience a greater sense of control over their feelings and mood, their behaviors (e. g., not acting on impulses), and their attitudes (e. g., more hopeful). For example, primary care physicians trained over 1 year in mindfulness skills reported improved personal well-being, including decreased burnout and improved mood (Kras-ner et al., 2009). They also experienced greater changes in empathy, a finding that seems to fit Greason and Cashwell's (2009) survey of counseling student interns. They found that these students' high mindfulness scores predicted greater empathy and greater self-efficacy. Coun-seling students who had taken a graduate level course that focused on mindfulness and self-care reported similar benefits (Christopher & Maris, 2010) and also spoke of the positive effects of mindfulness specific to their work with clients, such as increased calm and comfort with si-lence and reduced fears of inadequacy and incompetence. It appears that even though mindfulness is not prac-ticed for the specific purpose of changing mood, behavior, or attitude, the practice of mindfulness results in positive changes in these areas of functioning. Think of these changes as positive side effects or the benefits of mindful-ness. Davis and Hayes (2011) reviewed additional ben-efits of mindfulness from the research literature, including relationship satisfaction, improved physical functioning, and increased patience. These and other benefits seem to support Carmody's (2009) contention that the overall goal of mindfulness is the reduction of human suffering (p. 272). In both DBT and ACT, mindfulness is a skill taught to clients and is a skill practiced—and lived—by therapists. You do not have to be a religious or spiritual person to practice mindfulness. Consistent with our earlier discus-sion of skill and how it differs from technique, mindful-ness is how the helper interacts with clients—or, more precisely, how the helper is present with clients. The premise of DBT and ACT is that helpers cannot teach skills to clients that therapists do not practice themselves. Manuals are available to teach clients mindfulness skills (e. g., Linehan, 2015), but mindfulness cannot be learned simply by talking about it or lecturing on it. Mindfulness must be practiced in session and modeled by the therapist. The therapist who is purposefully attentive to the client in the immediacy of the counseling session is modeling for the client the skill of mindfulness. The therapist who routinely practices mindfulness in and outside of therapy also is able to guide the client through the process of learn-ing and continually practicing mindfulness. Mindfulness Skills In DBT, there are six specific mindful-ness skills divided into “what” and “how” skills. The three “what” skills are observing, describing, and participat-ing; the three “how” skills are remaining nonjudgmental, focusing on one thing at a time in the present moment, and being effective. Observing is the act of noticing what is in your awareness, using your sight, hearing, or tactile senses, for example. It does not label or categorize what is observed; it is simply the act of paying attention to what is taking place around you and what is being experienced inside you in the here and now. The skill of describing requires a kind of stepping back from the experience to identify what has been observed. This may include nam-ing the colors, sounds, and tactile sensations (e. g., soft, rough, warm temperature) observed and experienced. The third “what” skill is participating and refers to fully immersing yourself in the activity of the present moment. This has been described as throwing yourself into and becoming one with an activity or experience, and doing so without reservation or self-consciousness. This means that participating has the quality of spontaneity. Take, for example, the act of walking. When done mindfully, fully participating in walking means attending to your move-ments and the sensations as you walk, focusing on the act of walking, and immersing yourself in the activity. As its name implies, the three “how” skills of mindful-ness describe how the three “what” skills are used. First, observing, describing, and participating in the present Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 9 moment is to be done nonjudgmentally. This means not evaluating the experience as either bad or good. This practice is similar to that of accepting, a core skill in ACT. It means assuming a noncritical or neutral stance by dis-carding the need to control what is, even that which has been experienced as unpleasant. To walk nonjudmentally means to not ruminate on your movements or to experi-ence them as “stupid,” “difficult,” or “painful. ” It does mean accepting your experience as is, and continuing to walk with your full attention on the present moment, the second “how” skill of mindfulness. This means not walking and thinking about your destination at the same time. This would be doing two things at once—a practice inconsistent with remaining in the present moment by doing one thing at a time. The third “how” skill of mind-fulness is being effective, which is doing what works or what is helpful. Being mindful is not about doing what is right and avoiding what is wrong. It also is not about following orders or simply going through the motions (like pulling out tools from a toolbox!). It is about using your attentional “muscles” so that you can tune in to your immediate experience, using your sensory resources. It's a way of becoming acquainted with you—with where you are and who you are in this present moment! Mindfulness that is effective becomes a welcome, inviting, and mean-ingful activity, not a scary, suspicious, or worthless one. Each of the six mindfulness skills is not to be taken lightly. The skills also are to be used carefully with clients, not in a haphazard fashion or only because mindfulness may be regarded as a popular clinical perspective and practice. Again, mindfulness practice requires discernment and effort! To help you practice your mindfulness skills, we invite you to participate in Learning Activity 1. 2. Even if you have learned about mindfulness prior to read-ing this book, we ask that you pause to “flex” and “tone” your mindfulness muscles. Think back to the mollusk that makes its home in the nautilus shell—to continue to grow and expand, it uses its muscles continuously. Doing oth-erwise would result in shriveling up or being swept away by the tide. If you are new to mindfulness practice, we ask Learning Activity 1. 2 Mindfulness Practice You can engage in this practice by yourself after reading through the activity. It can also be done in a group with one person volunteering to lead the practice, reading aloud the following activity. Find a quiet spot where you know you will not be dis-turbed for approximately 10 minutes. Turn off or mute any mobile devices you may have around you. Sit down in a comfortable position, either on a chair or on the floor. Sit upright, with your feet firmly touching the floor (if sitting on a chair), or, if sitting on the floor, extend your legs, or cross them with one of your ankles resting comfortably on the knee or thigh of the other leg. Take three or four deep breaths in through your nose, noticing how it feels for the air to come in through your nostrils, and also notic-ing how your chest expands as it takes in new oxygen. As you breathe out through your nose, notice how your chest subsides and the motion of air in your throat and nostrils. Now take your hands and rest them on your thighs, palms up. Keep them separate for now. Notice the palms of both of your hands, the lines or “creases” that make up the inside of your hands. Observe the length and the direction of these lines, notice how they change as you bend your fingers slightly and then extend your palms. See the detail of the lines, and how they criss-cross, as you move your hands slightly in the light. Pay attention to the detail across the surface of your palms. As you do, remind yourself that these palms and these fingerprints are yours and yours alone—unique and one of a kind. Now notice any other visuals on your hands, such as the blood vessels below the skin, markings on the skin, or rings that appear on the in-side of your fingers. Simply use your eyes to scan the open palms of your hands, the hands that have lifted objects for you, opened and closed doors, helped you write and type, and held the hand and cupped the face of a loved one. Now take one of your hands and its fingers and touch the surface, the palm, of the other hand; notice how this feels. Glide your fingers and its palm across the palm and the fin-gers of the other hand. Simply notice the touch, how your open hand feels when gently touched by one or several fingers of the other hand. Describe this sensation without judging it as good or bad. Suspend any criticism. Hold off on assigning to the sensation any positive evaluation as well. Simply give a name to how the motion, the sensation, feels. Keep the motion of your fingers on the other palm slow, gentle, and deliberate so that you are able to notice the detail or the intricacies of the sensation. Continue do-ing this for a few moments, doing your best to remain focused on the activity in the here and now. To close this activity, take three or four deep breaths, holding for just a moment each time before breathing out. As you gaze again at the palms of your hands and glide your fingers of one hand over the palm of the other, remind yourself of your uniqueness, that these hands are yours and one of a kind. Offer a word of gratitude to both hands, thanking them for being a part of you, making you unique, and for working for you. This might even include a warm shake between your two hands or a gentle clap. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
10 Chapter 1 that you enter into this exercise with an open mind, ready to try something new—a skill we believe is central to all forms of helping. You will have the opportunity to practice yet again your mindfulness skills in Chapter 4, so think of this activity as a warm-up! Developing Skilled Intuition We believe the deliberate practice of mindfulness can assist new helpers in making the transition from relying on only intuitive judgments (decisions that are automatic, involuntary, and almost ef-fortless) to incorporating deliberate judgments (decisions based on controlled, voluntary, and effortful activities). Although acting on your intuition or gut may have some appeal because it is thought of as genuine or authentic practice, it also suggests a dismissal of learned theory and skills. Think about it. If all it took to be an effec-tive helper was the use of instinct and gut, why would graduate studies be necessary? The truth is that effective helping requires the application of genuine yet sophisti-cated skills—skills that have been learned, practiced, and revised over a period of time. If you hear a supervisor tell you to “just go with your gut,” or “stop using your head and simply use your instinct,” ask him or her to explain. It may be that your supervisor is encouraging you to integrate the skills you have learned (“head knowledge”) into your natural style of interpersonal communication. His or her recommendation may be for you to practice what Kahneman and Klein (2009) described as skilled intuition, or the testing of your cue recognition skills. They proposed that skilled intuition develops only in an environment of regularity (e. g., meeting with clients on a routine basis and receiving supervision consistently) that makes it possible to validate your observational skills or cue recognition (e. g., discerning symptoms from client presentation). We believe that mindfulness is a form of skilled intu-ition. In this case, what your supervisor may be trying to tell you is that in session with your clients, you must attend to the present moment in a more focused and de-liberate manner, accepting what is without trying to force change. Now, that requires skill, doesn't it? Maybe that explains the practice of skillful means! Self-Care Another core skill for helpers is self-care (Norcross & Guy, 2007). Although mindfulness is a form of self-care (Wise, Hersh, & Gibson, 2012), self-care is a broader concept and practice and has been identified as an ethi-cal imperative for counselors (American Counseling As-sociation, 2014), psychologists (Wise et al., 2012), and social workers (Lee & Miller, 2013). This is true not only in the United States but also in other countries. For example, the Canadian Code of Ethics for Psycholo-gists (Canadian Psychological Association, 2000) regards self-care as an activity that fulfills the ethical principle of responsible caring. In its Ethical Framework for Good Practice in Counselling and Psychotherapy, the British As-sociation for Counselling and Psychotherapy (2013) lists self-respect (the practice of “fostering self-knowledge and care for self”) as one of six ethical principles. Professional associations and accrediting bodies based in the United States also have recognized the importance of professional self-care. For example, counseling programs accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2009) must include in their core curriculum “self-care strategies appropriate to the counselor role” (Standard G. 1. D. ). In addition, the National Association of Social Workers (NASW, 2008) has a policy statement supporting the practice of profes-sional self-care, describing this practice as “a core essential component to social work practice” (p. 269). That self-care is an ethical imperative for all profes-sional helpers suggests four things: (1) it is not simply a personal matter or quality; (2) it is not an indulgence; (3) it is not optional; (4) it is not automatic; and (5) it is not to be practiced in a shallow or superficial man-ner. As a reflection of ethical conduct, self-care is a set of learned behaviors that must be demonstrated during graduate studies and throughout one's professional career. Just because you care for others does not automatically mean that you are able to care for yourself. More than likely, it is because you care for others that you are prone to not care for yourself adequately. It may be that for far too long you have prioritized the needs of others over your own, set aside your own goals to accommodate the goals of others, and sacrificed your own well-being to preserve your prize-worthy reputation as the devoted child, faith-ful spouse and partner, loving parent, generous friend, helpful neighbor, and dutiful employee. Although these are qualities many of us aspire to and would hope to have included in our eulogies and obituaries, they come with a price. And in the role of professional helper, you cannot afford what it costs to care for others while simultaneously ignoring caring for yourself. Baker (2007) stated that “self-denial or self-abnegation is neglectful not only of our real self-needs, but ultimately of the well-being of our clients” (p. 607). In other words, self-care must become routine practice for helpers for the sake of client well-being and remaining effective as a clinician—and we believe this practice must begin during graduate studies. It is meant to prevent helper impairment and inadvertent client maltreatment. Its purpose also is to Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 11 strengthen helper resilience and well-being. Self-care was identified by a group of 24 mental health practitioners from diverse ethnic backgrounds in the United States and Canada as an adaptive response and an essential practice to “detoxify from frequent forms of racial microaggres-sions they experience in their jobs” (Hernández, Carranza, & Almeida, 2010, p. 206). Self-care activities described by this group included physical exercise, meditation, visu-alizations, massage, acupuncture, chiropractic treatment, thinking positively and avoiding negative thoughts, and taking pride in their ethnic heritage. Self-care thus has a dual purpose: prevention of ineffective or even harmful client care (i. e., doing no harm, the ethical principle of nonmaleficence), and promotion of beneficial care (i. e., doing good, the ethical principle of beneficence). In your work as a professional helper, you have no choice! You must practice self-care. And this is not self-indulgent, selfish, or narcissistic behavior. It also is not to be practiced in a shallow or superficial manner “'dumbed down' to socializing and recreational pursuits” (Putter-baugh, 2015, p. 54). Rather, as a stipulation for living and working as an effective professional helper, self-care is a deliberate, purposeful practice that involves quiet and deep reflection on our lives. How do you practice self-care? In a recent study of psy-chology graduate students, Myers et al. (2012) found that three self-care behaviors predicted lower perceived stress: (1) engaging in better sleep hygiene; (2) having strong so-cial support; and (3) regulating emotion through cognitive reappraisal (changing the meaning of an emotion-filled situation) and suppression (changing emotional expres-sion, as in not acting on anger). Surprisingly, physical exercise and mindfulness practice did not predict reduced levels of perceived stress, which the researchers attributed to varying opinions on the benefit of these behaviors and lack disciplined engagement in these behaviors by gradu-ate students. In T urner et al. 's (2005) study of psychology interns, engaging in pleasurable activities outside of the internship, using humor, getting a sufficient amount of sleep, and engaging in physical exercise were activities re-ported to be beneficial. When working at the internship, these same graduate interns reported that consulting with fellow interns, obtaining clinical supervision, diversifying internship activities, and setting realistic internship goals were beneficial self-care activities. T urner and colleagues (2005) encouraged graduate in-terns to be intentional about participating in self-care strat-egies because “self-care is a life-long process and not limited to the internship year” (p. 679). Similarly, Jenaro, Flores, and Arias (2007) emphasized the importance of an appro-priate balance between work and private life throughout one's career. Concentrating only on active coping strate-gies at work, they noted, may actually “exacerbate the psychological tiredness of the worker” (p. 85). Engaging in relaxing activities during one's leisure time is therefore important because these “off-the-clock” activities serve to address the emotional exhaustion that has been found to be the primary culprit of burnout (see Wallace & Brinkerhoff, 1991). It is assertive self-care over the career life-span that is essential (Skovholt & T rotter-Mathison, 2013). Self-Compassion A newer concept applied to professional helpers is that of self-compassion. It is a form of self-care, but it is a broader concept that encompasses self-care. Self-care refers to specified behaviors, whereas self-compassion is an overall, foundational, and transformational attitude or perspective (Patsiopoulos & Buchanan, 2011) that could be said to fuel self-care activities. Borrowing from Buddhist philosophy, Neff (2003a) proposed self-compassion as a healthier and more constructive self-attribution than self-esteem because, unlike self-esteem, self-compassion does not compare self to others and does not endorse the processes of separa-tion and individuation in human development. Rather, self-compassion balances concern for self with concern for others, meaning that self-compassion fosters concern for others, and vice versa. In recent research, Neff and Pommier (2013) reported a significant association between self-compassion and concern for others. There are three components of self-compassion (Neff, 2003a; Neff & Pommier, 2013): 1. self-kindness, or self-understanding rather than harsh judgment or self-criticism; 2. common humanity, the recognition that all humans are imperfect, that they fail and make mistakes, so that one feels connected to—rather than isolated from—others in the midst of personal struggles; and 3. mindfulness, referring to the acceptance of painful emotions and thoughts while not overly identifying with them. Note the integral role of mindfulness in self-compassion. We contend that mindfulness sustains self-compassion, making it possible for persons to be kind to themselves because of their humanity. Said in another way, it is the heightened and concentrated awareness of one's self in the midst of current activity and surroundings (includ-ing people)—accepting what is without changing what is—that cultivates self-compassion. Neff (2003a) defined self-compassion as being open to and moved by one's own suffering, assuming an Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
12 Chapter 1 understanding and nonjudgmental attitude toward one's own shortcomings and failures, and recognizing that one's own experience is part of the common human experi-ence. This suggests that self-compassion promotes humil-ity rather than self-centeredness or narcissism. At the same time, it also demonstrates resilience and a striving toward psychological well-being. These hypotheses were supported when Neff (2003b) first administered to under-graduate students the Self-Compassion Scale she developed. As expected, she found an inverse correlation between self-compassion and symptoms of depression and anxiety, as well as rigid perfectionism. From this same study, self-compassion was associated with greater life satisfaction. In subsequent studies, self-compassion was found to predict mental health among adolescents and young adults (Neff & Mc Gehee, 2010; Neff, Kirkpatrick, & Rude, 2007), suggesting that self-compassion might be thought of as resilient humility or humble resilience. Specific to professional helpers, Patsiopoulos and Bu-chanan (2011) identified six overlapping dimensions of self-compassion from their interviews with 15 Canadian counselors. With an average of 14 years of psychotherapy practice, these counselors defined self-compassion as: (1) being gentle with yourself; (2) being mindfully aware; (3) having a sense that as humans “we are all in this together”; (4) the importance of speaking the truth to yourself and others; (5) the development of spiritual awareness; and (6) having an ethic of professionalism. Specific practices of self-compassion used during therapy sessions included assuming a stance of acceptance (e. g., recognizing the limits of helping, making appropriate self-corrections), mindfulness (i. e., nonjudgmental in-the-moment atten-tiveness) and not knowing (i. e., counseling from a nonex-pert stance), and participating in a caring and supportive work team as colleagues or supervisees. Counselors also described the importance of scheduling breaks in between therapy sessions and ending appointments on time as deliberate acts of self-compassion. According to the coun-selors in this study, these practices served to enhance their well-being, effectiveness in the work setting, and therapeu-tic relationships with clients. The self-compassion website (http://self-compassion . org) established by Dr. Neff posts updates on self-compassion research, includes informational videos, and provides information on trainings and workshops. One of these is the 8-week Mindful Self-Compassion program (Germer & Neff, 2013). Promoting Stamina and Resilience Given the many facets of practicing as a professional helper, it is understandable how such a lifestyle can be exhausting at times. It is! Skovholt and T rotter-Mathison (2011) said this loud and clear in their listing and descrip-tions of not one but 20 hazards of practicing as a helping professional. Among these are: (1) providing constant em-pathy, interpersonal sensitivity, and one-way caring; (2) realizing that one's effectiveness is difficult to measure and thus remains elusive; and (3) working with clients who are not “honor students” and whose readiness to change lags behind our own hopes and desires for them. These and other consequences of “emotional labor” (Wharton, 1993) may lead to burnout and compassion fatigue, or what Stebnicki (2009) referred to as empathy fatigue. Counselors who volunteered to help victims of natural disasters were found to have twice the rate of compassion fatigue and vicarious traumatization compared to other counselors (Lambert & Lawson, 2013). Burnout is a general term that describes emotional depletion, a lack of caring or empathy for clients, and a diminishing sense of personal accomplishment. The first two aspects of burnout describe what Skovholt and T rotter-Mathison (2011) termed caring burnout, whereas the third aspect of burnout, loss of meaning and purpose in one's work, is what they characterized as meaning burn-out. In broad terms, burnout can be understood as a lack of resilience and constricted coping abilities. Jenaro and colleagues (2007) characterized burnout “as an answer to chronic labor stress that is composed of negative attitudes and feelings toward coworkers and one's job role, as well as feelings of emotional exhaustion” (p. 80). Compassion fatigue can signal the onset of burnout and is regarded as mental and physical exhaustion resulting from taking better care of others than you do of yourself. Empathy fa-tigue can also be a precursor to burnout and describes the practitioner's diminished capacity to listen and respond empathically to clients whose stories convey acute and cumulative psychosocial stress (Stebnicki, 2009, p. 804). We may not have been fully briefed about the hazards of practicing as professional helpers before we submitted our own versions of informed consent and signed up for this career. It may not be until later in one's formal train-ing (e. g., during practicum and internship) that a novice helper actually experiences some of the stresses and strains that are part of this work. But knowing about all the chal-lenges may not have kept us away anyway, and perhaps some attraction to the challenge of this work spurred us to seek out this particular profession in the first place. It also may be that we are hardier than we realize and that it takes only a few reminders of our competence here and there—including some client success stories—to keep us going. Realizing that our experience of strain and exhaustion is not attributable to one thing or person but more than likely to an accumulation of factors over time, including Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 13 ones beyond our control (e. g., vague and ambiguous ex-pectations in the work setting), can ease our tendency to self-blame. Likewise, reframing our goals as helping clients manage or otherwise live with concerns rather than fixing, curing, or even solving difficulties may help us remain invested in this important work. There are additional and specific things we can do to help cultivate our resilience and stamina for providing professional care to others. Osborn (2004) identified seven salutary suggestions for stamina for those who serve in the helping professions. These recommendations are intended to assist helpers not only remain vigilant about the hazards of professional helping, such as compassion fatigue, but also maintain their resolve for rewarding work. Based on a review of the scholarly literature and reflections on her clinical practice, Osborn's recommendations comprise a proactive rather than a reactive or preventive approach and are intended to shift attention from a deficiency or pathological per-spective (i. e., “burnout prevention”) to a strengths-based or competency-based orientation (i. e., “stamina promo-tion”). Stamina is likened to resilience, endurance, and flourishing-not despite hardship but in the midst of challenges. Each suggestion for stamina corresponds to the seven letters in the word stamina, thus creating the acronym STAMINA. These are presented and described with examples in Table 1. 1. Although stamina and resilience are close cousins, we differentiate the two by thinking of stamina as the fuel for resilience. Resilience therefore refers to a set of specific skills that Tjeltveit and Gottlieb (2010) stated can be taught and then “marshaled when psychothera-pists are faced with difficult situations” (p. 100). Spe-cifically, resilience develops from social relationships and support networks (e. g., clinical supervision), but TABLE 1. 1 Seven Ingredients of Helper Stamina Ingredients of Helper STAMINA Definition Examples Selectivity ● ●Intentionally choosing and concentrating your efforts in only certain areas, such as limiting your areas of expertise ● ●Undertaking daily activities and long-term endeavors with care and focused attention● ●Setting limits on yourself and maintaining healthy boundaries with others (e. g., clients, family members) ● ●Modifying high and perhaps unrealistic expectations you have of others and yourself ● ●Not trying to “do it all” or be a “jack of all trades” Temporal sensitivity ● ●Being mindful of the constraints on your time and working within these limits ● ●Using time wisely ● ●Focusing more on current resources and circumstances compared to past or even future challenges● ●Joining with clients in the present moment ● ●Beginning and ending counseling sessions on time ● ●Engaging in mindfulness practice Accountability ● ●Practicing according to justifiable, ethical, theoretically guided, and research-informed guidelines ● ●Able to understand and to verbalize to others (e. g., clients, treatment team members) decisions made and actions taken ● ●Credibility ● ●Practicing self-regulation or operating from an internal locus of control within the parameters of professional standards● ●Routinely consulting and learning from colleagues and supervisors ● ●Attending quality workshops and professional conferences ● ●Reading professional literature Measurement and management ● ●Protecting and preserving those things that are important and valuable to you ● ●Holding onto and accentuating the resources associated with choices you have made in your personal and professional life ● ●Engaging in routine self-care activities during the workday and your personal time ● ●Engaging in personal therapy ● ●Limiting the amount of your volunteer or pro bono services ● ●Generating realistic goals with clients ● ●Clarifying with your supervisor your exact role and responsibilities (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
14 Chapter 1 TABLE 1. 1 Seven Ingredients of Helper Stamina (continued) Ingredients of Helper STAMINA Definition Examples Inquisitiveness ● ●Curiosity about other people and intrigue about how they function ● ●Fascination with human development and change ● ●Honoring client uniqueness and originality● ●Practicing idiographic client care ● ●Referring to diagnoses as conditions clients have, not who they are ● ●Suspending judgment ● ●Engaging in routine self-reflection ● ●Routinely soliciting feedback from clients Negotiation ● ●Flexibility and adaptation ● ●Engaging in give-and-take without necessarily giving-in ● ●Responding to and cooperating with others while simultaneously remaining steadfast to and upholding professional guidelines and standards● ●Engaging in collaborative and coconstructive conversations with clients and colleagues ● ●Remaining open to new ideas from colleagues ● ●Revising over time long-held beliefs and practices that are no longer helpful ● ●Becoming more assertive on a treatment team to advocate for a particular client's needs Acknowledgment of agency ● ●Salutary or strengths-based orientation ● ●Recognition and promotion of human instrumentality, intrinsic motivation, and resilience ● ●Remaining confident in the undeniably persistent strength, resourcefulness, and will of the human spirit● ●Assessing and promoting client strengths and resources ● ●Conveying hope to clients ● ●Living a life worth living ● ●Implementing a recovery plan ● ●Pursuing with diligence a new area of expertise ● ●“Blooming where I'm planted” Source: Osborn, C. J. (2004). Seven salutary suggestions for counselor stamina. Journal of Counseling & Development, 82, 319-328. because it is multidimensional, Tjeltveit and Gottlieb (2010) also defined resilience as a set of relatively stable personal characteristics (e. g., virtues). Using the acro-nym DOVE, they identified four assets that enhance therapist resilience while decreasing therapist vulner-ability to ethical misconduct. These therapist assets or dimensions of resilience are: having a Desire to help others, creating and making use of available Op-portunities for personal enrichment and professional development, consulting and revising core Values, and approaching Education as lifelong learning. Among their eight recommendations for cultivating resilience to “move toward ethical excellence” (p. 108) are en-gaging in regular self-assessment and seeking psycho-therapy and structured supervision. The need for helper stamina and resilience is evident in the reflections of a bereaved father that Neimeyer (1998) shared and that are presented in Box 1. 1 on page 15. This man's story underscores the importance of walking alongside and waiting with our clients rather than trying to “fix” them or “solve” their concerns. Before reading further, take a moment to read this father's reflections. Having read this father's reflections, you may need to pause for a moment. Some of what he has to say is not easy to hear. His grief is quite evident. Once you have paused to reflect on his words (per-haps rereading his reflections), what thoughts come to mind about your intended style of helping? What wisdom might he be conveying to you as you prepare for the work and lifestyle of a professional helper? How would you propose to offer help to this man at this time in his life? What would you tell him if you were working with him? In addition, what ingredients of stamina and resilience might you need to make use of intentionally as you work with this father? What aspects of temporal sensitivity or negotiation, for example, might be especially helpful to you? What further education would you need to pursue? As we ourselves read and reflect on his words, it seems that this father's loss cannot be “fixed” and that he resents the well-meaning advice others have offered. As much as we'd like to think of ourselves as problem-solvers, we real-ize that some hurts and pains simply cannot be “solved. ” This father may experience living in the metaphoric three-sided house for some time, and no one can build a fourth wall for him—that is, his son will never be restored, will not be brought back to life. This father and all the clients we work with are in charge of constructing their own lives (the ethical value or principle of autonomy that we must honor when working with them); they are the carpen-ters. As professional helpers, we may be likened to their Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 15 apprentices or at times consulting architects, but they themselves know best the constructed and reconstructed lives and houses that will fit them. In addition, clients need helpers who are “not daunted by the wreckage,” helpers who are able to deal with and make meaning from the “dust that clings” to them from the stories they (i. e., the helpers) have witnessed and in-directly participated in. Our clients deserve helpers who can demonstrate what Kenneth Minkoff characterized as “the courage to join them [clients] in the reality of their despair” (see Mental Illness Education Project, 2000). Incorporating the seven ingredients of stamina (see Table 1. 1) and the four dimensions of resilience (DOVE; see Tjeltveit & Gottlieb, 2010) may assist you in temper-ing the effects of this demanding work, work that is not for the faint of heart. Specifically, we encourage you to establish your own board of advisers with whom you can consult on a regular basis. These persons would include trusted friends, family members, a supervisor, respected colleagues, and your own therapist. Surrounding yourself with such a support system is essential. As you read the next section of this chapter, you may understand our decision to discuss core skills and at-tributes—self-awareness and self-reflection, mindfulness, self-care, and self-compassion, as well as stamina and resilience—prior to discussing issues of effectiveness, ac-countability, and evidence-based practice (EBP). Just as clients need to be equipped with certain skills (e. g., mind-fulness) before they can be expected to manage stressors and other symptoms effectively, professional helpers need to demonstrate core skills before they can be expected to deliver effective services. As we have already discussed, these core skills include self-care and self-compassion. Think of your clinical skills and your self-care activities as the provisions needed for the arduous journey of service delivery in an age of accountability and EBP. Only by mobilizing learned skills will you be able to hold yourself accountable for the client care you provide. Effectiveness and Accountability Today's practice continues to be highly influenced by regulatory requirements and ethical expectations regard-ing accountability. Use of empirically supported practice and evidence-based decision-making has become part of training accreditation requirements as well as work site expectations, although certainly not without issue. It is expected that in the next 10 years helpers will need to demonstrate the evidence base of practice decisions and outcomes and use practice guidelines in standard therapy, while at the same time conducting short-term and brief therapy (Norcross, Pfund, & Prochaska, 2013). It is for this reason that Putterbaugh (2015) reinforces the impor-tance of deliberate and purposeful practitioner self-care. Recent health care reform in the United States stipulates that all practitioners will need to demonstrate increased accountability for their work. In effect, this means that we as clinicians need to demonstrate that our work is safe and makes a difference in the lives of our clients. Goodheart (2011) made clear that insurers are now making decisions about allocating funds for treatment services based on a review of client outcomes rather than what had been a utilization review. This means that helpers increasingly will need to provide evidence that clients have improved while in treatment for services to be reimbursed. This certainly Steve Ryan, a bereaved father, wrote the following meta-phoric account of his life in the aftermath of the death of his 2-year-old son, Sean, from complications following a kidney transplant. I am building a three-sided house. It is not a good design. With one side open to the weather, it will never offer complete shelter from life's cold winds. Four sides would be much better, but there is no foundation on one side, and so three walls are all I have to work with. I am building this place from the rubble of the house I used to own... It had four good walls and would, I thought, survive the most violent storm. It did not. A storm beyond my understanding tore my house apart and left the frag-ments lying on the ground around me... And so I must rebuild. Not, as so many onlookers would suggest, because I need shelter once again. The storm now travels within me, and there is no shelter from the tempest behind doors or walls. Who can show me how to build here now? There are no architects, no experts in designing three-sided houses. Why is it then that so many people seem to have advice for me? “Move on, ” they say, quite convinced that another house can replace the one I lost... I grow weary of consultations based on murky insight, delivered with such confidence.... [And yet] among those who wish to see my house rise again[,] there are real heroes too. People who are not daunted by the wreckage. It is not a pleasant role for them to play because the dust clings to those who come to see and it will not wash off when they go home... Above all they know how difficult this task is, and no suggestion comes from them about how far along I ought to be. Box 1. 1 Story of the Three-Sided House Source: Neimeyer, 1998. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
16 Chapter 1 raises ethical concerns, but it also suggests that, more than ever, professional helpers will need to deliver services that are consistent with current and established guidelines. No longer can personal experience suffice as the sole or primary standard for justifying treatment decisions (Beutler, 2009). Although the helper's personal experience influences how he or she makes treatment decisions, it is only one source of influence. As discussed earlier in the chapter, Skovholt and Starkey (2010) identified it as one of three sources of knowledge that inform clinical expertise, with the other two being professional experience and academic research. Together, these represent what they referred to as the three legs of the professional helper's learning stool. A one-legged stool will not suffice! All three must be securely in place to supply a firm foundation and a balance of practice. Evidence-Based Practice The delivery of evidence-based practice (EBP) or the provision of empirically supported services is the expecta-tion of contemporary clinical and behavioral practice, not only in the United States but also in many other coun-tries. Thyer (2009; Thyer & Myers, 2011) noted that the major contributors to EBP, particularly in medicine and social work, were British and Canadian. Some might say it is only recently that U. S. health care providers are catch-ing up with their Canadian, European, and Australian counterparts. This may be true in light of recent health care reforms in the United States, primarily the Patient Protection and Affordability Care Act signed into law in March 2010 by President Obama and upheld twice by the U. S. Supreme Court. This means that translating research findings into everyday clinical practice and substantiating treatment decisions made in the throes of an emergency or during routine work are now the global norm for health care providers. Although psychologists have been at the forefront of EBP in the United States since the 1980s, what Thyer (2009) referred to as science-informed practice is not new to social work. He explained that it was this positivist focus that dis-tinguished social work from its beginnings in the late 1880s as faith-based ministerial outreach and as a charitable orga-nization. “Scientific charity” and “scientific philanthropy” actually were two of the original names for the social case work movement in the United States, leading Thyer (2009) to reinforce that “the principles of EBP are congruent with central core descriptions of social work dating back to the beginnings of our field” (p. 1117). Yet it has been the psy-chology profession in the United States that in many ways has framed the current conversation about EBP. LO2The Staying Power of EBP It is evident that EBP is here to stay. The Evidence-based Behavioral Practice project (www. ebbp. org) claims that “all major health professions now endorse the policy of evidence-based practice. ” Many of these same organiza-tions have developed what are known as evidence-based clinical practice guidelines, what Hollon et al. (2014) define as “a systematic approach to translating the best available research evidence into clear statements regard-ing treatments for people with various health conditions” (p. 214). The use of such guidelines in treatment planning is discussed in Chapter 9. Many states have adopted the practice of evidence-based policymaking, which includes performance-based budgeting. This entails cost-benefit analysis so that only programs that have demonstrated effectiveness continue to receive state funding. These programs include child welfare and corrections. Fourteen states facing economic difficulties have partnered with the Results First Initiative, a project of the Pew Charitable T rusts and the Mac Arthur Foundation, to help them identify ineffective programs to budget only proven programs (see www. pewtrusts. org). One of these states is Illinois, whose governor established in February 2015 a criminal justice commission to reduce the state prison population by 25 percent by the year 2025. To do so, “evidence-based programming” will be pursued such as diversion programs (i. e., drug and spe-cialty courts, intensive probation). Straus, Richardson, Glasziou, and Haynes (2010) argued, however, that evidence-based medicine is not necessarily a cost-savings endeavor because “providing evidence-based care directed toward maximizing patients' quality of life often increases the costs of their care and raises the ire of health economists” (p. 8; emphasis added). This serves as a reminder that EBP should not be regarded as strictly or only a way to save money; rather, EBP should be used to provide quality care. In the context of eco-nomic realities, the point is to use limited resources wisely. As Miller, Zweben, and Johnson (2005) noted, “It makes good sense to give priority to [evidence-based treatments], particularly within this era of fiscal austerity. We owe it to our clients to provide the best treatment that we can offer them within available resources” (p. 274). Discredited Therapies Some have stated that rather than identifying so-called best practices or effective practices, EBP has helped to iden-tify treatment interventions that are not effective (with-out effect or inert) or are potentially harmful. As Beutler (2009) indicated, “It appears to be easier to identify a Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 17 bad treatment than a very good one” (p. 310). Although defining what exactly constitutes harm and what is directly responsible for harm in psychotherapy is a complicated endeavor (Dimidjian & Hollon, 2010), it seems that one contribution of EBPs is that they have been able to weed out certain practices—despite their recognition, appeal, and popularity—that actually have been found to be harmful to service recipients (i. e., clients are worse off after receiving these interventions than before). These practices include rebirthing therapy, boot camp interventions for juvenile offenders, critical incident stress debriefing, and drug abuse and resistance education (or DARE; see Lilienfeld, 2007, for a listing of additional potentially harmful treatments). T reatments such as these are regarded as discredited thera-pies (Norcross, Koocher, Fala, & Wexler, 2010; Norcross, Koocher, & Garofalo, 2006), therapies that have undergone testing over time and have been found not to make a dif-ference or to exert a negative effect, in other words, to exert harm (e. g., exacerbated symptoms at follow-up, or even death as a direct result of treatment). It is thus important to recognize the reasons for EBP because helpers who do not “may fail to appreciate how readily they can be fooled by ineffective or harmful treatments” (Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2013, p. 884). Avoiding the use of discredited and harmful therapies or interventions actually is an ethical imperative. Sec-tion C. 7. of the ACA Code of Ethics (2014) stipulates the types or quality of techniques, procedures, or modalities counselors are to use with clients. Specifically, only those practices “grounded in theory and/or have an empirical or scientific foundation” (Section C. 7. a. ) are to be consid-ered. Furthermore, Section C. 7. c. is explicit in its state-ment that “Counselors do not use techniques/procedures/modalities when substantial evidence suggests harm, even if such services are requested. ” Discredited therapies must be differentiated from therapies that have yet to be tested or whose effects remain unknown or inconclusive—therapies that may be inert, beneficial, or detrimental but for which con-sistent and substantial evidence from methodologically sound investigations is absent. Solution-focused therapy (SFT) is one example. Although it is a popular therapy that has been practiced for more than 30 years, in many countries SFT has not been subjected to the rigorous testing that other therapies have undergone, such as motivational interviewing (MI). Unlike MI, SFT has not gained the recognition as an EBP. Recent efforts to examine the effects of SFT in more sophisticated ways are encouraging (see Franklin, T repper, Gingerich, & Mc Collum, 2012), and we discuss these research findings—and those of MI—in Chapter 10. Affirmative Therapies As with SFT, affirmative therapies developed specifi-cally for lesbian, gay, and bisexual (LGB) individuals (see Chernin & Johnson, 2003; Kort, 2008), transgender and gender nonconforming individuals, and lesbian, gay, bi-sexual, and transgender (LGBT) couples and families (see Bigler & Wetchler, 2012) have yet to establish a strong research base and to be recognized as an EBP (see Johnson, 2012). This has not thwarted their promotion by various professional associations (e. g., the American Psychological Association's 2009 Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts; see APA, 2011) and their depiction as synonymous with culturally competent therapy (Johnson, 2012). The APA (2012) also has developed Guidelines for Psychological Prac-tice with Lesbian, Gay, and Bisexual Clients and guidelines for working with transgender persons are forthcoming. It is because affirmative therapies endorse a strengths or empowerment perspective (see Boes & van Wormer, 2009) and represent a humanistic and nondiscriminatory practice that they are viewed today as the ethical alter-native to so-called conversion therapies. Conversion or reparative therapies have been determined to cause more harm than benefit to LGB individuals and to society as a whole because they reinforce stigma and prejudice. The APA (2011) has referred to “the emerging knowledge on” culturally affirmative therapies as “a foundation for an ap-propriate evidence-based practice with children, adoles-cents, and adults who are distressed by or seek to change their sexual orientation. ” The APA (2011) policy statement on affirmative therapies illustrates very well Thyer and Myers's (2011) contention that “EBP involves not just a consideration of research evidence but also of other factors... such as individual clinical expertise, patient preferences, values and circumstances, and no one of these elements is af-forded primacy over the others” (p. 18). In other words, determining what constitutes the “evidence” for an EBP should not be confined to the outcomes of randomized clinical/control trials (RCTs). Perhaps this is what Good-heart (2011) meant in her statement that EBP does not privilege certain types of data. Although RCTs are consid-ered the gold standard in medical research, the clinician's expertise, the client's culture and preferences, and ethi-cal standards of professional associations must also serve prominent roles in determining the “evidence” of an EBP. Defining EBP It should be apparent by now that there are many ways to define EBP. Given our review of the research literature Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
18 Chapter 1 and the proceedings of professional associations, we en-dorse the APA definition: EBP is “the integration of the best available research with clinical expertise in the con-text of patient characteristics, culture, and preferences” (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273). Derived from the definition of evidence-based medicine (see Straus et al., 2010), this definition of EBP highlights the essential contributions of clinicians and clients to what is considered evidentiary practice. In other words, EBP is not—or should not be—a top-down mandate from researchers to clinicians, but rather is—or should be—a dynamic discourse among clients, clinicians, and researchers. This exemplifies the contention made by Thyer and Myers (2011) that EBP is a process and there-fore is a verb, not a noun. This notion of process seems to be supported by Goodheart (2011) when she described EBP as that which incorporates new clinical phenomena, research, theory, and professional consensus (e. g., ethical codes) to provide clients with individualized and benefi-cial care. She and colleagues (Wampold, Goodheart, & Levant, 2007) also stipulated that EBP is not prescriptive but descriptive and serves as a guide in that EBP offers recommendations for the selection and implementation of treatment services. Lilienfeld et al. (2013) discussed other misconceptions of EBP. These are listed in Box 1. 2. Note that our discussion here is about evidence-based prac-tice, not evidence-based treatment. This is a very important distinction (La Roche & Christopher, 2009; Littell, 2010; Thyer & Pignotti, 2011; Westen, Novotny, & Thompson-Brenner, 2005). The former is inclusive of client and helper factors (e. g., client cultural diversity), treatment interven-tions and setting, and research findings (consistent with the 2006 APA definition); the latter is concerned only with interventions or techniques—the tools that we discussed earlier in this chapter that are external to the helper and therefore do not equate with helper skills. Furthermore, as Thyer and Myers (2011) noted, EBP is a dynamic process, a verb, whereas evidence-based treatment—or what have been referred to as empirically supported treatments, or ESTs (Chambless & Hollon, 1998)—is a static noun. This implies that EBPs are fluid and susceptible to revision and cultural adaptation, whereas ESTs are absolute fixtures that are resistant to change and can be mistaken for the once-and-for-all solution for all clients. Given these distinctions, it is extremely important that as an emerging professional helper you see yourself as an influential ingredient in the process of client change. This means that you not look to a specific treatment, technique, or tool as the sole answer to or the only source of healing for your clients. Thinking that all that is needed for client improvement is your selection of the best tool from your toolbox is thinking like a magician and investing power in a magic wand. In this era of EBP, magicians and magic have no place. Rather, the focus is on you as a skilled practitioner and your use of skillful means, which includes your ability to: (1) learn from and work in a collaborative fashion with each of your clients; (2) consult and critique empirical research findings; (3) understand the standards of professional ethics; (4) participate in and contribute to constructive dialogues with your clinical supervisor and other skilled practitioners in your profession and in related professions; and (5) adapt your therapeutic style over the course of your career based on what you have learned from these various constituents (i. e., clients, research literature, professional standards, supervisors and colleagues). It is this focus on skillful means—in the context of EBP—that we suspect contributed to Beutler's (2009) (re)definition of psychotherapy as “[t]he therapeutic management, control, and adaptation of patient factors, therapists' factors, rela-tionship factors, and technique factors that are associated with benefit and helpful change” (p. 311). Becoming Familiar with EBP To help you develop and calibrate your skillful means—your therapeutic management, control, and adaptation Evidence-based practices (EBPs): 1. Stifle innovation and the development of new treat-ments and practices 2. Require “cookie-cutter” and “one-size-fits-all” ap-proaches to treatment 3. Do not include nonspecific influences or common fac-tors in therapy 4. Do not generalize to clients who have not participated in re-search studies, including randomized controlled trials (RCTs) 5. Neglect evidence other than that obtained from RCTs 6. Are unnecessary because all treatments are equally ef-fective. 7. Are inherently limited because therapeutic changes cannot be measured or quantified 8. Are erroneous because human behavior defies predic-tion with certainty Box 1. 2 Eight Misconceptions of Evidence-Based Practices Source: Lilienfeld et al., 2013 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 19 of various clinical factors—we encourage you to consult the lists, registries, and reviews of EBPs that are avail-able currently from a number of professional organiza-tions. Although EBP lists have been criticized (Beutler & Forrester, 2014; Thyer & Pignotti, 2011; Wachtel, 2010), we believe they offer professional helpers the opportunity to learn more about and to scrutinize approaches heard about only in passing. They also may provide helpers with information not offered to them by superiors during mandated training on a recently instituted EBP. Seven online sources are presented in Table 1. 2. These include reviews of EBPs. The contents of these electronic sources are updated periodically as new research findings are introduced or new selection criteria implemented, so it is best to check these sites every few months to determine what, if any, changes have been made. Bear in mind that none of these lists is exhaustive and that each site may use different criteria for what it deems to be an EBP. Therefore, we recommend that you use your critical thinking skills as you read the reviews of a selected intervention or practice on one of these lists. Read carefully the purported benefits as well as the criti-cisms. Look for how often and how recently each prac-tice has been reviewed and updated. Take careful note of how the practices listed attend to cultural factors, such as the availability of treatment materials in languages other than English and the flexibility of extending or ab-breviating services to accommodate specific client needs and preferences. As you learn more about a specific practice and its interventions on one of these lists, you may wish to compare it against each of the nine ideal features of a mental health intervention proposed by Bond, Drake, and Becker (2010). According to their definition, the ideal features of a mental health intervention are that it should: 1. Be well defined2. Reflect client goals3. Be consistent with societal goals4. Demonstrate effectiveness5. Have minimum side effects6. Have positive long-term outcomes7. Have reasonable costs8. Be relatively easy to implement9. Be adaptable to diverse communities and client subgroups In addition to consulting the lists, registries, and re-views of EBPs, professional helpers will soon be con-sulting evidence-based clinical treatment guidelines (see Hollon et al., 2014) mentioned earlier in this sec-tion. Described as recommendations for psychological interventions for specific disorders, Goodheart (2011) reported that these guidelines are intended to “facilitate TABLE 1. 2 Registries, Lists, and Reviews of EBPs Registry Name Sponsoring Group Date Established Website National Registry of Evidence-Based Programs and Practices Substance Abuse and Mental Health Services Administration 1997 www. nrepp. samhsa. gov Cochrane Reviews The Cochrane Collaboration 1995 www. cochrane. org/cochrane -reviews Research-Supported Psychological Treatments Society of Clinical Psychology, Division 12 of the American Psychological Association2008 www. psychology. sunysb. edu /eklonsky-/division12 What Works Clearinghouse U. S. Department of Education 2002 http://ies. ed. gov/ncee/wwc Social Programs that Work Coalition for Evidence-Based Policy 2001 http://evidencebasedprograms. org The Campbell Collaboration Library of Systematic Reviews The Campbell Collaboration 2000 www. campbellcollaboration. org /library Results First Clearinghouse Database Pew-Mac Arthur Results First Initiative 2015 www. pewtrusts. org/en/multimedia /data-visualizations/2015/results-first-clearinghouse-database Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
20 Chapter 1 the integration of science into practice, offer a framework for clinical decision making, provide benchmarks for eval-uating treatments, benefit patients by promoting quality improvements and discouraging harmful practices, iden-tify gaps in research and care, and give clinicians flexible tools to support their work” (p. 341). She stipulated that these guidelines are decision aids and are not to be viewed as prescriptive protocols or a substitute for clinical judg-ment. Unlike practice guidelines that are practitioner-focused, these treatment guidelines are client-focused. Concerns, Critiques, and Caveats of Evidence-Based Practice EBP has become big business. You will likely find fre-quent references to practices or interventions that are “evidence-based” as you scan the issues of recent schol-arly journals, peruse the titles of new books for profes-sional helpers from a variety of publishing companies, and browse the listings of workshops offered at professional conferences. As we mentioned, this appeal of EBP is due in part to the belief that adopting an EBP will save time and money, apparent in the mandates of state legisla-tive bodies in the United States. Morales and Norcross (2010) also discussed the trend among federal agencies that, to be considered for grant funding, applications must include an intention to implement one or more EBPs. Third-party payers and other funding sources—as well as accrediting bodies—thus have been known to latch onto certain evidence-based treatments because they are viewed as cost-effective and hence “successful. ” Short-term cognitive behavior therapy, for example, may be heralded by certain insurance companies as the “best” treatment for all their providers to practice because, in the long run, it is not as protracted or long-term (and hence expensive) as, say, certain types of expressive-supportive therapies. However, marketing EBPs as the solution to cash-strapped state and federal budgets exemplifies what Gambrill (2010) described as propaganda. In other words, it is misleading. It reflects a one-size-fits-all ap-proach (see Bernal, Jiménez-Chafey, & Rodríguez, 2009) that Wachtel (2010) described as “the Walmart approach to mental health care” (p. 264). As we stated, Straus et al. (2010) noted that evidence-based medicine actually is not an effective cost-cutting tool. For certain interventions to be effective, they noted, longer and more intensive care may be necessary. We believe this is also true for mental health and addictions treatment. The hype surrounding EBP therefore requires careful scrutiny and the EBP bandwagon must be approached with caution. Although EBP in social work is, accord-ing to Thyer (2009), differentiated from “impulsive altruism, the efforts of faith-based social missionaries, or unsystematic secular efforts aimed at helping others” (p. 1116), EBPs as a whole are not “magical answers for complex questions [or] over-simplistic approaches to complex problems” (Sexton & Kelley, 2010, p. 85). Healthy skepticism is in order. This includes inspecting what is meant by “evidence. ” For example, should only the findings from randomized clinical/control trials (RCTs) constitute the evidence for treatment practice? Or should findings from studies conducted in applied settings (e. g., a community mental health agency) following normal, routine clinical procedures also be included? The first type of research comprises studies conducted in the most ideal experimental conditions (e. g., controlled and manu-alized treatments, random assignment, selected clients and helpers), usually comparing one type of treatment to another or to a control group (e. g., clients on a wait list), or both. These are referred to as efficacy studies. The second type of research comprises effectiveness studies and does not adhere to the strict (or some might say “sterile”) laboratory research standards of RCTs. Effectiveness stud-ies exemplify what has been referred to as “pragmatic, utilitarian research” (Sanchez & T urner, 2003, p. 126) and may emphasize more idiographic than traditional nomothetic subject research. A concern about efficacy studies is that their findings may not easily transfer to actual, everyday practice (Beutler & Forrester, 2014). In a similar vein, a concern about effectiveness studies is that their findings may not be generalizable to other practitio-ners, treatment facilities, or clients. Hence, the evidence derived from the research question, “What works for whom under what conditions?” may have limited utility from either an efficacy or an effectiveness perspective. In addition to the overreliance on RCTs (i. e., efficacy studies) as the gold standard for determining what con-stitutes an EBP, EBPs have been criticized for confining themselves to a single diagnostic category. It is true that many EBPs were developed for clients presenting with specified diagnostic disorders. For example, motivational interviewing (MI) is an EBP for persons with substance use disorders, and dialectical behavior therapy (DBT) is recognized as an EBP for persons with borderline person-ality disorder. According to Wachtel (2010), the solitary diagnostic confinement of EBPs dismisses the majority of persons with more than one disorder (i. e., comorbidity) and does not account for persons in therapy who do not fit the minimal criteria for any mental health or substance use disorder (i. e., at a subthreshold for a diagnosis). These are valid concerns. However, a greater number of EBPs Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 21 now are being applied to persons presenting with a range of concerns. Seeking Safety (Najavits, 2002), for example, is intended for persons with a history of trauma and substance-related problems. Likewise, DBT now is con-sidered appropriate for persons with multiple diagnoses (e. g., eating disorder, substance use disorder, and bipolar disorder) and concerns (e. g., chronically suicidal), and MI has expanded its application to include persons with a va-riety of health problems such as diabetes, high cholesterol, and obesity (Rollnick, Miller, & Butler, 2008). EBPs also have been criticized for an overreliance on manuals. It is true that many if not most EBPs have a treatment manual and perhaps a separate training man-ual. To be included in the U. S. Substance Abuse and Mental Health Services Administration's (SAMHSA) Na-tional Registry of Evidence-Based Programs and Practices (NREPP), for example, recognized programs need to have developed training and support resources, implementa-tion materials (e. g., treatment manual), and quality as-surance procedures, all of which are ready for use by the public. The development and use of a treatment manual is an example of internal validity, allowing the interven-tion to be distinguished from and compared to other treatments in RCTs. T reatment adherence is referred to as fidelity and allows researchers to determine whether the intervention being tested was faithful to its design or purpose. The concern about treatment manuals is that the practice can become “manualized,” resulting in an approach that is too rigid and objectifies clients (Littell, 2010). Clinicians themselves can feel “manualized”—that is, feel coerced and confined to one type of treatment—resulting in a restriction of their autonomy, flexibility, and creativity. According to Overholser (2010), adhering to a treatment manual can compromise clinical expertise, such as inhibiting clinical judgment/decision-making and complex reasoning skills. This is a valid concern and ex-plains Barkham, Hardy, and Mellor-Clark's (2010) prefer-ence for practice-based evidence or the pursuit of effective care based on the “evidence” from routine clinical practice (consistent with effectiveness studies), whether or not a treatment manual is followed. This illustrates the practice of what Scott and Lewis (2015) refer to as measurement-based care wherein client feedback is routinely solicited. A resolution to these criticisms and concerns of EBP is premature. We suspect that the controversies surround-ing EBPs will continue for some time. Although it is frustrating for helpers and researchers alike (perhaps for different reasons), we believe there has been merit in this controversy over the past 20 to 25 years. For one thing, the debate has opened lines of communication between practitioners and researchers. Second, such conversations perhaps have helped to keep the focus on what is in the best interest of the client, including prioritizing client experiences of treatment by soliciting their feedback (see Lambert, 2010). Third, discussions about evidence-based practices appear to have ushered in a more integrative or both/and perspective about client care, consistent with the APA (2006) definition of EBP. One example of an integrative approach to EBP is that of cultural adaptation, an overdue initiative given that racially and ethnically diverse participants historically have not been included in RCTs (Bernal & Sáez-Santiago, 2006; Comas-Díaz, 2006; Whaley & Davis, 2007). We discuss the role of culture in EBP in the following section. Multiculturalism and Evidence-Based Practice T raditional psychotherapy and EBPs for the most part have been developed, validated, and promoted by white European Americans for use with a predominantly white European American client population. The research to support these approaches has been conducted with a similarly privileged client population—that is, white Eu-ropean American, middle class, and heterosexual. The evidence to substantiate that these approaches are appro-priate for culturally diverse and nondominant/minority group clients therefore is lacking, and implementing an EBP for clients for whom the EBP was not developed could potentially harm ethnic minority clients (Bernal et al., 2009). Thus, the challenge is to conduct method-ologically sound research of culturally specific practices and interventions and adapt existing EBPs to fit the needs of culturally diverse clients. Doing both represents the in-herent tension or dialectic of EBP: maintaining scientific soundness/rigor while ensuring clinical relevance. This dialectic is evident in Morales and Norcross's (2010) con-tention that “Multiculturalism without strong research risks becoming an empty political value, and EBP without cultural sensitivity risks irrelevancy” (p. 823). Morales and Norcross (2010) describe the relationship between multiculturalism and EBP as transitioning from “strange bedfellows” to “fast friends. ” This suggests that cultural adaptation of EBPs or the integration of EBP and multicultural therapy is a promising initiative. However, Hwang (2009) noted that this focus must shift from sim-ply being a set of abstract ideas about cultural competence to an emphasis on developing specific helper skills and strategies that can be implemented effectively with cul-turally diverse clients. This is not an easy task. It does not Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
22 Chapter 1 mean simply using existing EBPs with culturally diverse clients. And it involves more than a helper simply learning about a particular cultural group of which the client is a member or matching culturally diverse helpers with cli-ents of their same cultural group (e. g., African American helpers working with African American clients). Accord-ing to Helms (2015), EBPs must be culturally responsive by considering client and helper racial socialization (e. g., racism), client responses to EBPs, and client-helper cul-tural dynamics. Culturally Adapted EBPs Considerable attention has been given to what are referred to as culturally adapted EBPs. This involves systematically modifying, supplementing, or sequencing an interven-tion (e. g., thought-stopping technique) or intervention protocol (e. g., cognitive behavior therapy for anxiety) to accommodate or to be compatible with the client's cul-tural patterns, meanings, and values (Bernal et al., 2009; Morales & Norcross, 2010). According to Bernal and Sáez-Santiago (2006), this includes, among other things, a consideration of: (a) interdependent value systems (i. e., family system) rather than individualistic value systems; (b) spirituality in the healing process; and (c) poverty. Benish, Quintana, and Wampold (2011) emphasized understanding and explaining illness from the client's cultural milieu and adapting interventions to fit this ill-ness explanation. Their research found that when helpers were able to do this, racial and ethnic minority clients benefitted more from culturally adapted EBPs than from conventional psychotherapy approaches. Aguilera, Garza, and Muñoz (2010) further noted that adaptation is a fluid process that must take into account not only broad ethnocultural values (e. g., family system) but also local and specific elements that are part of each client's social reality (e. g., level of acculturation, substance use, access to health care). Culturally Adapted CBT One EBP, cognitive behavior therapy (CBT), has been adapted to various cultural groups because of what Hays (2009) noted as the “remarkable number of assumptions” (p. 355) shared by CBT and multicultural therapy. These include the emphasis on: (a) tailoring treatment to the unique strengths and needs of each client; (b) empower-ment; and (c) conscious processes (e. g., observed behav-iors) that can be verbalized and assessed fairly easily. The latter emphasis, she stated, is suitable for persons whose primary language is not English or who do not share belief systems that are common among European Americans. In their work with American Indians and Alaska Na-tives, Big Foot and Schmidt (2010) acknowledged that CBT principles complement many traditional tribal heal-ing and cultural practices such as storytelling and express-ing emotions in ceremonies. Bennett-Levy et al. (2014) reported that Aboriginal Australian counselors trained in CBT found CBT useful with their Aboriginal clients for several reasons. These included that CBT: (a) is prag-matic (simple interventions can be effective for complex problems); (b) highly adaptable and useful as a preven-tive measure (e. g., mental health hygiene); (c) provides structure that maintains focus; and (d) is empowering and promotes self-agency. One CBT method reported to be most useful with clients was the use of visual diagrams. Aboriginal counselors also found that CBT enhanced their skills and confidence, as well as their well-being (i. e., protecting from burnout). Specific examples of culturally adapted EBPs based on CBT principles include: Aguilera et al. 's (2010) 16-week group CBT in Spanish for adults with depres-sion; Nicolas, Arntz, Hirsch, and Schmiedigen's (2009) 8-week adolescent Coping with Depression Course for Haitian American adolescents; Big Foot and Schmidt's (2010) program for American Indian/Alaska Native chil-dren who have experienced trauma, Honoring Children, Mending the Circle (see www. icctc. org), an adaptation of trauma-focused CBT (Cohen, Mannarino, & Deblinger, 2006); and Cunningham, Foster, and Warner's (2010) adaptation of multisystemic therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009) specifically for African American youth and their caregiv-ers (e. g., parent, grandparent) to address the adolescents' delinquency and substance misuse. In all three of these culturally adapted programs, importance is placed on: (a) the use of culturally and clinically relevant language (e. g., reference to proyecto personal or “personal project” rather than “homework”); (b) maintaining a strength fo-cus; (c) routinely soliciting feedback from clients and their caregivers or other family members about the helpfulness of therapy (including the formation of an advisory board comprising cultural experts to help develop a culturally relevant program before it is implemented); and (d) prac-ticing reinforcement of positive behaviors, validation, and empathy among therapists as well as among clients (e. g., promoting simpatía or healthy social interactions among group members). Evidence for Culturally Adapted EBPs Evidence suggests that cultural adaptation of therapeu-tic approaches results in significant client improvement across a range of presenting concerns and conditions Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 23 and according to a variety of outcome measures (Benish et al., 2011; Griner & Smith, 2006). But as Morales and Norcross (2010) contend, adaptation presumes that the helper “is competent in the cultural and linguistic aspects of the client and has experience in integrating these vari-ables in a culturally competent and congruent manner” (p. 826). This means that a prerequisite for the cultural adaptation of any EBP is competence in multicultural counseling and therapy and, specifically, the ability to understand and empathize with the client's unique cul-tural identity and context. This means, for example, that helpers should not assume that all tribal and native people have similar traditions, a reminder offered by Big Foot and Schmidt (2010). This also means that helpers are able to appreciate the meaning each client has rendered to the intersection of his or her multiple identities, such as age, gender, sexual orientation, and race/ethnicity. These overlapping “selves” comprise the client's own cultural identity (a concept we discuss in more detail in Chapter 2), requiring the adaptation of any EBP to be tailored to that particular client. This constitutes an idiographic EBP adaptation rather than a nomothetic EBP adaptation. The former is tailored to a specific client, whereas the latter is considered applicable to persons who are members of a certain cultural group, such as lesbian, gay, bisexual, and transgender (LGBT) persons or persons of Latino/ Hispanic descent. Duarté-Vélez, Bernal, and Bonilla (2010) provide a helpful clinical example of an idiographic adaptation of an EBP (in this case, CBT) for a gay Latino adolescent male who was raised in a Christian home. Griner and Smith (2006) reviewed 76 studies published through 2004 to determine the effectiveness of culturally adapted treatment interventions. They identified 10 com-mon types of cultural adaptations used in these studies. To their list we have added (number 11) the one recom-mended by Benish et al. (2011): 1. Explicitly incorporating cultural values/concepts into the intervention (e. g., storytelling of folk heroes to children) 2. Matching the client and helper according to race or ethnicity 3. Providing services in the client's native language (other than English) 4. Providing services in a treatment facility specifically targeting clients from culturally diverse backgrounds (e. g., Africentric programming for African American youth in a substance abuse treatment facility) 5. Collaborating/consulting with individuals familiar with the client's culture (e. g., family members, elders, tribal leaders) 6. Engaging in outreach efforts to recruit underserved clients 7. Providing extra services to increase client retention (e. g., child care, transportation) 8. Orally administering written materials for illiterate clients 9. Conducting cultural sensitivity training for profes-sional staff 10. Providing referrals to external agencies for additional services 11. Understanding and explaining illness from the cli-ent's cultural beliefs and adapting interventions to this illness explanation From their meta-analysis of outcomes reported in these studies, Griner and Smith (2006) found, overall, that clients improved significantly as a result of having received at least one culturally adapted intervention. One noteworthy finding was that groups of same-race clients who received services tailored specifically to their cultural group (e. g., older Cuban Americans seeking help for depression) improved considerably more than clients who were in mixed-race treatment groups (e. g., African American and Hispanic adolescents attending the same facility and receiving services for substance abuse). This reinforces the contention that optimal ben-efit is derived when services are tailored to a specific cultural context. Greater improvement was also found among older clients compared to younger clients (pos-sibly due to the protective effects of lower accultura-tion levels among older clients) and when clients were matched with a therapist based on language (other than English) compared to clients who were not as-signed to therapists who spoke their native language. An unexpected finding was that clients matched with therapists of their own race or ethnicity fared no better than clients who did not work with a therapist of their own race or ethnicity. The failure of client-therapist ethnic matching by itself to effect positive change in clients is consistent with previous studies, however (e. g., Knipscheer & Kleber, 2004), and suggests that therapist multicultural competence and organizational cultural competence (referred to as cultural congruence by Constantino, Malgady, & Primavera, 2009) is a mul-tifaceted construct. To investigate the effects of cultural adaptations of specific interventions and EBPs in general, research meth-ods other than RCTs need to be used (Helms, 2015). One is the participatory action research method used with Aboriginal Australian counselors by Bennett-Levy Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
24 Chapter 1 et al. (2014) and praised by Hays (2014). Other research methods include naturalistic, quasi-experimental process-outcome studies (e. g., assessing in-session client-helper behaviors through audio or video recording or third-party live observation and rating) and single-case or N = 1 stud-ies. As an example of practice-based evidence, Mc Millan and Morley (2010) described the process of conducting single-case quantitative research, which necessarily in-cludes repeated measurement of client concerns and goals after baseline. We discuss these assessment practices in Chapters 7 and 8. Big Foot and Schmidt (2010) described the cultural adaptation of EBPs as “the blending of science and indig-enous cultures” (p. 855). They posited that the success of this blending or integration “is the translation of not just language but also core principles and treatment concepts so that they become meaningful to the culturally targeted group while still maintaining fidelity” (p. 855). Adapting and Adopting Evidence-Based Practices Most EBPs began as innovations in that they represent the integration of two or more therapies. For example, dia-lectical behavior therapy (DBT) is an adaptation of CBT in its incorporation of Eastern philosophy, namely Zen, and mindfulness practice. The balance of behavior change and acceptance—the fundamental tension or dialectic of DBT—is a treatment goal and reflects the innovative style of DBT. Although DBT is an EBP for borderline person-ality disorder, it must continue to undergo adaptation for it to be relevant and remain clinically useful for helpers and clients alike (see Dimeff & Koerner, 2007). This is true for all EBPs. If, as Thyer and Myers (2011) noted, EBP is a verb or a dynamic process rather than a static noun, and if, as Wampold et al. (2007) stipulated, EBPs are guidelines rather than absolutes and mandates, then EBPs must be subjected to ongoing modifications (e. g., cultural adaptations) that are able to demonstrate benefi-cial effects for clients and their families using a variety of sound measures. Only in so doing will EBPs shed their notoriety as reflections of what Wachtel (2010) termed “a poverty of imagination” (p. 254). It is from the (healthy) tension between science and clinical practice/expertise that innovations and future EBPs are born. As innovations, adopting EBPs and implementing them into routine clinical practice (a process known as diffusion or technology transfer) is not a simple task. Klein and Knight (2005) discussed several reasons why innovations are difficult to implement. Among these are that many innovations are unreliable and imperfectly designed, a concern raised by De Los Reyes and Kazdin (2008) with respect to inconsistent findings among evidence-based interventions. They noted, however, that “some evi-dence, although inconsistent, is clearly better than none” (p. 50). Innovations also require prospective users to acquire new technical knowledge and skills—a time-consuming and often costly endeavor—and to change their roles, routines, and norms. Practitioners accustomed to meet-ing clients in an office setting, for example, would likely have difficulty transitioning to and adopting the EBP of multisystemic therapy (MST) because MST services are provided to adolescents and their caregivers in their natu-ral environments, such as their school and their home. In addition, the decision to adopt an innovation is typically made by persons in authority. We discussed this earlier in the chapter with respect to state legislative bodies in the United States limiting funding only to those state-supported agencies that implement EBPs. The final rea-son innovations are difficult to implement, according to Klein and Knight, is that organizations (e. g., treatment fa-cilities, schools, local communities) are a stabilizing force and therefore any change that disrupts stability, status quo, and homeostasis is not necessarily “welcomed with open arms. ” This might explain why certain discredited practices (e. g., DARE) continue to be popular despite the evidence that they are ineffective and potentially harmful. It also might explain why some in the scientific commu-nity remain skeptical of culturally adapted EBPs because they did not derive their evidence from RCTs. The likelihood of adopting an innovation, such as an EBP, increases when it meets certain criteria. In his sem-inal book, Diffusion of Innovations, sociologist Everett Rogers (1995) identified five attributes of an innovation that, when perceived by members of a particular group (e. g., clinical team), determine whether or how quickly the innovation will be adopted and implemented into routine practice. The five attributes of an innovation are: 1. It must be perceived as having a relative advantage; that is, it must be viewed as being better than or an improve-ment on current practice. This advantage might be the perceived convenience, prestige, or cost of an EBP. 2. It must be perceived as being consistent with the adopter's experience, values, and goals; in other words, for a helper to use an EBP, it must be compatible or resonate with his or her own values and beliefs as well as previously introduced ideas and practices (e. g., theoretical orientation, cultural competence). 3. It must be easy to understand and use; it must be per-ceived as simple rather than as complex. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 25 4. Potential users must be able to sample or try it out on a limited basis before making a decision. This is the innovation's attribute of trialability and can be lik-ened to test-driving a car before making a purchase. A trial period is designed to dispel uncertainty about a new idea. 5. The benefits of adopting an innovation must be visible to others. This is the attribute of observability. In the case of EBPs, this is not limited to reading or hear-ing about research findings; it also includes—perhaps more so—helpers being able to directly witness and testify to the beneficial effects of the EBP for their clients. This appears to support the efforts of practice-based evidence. Researchers and health care administrators cannot ex-pect helpers to automatically and enthusiastically embrace EBPs simply because “the research says so. ” Rather, adopt-ing and then implementing these practices is a process that requires time, involvement of and collaboration with clinical staff, provision of staff support (e. g., training, on-going supervision, financial compensation), and evidence beyond research findings. Just as clients engage in a pro-cess of personal change—moving through various stages of readiness to change over time—practitioners also par-ticipate in a professional change process when introduced to new practices. Miller et al. (2006) likened this process to learning any new skill, which often entails three aids: ground school or basic training (e. g., graduate school, reading, attending workshops), practice with feedback, and coaching or supervision to reinforce correct practice and cultivate enhancement. We believe that researchers, clinical directors, and supervisors need to engage practi-tioners (as well as the systems or organizations they repre-sent) in a similar stage of change process when attempting to disseminate innovative approaches. As you learn more about EBPs in your coursework and in your clinical practice (e. g., from in-service training, pro-fessional workshops), we encourage you to consider each EBP you are introduced to according to the five attributes that Rogers (1995) identified. For example, be willing to ask, “How is this EBP intended to benefit clients in ways that that are currently not available?” and “Will I be able to explain this EBP to clients in a way they can understand, in a way that is simple and not confusing to them?” Innovations with Integrity T wo therapies recognized as EBPs exemplify the benefit of a comprehensive and integrative perspective result-ing from ongoing discussions between scientists and practitioners. They have become familiar practices in certain sectors, and the concepts that undergird and guide their respective approaches are not new. However, only in recent years have assertive community treat-ment (ACTx) and dialectical behavior therapy (DBT) gained wide prominence. An integration of ACTx and DBT also has been proposed (Reynolds, Wolbert, Abney-Cunningham, & Patterson, 2007). We discuss each of these EBPs briefly and encourage you to com-plete Learning Activity 1. 3 on page 26 once you have familiarized yourself with ACTx and DBT. Assertive Community Treatment According to Bond, Drake, Mueser, and Latimer (2001), assertive community treatment was first developed in the 1970s as an intensive and holistic approach to the treat-ment of persons with severe and persistent mental illnesses (e. g., schizophrenia, bipolar disorder). (In this chapter we abbreviate assertive community treatment as ACTx to dif-ferentiate it from the acronym ACT that designates accep-tance and commitment therapy mentioned earlier in the chapter. ) Key features of ACTx (see Box 1. 3 on page 26) are that integrated services (e. g., medication management, vocational rehabilitation) are provided not by one person but by a group of professionals (e. g., substance abuse counselor, case manager, nurse) who work as a team. All team members, therefore, share responsibility for caring for the same clients. It is highly unlikely that persons with severe and persistent mental illnesses initiate and maintain active involvement in formal services. Therefore, the ma-jority (approximately 80%) of ACTx services are delivered in the field or in vivo (i. e., in the community rather than in a clinical setting) to engage and remain connected with persons challenged by a multiplicity of concerns and prone to frequent relapses and overall instability. In this manner, ACTx is regarded as a proactive, assertive, and persistent treatment approach. It is a “living-systems” alternative to hospital and residential care (see Ellenhorn, 2015) that often is described as “a hospital without walls. ” Specific ACTx services target what some might con-sider basic client needs, such as obtaining housing, food, and medical care as well as managing finances. Although it resembles case management, ACTx is different from and far more comprehensive than intensive case manage-ment in that a range of services is delivered directly to the client (rather than linking the client to other service providers) by members of a team (rather than one case manager). In addition, ACTx services are tailored to the individual client, include individual counseling and crisis intervention, and are unlimited. The most encouraging and compelling aspects of ACTx are that it has been Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
26 Chapter 1 found to contribute to reduced psychiatric hospital stays, increased housing stability, and engaging and retaining clients in mental health services (Bond et al., 2001). Compared to case management or to a standard treat-ment, a review of research found that ACTx services specifically for homeless persons increased their engage-ment in medical, mental health, and substance use treat-ment services (Nelson, Aubry, & Lafrance, 2007). Early engagement and retention in ACTx also was found for older persons with severe mental illnesses (Stobbe et al., 2014). For helpers (specifically case managers), the ben-efits of ACTx participation include a decrease in burnout and an increase in job satisfaction (Boyer & Bond, 1999). The Assertive Community T reatment Association (www. actassociation. org) was founded in the late 1990s and sponsors an annual conference. Dialectical Behavior Therapy Dialectical behavior therapy (DBT) was developed by Marsha Linehan (2015) as a highly structured, multi-modal treatment program for suicidal clients meeting the criteria of borderline personality disorder (BPD). It is informed by cognitive behavior theory, biosocial the-ory (i. e., biological irregularities combined with certain dysfunctional environments), and Eastern philosophy, namely Zen. Although DBT is now regarded as an EBP Learning Activity 1. 3 Compelling Evidence Exercise This activity is intended to assess your own motivations for adopting and implementing an evidence-based practice. It can also be used as a classroom activity to generate discus-sion. As you complete the activity, consult the five attri-butes of an innovation identified by Everett Rogers (1995) that are listed and defined on pages 24-25. Consider for a moment that you are on the clinical staff of a community-based mental health facility primarily serving a low-income population, many of whom have severe and persistent mental illnesses (e. g., schizophrenia, personality dis-orders). In response to the accrediting body's new policy that all accredited treatment facilities adopt and deliver evidence-based practices as standard service, you have been informed that you will soon become a member of a new assertive com-munity treatment (ACTx) team and will need to attend training in dialectical behavior therapy (DBT). Given what you know about ACTx and DBT, what “evidence” will convince you that these two treatment approaches will be worth the investment of your time and energy? What information will compel you to adopt and begin implementing these two practices? Check all of the following that apply, and add two of your own reasons, too. 1. ____ Learning about research findings from published clinical trials that justify both ACTx and DBT's designa-tion as evidence-based practices. 2. ____ Knowing that I will be receiving close supervision and training tune-ups in the first few months of using these two approaches. 3. ____ Receiving training from seasoned practitioners who themselves have used both ACTx and DBT. 4. ____ Learning that my salary will remain the same and that I will have to pay for half of the DBT training costs. 5. ____ Knowing that I will be part of a team of other clini-cal staff who will meet at least once per week not only to review client cases but also to offer one another support. 6. ____ Learning that after 6 months of implementing ACTx and DBT, our facility saved the county mental health board several thousands of dollars due to our clients needing fewer psychiatric hospital bed stays. 7. ____ Hearing the stories of (and even being able to interact with) clients of other treatment facilities who have participated in ACTx and DBT and are now man-aging their symptoms fairly well. 8. ____ Receiving training from prominent researchers who have studied ACTx and DBT for a number of years. 9. ____ Learning that I will be provided with a mobile phone (at no expense to me) so that I can be on-call 24 hours once per week. 10. ____ Knowing that my current caseload will be reduced and that all members of the ACTx team (approximately six to eight) will assume responsibility for the same clients (approximately 50 to 60). 11. ____ Knowing that DBT is a highly structured approach that holds clients accountable for their behaviors while validating their experiences and circumstance in a nonjudgmental and empathic manner. 12. ____ Learning that after 6 months of implementing ACTx and DBT, approximately one-third of the clients our team serves have taken their medications as pre-scribed and have not been actively suicidal. 13. ____ Learning that client-helper collaboration is a pri-ority in ACTx and DBT, and this resonates or fits with my own belief system of effective therapy. 14. ____ After 6 months of implementing ACTx and DBT, hearing one of my previously hostile and unstable clients describe a recent incident in which he was able to keep his cool after practicing one of his mindfulness exercises. 15. ____ ________________________________________ 16. ____ ________________________________________ Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 27 for the treatment of BPD, recent adaptations of DBT have expanded its application to persons with eating disorders (Wisniewski & Kelly, 2003; Wisniewski, Safer, & Chen, 2007), comorbid personality disorders (i. e., paranoid and obsessive-compulsive personality disorders; Lynch & Cheavens, 2008), and comorbid substance use disorders (i. e., substance use and borderline personality disorders; Lee, Cameron, & Jenner, 2015), whether or not BPD or suicidal intent is present. For adolescents with repeated suicidal and self-injurious behavior, DBT has been found to be effective in reducing those and depresssive behaviors (Mehlum et al., 2014). DBT also has been modified for deaf individuals (O'Hearn & Pollard, 2008), an example of a culturally adaptive EBP. DBT is based on behavior theory and includes the prin-ciples of acceptance, mindfulness, and validation (Neacsiu, Ward-Ciesielski, & Linehan, 2012). Although it is highly structured and calls for the implementation of specific helper skills and client behaviors, DBT is not a rigid or prescriptive approach, and it fits well with the helper skill of flexibility discussed earlier in the chapter. Helpers are instructed to provide individualized care and there-fore tailor specific practices to the needs of each client. For example, for persons with bulimia nervosa, Hill, Craighead, and Safer (2011) incorporated appetite aware-ness training into the first 4 weeks of DBT and modified the DBT diary card to include appetite monitoring. A guiding premise of DBT is that a convergence or synthesis of what appear to be opposing forces is possible. This process of balancing and regulating conflicting feel-ings and behaviors is what is meant by dialectical in the name DBT. Take, for example, an adult woman with a history of sexual and physical abuse who has attempted suicide on several occasions (symptoms or characteristics often associated with BPD). Although she may interpret the violations she experienced as “proof” that she is “not fit to live,” she also has a strong desire to experience an in-timate connection with another human being, to be loved (a need that might be interpreted by some as an “attach-ment disorder” or traits of “dependency”). It is not that one experience is “wrong” and the other is “right. ” Rather, both have validity, and in her work with a professional helper this woman would strive to acknowledge and ac-cept both experiences, live with the tension or paradox (i. e., “not fit to live” vs. someone deserving of love), and arrive at a synthesis of the two polarities (e. g., “I have been violated and I am a survivor worthy of love”). As a comprehensive approach, DBT offers an array of behavioral strategies, including problem-solving, skills training, contingency management (e. g., behavioral contracting), exposure-based procedures, and cognitive modification. These are complemented by what Linehan (2015) refers to as acceptance-based procedures, such as validation, mindfulness, and distress tolerance. Validation and problem-solving strategies form the core of DBT, and all other strategies are built around them. Validation conveys to the client that the choices he or she has made and the behaviors he or she has engaged in make sense and are understandable, given the client's life situation (i. e., history, current circumstances). Problem-solving is un-dertaken only after validation has been conveyed (it may need to be repeatedly conveyed), and it includes clarifying the primary concern at hand and then generating alterna-tive solutions. One such strategy, chain analysis, involves the development of “an exhaustive, step-by-step descrip-tion of the chain of events leading up to and following the behavior... [so as to examine] a particular instance of a specific dysfunctional behavior in excruciating detail” (Linehan, 1993a, p. 258). This exercise not only informs the helper about the client's cognitive schema (e. g., the specific details that are remembered) but also teaches the client important self-observational and self-assessment skills, as well as the connections among many different variables, and it teaches that the client has the ability to exert control over those linkages and create new patterns of behavior. We believe that both ACTx and DBT warrant further consideration by practitioners and scientists/researchers alike. They not only have compelling empirical evidence to justify their continued practice but they also have ● ●Multidisciplinary staffing ● ●Integration of services ● ●Team approach ● ●Low patient-to-staff ratios ● ●Locus of contact in the community ● ●Medication management● ●Focus on everyday problems in living ● ●Rapid access ● ●Assertive outreach ● ●Individualized services ● ●Time-unlimited services Box 1. 3 Key Principles and Practices of Assertive Community Treatment (ACTx) Source: Bond et al., 2001. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
28 Chapter 1 practical appeal (i. e., they make sense, can be imple-mented in everyday practice settings), and this is not always the case with evidence-based practices. CHAPTER SUMMARY We end this chapter as it began, with the story of the cham-bered nautilus. Before you complete the two activities at the end of the chapter, we ask once again that you pause to inspect the cover of the book. Think of this as another mind-fulness activity! Once you have the book cover in sight, focus your gaze on the center of one of the three spirals, where the life of the mollusk began. Notice that as the mollusk grew and built new and bigger living spaces or compartments, those chambers remained connected to and wrapped them-selves around its center, its beginning. It did not distance itself or grow away from its center—it embraced it. Likening the story of the chambered nautilus to your own change and growth as a professional helper, consider the center of the shell's spiral as your own beginning and foun-dation as a professional helper, a foundation that includes the core skills and attributes we discussed in this chapter, the skills of self-awareness and self-reflection, mindfulness, and self-care and self-compassion. You will learn more skills and expand your repertoire as you continue in your career, but our wish for you is that you remain connected to these core skills—that you embrace and wrap yourself around these skills and build your practice on them. As you return your gaze to the visual of the chambered nautilus on the cover of the book, also consider that the expansion of the shell, the ever-expanding and larger compartments, is symbolic of the growth and change of the helping profession. Specifically, think of the adapta-tions being made to evidence-based practices (EBPs) so that they will be relevant to a wider and more diverse client population. Our helping professions and our way of practice must expand! We cannot limit our work only to certain privileged groups of persons. This is not only disrespectful and discriminatory—an affront to persons who, by no fault of their own, are disadvantaged and have experienced disenfranchisement for perhaps their entire lives—but also stifling. By this we mean that help-ing professions that remain locked into “same-old, same-old” ways of thinking and practicing become irrelevant and obsolete. Choosing to remain in the same compart-ment or chamber almost guarantees one's demise. That is why—as with the chambered nautilus and individual professional helpers—helping professions must continu-ally expand. This includes continuing to adapt EBPs to be culturally relevant to an ever-widening and more diverse population. Our intent and hope is that the remainder of the chap-ters in this book will assist you in your efforts to grow and change as a helping professional, all the while remaining fastened to and informed by your firm foundation. Keep the story of the chambered nautilus front and center as you move through the book and through your career. Visit Cengage Brain. com for a variety of study tools and useful resources such as video exam-ples, case studies, interactive exercises, flash-cards, and quizzes. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 29 Building Your Foundation as a Helper 29 1 Knowledge and Skill Builder Part One Part One is designed to help you recognize the need for the core helper skills of self-awareness and self-reflection, mind-fulness, and self-care and self-compassion, consistent with Learning Outcome 1. It is also intended to highlight specific activities to develop each of these three skills to promote your stamina and resilience as a professional helper. Read through the following dialogue between a counsel-ing student and her practicum supervisor. In what the coun-seling student says or in what the supervisor says, identify one example (three examples total) of the supervisee's need for: (1) self-awareness and self-reflection; (2) mindfulness; and (3) self-care and self-compassion. For each of the three needs you identified, locate an example of a specific activ-ity that either the supervisor mentioned or the counseling student verbalized. You can write the identified needs and the corresponding activities on a separate sheet of paper, or simply circle or underline the text in your book. Compare your responses to those provided on pages 33-34. Jasmine is a full-time clinical mental health counseling student who also works part-time as a server at a popular fine dining restaurant in town. She is in her second semester of practicum and her clients are primarily traditional age col-lege students seeking services at the university counseling center. Jasmine is directly supervised by Dr. Sarah Morton, a full-time professor in the counseling program who teaches practicum. Because it serves as a practicum site, the uni-versity counseling center is equipped with video recording equipment and Dr. Morton routinely views the video record-ings of Jasmine's counseling sessions. In a recent individual supervision session, Dr. Morton (Dr. M. ) and Jasmine discuss specific skills Jasmine has dem-onstrated and skills she needs to improve. They also discuss how these skills are needed inside and outside the counsel-ing room. Dr. M. : You use your time well in session, Jasmine. You know how to begin a session and how to bring it to a close. You also provide your clients with a wealth of information related to resources on campus. You know this university pretty well! Jasmine: Well, I did go to undergrad here, and being at the restaurant where I am, you have to be efficient. I mean, you can't be lazy, especially when the customers are paying top dollar for their meals. Dr. M. : Sounds like you're kept on your toes at work. Now, in session with clients, I'd like to see you pace yourself a little better. Sometimes it seems like you're in a hurry to get the session over with. And I wonder, especially with the new client you saw last week, if he felt bombarded with all of the resources on campus you gave him—all in the first ses-sion. I noticed that he canceled for this week. Jasmine: Hmm. I thought that session went fine. He really didn't seem bothered by what I had to say. And I just thought he canceled because he realized he got what he needed in that first session. We have been learning about brief therapy in my advanced theories class, you know, so I thought getting right to the issue and moving things along in the session was a good thing. Dr. M. : But unless you asked the client directly at the end of the session, or followed up with him after he canceled, you don't really know whether he got what he needed. Jasmine: Yeah, I guess that's true. Dr. M. : Have you been able to watch your counseling sessions over the past 2 weeks? Jasmine: Actually, no. I haven't had a chance. It's been real crazy at work and I've had to babysit my two nephews because my sister's work schedule changed. And on top of everything, I've been applying for an internship posi-tion for this fall. The deadline, you know, for getting a site is next week. And I need to graduate this December. My mom's counting on it! Dr. M. : You have a lot going on right now. And you're trying to meet the expectations that others have for you. How are you managing everything? Jasmine: Just doing what I need to do to get by. I'm pretty good at multitasking! Dr. M. : Well, there's only so much that any one of us can handle at one time. Too many things on one plate—or a serving tray—can turn into a stumble or a fall. I imagine you know well from work that you can carry only so much on a tray at one time. Jasmine: I've gotten pretty good at balancing heavy loads— even with one hand. Dr. M. : It sounds to me, though, that things have gotten unbalanced for you recently, kind of lopsided. I have this image of you rushing around from one place to another. And in your last two or three counseling sessions, you've seemed distracted—sitting on the edge of your seat for most of the session, not allowing for silences, and providing quite a few suggestions—advice—to clients without first inviting them to come up with their own ideas. This is part of what I mean by needing to pace yourself better. Jasmine: But they're obviously coming in for help. I mean, the two I saw last week actually asked me what they should do. How can I not tell them? And it just seems like a waste of time to sit there in silence, staring at each other... or the floor. Dr. M. : Be careful that you're not doing all the work in session. This is one example of being lopsided. It really isn't our job as helpers to figure things out for clients—as much as they may want us to, you know, give them answers. It would be like you deciding for each of your customers what they should eat. No menus necessary! Not only does this go against the philosophy or ethic in counseling of a client-helper partnership and also helping clients make decisions for themselves—the idea of empowerment—it (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
30 Chapter 1 1 Knowledge and Skill Builder (continued) also is draining on us. It would be like you having to de-cide for your customers what they should eat and then going into the kitchen to prepare it for each of them! You wouldn't be able to keep up, would you? And you'd be exhausted. Jasmine: Yeah, I can see how I've been trying to do too much for my clients, you know, kind of wanting to spoon-feed them or rescue them. And... [pausing] I am tired. Dr. M. : I'd be surprised if you weren't, especially with all that you have going on in your life right now. How have you been managing? I mean, are you getting enough sleep, eating properly, exercising? Jasmine: No time, Dr. Morton. This is grad school, you know!Dr. M. : Yes, it is, Jasmine. And grad school is also the time to learn ways of taking care of yourself so that you can en-dure and remain resilient—and do well—in this challeng-ing work of counseling. If not now, I don't know when. It's not like you can be superwoman forever. You might need to set some time limits and possibly negotiate some of your responsibilities with family and people at work. Jasmine: That really just seems so selfish, though. I mean, I want to help people. Dr. M. : In this case, though, when clients are involved, it's not really selfishness; it's actually about self-care. A wise super-visor told me that one time. And it's a part of being a help-ing professional. When we're not taking care of ourselves, we're not taking care of our clients. Self-care is actually a standard for counselors in the ACA Code of Ethics. Jasmine: Yeah, I guess we talked about it in my ethics class. It's just so different when you get to prac! Dr. M. : Now's the time when you realize that you are practicing as a professional. And it's probably the time when students learn that they can't do everything—like “fixing” their cli-ents, or giving them the so-called “answers. ” Maybe it's the time when we learn to accept ourselves as human, as not perfect. And, you know, this is what makes it possible to empathize with our clients. Jasmine: Huh. I never thought about that before—that learn-ing my limits makes me better able to empathize with clients. Dr. M. : We're human helpers. And that means there's really only so much that any one of us can do. That's just part of being human. Now, speaking of setting limits, I don't know how much leeway you have at work and with your family. Jasmine: Well, I have to work to pay for school, and with the holidays coming up, I really can't reduce my hours or ask for time off. That's the busiest time at the restaurant, you know, holiday parties and all. And I can't let my sister down. I promised her I'd help out. She's going through a rough time and being the big sister and all, my mom has expected me to take care of her. Dr. M. : You're stretched to the limit, it seems. Jasmine: Yeah, that's just how it is right now. Dr. M. : Well, can I share something with you?Jasmine: Sure. Dr. M. : My concern is that all that you are trying to man-age outside of counseling is having an effect inside of counseling—on the quality of care you're providing to your clients. I'm particularly concerned that you haven't been able to watch your counseling sessions. Taking the time—stepping outside the routine—to observe and cri-tique yourself is really one of the best ways to improve your skills. Who knows? It might also help you better learn how to manage relationships outside of counseling. What do you think about what I just said? Jasmine: Hmm. I never thought of it that way before. Dr. M. : Yes, in many ways, who we are outside of counseling is who we are inside of counseling, and vice versa. And only by setting aside time to really pay attention to what's go-ing on in session, in the present moment, can we really be genuine—with ourselves, and with our clients. Jasmine: Kind of like doing therapy on yourself, I guess; you know, practicing what you preach. Dr. M. : Yes, that's good awareness on your part. Jasmine: But I have to graduate in December. I promised my mom. Dr. M. : Is that promise set in stone? I mean, what will happen if you delay graduation until May and give yourself some time to do an extended internship, one that perhaps will be more effective in the long run, or at least healthier? Jasmine: It's just that my mom has such high hopes for me, especially with my sister having problems right now. I've always been the high achiever—first one in my family to get a master's degree—and my mom's real proud of that. Dr. M. : She has reason to be proud. I'm just wondering about the cost to you—and to your clients, both now in practi-cum and then in internship—of your rush to get done. I imagine that your customers at work would rather wait for a well-prepared meal—and one served by you when you're not out of breath or sweating from rushing around—than have a fast-food meal. I guess that's why they're paying, as you said, the top dollar that they are. They want attentive, quality service. Jasmine: True. I'd never thought before about the connection between what I do at the restaurant and my work as a counselor. Dr. M. : Well, they're both demanding positions because they're about working directly with people, and so you've developed some good people skills in your work at the restaurant that I can see you using here in your work with clients. But you will need to develop the skill of being able to engage clients more in session—working with them rather than leading them or pulling them along. And this means staying with them in the moment, sitting with si-lence from time to time, rather than rushing ahead just so you can clear the table and welcome a new customer. And Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 31 Building Your Foundation as a Helper 31 brief therapy, if I may say, is not about just the number of sessions provided. It's really more about being purposeful and intentional in your work with clients. And to do this, you need to be fully alert or awake to what's going on with the client in each moment of the counseling session—facial expression, words used, gestures and mannerisms, voice inflection, and so forth. So, using your good obser-vational skills—and not just with the client but also with yourself. For example, being sure that you're not spending more time thinking about what you need to get done after the session while you're in session with the client. Just be-ing aware of being distracted is a start. It's then a matter of pulling yourself back to what's going on now, in the pres-ent moment. Well, I've gone on a bit here, but does any of this make some sense? Jasmine: Yeah, it does. In fact, just sitting here and listening to you—and, just so you know, I have been listening to you—I've realized just how frantic I've been recently. And rushing around and being so concerned about getting my hours for practicum, getting an internship site, and gradu-ating in December, I see that I have missed some impor-tant details right in front of me, right before my eyes. Like what you said earlier about the client who canceled this week. I had always thought I had a good eye for details, but maybe not in the past few weeks. Dr. M. : You know, hearing you say that right now is encouraging. I mean, you've been able to catch yourself, so to speak, and to make some meaningful connections for yourself right now—connections between the kind of person and coun-selor you want to be and how what you're doing now is not making that happen. And you did that right here and now. Jasmine: Yeah, this has been good, actually. I mean, it feels like supervision today has been the first breather I've had in a long time. Just being able to listen to you and talk about this stuff has been helpful, like I can breathe easier now, like I don't have to make things happen all at once. And that I really do have some options. Dr. M. : Yeah, “breather breaks” are really essential for the kind of work we do. It's a way of being kind to yourself, too. [smil-ing] Something I can hear you saying to one of your clients! Jasmine: [laughing] Yeah, you're right! Dr. M. : So one thing we need to work on is making it possible for you to be okay with being still—inside and outside of counseling. You've done that here in supervision today, and you said it's been helpful. Jasmine: Yeah, it's that whole time issue. Dr. M. : But trying to do a whole lot at once—you know, mul-titasking—hasn't been working for you. In fact, some research suggests that multitasking is not any more pro-ductive than doing one thing at a time. It can actually make things worse. Jasmine: Hmm. I hadn't heard that before. But now it makes sense to me. Dr. M. : Okay, so I'm going to start by having you make time this week to watch your counseling sessions from last week. Because the one client canceled, [smiling] you do have that hour already to be still in and to work on your good attending skills so that you don't miss important details—about clients and about yourself. Jasmine: Thanks, Dr. Morton. I'll go ahead and schedule that hour for viewing now [smiling]... I mean, when we're done. Part Two Part Two addresses Learning Outcome 2 and is intended to help you define evidence-based practice (EBP)—what it is and what it is not. This activity is also designed to help you identify the intended benefits and criticisms of EBP as well as recent efforts to adapt EBPs for culturally diverse populations. 1. Imagine that you have been asked to give a brief pre-sentation in class or at your internship site on the topic of evidence-based practice (EBP). Because of your grad-uate studies, you are regarded as someone who has re-ceived some training in EBP, specifically what it is, what it is not, its benefits and its criticisms. a. From the list of 18 descriptors below, select 10 that are consistent with the definition of EBP presented and discussed in this chapter. Place a check mark (❒) in the box next to each of the 10 descriptors se-lected. Place an x (❒) in the boxes (or simply strike out the text) that are not consistent with the defini-tion of EBP provided in this chapter. ✓ ✕ ❒ Absolute truth❒ Cost-saving measure❒ Integration ❒●Best available research❒ Noun ❒ Dynamic process ❒ Set of techniques❒ Subject to revision❒ Best practice ❒ Verb ❒ Superior treatment❒ Client focused ❒ Prescriptive ❒ Clinical expertise❒ Beneficial care ❒ Ethical standards❒ Characteristics, culture, preferences❒ one-size-fits-all b. once you have selected 10 descriptors, use them to construct a two-sentence definition of EBP. This will be the definition you will use—and will be able to support and explain—during your presentation to classmates or to other professionals at your intern-ship site. Write out this two-sentence definition us-ing the 10 descriptors selected in the space below. Evidence-based practice is... (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
32 Chapter 1 1 Knowledge and Skill Builder (continued) c. From the list below, select at least two intended benefits of EBP and also two criticisms of EBP. Add additional benefits and/or criticisms not on the list. Be prepared to explain each of your selections or additions. ❒● ●Identify potentially harmful therapies ❒ Adhering to a treatment manual may have the effect of helpers feeling “manualized” ❒● ●Limits helper creativity ❒ Research often not based on culturally diverse clinicians or clients ❒● ●often mandated by persons in authority ❒ Engage practitioners and researchers in conversations about effective care ❒ Mistakenly promoted as a cost-saving measure ❒ __________ ❒●__________❒ Identify therapies that are most helpful to clients ❒ often based on the “gold standard” of randomized/clinical control trials (RCTs) ❒ Holds clinicians more accountable for their decisions and practices ❒ often misused as one-size-fits-all care ❒ Research often limited to single diagnostic categories, without consideration for complex client concerns ❒● __________ ❒●__________ 2. From the list below, identify at least six practices used to adapt EBP to culturally diverse populations. Place a check mark (❒) in the box next to each of the six practices selected. Place an x (❒) in the boxes (or simply strike out the text) that are not consistent with the practice of culturally adapting EBP described in this chapter. For each one selected, be prepared to explain how the practice is intended to provide ben-eficial care to a specific client or group of clients who share a similar cultural identity or background. Pro-vide an example of how each one selected could be implemented. ❒ Explicitly incorporating cultural values/concepts (e. g., storytelling) ❒ Using materials (including a treatment manual) that are written only in English✓ ✕❒ Providing services in the client's native language (other than English) ❒ Matching the client and helper according to race or ethnicity ❒ Providing services only in a treatment facility so that clients and their families are required to physically arrive for scheduled appointments ❒ Collaborating/consulting with family members ❒ Extending length and number of treatment sessions to accommodate specific needs of clients (e. g., use of American Sign Language for deaf clients in DBT skills groups) ❒ Understanding and explaining the client's presenting concern consistent with the client's cultural beliefs ❒ Conducting cultural sensitivity training for profes-sional staff ❒ Limiting services only to talk therapy and discourag-ing other expressive means of communication (e. g., art, dance, singing) because the treatment manual does not include these ❒ offering child care and transportation services to increase client retention ❒ Providing services in a treatment facility spe-cifically targeting clients from culturally diverse backgrounds ❒ Discouraging social interaction among clients out-side of group sessions because the treatment man-ual does not mention this activity ❒ Routinely soliciting feedback from clients about the helpfulness of services ❒ Engaging in outreach efforts to recruit underserved clients ❒ Establishing an advisory board of cultural experts to help develop a new program for persons in the com-munity from a specific cultural group ❒ Maintaining a problem focus so that the core issue or the reason for the problem can be identified ❒ orally administering written materials for illiterate clients ❒ Hiring only staff who live outside the local commu-nity to maintain clear boundaries between clients and professional staff ❒ Providing referrals to external agencies in the com-munity (e. g., free health clinic, job skills training) for additional services Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Building Your Foundation as a Helper 33 Building Your Foundation as a Helper 33 1 Knowledge and Skill Builder Feedback Part One 1. Examples of Jasmine's need for: (1) self-awareness and self-reflection; (2) mindfulness; and (3) self-care and self-compassion. a. Need for self-awareness and self-reflection: (1) She had not been watching her video recorded counseling sessions and so was not aware of her tendency to offer advice and too many sugges-tions to clients or of client reactions in session. (2) As a full-time student working part-time and trying to get an internship completed in one semester—while upholding family obligations (not letting her sister, nephews, or mother down)—she may not have the time or the space for honest self-reflection. b. Need for mindfulness:(1) She describes herself as a multitasker, someone who is efficient and not lazy, and one who has been rushing around recently—from school (and coun-seling center) to work to family commitments. (2) She describes brief therapy as “moving things along” in session. (3) She describes silence in session as being “a waste of time. ” (4) She has been more concerned about her fu-ture (e. g., accruing hours for practicum, getting an internship site by next week, graduating in December) than about her present. c. Need for self-care and self-compassion: (1) She describes herself as being tired. (2) She recognizes that she's been “trying to do too much” for her clients, wanting to “spoon-feed” them or “rescue them. ” (3) She appears to think that she cannot set lim-its on her responsibilities, that she must fulfill the expectations that others have for her, what Dr. Morton described as being “superwoman. ” 2. Examples of specific activities mentioned in the su-pervision session for Jasmine to engage in to meet her need for: (1) self-awareness and self-reflection; (2) mindfulness; and (3) self-care and self-compassion. a. Specific activities for self-awareness and self- reflection: (1) Watch the video recordings of her counseling sessions. (2) Realize that genuineness in counseling means “practicing what you preach” outside of counseling. (3) Recognize that being unbalanced or lopsided as a counselor is like carrying too much on the serv-ing tray as a server in a restaurant. (4) Continue to be an active participant in supervision. b. Specific activities for mindfulness: (1) Allow for moments of silence in counseling sessions. (2) Remain alert and fully attentive to the present moment while in session. (3) Consider her work with clients as offering them a fine dining experience rather than a fast-food experience. (4) Elicit feedback from clients at the end of each session about their experience in counseling, and follow-up with clients when they have canceled. c. Specific activities for self-care and self-compassion: (1) Negotiate her work schedule, as needed. (2) Make time for additional “breather breaks. ” (3) Consider doing her internship over two semes-ters and graduating in May rather than doing it in one semester and graduating in December. (4) Accept that she is a human being, not “superwoman, ” and therefore has limits regarding what she can and cannot do, including not being able to “rescue” or “fix” clients. Also, realize that this self-acceptance will allow her to improve her empathy skills. (5) Reframe “selfishness” as “self-care” in her work as a counseling student and future counseling professional. Part Two 1. a. Evidence-based practice (EBP) is defined using the 10 descriptors checked below and highlighted in bold font, and not using the descriptors that have an x in the box next to them (we have used the strike-out key to further clarify those descriptors not to be used in a definition of EBP). ❒●Absolute truth❒●Cos t-saving measure❒●Integration/ Integrating ❒ Best available research❒●Noun ❒ Dynamic process ❒●Set of techniques❒ Subject to revision❒●Best practice ❒ Verb ❒●Superior treatment❒ Client-focused ❒ Prescriptive ❒ Clinical expertise❒ Beneficial care ❒ Ethical standards❒ Characteristics, culture, and preferences❒●one-size- fits-all✕ ✕ ✓ ✓ ✕ ✓ ✕ ✓ ✕ ✓ ✕ ✓ ✕ ✓ ✓ ✓ ✓ ✕ (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
34 Chapter 1 1 Knowledge and Skill Builder Feedback ( continued) b. Using the 10 descriptors selected above with a check mark (and in bold font above and underlined below), a two-sentence definition of EBP is: Evidence-based practice is the dynamic process of integrating the best available research with clinical expertise to provide beneficial care to clients. It is cli-ent focused, which means that it takes into consider-ation client characteristics, culture, and preferences, and is therefore a verb, or always subject to revision and innovation, while maintaining ethical standards. 2. The specific practices selected below with a checkmark (❒) are ones that should be considered as appropriate activities for adapting EBPs for culturally diverse per-sons. The practices that have been marked with an x (❒) are activities that are not considered appropriate as cultural adaptations. We do not recommend the ones marked with an x and this is emphasized by striking out the text. ❒●Explicitly incorporating cultural values/concepts (e. g., storytelling) ❒ Using materials (including a treatment manual) that are written only in English ❒●Providing services in the client's native language (other than English) ❒●Matching the client and helper according to race or ethnicity ❒ Providing services only in a treatment facility so that clients and their families are required to physically arrive for scheduled appointments ❒●Collaborating/consulting with family members ❒●Extending length and number of treatment sessions to accommodate specific needs of clients (e. g., use of American Sign Language for deaf clients in DBT skills groups)✓ ✕ ✓ ✕ ✓ ✓ ✕ ✓ ✓❒●Understanding and explaining the client's presenting concern consistent with the client's cultural beliefs ❒●Conducting cultural sensitivity training for professional staff ❒ Limiting services only to talk therapy and discouraging other expressive means of communication (e. g., art, dance, singing) because the treatment manual does not include these ❒●offering childcare and transportation services to increase client retention ❒●Providing services in a treatment facility specifically targeting clients from culturally diverse backgrounds ❒ Discouraging social interaction among clients outside of group sessions because the treatment manual does not mention this activity ❒●Routinely soliciting feedback from clients about the helpfulness of services ❒●Engaging in outreach efforts to recruit underserved clients ❒●Establishing an advisory board of cultural experts to help develop a new program for persons in the community from a specific cultural group ❒ Maintaining a problem focus so that the core issue or the reason for the problem can be identified ❒●orally administering written materials for illiterate clients ❒ Hiring only staff who live outside the local community to maintain clear boundaries between clients and professional staff ❒●Providing referrals to external agencies in the community (e. g., free health clinic, job skills training) for additional services✓ ✓ ✕ ✓ ✓ ✕ ✓✓✓ ✕ ✓ ✕ ✓ Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
35 Critical Commitments Diversity Issues and Ethical Practice for Helpers Toward Skillful Practice Your decision to pursue a career in a helping profession (e. g., counseling, social work, psychology) suggests that you value and are committed to meaningful work. We suspect that working as a helping professional represents for you more than a job or a way to earn a living. More than likely it reflects your desire that your work become a way of living, a lifestyle. This means that it is important to you that who you are as a professional is consistent with who you are as a person. Being a genuine or authentic person is therefore a priority in the varied roles you serve, both on the job and off the job. Although this chapter and the entire book present and describe strategies for practitioners, we realize that being a helping professional is not simply about implementing techniques. As we discussed in Chapter 1, there is more to this work, this lifestyle, than merely selecting and using “tools” from a “toolbox. ” In her review of the literature on the role and impact of the therapist in the work of psychotherapy, Reupert (2006) observed that “the 'self' or the 'person' of the counsellor is more important than the orientation chosen, or the interventions employed, in both the process and outcome of therapy” (p. 97). She added that “counsellors bring to therapy more than their professional skills and knowledge” (p. 101). Skills, however, clearly are essential to the work of help-ing professionals. Without the intentional use of theo-retically informed and research-guided practices learned in formal training (e. g., graduate school) and at professional workshops, our work would be little more than shooting from the hip, relying more on gut and intuition than on discernible, reliable, and, ideally, tested and practiced skills. We contend that a helper's skills are an integration of who the helper is as a person and his or her training in a behavioral health discipline. This is consistent with the contention made by Hoop, Di Pasquale, Hernandez, and Roberts (2008) that “ethics and culture are inti-mately intertwined” (p. 353), and supports our decision to address diversity issues and ethical practice in the same chapter. Your skill as a practitioner is the product of your personal characteristics (e. g., the values you espouse, the cultural traditions you maintain, the decisions you make in your daily life) and your knowledge (e. g., what you have learned and what you are continuing to learn in your graduate studies). Who you are as a person and what you bring to this time of formal preparation inform the mate-rial you are learning (e. g., ethical practice) and, in turn, the theories and strategies you are learning help shape who you are as a person (e. g., your emerging cultural identity). This dynamic intersection constitutes what we regard as your professional skills—skills that are ever-evolving, influenced by past and current life experiences, and subject to ongoing refinement. This chapter and the entire book are devoted to the skill of the helping professional, that dynamic intersection of Learning Outcomes After completing this chapter, you will be able to 1. Identify values you hold as well as attitudes and behaviors that might aid in or interfere with establishing and maintaining a positive helping relationship. 2. Identify, in the context of contemporary service provision, issues related to values, diversity, and ethics that might affect the development of a helping relationship and the provision of appropriate services. chapter 2 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
36 Chapter 2 4. is always under construction. 5. is a commitment to personal and professional excellence. 6. requires self-awareness and self-exploration. 7. is not self-defined. First, we regard competence as a practitioner's ability to demonstrate certain skills based on his or her knowledge and experience. As with Welfel (2016), our emphasis is on the actual demonstration or performance of skills, not simply the promise of or the capacity to mobilize learned skills into effective action. Welfel (p. 91) underscores that “[a]bility is a prerequisite for competence but is not iden-tical with it. ” The skills for helpers to demonstrate must meet or exceed minimal standards of practice agreed upon or codified by a professional body of which the practitio-ner is a member, such as passing a state licensure exam. The British Association for Counselling and Psychother-apy (BACP; 2013) includes competence as one of the 10 personal moral qualities in its Ethical Framework for Good Practice in Counselling and Psychotherapy and defines it as “the effective deployment of the skills and knowledge needed to do what is required” (p. 03). The second and third features of competence are in-formed by self-determination theory (Deci & Ryan, 2012), a theory of motivation. This theory posits that competence is one of three universal psychological needs or basic necessities for health (the other two are autonomy and relatedness). As a psychological need, competence is the hunger for confidence or self-efficacy. It propels people to seek challenges that will optimize their capacity for growth and well-being. This means that competence is never attained once and for all but instead is “an ongoing process... that... is in a constant state of flux and re-newal” (Nagy, 2005, p. 29). Implied in this statement are the fourth and fifth features of competence: competence is always under construction because it reflects the practi-tioner's pursuit of personal and professional excellence. And it is this perpetual striving for excellence that differentiates competence from proficiency. Whereas competence as-sumes meeting minimal standards of practice, proficiency transcends these minimal standards by virtue of extended and rigorous study in a particular area that has been tested and refined in practice. The pursuit of excellence requires self-awareness and self-exploration, the sixth feature of competence. To be self-aware is to be attentive to your idiosyncracies in relation to others, such as how your learned beliefs and values are similar to, different from, and also influence others in your life. This infers attending to and exploring your own cultural identity and how it continues to be shaped. Think of self-awareness person and professional as well as culture and ethics. Few professions rival the helping practice in the importance of understanding oneself and one's culture, the dynamics of human interaction, the ways in which diversity among us as people contextualizes both problems and solutions, and the complexity of implementing ethics into practice. These represent the issues and the critical commitments discussed in this chapter. Your personal work in sorting through these issues so that you can make the critical commitments essential to effective practice becomes a fundamental part of your professional identity and work. This is not an easy task, but it creates a strong founda-tion on which to build a resilient lifestyle as a helping professional. Growing Into Professional Competence If you attend professional conferences in the helping field today, pick up a current mental health journal and listen to conversations among faculty and researchers from the helping professions, you will no doubt hear and see numerous references to competence and specific competencies. The idea of professional competence is not new. For example, most state laws stipulate that a licensed helping professional maintain a self-disclosure statement describing his or her areas of competence. In recent years, however, professional competence has received quite a bit of press in academic institutions, accrediting bodies, and the scholarly literature. Despite its liberal usage, the term competence often is not clearly defined and remains elusive. Does the word imply proficiency, effectiveness, having expertise, or sim-ply meeting minimal standards of practice? Does earning a graduate degree, obtaining licensure as a professional helper, or completing certification in a specialized prac-tice constitute competence? Is competence, once dem-onstrated, stable and here to stay? Is competence—like cultural identity—self-defined, or is it determined only by another person or group, such as a supervisor or licensure board? These questions are not easily answered! They deserve our careful consideration. Growing into professional competence necessitates clarity about what it is we are growing into. Our own study of competence has revealed several of its key features. In a nutshell, competence... 1. is the demonstration of certain skills. 2. is a psychological need. 3. involves helper confidence or self-efficacy. LO2 LO1 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 37 begun. In your work with clients as a professional helper, you will realize that there are many things you don't know, things you believe you should have learned during your formal academic training. This is a common experience of practitioners early in their careers (Rønnestad & Skovholt, 2003, 2013; Skovholt & T rotter-Mathison, 2011). At-tending professional workshops and conventions, reading scholarly journal articles and books, and participating in ongoing supervision or your own personal counseling will all serve as primary sources of learning and development beyond graduate school. In their study of psychotherapist development, Orlinsky and Rønnestad (2005) found that clinicians worldwide who reported high levels of profes-sional progress were those who said, among other things, that they were committed to their professional develop-ment and were currently receiving specialty training or supervision as well as personal therapy. Having a desire and being willing to continually learn is an essential disposition for all effective helpers. It also is central to developing clinical expertise (Overholser, 2010). Stretching one's clinical repertoire and flexing new helping skill muscles serve to prevent stagnation and boredom, ethical misconduct, burnout, and, most impor-tant, client deterioration. Skovholt (2001) very aptly de-scribed the choice practitioners have in their professional development: “The practitioner can have years of experience—rich, textured, illuminating, practice-chang-ing professional experience in a helping, teaching, or health occupation. Or a person can have one year of experience repeated over and over” (p. 27). Assuming the role of perpetual student therefore contributes to the experience of a “rich, textured, illuminating, and practice-changing” career, one that requires of therapists the “courage to move outside their comfort zone” (Bridges, 2005, p. xiii). As mentioned, a primary source of learning for practi-tioners is their clients. From their extensive interviews with approximately 100 therapists, Rønnestad and Skovholt (2003, 2013) found that a major theme for counselors who reflected on their professional development was that clients are a continuous source of influence and serve as primary teachers. What other opportunities would we have to sit and listen to an African American male who lives in Appalachia describe his method of pig farming? When else would we choose to sit in an emergency room and learn the details of her recent sexual assault from a 15-year-old female? If not for our role as professional helper, how else would we be able to witness a father's gradual acceptance of his son's decision to undergo gender reassignment surgery? Living and working as professional helpers affords us the privilege of learning from others—“a delightful side effect” of being a professional helper (Kottler & Shepard, and self-exploration as the practice of humility, a personal moral quality that the BACP (2013) defines as “the ability to assess accurately and acknowledge one's own strengths and weaknesses” (p. 03). Improving your skills as a helper will in-volve this type of heightened awareness and self-monitoring, exposing yourself to new challenges and regulating your responses as you do so. This is not done solo. Instructors and supervisors are charged with the task of promoting and evaluating your skills. Competence, therefore, is not self-defined. This sev-enth and last feature of competence means that compe-tence is the product of incorporating feedback from others, including clients, who, from the perspective of motiva-tional interviewing (Miller & Rollnick, 2013), are our best teachers. Our clients are the ones who determine whether or not we have established an empathic connection with them. They remain the final arbiters of effective helping. Competence is a dynamic construct that resists repeated efforts to be tied down and operationalized once and for all. It is a mindset and a skill set that requires continued adjustment and refinement to be responsive and helpful to clients. Perhaps like ethical decision-making, competence is understood only in consultation with another person (e. g., supervisor) and in response to client feedback. Four Critical Commitments Kottler and Shepard (2015) state that becoming a professional helper means making a commitment to a profession and to a lifestyle. Such a commitment is neces-sary to grow into professional competence and to con-tinue striving for excellence. In this section we highlight four critical commitments that helpers are encouraged—if not expected—to make as part of growing into profes-sional competence: 1. commitment to lifelong learning2. commitment to collaboration3. commitment to values-based practice4. commitment to beneficence These four commitments are essential throughout one's career and are established during formal training, includ-ing graduate studies. Commitment to Lifelong Learning The task of learning to be a professional helper is never done. Although you may be eager to have formal course-work completed and a graduate degree conferred, the process of professional learning and development has only LO2 LO1 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
38 Chapter 2 2015, p. 6). Assuming the posture of lifelong learner not only enhances our helping skills but also can make us bet-ter people through reflection, consultation, supervision, and therapy. More than 90 percent of psychologists sur-veyed in one study (Radeke & Mahoney, 2000) reported that their work as clinicians had made them better and wiser persons. Commitment to Collaboration A second critical commitment in our work as professional helpers is a commitment to collaboration—collaboration with clients and their families, and collaboration with supervisors and other professionals. Collaboration is an interpersonal style, a specific philosophy, and an approach to working with another person or group of persons. Collaboration in therapy is the active and mu-tual involvement of client and helper. It is the process of the client and helper negotiating the goals and tasks of therapy (T ryon & Winograd, 2011) and also the therapist incorporating client preferences into therapy (Tompkins, Swift, & Callahan, 2013). This has been described in health care as shared decision-making (Adams & Drake, 2006). In dialectical behavior therapy (DBT; Linehan, 2015), collaboration is exemplified in the consultation-to-the-client strategy. This approach reflects the helper's belief in the client's capacity to learn how to effectively interact with and manage his or her own environment, including other people. The helper consults the client about how to skillfully man-age stressors and build a life worth living, rather than the helper consulting other persons on behalf of the cli-ent, such as other professionals or family members. The client is considered the “responsible party” in DBT and therefore is the one the helper consults about solutions. As helpers, we are clearly in a position of authority in relation to clients, and we are obligated by law in certain instances to exert influence over our clients even when they resist. This is true, for example, when we learn of suicidal or homicidal intentions or suspect child or elder abuse/neglect. In these instances, influ-encing the actions of our clients is done to protect their welfare and that of persons associated with them, such as family members. Clients often initiate contact with us in a state of vulnerability, and the decisions we make concerning client care can be life-changing. Because of this circumstance, there is an imbalance of power. The power vested in us as professional helpers—by virtue of our graduate training, license to practice, length of experience, and areas of expertise, to name a few—is not something to crave or to flaunt. Rather, the power afforded us should be handled with great care and prac-ticed with respect and humility. Thwarted Collaboration Even well-meaning helpers can miss the mark in their attempts to collaborate with clients and colleagues. Collaboration is thwarted when helpers misuse their power. This is evident in a helper's attempts to convince a new client that the assigned diagnosis is “right” and that interventions outlined in the prelimi-nary treatment plan are “correct,” sending the message that the client “should” participate in care or otherwise risk being viewed as “noncompliant. ” A helper also may mishandle power when others are not consulted in the event of a crisis or an ethical dilemma. This can happen with novice and experienced helpers alike when they think they should be able to handle complex client issues on their own. The seasoned and overly confident helper may say, “Heck, I've been doing this for many years. I know what to do. Besides, it'll take too much time to get oth-ers involved at this point. ” The novice helper may think, “I don't want to appear incompetent, so I'll figure this out on my own. Besides, my supervisor is in a meeting. ” As one clinical director once noted, “Because of the responsi-bility we assume, supervisors are meant to be interrupted. ” The misapplication of power often is subtle and does not pertain exclusively to flagrant behavior such as entering into sexual relationships with clients. We misuse our power when we assume we know more things about a client's situation or experience than is possible. For example, saying with certi-tude that someone is “shy because she is Japanese American” assumes that this person's gender and ethnic/racial heritage is the direct cause of or fully explains a presumed or known interpersonal characteristic. Such an assumption may ex-emplify “all-knowing” thinking wherein the helper's frame of reference is considered central or true. We regard this kind of unchecked certainty as a subtle misuse of power. This type of thinking is evident in clinical decision-making errors, such as selective attention and confirmatory search strategies (Nezu, Nezu, & Lombardo, 2004). When help-ers rely only on certain types of information (i. e., selective attention) and seek information that only confirms their initial impressions of clients, we believe they mismanage their power as professionals in their care of clients. We also misuse our power and hence thwart collabora-tion when we assume a greater degree of intimacy with our clients than has been established. This is true, for example, when we use a nickname for a client when he or she has not given us permission to do so. Our power is further mishandled when we assure clients that their difficulties and challenges are manageable when we are not certain about this. Statements such as “Everything will be okay” or “You will get through” when there is little evidence to support them are a few examples. Offering a client glib or insincere reassurances might be associated with an expert stance or the belief that one has the ability Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 39 to cure, fix, or solve a client's concerns. It can be experi-enced by the client as patronizing and invalidating. Such a helper may take unwarranted advantage—consciously or not—of his or her influence in a helping relationship by attempting to convince the client to believe or behave a certain way. A helper in recovery from alcoholism may earnestly believe that if her clients simply followed the same program she did to get sober, then they, too, would attain and sustain sobriety. Another helper may think that if his client would just take her medication as prescribed, then she would remain stable and not recycle back into the hospital. These examples are reminders that our power as helpers can be determined by our cultural identity. This includes being a member of a privileged class (e. g., het-erosexual, white) and having certain societal advantages by virtue of having earned a graduate degree and possibly occupying a higher socioeconomic status than our clients. Conversely, instead of exerting power, some helpers may be afraid of power or deny the degree of influence inherent in their professional role. These helpers unwit-tingly may attempt to escape from as much responsibility in counseling as possible. This might be the case when the helper explains to his or her supervisor, “Well, I didn't want to offend him [the client], so I didn't say any-thing, even though I didn't really think it would be in his best interest. ” Professional relationships between helping practitioners and clients have aspects of unequal power of various types. When helpers avoid acknowledging or dismiss this power differential, their ability to manage it productively is constrained and their collaboration with supervisors, peers, and clients is thwarted. Enhancing Collaboration A commitment to collaborat-ing with clients and other professionals is a commit-ment to making appropriate use of your power as a professional helper. T ryon and Winograd (2011) outlined several helper behaviors that reflect a commitment to client-helper collaboration. Among these are: ● ●Encourage clients' contributions throughout counsel-ing by inviting their perspectives, elaborations, prefer-ences, and feedback. ● ●Check in with clients frequently to ensure that you un-derstand each other and are “on the same page. ” ● ●Inform clients about the importance of their contribu-tions to the work of counseling, perhaps by referencing research linking client active participation in therapy to beneficial client outcomes. ● ●Encourage between-session home practice of skills (i. e., “homework”) that relates to work done in session. ● ●Rarely push your own agenda. Listen to what your clients tell you. ● ●Modify your approach based on feedback from clients. In your work with other professionals, a commitment to collaboration means remaining open to learning about and practicing from different approaches that demon-strate effective and valid care rather than believing that there is only one universal or correct way to care for cli-ents. It also means seeing yourself as a member of a team of professionals caring for shared clients rather than seeing yourself as an individual client's only treatment provider. In this regard, we encourage helpers to discard the refer-ence to “my client”—which connotes a sense of owner-ship as well as clinical isolation—and to refer instead to “our client. ” Commitment to Values-Based Practice The word value denotes something that we prize, re-gard highly, or prefer. Often it suggests something very personal and private and therefore not discussed openly on a routine basis. This explains the frequent reference to personal values. Although personal and private, they are expressed in how we go about our everyday lives: how we begin our day, what we eat, who we speak to, and how we interact with people. Just as “actions speak louder than words,” so do our behaviors reflect our values. For example, if you say that you value spending time with friends but you hardly ever do this, then other activities and actions probably have more value for you. Think of values as the guiding principles of life that organize your attitudes, emotions, and behaviors (Kasser, 2002). Because of this, there is an enduring quality to the values we hold, and thus they retain some consistency across time and different situations. This is not to say, however, that certain values we have held for a long time cannot be modified or reprioritized, or that new values cannot be developed. This can happen as a result of extended travel and cultural immersion experiences, personal tragedy and loss, or entering into a new relationship. Values are shaped over time and how they are expressed can vary as we encounter the values of others. Aponte (1994) stated that “Values frame the entire process of therapy... All transactions between thera-pists and clients involve negotiations about the respective value systems that each party brings into the therapeutic process” (p. 170). Because the values of both clients and helpers permeate the entire helping process, we devote an extended discussion to values in this section of the chap-ter. This includes a discussion of what Fulford, Caroll, and Peile (2011) described as values-based practice, a multidisciplinary treatment team approach that respects different values. Specifically, values-based practice begins with prioritizing the values of the client, respects the Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
40 Chapter 2 diversity of values represented by other professionals on the treatment team, and is consistent with and is intended to complement evidence-based practice. Three principles guide values-based practice: 1. All decisions rest on values as well as evidence. This is referred to as the “two feet” principle. 2. Often values are noticed only when they cause trouble, including those that prompt ethical conflicts. This is referred to as the “squeaky wheel” principle. 3. Advances in science should promote not only evi-dence-based practice but also values-based practice. This is the “science-driven” principle. Personal Values in the Helping Process Our reference to values-based practice throughout this section highlights the helper's need to respect the values of the client while also upholding the standards of professional and ethi-cal practice. These include consulting other professionals, providing culturally affirmative therapy, and substantiat-ing counseling decisions and behavior based on available research. To help you clarify and reflect on your own values and your reactions in different practice situations, we encourage you to engage in Learning Activity 2. 1 before you read the remainder of this section. It is intended as a self-check exercise to gauge or evaluate your attitudes and anticipated behaviors in different situations. When Helper and Client Values Collide Obviously, not all of our personal values will influence the helping process. The helper who is a pet lover can probably work without any dif-ficulty with a client who has never had an interest in owning pets. The helper who does not smoke may be able to provide quality care to a client who smokes two packs of cigarettes per day. Even the clinician who is a strict vegetarian may say that maintaining a strong working alliance with a client who eats red meat on a regular basis is not impossible. Learning Activity 2. 1 Personal Values This activity presents descriptions of six clients. If you work through this activity by yourself, we suggest that you imagine yourself counseling each of these clients. Try to generate a vivid picture of yourself and the cli-ent in your mind. If you do this activity with a partner, you can role-play the helper while your partner assumes the role of each client. As you imagine or role-play the helper, try to notice your feelings, attitudes, values, and behavior during the visualization or role-play process. After each example, stop to think about or discuss these questions: 1. What attitudes and beliefs did you have about the client? 2. Were your beliefs and attitudes based on actual or on presumed information about the client? 3. How did you behave with the client? 4. What values are portrayed by your behavior? 5. Could you work with this client effectively? There are no right or wrong answers. Feedback to Learn-ing Activity 2. 1 is located on page 42. Client 1 This client is a young white woman who has become ad-dicted to heroin. She is the sole supporter of three young children and has worked as a nightclub dancer. She reports a history of childhood sexual abuse and recent incidents of unreported sexual assault from her so-called clients. She is primarily concerned about her finances but can't make enough money to support her kids. Client 2 Your client is charged with rape and sexual assault. The cli-ent, a man, tells you that he is not to blame for the incident because the victim, a woman, was a “slut” who “asked for it. ” Client 3 This client is concerned about general feelings of depres-sion. Overweight and unkempt, the client is in poor physi-cal condition, appears to lack proper hygiene practices, and acknowledges smoking on average two packs of cigarettes per day (and smells of tobacco smoke) during the interview. Client 4 The client is a young white woman who comes to you at the college counseling center. She is in tears because her parents threatened to disown her when they learned that her boyfriend is African American. Client 5 Your client, a gay man recently engaged to marry his male partner of 2 years, is angry and deeply hurt because he just found out from a mutual friend that his fiancé has been cheating on him. Client 6 The client, an older man, confides in you that he is taking two kinds of medicine for seizures and “thought control. ” He states that occasionally he believes people are out to get him. He hasn't been employed for some time and is now thinking of returning to the workforce, and he wants your assistance and a letter of reference. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 41 There are values we hold that may make it extremely difficult for us to generate or sustain empathy for cer-tain clients. These might be values we would consider inviolate, values we might say comprise our essence or have shaped our identity—values such as the sanctity of human life, belief in a higher power, and the conviction that people create their own destiny, as in, “You only get out of life what you put into it. ” The helper whose family member recently died of lung cancer—a family member who never smoked—may find it difficult to remain non-judgmental of a client who is a two-pack-per-day smoker and does not intend to quit. Likewise, the helper who is an ardent animal lover and a vegan may not be able to provide unconditional positive regard for a client who has a history of torturing and killing animals. Although benevolence is a primary value of helpers (Kelly, 1995) and may provide the impetus for entering a helping profession, a referral may be necessary if the helper lacks the competence to be able to promote and re-spect a client's welfare (American Counseling Association, 2014; American Psychological Association, 2010; Na-tional Association of Social Workers, 2008). The decision to refer, however, is never automatic, is not that of helpers whose work is supervised (e. g., students in practicum or internship), and should never be done simply because the helper's personal values seem to differ from those of the client's. Kaplan (2014) reinforced that referral is an action of last resort, based on the helper's skill-based compe-tency, not his or her personal values. When Courts Intervene Four court cases in the past 15 years illustrate value conflicts in the helping relation-ship and when referral is not indicated. T wo of the cases involve already licensed and practicing counselors; two involve former counseling students. All involve helpers who claimed their religious beliefs prevented them from providing services to gay or lesbian clients. The first court case, Bruff v. North Mississippi Health Services Inc., took place in 2001 and involved a professional counselor and her former employer. It is discussed by Her-mann and Herlihy (2006) and then revisited by Herlihy, Hermann, and Greden (2014). The counselor in question, Ms. Bruff, was one of three counselors in an employee assis-tance program (EAP) and was dismissed from her position for refusing to continue counseling a client after the client disclosed that she was a lesbian and had requested help to improve her relationship with her partner. Ms. Bruff explained to the court that “a homosexual lifestyle” con-flicted with her Christian beliefs and therefore she could not counsel a lesbian client on relationship issues with the client's significant other. The employer stated that refusing to provide services to this client had a discriminatory effect and resulted in undue hardship on the counselor's two colleagues because additional referrals represented a dis-proportionate workload for them. Although Ms. Bruff ap-pealed her termination and subsequently filed suit against her employer, an appeals court determined that making reasonable accommodations for the employee's religious beliefs did not extend to excusing the counselor from work-ing with homosexual clients on relationship issues. Herlihy et al. (2014) describe the second case, Walden v. Centers for Disease Control and Prevention, which has many parallels to the first case. Ms. Walden, another EAP counselor, was fired from her position with the Centers for Disease Control and Prevention (CDC) for informing a new client at intake that she would need to refer the client because Ms. Walden's “personal values” would “interfere” with the client-helper relationship. The client was a lesbian seeking counseling to address rela-tionship concerns with her same-sex partner. Although Ms. Walden did not disclose to the client that it was spe-cifically her Christian beliefs opposing same-sex relation-ships that prevented her from working with this client, the client later reported feeling “judged and condemned” by Ms. Walden. As with Ms. Bruff, Ms. Walden appealed her dismissal and filed suit against the CDC. The court sided with the CDC, stating that Ms. Walden's disclosure to the client of “personal values” conflict was contrary to the CDC's EAP providing a “welcoming environment” for any CDC employee seeking counseling services. In 2010, two separate courts ruled that two different counseling students could not be excused from fulfilling academic requirements because of their religious beliefs. Although enrolled in two different graduate counseling programs at two different public universities in two dif-ferent states, both students expressed strong disapproval about working with gay and lesbian clients because of their Christian values. In the case of Keeton v. Anderson-Wiley et al. (2010), Ms. Jennifer Keeton, a counseling stu-dent at Augusta State University in Georgia, had voiced in written assignments and in the classroom her con-demnation of “the gay and lesbian lifestyle” based on her reading of the Bible, and also had expressed her support of conversion therapy (i. e., assisting clients in “returning to” a “normative” and heterosexual identity, a practice that lacks empirical support and has been discredited by major professional associations (see Cramer, Golom, & Lo Presto, 2008). The faculty became concerned that Ms. Keeton would not be able to separate her personal values from her professional obligations (i. e., provide nondiscriminatory counseling services) and developed a remediation plan that the student subsequently refused to enter. Ms. Keeton was then dismissed from the program and lost her appeal in court. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
42 Chapter 2 In the case of Ward v. Wilbanks et al. (2010), Ms. Julea Ward, a counseling student at Eastern Michigan Univer-sity, told her practicum supervisor that she could not meet with a new client because the client had identified as gay in counseling records from previous counseling and the counseling student could not affirm the client's homosex-ual behavior. Ms. Ward's faculty supervisor cancelled the scheduled client's appointment for that day and resched-uled the client for a later date with another counseling practicum student; Ms. Ward was not assigned any more clients. A remediation plan was developed by counseling faculty for Ms. Ward, which the student refused to enter, opting instead for a formal hearing with counseling faculty. It was after this formal hearing that Ms. Ward was in-formed that she had been dismissed from the program for refusing to fulfill an academic assignment (i. e., the reme-diation plan). Ms. Ward lost her initial appeal in court, but Eastern Michigan University settled the case out of court in December 2012 rather than continue to hear her appeal. In response to these court cases, Kocet and Herlihy (2014) describe one strategy for addressing value con-flicts in the helping relationship. Ethical bracketing is the helper's intentional practice of separating his or her per-sonal values from his or her professional values as well as the “intentional setting aside of the counselor's personal values in order to provide ethical and appropriate counsel-ing to all clients, especially those whose worldviews, val-ues, belief systems, and decisions differ significantly from those of the counselor” (p. 182). This is accomplished by engaging in specific tasks, including helpers immers-ing themselves in self-reflection, seeking consultation and supervision, enlisting the services of a co-counselor or co-helper (only with client permission, of course), and seeking personal counseling. Microaggressions toward LGBTQ Persons Making a client referral and excusing a counseling student from working with sexual and gender minority clients based simply on the helper or student's professed religious beliefs con-stitutes what we believe is further discrimination and marginalization of persons who identify as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ), with queer defined as anyone who refuses to be constrained by so-cially accepted and binary categories of sex and gender (Levy & Johnson, 2011). For heterosexual helpers to think they can opt out of working with LGBTQ clients is an example of heterosexual privilege, a privilege or social advantage that affords access to decision-making power that sexual and gender minority individuals do not have. This also exemplifies what Pachankis and Goldfried (2013) define as heterocentrism, the individual and sys-temic bias against sexual minorities. Acting on these biases, whether subtly or overtly, con-stitutes behavior that Sue (2010) refers to as a micro-aggression. Microaggressions are communications of prejudice and discrimination that are conveyed in seem-ingly meaningless or unharmful ways. Sexual-orientation microaggressions identified by Sue include oversexual-ization, or regarding sexual minority individuals (e. g., lesbian, gay, or bisexual persons) as mere sexual beings who “flaunt” their sexuality in Gay Pride parades. An-other sexual-orientation microaggression is the disavowal of individual heterosexism, as in a straight person saying, “I don't have anything against gay people. God loves them, too. ” And a third sexual-orientation microaggres-sion is the endorsement of heteronormative culture and behaviors, or the assumption that heterosexuality is the norm and that everyone is heterosexual. Shelton and Delgado-Romero (2013) reported addi-tional sexual-orientation microaggressions experienced by lesbian, gay, bisexual, or queer (LGBQ) clients when meeting with a mental health professional. These included therapists avoiding or minimizing the LGBQ clients' sex-ual orientation, assuming that sexual orientation was the cause of the clients' presenting concern(s), attempting to overidentify with their LGBQ clients, and warning about the dangers of identifying as LGBQ, as in, “Well, you should expect those sorts of things to happen with this lifestyle” (p. 65). As a result, these former clients felt misunderstood and invalidated by their former therapists, withheld information, and failed to discuss issues relevant to their sexual orientation. Microaggressions also extend to gender minority per-sons, including transgender and transsexual individuals. 2. 1 Feedback Personal Values Did your visualizations or role plays reveal to you that you have certain biases and values related to substance use, socioeconomic status, impact of poverty, sexual behaviors, sexual orientation, age, cultures, race, physi-cal appearance, healthy lifestyle and self-care, medical conditions, and mental health issues? Do any of your biases reflect your past experiences with a person or an incident? Most people in the helping professions agree that we communicate some of our values to our clients, often unintentionally. Try to identify any values or biases you hold now that could signal disapproval to a client or could keep you from promoting the welfare of your cli-ent. With yourself, a peer, or an instructor, work out a plan to re-evaluate your biases or to help you prevent yourself from imposing your values on clients. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 43 When left unchecked and not corrected, these and other microaggressions serve to dehumanize LGBTQ persons or at least characterize them as somehow inferior, and strengthen a culture of discrimination. The effects of discrimination may be partially responsible for a greater prevalence of mental health concerns among LGBTQ adults compared to heterosexual adults (Cochran, Sul-livan, & Mays, 2003), and the higher rates of suicidal ideation and suicide attempts observed among gay, les-bian, and bisexual adolescents compared to heterosexual adolescents (Silenzio, Pena, Duberstein, Cerel, & Knox, 2007), especially in neighborhoods with high rates of hate crimes against LGBT persons (Duncan & Hatzenbuehler, 2014). The number of gay and lesbian youth suicides in the United States publicized by social media outlets in 2010 led to the creation of the It Gets Better Project™ (www. itgetsbetter. org) to support gay and lesbian youth. Stories of LGBTQ persons whose lives have gotten better also are available in the book entitled It Gets Better (Savage & Miller, 2012). Generally, straight persons do not feel a need to hide their sexual orientation for fear of reprisal. The same is true for cis persons, those who are comfortable with the gender they were assigned at birth. For many LGBTQ persons, however, keeping silent about their sexual orien-tation and/or gender identity for fear of the consequences is a perpetual concern. This is particularly true of LGBTQ persons who were raised in devout Christian homes, in-cluding randy roberts potts (2012), the grandson of the late televangelist Oral Roberts. He describes his coming out process as “TERRIFYING,” due in no small measure to the suicide of his uncle, Ronnie, the oldest son of Oral Roberts, who also was gay. He writes, “while the Evangelical community might not pull the trigger when one of their gay members commits suicide, they provide the ammunition” (p. 182). The coming-out stories of other LGBTQ persons who were raised in a Christian home are featured in the 2007 award-winning docu-mentary entitled For the Bible T ells Me So (see www. forthebibletellsmeso. org). Affirming LGBTQ Persons Because of what Greene (2009) described as the selective use and the literal interpretation of scripture and other religious writings, many LGBTQ persons experience discrimination and oppression within their religious communities. In their study on the intersec-tion of religion and sexuality, Sherry, Adelman, Whilde, and Quick (2010) reported that 40 percent of their LGBT respondents either rejected religion or God or converted to a religious view more affirming of their sexual orientation. Although the professional helper's own professed religious beliefs are to be respected—as is true of clients and their own religious beliefs—Greene (2009) asserted that the professional helper's religious beliefs that do not support LGBTQ sexual orientation, gender identity, and expres-sion may compromise client welfare and thus do harm. Because more LGBTQ persons make use of the mental health system than do heterosexual persons (Cochran et al., 2003), we believe it is imperative for all helpers to practice what has been described as affirmative therapy for LGBTQ clients (Chernin & Johnson, 2003; Kort, 2008). Affirmative therapy is a form of culturally compe-tent therapy (Johnson, 2012) and includes acknowledg-ing the microaggressions you may have committed and addressing them with clients in a nondefensive and trans-parent manner (Shelton & Delgado-Romero, 2013). We also encourage helpers to follow the practice guidelines for working with LGBT clients developed by professional associations, such as the American Psychological Asso-ciation's (APA, 2012) Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients. Kort (2008) defined gay affirmative therapy as the practice of helping to repair the harm done to LGBTQ persons (through acts of discrimination and microag-gression) and helping them move from shame to pride. This practice assumes that being a sexual minority is not an abnormality and therefore there is nothing wrong with being LGBTQ. What is wrong is how LGBTQ persons are treated by a nonaffirming society, including a nonaffirming professional treatment community. Gay affirmative therapy thus serves to enhance both helper and client awareness (e. g., by debunking myths about lesbians and gays, including the myth that homosexuality is attributed to childhood sexual abuse; see Kort, 2008, pp. 14-17), and to facilitate client empowerment and re-silience. This is done by addressing several key issues with clients (Pachankis & Goldfried, 2013), such as identity development, intimate relationships and parenting, legal and workplace issues, and unique experiences of under-represented sexual minority populations (e. g., ethnic mi-nority, religious, older, and bisexual individuals). We regard gay affirmative therapy as an example of values-based practice because it prioritizes the needs of the client to provide individualized care, seeks to enhance the values and beliefs of both client and helper, and follows ethical guidelines regarding standards of practice while es-chewing the imposition of nonbeneficial interventions for each individual client following consultation with peers. This also resembles what Brown (2009) defined as cul-turally competent practice wherein helpers attend to the multiple identities of each client and seek to understand the intersection or integration—and meaning—of those identities for each client. In addition to sexual orientation, these identities include age, disability status, race and Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
44 Chapter 2 ethnicity, and gender. These particular identities, or cul-tural influences (Hays, 2008), exemplify minority groups, or target groups (Brown, 2008), in the United States today with histories of disempowerment and disenfranchise-ment. Learning about the challenges these persons con-tinue to face promotes values-based helping, as well as culturally competent and culturally affirmative therapy. Affirming Other Cultural Groups With respect to issues of race, Miller and Garran (2008) maintained that although no one person is responsible for racism's “long history and deep tentacles” (p. 3) in the United States, all helping pro-fessionals are responsible for responding to the racism that persists, because “[n]one of us is a bystander in a society structured by racism” (p. 2; emphasis theirs). Racism can be direct, overt, and intentional, or it can be indirect, co-vert, and unintentional, such as in microaggressions (Sue, 2010). Regardless of type, the experience of racism is asso-ciated with mental health concerns such as depression and anxiety (Nadal, Griffin, Wong, Hamit, & Rasmus, 2014). Racism exists at individual, group, institutional, and ideo-logical levels; as Ridley (2005) indicated, anyone can be a racist, including members of racial minority groups. Racial and ethnic disparities in the quality of mental health services have existed for quite some time in the United States (U. S. Department of Health and Human Services, 2001). They continue today for children and their families (Lê Cook, Barry, & Busch, 2013) and for older adults (Jimenez, Cook, Bartels, & Alegría, 2013), and are associated with worse client outcomes (Smedley, Stith, & Nelson, 2003). These disparities are not due to accessibility issues, clinical needs (e. g., severity level), or to client preferences, nor are they explained by socioeco-nomic factors only. Rather, these disparities are attribut-able to the race and/or ethnicity of the client and therefore exemplify one form of discrimination. Disparities include overdiagnosing or rendering inappropriate diagnoses and withholding services or providing unnecessary services. With respect to closing the disparity gap between His-panic and non-Hispanic clients who have mental health concerns, Blanco et al. (2007) recommended that non-Hispanic English-speaking helpers become more familiar with Hispanic culture, acquire specialized skills appropri-ate for Hispanic clients with mental health concerns (e. g., problem-focused and direct style when working with depression; see Kalibatseva & Leong, 2014), and learn Spanish. Language has been identified as the most sig-nificant barrier to quality mental health care among racial and ethnic minorities (Chen & Rizzo, 2010). Affirmative therapy for racial and ethnic minorities therefore neces-sitates ensuring that clients can be heard and understood in their preferred language. According to Walsh, Olson, Ploeg, Lohfeld, and Mac Millan (2011), older adults who are members of cul-tural groups with histories of discrimination and oppres-sion are particularly vulnerable to abuse. These include persons with disabilities. The Americans with Disabilities Act (ADA) of 1990 was intended to protect persons with documented dis-abilities, or who are regarded as having a disability, from discrimination and, when needed, to offer them reason-able accommodations and modifications so that they can participate fully in society, including having employment opportunities. Disability was defined at that time as phys-ical or mental impairment that substantially limits one or more major life activities. Since then, however, U. S. Supreme Court rulings have consistently excluded from protection persons with serious diseases such as epilepsy, AIDS, cancer, and mental illness because of the Court's focus on a person's functioning at a given time rather than on his or her medical condition (Petrila, 2009; Thomas & Gostin, 2009). Furthermore, the Court's record has been to define “substantial limitation in a major life activity” according to the definition provided by the person or entity accused of discrimination rather than focusing on the discrimination itself. The effects of these rulings have been that persons with physical disabilities (e. g., multiple sclerosis), psychiatric disabilities (e. g., post-traumatic stress disorder), or other mental disabilities (e. g., trau-matic brain injury) have experienced barriers to employ-ment because of the stigmatizing attitudes of employers and coworkers (Scheid, 2005). This kind of discrimina-tion has resulted in denied access to health care coverage (including medication) due to lack of employment and lower wages for employed persons with psychiatric dis-abilities who report stigmatizing experiences (Baldwin & Marcus, 2006). The ADA Amendments Act was signed into law in 2008 and became effective in 2009 to address these gaps and the misapplication of the original law. The ADA Amendments Act expanded the list of “major life activi-ties” that qualify for ADA review (including work or em-ployment) and restored the broad coverage of disabilities intended in the original ADA, including conditions that are episodic (e. g., epilepsy) or in remission (e. g., cancer). It remains to be seen how the Court will rule on cases involving what Fox and Kim (2004) defined as emerging disabilities, or disabling conditions resulting from “newly recognized causes or diseases or expanded disability defi-nitions” (p. 329), including environmental illnesses (e. g., asthma, Lyme disease), autoimmune deficiencies (e. g., lupus), and conditions related to poverty and violence (e. g., chronic pain from gunshot injury). Compared to persons with traditional or more socially recognizable Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 45 disabilities (e. g., visual or hearing impairment), Fox and Kim reported that persons with emerging disabilities: (a) have less education; (b) experience greater difficulties with activities of daily living; (c) are insured more frequently with Medicaid (suggesting lower income); (d) are less likely to be working; and (e) seek medical assistance more frequently. Persons with emerging disabilities therefore may experience more widespread discrimination due to skepticism regarding the legitimacy of their condition (even from physicians) and the invisibility of their con-dition (e. g., fibromyalgia). For these and other persons with disabilities, a form of culturally affirmative therapy, disability-affirmative therapy (Olkin, 2009), is essential. Summary of Values-Based Practice Values-based practice is a commitment to learning from others—clients and other professionals—for the sake of providing quality care to a range of clients, many of whom present to counseling with the fresh or hardened scars of societal prejudice and discrimination. It is for this reason that we must not act in kind, that we not treat them in ways similar to how other persons (including their families) have treated them. We must not do (further) harm. Instead, we must do good. Commitment to Beneficence It should be evident that the values we hold about people, life, and the world around us impact our work as profes-sional helpers. Our views on such things as same-sex partnerships and marriage equality, the death penalty, racial profiling, abortion and the time when human life begins, transitioning from one gender to another, illegal immigration, and various religious principles and prac-tices (e. g., not ordaining women in the Roman Catholic Church) will more than likely filter into our conversations with clients and influence how we provide them with care. Although certain values—and the intensity with which we and our clients ascribe to or endorse such values—may not be cause for concern, others are. As professionals, we are bound to certain codes of ethics that are founded on ethical principles. T wo of these principles are beneficence and nonmaleficence. The BACP (2013) has defined be-neficence as the commitment to acting in the client's best interests and promoting the client's well-being; in other words, doing good. Beneficence is implied in the value of service espoused by the National Association of Social Workers (NASW, 2008) in its Code of Ethics and used to inform the principle of elevating service to others above one's own needs. For professional helpers it is not enough to simply do no harm, the ethical principle of nonmaleficence. However, nonmaleficence is a prerequisite to beneficence and often can be missed, minimized, or explained away. In other words, professional helpers may not think they have done harm to a client when they have, or if they are made aware of this harm, they may minimize its effect on the client or explain, “I didn't mean it that way” or “You misinterpreted me. ” This might be the case when a helper engages in the unconscious gender microaggressions of inferring a female client's inferiority or traditional gender role (see Sue, 2010) by questioning the client's decision to join the military and “leave behind” her two young chil-dren to start basic training camp. Such questioning, even subtly, may add to this client's guilt about child aban-donment as well as her lack of confidence in being able to measure up to the achievements of her older brother who also is in the military. Helpers likewise may engage in nonmaleficence when they refuse to continue working with a particular client once it is learned that the client's relationship status (e. g., in a same-sex relationship) is not consistent with the helper's value system. Even when the helper's religious values are cited as the conflict of interest (e. g., the religion-based assertion that marriage is limited to a man and a woman), the helper's decision to refer to another professional or withdraw care altogether may be experienced by the client as yet another form of discrimi-nation. The importance of nonmaleficence is highlighted in Johnson and Buhrke's (2006) listing of the first of 15 recommendations for providing care to LGBT person-nel in the U. S. military: first, do no harm (p. 94). As persons committed to beneficence, we really cannot fake empathy or only pretend to really care about our clients' well-being. The life of a professional helper does require continuing education and perpetual learning; col-laboration with clients, supervisors, and other profession-als; and engaging in values-based practice and culturally affirmative therapy. It is not for the timid or faint of heart. Being a professional helper means that many of our values are continually challenged and that we need to critique and perhaps even change some long-held views to be able to effectively care for a variety of clients. Such views might include how we regard persons whose cultural identities, beliefs, and practices are different from our own. Diversity Issues Given the increasingly migratory and pluralistic world in which we live, we cannot expect to encounter only clients who share cultural backgrounds similar to ours or who look, sound, think, believe, and behave like us. Being able to provide quality services to a range of persons representing different backgrounds, professing different beliefs, and engaged in different customs is imperative for all helping professionals, regardless of LO2 LO1 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
46 Chapter 2 the geographic location or setting of service delivery (e. g., private practice, rural hospital, suburban school). It must be emphasized that there are many forms of hu-man diversity. The framework offered by Hays (2008, 2013) is quite informative and useful, and therefore we refer to it at various places in this book. Nine cultural influences comprise Hays's framework and each one is identified by a letter in the acronym ADDRESSING. (Although there are 10 letters in the ADDRESSING acronym, Developmental and other Disabilities is con-sidered one cultural influence. ) The ADDRESSING framework's nine cultural influences are listed in Box 2. 1. Another way to refer to these is as experiences and expressions of culture. Generally speaking, culture can be defined as a com-mon heritage or a collection of beliefs and values that influence traditions, norms or standard practices, and so-cial environments or institutions. Bryan (2007) contends that this collection of beliefs and behaviors or customs is “learned and reinforced through a socialization pro-cess” (p. 8), one that Bernal and Domenech Rodríguez (2012b) regard as “an intergenerationally transmitted sys-tem of meanings shared by a group or groups of people” (p. 4). Culture also is not static, but is constantly evolving (Falicov, 2014). That culture is learned and reinforced by interactions with others across generations, and that it is always evolving suggests that cultural identity is not inherited but develops over time. The broad and inclusive term multicultural captures the array of human diversity; multiethnic is a narrower term focusing on specifically ethnographic character-istics, such as race and ethnicity. Ethnicity connotes a shared history, language, belief system, and rituals (per-haps by virtue of sharing the same or similar geographi-cal place of origin, e. g., Latin America), and although race often is regarded as a biological category (i. e., identifying persons according to genetic traits such as skin color, shape of eyes and nose), it is not. According to the American Psychological Association (APA, 2003), “the definition of race is considered to be socially con-structed rather than biologically determined” (p. 380). This means that race has more to do with how social groups “are separated, treated as inferior or superior, and given differential access to power and other valued resources” (U. S. Department of Health and Human Ser-vices, 2001, p. 9). Likewise, gender refers to a changing set of qualities culturally assigned to social categories such as masculine or feminine. This differs from the more biologically based understanding of sex (i. e., male or female), although the latter is not defined exclusively by genitalia or even by birth. Many textbooks addressing diversity and multicul-tural considerations begin by presenting and discussing group characteristics. Learning about and understand-ing the commonalities of members of a particular cultural group (or “the ties that bind”) are important. However, if this nomothetic or broad-brush approach to understanding diverse populations is the only one discussed, then it can promote overgeneralizations, ste-reotyping, gross misrepresentations (Bryan, 2007), and further divides by promoting “us versus them” kinds of thinking (Chisholm & Greene, 2008). As a result, helpers may be inclined to assess and make interpre-tations about an individual client based solely on his or her racial and/or ethnic group membership. This prevents a here-and-now focus in therapy (Chisholm & Greene, 2008) because the helper is distracted by the categorical and manualized definitions of diversity. This is evident in statements such as, “Amish people are healthy and hardy” and “Filipino Americans have strong family ties. ” Although these characterizations may ap-ply to many individuals who identify as Amish and as Filipino American, respectively, they may not neces-sarily define the individual client who is seeking or in need of services, and therefore can represent “poten-tially misleading” information (Brown, 2009, p. 346). Assuming that clients who appear to represent a par-ticular ethnic or racial group meet all of the stereotypical criteria of persons from that particular group “is actually one of the worst manifestations of prejudice” (Brems, 2000, p. 9). Age and generational influences Developmental disabilities (e. g., disabilities related to Down syndrome, fetal alcohol syndrome, autism spectrum) Disabilities acquired later in life Religion and spiritual orientation Ethnic and racial identity Socioeconomic status (e. g., income, occupation, education) Sexual orientation Indigenous heritage (e. g., Aboriginal, Native, First Nations people) National origin (e. g., birthplace, first or primary language, immigration experiences) Gender (male or female or transgender, gender expres-sion as masculine/feminine) Source: Hays, 2008, 2013. BOX 2. 1 Cultural Influences: The ADDRESSING Framework Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 47 Neufeldt et al. (2006) regarded a helper's consideration of individual or within-group differences as a “relatively advanced-level multicultural competence” (p. 474). This is similar to considering the intersection of multiple identities (Brown, 2009; Greene, 2009). In their study of case conceptualization practices—specifically, the in-corporation of diversity issues—Neufeldt et al. found that only 3 of 17 therapists in training considered within-group differences when they were presented with the case of a female Chinese American client. The majority of these therapists in training did not consider ways in which this young woman differed from other members of her identified group, a practice that exemplifies the assump-tion of homogeneity. Similarly, Schomburg and Prieto (2011) found that an overwhelming majority of trainees in marriage and family therapy did not attend to racial factors when presented with a vignette of either an African American couple or a white couple attending therapy. Attending to both the nomothetic, homogeneous, or general descriptions of a client's cultural group and his or her idiographic, idiosyncratic, or unique characterizations is essential in all cross-cultural interactions. This is the fo-cus of multicultural counseling and therapy—the unique individual embedded in a cultural group or in multiple and overlapping/intertwined cultural contexts. Multicultural Counseling and Therapy Although all therapy could be thought of as cross-cultural therapy, multicultural counseling and therapy is a specific and very intentional approach that considers the cultural factors in all client-helper interactions. It operates from an idiographic and a nomothetic bifocal perspective that deliberately focuses on how culture influences coun-seling and therapy. It keeps culture front and center in the helping process to not dilute its significance. As Sue and Sue (2013, p. 83) emphasize, “Multicultural counseling and therapy is not for White helping professionals only!” It challenges all helpers to confront and work through their biases. Multicultural counseling and therapy makes use of the tripartite framework of personal identity development that Sue (2001) developed. The three-level framework can be visualized as three concentric circles, each larger than the other and each corresponding to a level. As can be seen in Figure 2. 1, the individual level is the center circle that de-picts what is unique or idiosyncratic about the individual, such as genetic endowment and personal and private ex-periences. It is surrounded by or embedded in the second LO2 LO1and larger circle, the group level, which represents vari-ous cultural influences (e. g., the nine influences in Hays's ADDRESSING Framework, 2008, 2013) and the cultural groups the individual is similar to and different from. The third and largest circle, in which both the individual and group levels are embedded, is the universal level. This level represents what all human beings have in common—for example, the use of language, biological, and physical simi-larities, and experiences of birth and death. The premise of multicultural counseling and therapy is that individuals cannot be understood from only one of the three levels of personal identity development—all three levels must be considered. And one of the major contributions of multicultural counseling and therapy is that level 2, the group level, is given prominence. That is, no two persons are alike because of cultural influences. The professional helper therefore must assess and appre-ciate the influence of age, race/ethnicity, and socioeco-nomic status, for example, on the client's past and current functioning, even if the client is not fully aware of these influences. The helper also participates with the client in learning more about the meaning for the client of the integration or intersection of these cultural influences or cultural identities (Brown, 2009; Chisholm & Greene, 2008; Greene, 2009). In other words, how is uniqueness (level 1) shaped over time by belonging to more than one group (level 2) as well as by challenging certain group norms? How am I similar to and how am I different from others? Individual Level Group Level Universal Level FIGu RE 2. 1 Tripartite Framework of Personal Identity Development Source: Sue (2001) and Sue and Sue (2013). Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
48 Chapter 2 Practicing Idiographically Ridley's (2005) idiographic perspective remains instructive for us. This perspective regards each client as unique, “a mixture of characteristics and qualities that make him or her unlike anyone else” (p. 85). It focuses on the person at the individual level, whose uniqueness is embedded in group level similarities and differences, as well as in universal level commonalities. Just like the focus on the intersection or matrix of multiple identities within each person (Brown, 2009; Chisholm & Greene, 2008; Greene, 2009), an idiographic perspective eschews broad-brush and potentially misleading categorical de-scriptions in favor of a kaleidoscopic description of each client. For example, an idiographic perspective would ask: “Who is this person who happens to be a 75-year-old first-generation Latina American widow who is a mother of six, grandmother of 10, and whose primary language is Spanish?” An idiographic perspective also seeks to under-stand what the convergence of multiple identities means for this and other clients. Certainly the helper will gener-ate assumptions or hypotheses about individual clients. This is the practice of case conceptualization discussed in Chapter 8. By definition, hypotheses are tentative and remain so unless or until they are confirmed by the client. Cultural identity is always self-defined. An idiographic perspective therefore encourages clients to formulate and articulate their own cultural identity—or tapestry of cul-tural identities—prioritizing their own values and prac-tices at particular times in their lives. Ridley (2005) offered five principles of an idiographic perspective in mental health care, each of which is dis-cussed briefly in this section. These principles assert that an idiographic perspective: 1. understands each client from the client's unique frame of reference. 2. considers nomothetic or general information, but rec-ognizes that such broad information may not always fit particular individual clients. 3. considers each person to be a dynamic blend of mul-tiple roles and identities. 4. is compatible with the biopsychosocial model of men-tal health. 5. is transtheoretical. The first principle of an idiographic perspective is that practitioners should attempt to understand each client from the client's unique frame of reference. This might be similar to regarding each individual as “a self-contained LO2universe with its own laws” (Shontz, 1965, cited in Cone, 2001, p. 14). Asking a light-skinned African American les-bian who lives in a fairly small town in the Midwest what she means by “passing” might be an example. Respecting and seeking to understand the reasons a young soldier has for requesting to return to the battlefront rather than remain at home after recovering from his physical wounds might be another example. Although the idiographic per-spective appears to pertain only to working with indi-vidual clients, it does have application to families. The second principle of an idiographic perspective (Ridley, 2005) is that nomothetic, normative information needs to be considered but may not always fit particular individual clients. For example, homelessness does not imply unemployment, drug addiction, or mental illness. One young African American man who spent nights and weekends in a San Francisco shelter and the subway restroom for several months did not “fit the mold” of a “down-and-out” “druggie” or “criminal. ” Christopher Gardner, whose true rags-to-riches story is featured in the motion picture The Pursuit of Happyness (Muccino, 2006), broke all the rules of such stereotypes. Although lacking a college education and providing the sole care for his young son, Mr. Gardner managed to succeed in a nonpaid internship at a top brokerage firm, pass the licensing exam on the first try, get hired by the firm, pro-ceed to establish his own brokerage firm, and eventually become a millionaire. This one example underscores the importance of an idiographic perspective and is consistent with the adage “Don't judge a book by its cover. ” Ridley's (2005) third principle of an idiographic perspec-tive in the helping process is that people are a dynamic blend of multiple roles and identities. This is certainly true for multiracial or multiple heritage persons (Kenney & Kenney, 2012). It also matches the concept of multiple identities and the intersection of those identities (Brown, 2009; Greene, 2009), which is a more pronounced focus in social work (see Lee, 2010). From this perspective, it is impossible to understand and fully appreciate a client's experience if the client's race or ethnicity, for example, is thought to develop and operate in isolation from his or her gender or sex. The intersection of multiple identities is evident in more than 9 million people, or 2. 9 percent of the U. S. population, reporting two or more races in the 2010 cen-sus (U. S. Census Bureau, 2011). An astute helper, there-fore, will not assume that a new client's racial identity is either black or white, for example. Rather, the helper may inquire about the intersection of racial/ethnic identities—or, more broadly, about cultural identities—and will elicit the client's own meaning of such an intersection or blend-ing, what Lee (2010) referred to as internalized culture. For example, how might the son of a black African father Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 49 and a white European American mother describe his cul-tural identity, particularly when influenced by his being raised in Indonesia? According to Ridley (2005), the idiographic perspective is compatible with the biopsychosocial model of mental health. This fourth principle reinforces a comprehensive or holistic view of individuals. Rather than understanding someone from only one perspective (e. g., medical model), the biopsychosocial model challenges helpers to formulate their understanding of clients from a variety of perspectives. The fifth and final principle of an idiographic perspec-tive (Ridley, 2005) is that it is transtheoretical. This refers to the use of a variety of theoretical orientations and interventions with clients, not just one tried-and-true approach. A helper who identifies with the same general racial/ethnic group as one of his or her clients (e. g., both identify as Native American) may inadvertently assume that a particular therapeutic intervention (e. g., participat-ing in a healing service) may be appropriate for the client based on the helper's own participation in such an activ-ity. An idiographic perspective that is transtheoretical, however, would entertain several possible theories and strategies for the benefit of the individual client, even if such options did not fit the helper's own experience as a member of the same general racial/ethnic group. Guidelines for Practicing Idiographically To assist helpers in transferring principles to practice, Ridley (2005) developed 12 guidelines for providing idio-graphic care. These are listed in Box 2. 2, and five of them are discussed in some detail. Developing Cultural Self-Awareness Providing idiographic care implies that helpers remain cognizant of the significance of cultural issues in their interactions with all clients. We believe that all conversa-tions with clients are cross-cultural, that culture is em-bedded in all forms of professional helping. This means that cultural influences (e. g., sex, age, racial and ethnic identity, socioeconomic status, sexual orientation) are al-ways pertinent and inform our work with all clients. If, as former U. S. Surgeon General Dr. David Satcher stated, “culture counts” (U. S. Department of Health and Human Services, 2001), then cultural factors should always be at the forefront of our awareness in our work with clients and our life as helpers. Cultural self-awareness includes becoming aware of our own identities that are either privileged or disadvantaged (see Okun & Suyemoto, 2013; Hays, 2013). Privileged status means having access to power and decision-making in a particular society and being part of the dominant group in that society. Being socially disadvantaged means not having access to the benefits of power and decision-making in a society. Persons who are privileged are able to define societal norms, and persons who are disadvantaged are outside of those norms, prevented by those in power from enjoying the benefits of power. Regardless of num-bers or population size, those who are privileged to power are in the majority, whereas those who are disadvantaged from power are in the minority. Chisholm and Greene (2008) asserted that understand-ing the meaning of social privilege is a prerequisite to realizing whether or not one has it. Privilege essentially is a gift of advantage, a benefit that is not earned; it is an identity and a status that is not acquired through merit, such as working hard to earn a graduate degree. Josh, a white male born in the United States to a middle class or upper-middle class well-educated family, is privileged, even if he does not know it and even if he does not go to college. The meaning of privilege also can only be under-stood by comparison and in context; that is, someone is privileged only in comparison to someone else and only in the context of sociopolitical history and current cir-cumstance. Once we learn that Josh was born deaf, came out as gay in high school, and has left home because his conservative Christian parents viewed him as a “pervert” and an “abomination” to their home, we realize that his privileged status is less compared to Evan, another white male who also was born in the United States to a middle class or upper-middle class well-educated family, who is heterosexual, and who since birth has not experienced any physical limitations. 1. Develop cultural self-awareness. 2. Avoid imposing one's values on clients. 3. Accept one's naïveté regarding others. 4. Show cultural empathy. 5. Incorporate cultural considerations into counseling. 6. Avoid stereotyping. 7. Determine the relative importance of clients' primary cultural roles. 8. Avoid blaming the victim. 9. Remain flexible in the selection of interventions. 10. Examine counseling theories for bias. 11. Build on clients' strengths. 12. Avoid protecting clients from emotional pain. BOX 2. 2 Guidelines for Practicing Idiographic Helping Source: Ridley, 2005. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
50 Chapter 2 The comparison of Josh and Evan illustrates well the concept of multiple identities and the focus on the inter-section or the convergence of multiple identities and its meaning for each person (Brown, 2009; Greene, 2009). Although socially disadvantaged in terms of his sexual orientation and his physical limitation, Josh is part of a privileged group in terms of his sex, race/ethnicity, and family-of-origin socioeconomic status. Whereas Evan's sexual orientation and physical ability status are two cultural identities that are privileged, these same cultural identities are disadvantages for Josh. Developing and enhancing cultural self-awareness can be accomplished in many different ways. One way to do this is to use Hays's (2008, 2013) ADDRESSING Framework (see Box 2. 1) and to consider the notion of multiple identities. We encourage you to pause at this time to engage in Learning Activity 2. 2 before reading further. Learning Activity 2. 2 Cultural Self-Awareness: Tapestry of My Cultural Influences and Identity This activity is intended to further enhance your own cultural self-awareness by considering the elements or ingredients of your cultural identity today. You will need a blank piece of paper and something to write with (having a selection of writing instruments of different colors may enhance the ef-fect of this activity for you). We encourage you to find a quiet place where you will not be disturbed and to spend approxi-mately 20 minutes on this activity. If done in the classroom, this could be done as an individual activity first, and then responses could be shared in student dyads or small groups. Turn to the ADDRESSING Framework developed by Hays (2008, 2013) and presented in Box 2. 1 on page 46 as you go through this activity. Follow the steps below. An example of another person's responses to step 4 is located on pages 53-54 (client Katrina, discussed in Learning Activity 2. 3). 1. Read through the nine cultural influences in Hays's AD-DRESSING Framework. These might also be considered multiple identities, as well as the elements, ingredients, or components of your cultural identity. (Although there are 10 letters in the word ADDRESSING, two of them fo-cus on disabilities: Developmental and other Disabilities. Hays, 2013, thus refers to nine cultural influences. ) 2. Consider who you are and where you are today in your personal and professional development. How does each of the nine cultural influences or multiple identities rep-resent for you today either a social advantage/privilege or a social disadvantage? Do not skip any! Now, on a separate sheet of paper, create two columns, one with the heading Privilege and the other with the heading Disadvantage. One by one, place each of the nine cul-tural influences under the appropriate column based on whether you believe that it constitutes for you today a social advantage/privilege or a social disadvantage. 3. Think of a family member who was instrumental in your formative development. This could be a parent or grand-parent who helped raise you as a child. How do your responses to Question 2 compare to the responses this family member might provide for himself or herself—when you were growing up and also today (if this person is still living)? That is, how do your social advantages/privileges and social disadvantages today compare to those of your family member? 4. From Hays's list of cultural influences, select those you believe are prominent elements or ingredients in your cultural identity today. These may be all 10, or only four or five. You decide. Give a name to each cultural influence you selected, a name that makes sense and applies to you. Once you have made your selection of prominent elements or ingredients, on a blank sheet of paper draw a shape or symbol (e. g., circle, square, triangle, oval, octa-gon, free-flowing) for each cultural influence. The shape selected for each cultural influence, as well as the size, color, thickness of the lines used, and placement on the paper are up to you because only you can determine your cultural identity—no one else! You may wish to consult the sample tapestry of client Katrina's cultural identity located in Figure 2. 2 on page 51. Although the shapes of Katrina's tapestry are not presented in multiple colors, this example might assist you in creating your own tap-estry. Notice the shapes used for each cultural influence in the drawing, as well as which shapes have thicker out-lines than the others. As you draw and create your own tapestry, consider the following questions: a. What shapes or symbols did you include? Were you aware of ascribing personal relevance to any of these? b. What do you notice about the relative size of each shape or symbol? c. Was your choice of color influenced by personal meaning attached to the color? d. How did you determine the thickness of the lines for each shape or symbol? e. Where did you locate each shape or symbol on the paper? Is there any overlap? f. Once you have illustrated your prominent cultural influences, step back to observe your drawing, a drawing that represents a tapestry of your cultural identity. If you were to name your tapestry, what title would you give it? 5. Guided by your comfort level and your desire to learn from another person, share your drawing, your tapestry, with a classmate. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 51 After you have completed Learning Activity 2. 2, we hope it has become evident that cultural self-awareness is enhanced by recognizing and naming the prominent identities or influences that comprise your own cultural tapestry. This is the first step. And remember, no one lacks a cultural identity or a mixture of cultural identities. It is simply more prominent or of a higher priority for some persons than for others. Persons with more traditional or visible physical disabilities (e. g., cerebral palsy), for ex-ample, may have developed a more pronounced cultural identity based in large part on their disability/ability status compared to able-bodied persons. This is particularly true if the disability is longstanding. Add to this the identity of race/ethnicity (e. g., black Hispanic), immigration status and level of acculturation (e. g., born and raised in Cuba, recent immigrant to the United States), and the identity of gender (e. g., female), and the resulting intersection is much more pronounced than would be the case for an able-bodied white male born and raised in the United States, for example. The second step to enhance your cultural self-awareness is to assess your own stage of cultural identity develop-ment. Questions you may ask yourself include: ● ●“As a dark-skinned African American, have I adopted what Boyd-Franklin (2003) described as a 'blacker than thou' mentality by not trusting light-skinned African Americans?” ● ●“As a conservative Christian, have I secretly attributed severe mental illness and co-occurring alcohol depen-dence to a lack of morality and divine judgment?” ● ●“As an 'out' LGB helper, have I become intolerant of cli-ents who continue to struggle with internalized shame that keeps them from coming out as LGB?” ● ●“As a bilingual second-generation Latina American, have I unknowingly become critical of recent immi-grants who refuse to become proficient in English?” The third step in the process of enhancing your cul-tural self-awareness is to evaluate the influences that have shaped you, and then to evaluate how your attitudes affect the helping process. Helpers are strongly encouraged to engage in activities that challenge long-held stereotypes and broaden their understanding of and appreciation for the experiences of others. Hays (2013) refers to stereo-types as the development of “hardening of the categories” (p. 25), believing that individuals can only or primarily be defined by rigid categories or overly broad generalizations. Activities that challenge rigid or “hardened categories” might include cultural immersion experiences, such as attending an international fair and worship services of a religious group different from one's own (e. g., visit-ing a mosque, temple, or synagogue). Processing these and other experiences is just as important as engaging in the activities. Ridley (2005) recommended seeking therapeutic services (i. e., assuming the role of client) from a professional of another race, someone whose ancestors have not held positions of sociopolitical power. Okun and Suyemoto (2013) include in Appendix B of their book several self-reflection activities intended to enhance help-ers' understanding of their ethnic culture and also power and privilege. Daughter (estranged from mother )African American Construction worker, landscaper, home renovation worker42 years ol d Light-skinned Female Lesbia n Mother of 2 sons Partner to White girlfriend2-yea r colleg e graduat e Born, raised in NY CDivorced from sons ' father Lives in smal l Midwestern town FIGu RE 2. 2 Sample of Katrina's Cultural Tapestry Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
52 Chapter 2 Acknowledging and Accepting One's Naïveté about Others Assuming a genuine posture of curiosity about clients is regarded as an essential skill for helpers in all cross-cultural conversations. Solution-focused and narrative therapies refer to the “not-knowing” (Anderson & Gool-ishian, 1992) approach wherein the helper conveys genu-ine interest and a sincere desire to be informed by the client without preconceived opinions and expectations about the client. Some might interpret this as helper ignorance and, indeed, it is! It is impossible for anyone to fully understand, let alone know, another's experience. Therefore, maintaining a stance that is naïve, curious, and genuinely open to being with clients actually represents a primary form of respect for the experiences of clients. To present otherwise would be disrespectful and insulting. Acknowledging our naïveté about the experiences of culturally diverse clients means that we view clients as the experts on their self-defined cultural identity, regarding them as our “cultural consultants” (Vicary & Andrews, 2000). We are the students of our clients' cultural ex-periences, not the authorities. With that said, two very important points must be made: 1. It isn't the job of a client to educate the helper about the client's culture (Hays, 2014). It is our job as helpers to learn about our clients, not from them. We do this by engaging in activities outside of session (e. g., read-ing, attending cultural events) that expand our under-standing of different cultural groups and provide us with a backdrop or a reference point for appreciating the nuances of each of our client's unique experiences and identity. 2. No client is the representative of or spokesperson for a cultural group (Falicov, 2014). The primary focus of an idiographic approach is on the individual, not the gen-eral cultural group(s) of which he or she is a member. Learning about our clients may be possible only when we set aside or modify certain expectations (e. g., use of grammatically correct English), pause to consider a new or an alternative perspective, and flex our empathic muscles with each new client or family. As Ridley (2005) pointed out, “Only when counselors accept the limits of their own expertise are they likely to interpret their clients' problems and needs realistically” (p. 95). This exemplifies helper humility, which Hays (2013) regards as one of the most essential qualities for working across cultures. For one thing, humility may make it possible for the helper to envision more realistic goals for the client as well as of-fer culturally adaptive services (see Bernal & Rodriguez, 2012a). Determining the Relative Importance of Clients' Primary Cultural Roles Given the dynamic intersection of identities in the in-creasingly diverse United States and wider world, it seems important to explore with clients how these roles and identities intersect for them. For example, what mean-ing has a particular client constructed (or what meaning is still “under construction”) about being a middle-aged white male veteran who was widowed 2 years ago, is now raising a 15-year-old daughter (the youngest of his three children), and is not able to secure full-time employ-ment at this time because of a medical disability? From an idiographic perspective, this client might be asked about which of his roles and responsibilities is now most important to him. Such an inquiry also may assist in goal formulation and prioritization. For example, does he want to focus his energies during the helping process on how to be an effective single parent? Does he want to discuss what it is like to be a medically disabled war veteran and how such an identity represents a significant shift from his being a physically fit, mobile, and active man able to provide financially for his family? Promoting the client's right to determine the importance of his or her various roles and responsibilities is an opportunity for the helper to learn about the client's idiographic experience and unique cultural kaleidoscope. Avoiding Blaming the Victim Despite fulfilling multicultural competency, helpers may unwittingly blame their clients for the stressors and chal-lenges they report having experienced. Such blame may be evident when the helper attributes a client's drug use, for example, to his being a young African American man who did not finish high school, grew up in subsidized housing, and was raised by a single mother. Although perhaps not verbalizing the idea, the helper might think to himself or herself, “Well, that explains it all. He's black and grew up poor. If he had just stayed in school, he could have stayed away from drugs. ” Unbeknownst to the helper, such think-ing may exemplify in part what Ridley (2005) referred to as “unintentional racism,” a practice he described as “the most insidious form of racial victimization” (p. 39). Ridley (2005) contended that therapist inaction (e. g., not addressing the issue of race in session) perpetuates the victimization of racial minorities. This might be evident when a helper professes to be “color blind” or “culture blind,” implying that the race, ethnicity, or other cultural identity (e. g., sexual orientation) of others really doesn't matter or is not important. Not only does this discredit Dr. David Satcher's (U. S. Department of Health and Human Services, 2001) admonition that “culture counts,” but it Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 53 dismisses the very identity of another human being. In-deed, such comments represent the ultimate form of insult. Ridley (2005) cautioned, however, that “white professionals are not the only ones guilty of therapist inaction” (p. 40). He stated that minority professionals can be said to engage in unintentional racism when they “assume they understand the dynamics of racism when they may not” and “posture as experts on treating minority clients” (p. 40) when they have avoided examining their own racism or have failed to become competent in dealing with minority issues. Avoiding Protecting Clients from Emotional Pain At the other end of the spectrum of blaming a racial or ethnic minority client's condition or circumstances on his or her status as a member of a racial or ethnic minority group is the practice of shielding the client from emo-tional pain. This protection may be a form of paternalism that the helper may initially justify as empathy, although others would regard it as condescension. Ridley (2005) termed it a “tactical error” to select “interventions that will cause the least pain rather than those that are most appropriate for helping” clients (p. 104). A multiracial college student may need to talk about feeling ostracized by mono-racial peers on campus, peers who are members of the racial groups that comprise this client's multira-cial identity (see Kenney & Kenney, 2012). If a helper squelches exploring the issue in some way (e. g., “I'm sure they didn't mean to treat you that way”)—all for the sake of protecting or rescuing the client from what may be regarded as undue distress or pain—the client may interpret this response as not being taken seriously or as an indication that feeling ostracized is not acceptable, and the client's emotional pain may be prolonged. As mentioned, helpers need to assume the role of learner or student by allowing their clients to teach them about what it's like to live the life of the client. Such help-ers often will hear stories that are unsettling—accounts of discrimination and other forms of unfair treatment, for example—that cannot be tidied up for the client and re-moved from his or her experience. A significant challenge for helpers is to muster what Kenneth Minkoff eloquently phrased as “the courage to join [clients] in the reality of their despair” (featured in the Mental Illness Education Project, 2000). Doing so is intended not to “fix” or eradi-cate clients' pain but to provide clients with the company, companionship, and sense of safety that may assist them in becoming able to work through such difficulties. The work and process of healing or recovery not uncommonly is accompanied by pain, and helpers actually do their cli-ents a disservice when they make the eradication of pain the primary purpose of helping (Ridley, 2005). At this point we invite you to participate in Learning Activity 2. 3. This is designed to help you apply Ridley's (2005) guidelines for idiographic helping (see Box 2. 2) by also making use of Hays's (2008, 2013) ADDRESS-ING Framework (see Box 2. 1). The case of “Katrina” is presented in Learning Activity 2. 3 on pages 53-54 and a sample tapestry of her cultural identity (responding to Question 4 in the Learning Activity) is presented in Figure 2. 2 on page 51. Learning Activity 2. 3 Idiographic Helping Applied Read through the following case and then refer back to Hays's (2008, 2013) ADDRESSING Framework (Box 2. 1) as well as Ridley's (2005) 12 guidelines for practicing idio-graphic counseling (Box 2. 2). Once you have done so, re-spond as best you can (by yourself or with a classmate) to the eight questions related to Katrina's case, your assess-ment of her cultural intersection or integration, and your work with her. This also might be an activity for the entire class to engage in. “Katrina” is a 42-year-old light-skinned African Ameri-can female who moved from New York City approximately 15 years ago to the small midwestern town where she currently resides. She moved after a failed marriage to an African American man and a fallout with her mother, and out of a desire to raise her then 3-and 5-year-old sons in a “safer” place. Katrina seeks counseling at this time because of increased stressors at home and at work. Her work history includes construction and she is proud of the marble inlay and columns she was responsible for erecting in a prominent building in downtown New York City. After earning an associate's degree in horticulture at a local community college, she now manages a landscap-ing business and also does home renovation during the off season. Katrina discloses that she is a lesbian and that her white girlfriend, “Elaine, ” is planning to move out. They had a fight last week, and Katrina states she became enraged when Elaine proposed “cooling things” between the two of them and moving out of the apartment they have shared for 2 years. “Look, without her I have no one, not one person who really, I mean, really knows me and accepts me as I am. Even my sons, I know they think we're freaks... they haven't been around for a while... and I haven't heard from my mom since last Thanksgiving. She believes I've 'sinned' and 'gone astray, ' and that I have 'brought on' my 'trials and (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
54 Chapter 2 Beyond Multicultural Competencies to Cultural Attunement For more than 25 years, educators in the helping professions have emphasized the teaching and acquisition of specific competencies deemed essential to work effec-tively with diverse groups of clients. Several professional organizations have adopted multicultural competencies, including the American Psychological Association (APA, 2003), the National Association of Social Workers (2001), and the American Counseling Association (Sue, Arre-dondo, & Mc Davis, 1992). First introduced by Sue et al. (1982), multicultural competencies have been conceptualized according to three domains: beliefs and attitudes, knowledge, and skills. In developing their set of multicultural counseling com-petencies, Sue et al. (1992) paired each domain with the three characteristics of a culturally skilled practitioner described by Sue and Sue (2013): (1) helper's awareness of his or her own assumptions, values, and biases; (2) un-derstanding the worldview of the client; and (3) develop-ing appropriate intervention strategies and techniques. This pairing resulted in nine competency areas. According to this matrix, the multiculturally competent helper is some-one who, for example, is aware of his or her own attitudes toward persons of a different ethnic background, includ-ing stereotypes or instances of unintentional racism. Each LO2of the three helper characteristics can therefore be thought of as finding expression within each of the three domains. Numerous studies have sought to determine the im-pact of multicultural competence on the helping process and client outcome (see Worthington, Soth-Mc Nett, & Moreno, 2007, for a review of the research literature). For example, it appears that therapist multicultural compe-tence impacts client ratings of therapist empathy and gen-eral competence (i. e., therapist attractiveness, expertness, and trustworthiness), suggesting an association between therapist multicultural and general competence (Fuertes et al., 2006; Owen, Leach, Wampold, & Rodolfa, 2011). These and other research findings are complicated, however, by the lack of clarity as to how competence is defined and who determines competence, as discussed in this chapter. For example, therapists have been found to rate their multicultural competence significantly higher than do their clients (Fuertes et al., 2006). Therapists and those in training may therefore overestimate the extent of their multicultural competence, and neither level of racial identity development nor purported multicultural com-petence may translate into multicultural counseling skill. An alternative to the term multicultural competence is that of cultural attunement. Roberts (2008) defined cul-tural attunement as “the dynamic nature of understand-ing diversity and cultures” involving “ongoing and active 'tuning in'” that exemplifies mindfulness and cultural hu-mility. It is a practice adopted by behavioral health care workers in rural Alaska (Nelson, Hewell, Roberts, Kersey, & Learning Activity 2. 3 (continued) tribulations. ' Her words, not mine. This can be too small of a town, you know? Kind of suffocating. Don't get me wrong, there are times when I really like it here and there are some good people around. I get by, you know, I pass, but... ” Questions to Consider 1. What are your initial impressions of Katrina?2. Given the information presented and using your cultur-ally empathic skills, what do you think life must be like for her? 3. What challenges has she likely encountered and experi-enced over at least the past 15 years? 4. How do these challenges correspond to the cultural influ-ences that may be prominent in Katrina's cultural identity? To answer this question, consult Hays's (2008) ADDRESS-ING Framework in Box 2. 1 and select any cultural influ-ences that may apply to Katrina. Of the ones selected, which two or three might be more prominent for Katrina at this time? (A sample of Katrina's tapestry of her cultural identity is presented in Figure 2. 2 on page 51. Notice the influences represented and which ones appear to be more prominent for Katrina at this time, based on the thickness of lines used to draw the shapes. ) 5. How would you begin a conversation with Katrina?6. What questions might you ask or what things might you say that you believe would help you and Katrina estab-lish initial rapport? 7. What additional information would you like for Katrina to share with you that would help you understand or resonate with her self-described cultural identity? How might the imparting of this information represent a risk for you? 8. Select at least three of Ridley's (2005) 12 guidelines for practicing idiographic counseling (listed in Box 2. 2. ) and apply them to your work with Katrina. For example, what things do you think would be helpful for you to do to en-hance your own cultural self-awareness as you continue working with Katrina? Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 55 Avey, 2012) who view routine consultation with elders as integral to the development of new trainings and practices. Elders are those persons who have earned the respect of their communities, can articulate the needs of their villages, and are the “wisdom keepers” of their culture. Helpers who thus prac-tice cultural attunement are open to continuous learning, not only from clients but also from other members (and leaders) of the cultural groups with which the helper's clients identify. We prefer the term cultural attunement (Roberts, 2008) to that of “achieving” multicultural “competence. ” Cul-tural attunement is consistent with Lee's (2007) depiction of multicultural “literacy,” or what we regard as multicul-tural fluency. Lee described multicultural literacy as going “beyond mere competency to embracing a way of life that encourages maximum exposure to and understanding of the many-faceted realities of multiculturalism” (p. 261). Cultural attunement is a way of being with clients that suggests that we as helpers are always learning, remaining humble, and negotiating our way in a world of human di-versity. This suggests that we cannot work effectively with all individuals and their families, but that we can learn and speak the language of cultural empathy (Brown, 2009), a language that we believe is an ethical imperative. In the pursuit of cultural attunement, cultural fluency is fostered by working with and intentionally learning about persons who are different from me, persons whose values and customs are different from mine. This implies that con-versations with one client may generate a different language or dialect than those conversations I have with other clients. The meaning or constructed realities of those conversations also are different from those with other clients. Furthermore, cultural attunement conveys that my beliefs and attitudes, knowledge, and skills about cultures and the persons who identify with such cultures are continuously in flux, never es-tablished, and open to reshaping. This suggests that my own values and behaviors may change as I learn from my clients, shifting me from being rigid, dogmatic, and absolutistic, for example, to being more accepting and affirmative of cultural differences. And because “ethics and culture are intimately intertwined” (Hoop et al., 2008, p. 353), we continue the chapter with a discussion of ethical practice. Ethical Practice We believe that ethical practice is the foundation, the cornerstone, of all helping professions, and therefore it is at the very heart of what we do as professionals. If we lack awareness of or if we don't adhere to the values, principles, and codes of professional ethics, then we are at the very least isolated practitioners, if not persons without a profession. LO2As mentioned in this chapter, professional helping is an in-timate business: we are in close contact (both in proximity and at an affective level) with other persons and we engage other people during critical, life-changing moments, oc-casions when clients are vulnerable, impressionable, and susceptible to the potentially harmful consequences of their life situation or mental illness (e. g., trauma of intimate partner violence, a couple struggling with the suicide of their teenage daughter). How we conduct ourselves as pro-fessional helpers has a significant impact on the lives of our clients and their family members and can sometimes be a matter of life or death (e. g., ordering involuntary psychiat-ric hospitalization, reporting suspicion of child abuse). This work is definitely not for the faint of heart. We believe that being a professional helper is not simply a matter of earning a graduate degree in mental health counseling or in another behavioral health discipline. It also is not restricted to passing a multiple-choice state licensure exam and being able to sign off on clinical documentation with your academic credentials (e. g., MA, MSW, or Ph D) and your professional credentials (e. g., LISW, LPC, or LMFT). Credentials alone do not guarantee professional competence (Welfel, 2016). They signify a professional helper in name only, the bare minimum of what one needs to earn the legal right to practice as a professional helper. The word professional in the phrase professional helper actually signifies or reflects who the helper is as a person, including such things as the helper's communication and interactional style, mannerisms, how he or she wrestles with and manages personal demands and dilemmas, and his or her own decision-making and problem-solving methods. This means that we cannot separate or segregate who we are as persons from who we are as professionals. Practicing as a professional helper—a practice conducted and lived out purposefully and authentically—demands the helper's whole self, not just a part or piece or slice of the helper. Who we are as helpers is therefore not simply determined by who we are “on the clock” or on the job, including how we conduct ourselves with clients and colleagues. Rather, being a professional helper requires the investment of a person's whole self—that is, the integration or intersection of (1) one's personal life and private self with (2) one's professional life and public self. In our opinion, this work is more of a lifestyle than a job, so being a professional helper is an iden-tity we take with us wherever we go. Perhaps there is never a time when we are not professional helpers—it is an identity that defines both our personal and our professional conduct. Ethical practice is therefore very much influenced by who we are as persons, what we believe, and what we sanc-tion. Ethical practice consists of much more than know-ing and having memorized ethical codes and guidelines Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
56 Chapter 2 or key vocabulary (the cognitive mechanics, if you will, of ethical practice). As some have described (e. g., Fisher, 2008), this is the “ethical floor” or the bare minimum of ethical practice. We believe that ethical practice represents the helper's behavior as a professional, the visible demon-stration of his or her identity as a professional helper, and the meaning the helper ascribes to that identity. For such practice to be genuine and credible, the helper must un-derstand the need or the rationale for such behavior. The explanation that a particular behavior is simply ethical or unethical bespeaks ignorance or a lack of appreciation for the necessity of certain professional behaviors. For example, suppose that a client in your weekly therapy group informs you that he felt snubbed when you did not speak to him at the mall last weekend. Responding with any of the following statements would fail to explain the purpose of your behavior: “It's not ethical for me to initi-ate contact with you outside of counseling” or “I'm not allowed to meet with my clients outside the agency” or “My supervisor would be very upset with me if she knew I had talked with you in public. ” Any of these responses also would suggest a lack of ownership of or an identification with such practice (i. e., “I'm not allowed” insinuates invol-untary behavior). A better explanation to the client for your behavior might be: “I respect your privacy enough that I would not want to publicize how I know you. ” Rather than referring to rules or mandatory codes, this response conveys an understanding of ethical practice as primarily that of protecting or enhancing the client's well-being. It also signals your adoption or integration of this behavior so that it is consistent with your own beliefs and values. Returning to the notion of the connection or intersec-tion of helper values with ethical conduct, Okun and Kantrowitz (2008) stated that those helpers whose behavior is consistent with their definition of helping, who are committed to examining their own behaviors and motives, and who seek consultation from others are less likely to function unethically than those who are closed to such reflections. (p. 292) This suggests that values endorsed and prioritized by helpers—both on and off the job—do impact helper professional behavior. Bass and Quimby (2006) argued that “professional judgments are influenced by personal values” (p. 78). We believe, therefore, that when the per-sonal values of helpers are consistent with professional standards of conduct, helpers are more likely to interact genuinely and credibly with clients and other profes-sionals. According to the Preamble of the NASW (2008) Code of Ethics, such practice reflects the value of integrity (one of six core values listed). Put another way, consis-tency of personal values and professional conduct signals an authentic lifestyle of helping. Ethics usually are understood as professional stan-dards regarding what is deemed appropriate, proper, or acceptable behavior and what is deemed inappropriate, improper, or unacceptable professional behavior. Be-haviors that comprise professional conduct typically are determined by a subgroup of members (e. g., ethics com-mittee) charged with the task of outlining the behavioral expectations of all members of a particular organization or profession. Ethical codes are thus the product of a collective gathering and consensual validation by pro-fessional members of an organization or profession and are intended to guide professional conduct, discharge of duties, and the resolution of moral dilemmas. These codes include the American Counseling Association's (ACA; 2014) ACA Code of Ethics, the American Psycho-logical Association's (APA; 2010) Ethical Principles of Psychologists and Code of Conduct (hereinafter referred to as APA's Ethics Code), and the NASW's (2008) Code of Ethics. Marriage and family therapists, rehabilitation counselors, school counselors, health care providers, and members of other helping professions have their own sets of ethical standards. Outside of the United States, the BACP's (2013) Ethical Framework for Good Prac-tice in Counselling and Psychotherapy includes six ethical principles and outlines nine values and 10 personal moral qualities for its members. The Canadian Code of Ethics for Psychologists (Canadian Psychological As-sociation, 2000) lists four principles, one of which is responsibility to society. Ethical Values and Principles All helping practitioners should be familiar with the ethical codes of their respective professions. As already mentioned, however, simply knowing the codes does not ensure ethical conduct. This is simply being on the ethical ground floor. It is the helper who reaches for the ethical ceiling by embracing, intentionally reflecting on, and honoring the values of helping (e. g., care and concern for the welfare of others, openness to learning) who is often more ethical than the one who simply memorized and can recite ethical codes. As we emphasize throughout this chapter, our values about diversity, power, relationships, the helping process, religion and spirituality, and competence, to name a few, influence and guide our professional behavior. Simply practicing a certain way because “I have to” (insinuating a lack of agreement or at least an incongruence between values and actual practice) does not engender confidence in the helper's dedication to a lifestyle of helping. Con-sidering the values and principles of ethical practice is therefore appropriate, and doing so in this chapter prior to discussing specific ethical issues is intended to inform Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 57 and guide (perhaps even structure) the decision-making process of each issue. Using extant data derived from in-depth interviews with 10 therapists (seven women, three men; all European American) who were nominated and deemed by their peers as “the best of the best,” Jennings, Sovereign, Bottorff, Mussell, and Vye (2005) identified nine themes or ethi-cal values held by these “master therapists. ” Because the original study (Jennings & Skovholt, 1999) did not focus specifically on ethics, transcripts of the therapist interviews were compared with ethical values embedded in ethical codes (e. g., APA's Ethics Code, 2010) and in the four ethical principles recognized by most helping professions: nonmaleficence, beneficence, respect for autonomy or self-determination, and justice or fairness (Beauchamp & Childress, 2013). Additional ethical principles often cited in professional codes of ethics include fidelity, veracity, and integrity. The resulting nine ethical values of well-respected thera-pists from the study of Jennings et al. (2005) are presented in Box 2. 3 and are referenced in the discussion of ethical issues highlighted in the remainder of the Ethical Practice section of the chapter. We should note that ethical values sometimes are referred to as morals, virtues, or moral vir-tues by different sources and can include the additional helper qualities or characteristics of truthfulness, courage, integrity, sincerity, discernment, resilience, acceptance of emotion, service, interdependence with the com-munity, and social justice (BACP, 2013; Beauchamp & Childress, 2013; NASW, 2008). Client Rights and Welfare Jennings et al. (2005) grouped the first four ethical values of “master therapists” (i. e., relational connection, auton-omy, beneficence, and nonmaleficence) into a category they labeled “building and maintaining interpersonal at-tachments. ” It is therefore clear that attending to the rela-tional connection with clients is a primary ethical value. This is demonstrated in the listing of “The Counseling Relationship” as the first of eight sections in the ACA Code of Ethics (2014). Helpers are obligated to protect the wel-fare of their clients. In most instances, this means putting the client's needs first. It also means ensuring that you are intellectually and emotionally ready to give the best that you can to each client. The helping relationship needs to be handled in such a way to protect and promote the client's well-being. Es-tablishing an effective helping relationship entails being open with clients about their rights and options during the course of therapy. Nothing can be more damaging to trust and rapport than to have the client discover midstream that the practitioner is not qualified to help with a particular issue, that the financial costs of therapy or other forms of helping are prohibitive, or that ser-vices involve certain limitations and that their outcome cannot be guaranteed. Any of these occurrences might help explain what Safran, Muran, and Eubanks-Carter (2011) described as therapeutic alliance “ruptures. ” At the outset, the practitioner should provide the client with enough information about therapy to help the client make informed choices (also called empowered consent; see Brown, 2010). There appears to be consensus about what should be disclosed to prospective clients to inform their consent about participating in mental health care (Carlisle & Neulicht, 2010; Fisher & Oransky, 2008; Pomerantz, 2005; Wheeler & Bertram, 2015). Informed consent should include: 1. the kind of service, treatment, or testing being pro-vided (including whether interventions are substan-tiated in research trials or are more exploratory or innovative in nature); 2. the risks and benefits of the service, treatment, or testing; 3. the logistics involved and the policies of the individual provider or facility regarding the length of appoint-ments, number of sessions, missing appointments, fees, and payment methods; 4. information about the qualifications and practices of the helper (including whether the helper is be-ing directly supervised and the involvement of other professionals who may comprise a multidisciplinary treatment team); 5. risks and benefits of alternatives to the treatment, ser-vice, or test or of forgoing it; 6. the meaning, extent, and limits of or exceptions to confidentiality;1. Relational connection 2. Autonomy3. Beneficence4. Nonmaleficence5. Competence6. Humility7. Professional growth8. Openness to complexity and ambiguity9. Self-awareness Source: Jennings et al., 2005. BOX 2. 3 Nine Ethical Values of “Master Therapists” Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
58 Chapter 2 7. records preservation and release policies, includ-ing risks associated with electronic communica-tion (electronic health records, as well as electronic communication with the helper, such as texting and email); 8. involvement of an insurance company or third-party payer; 9. procedure for resolving disputes or complaints; and 10. emergency procedures. Pomerantz (2005) emphasized that providing all cli-ents with information about available interventions and resources is an ongoing process and that specific topics (e. g., fees, method of payment) should be introduced and discussed with clients sooner than other topics (e. g., total number of sessions anticipated). He characterized this type of sequencing as “increasingly informed consent. ” An additional layer of consideration arises when chil-dren and adolescents or other vulnerable groups are in-volved. For example, particular care is needed regarding consent when working with children and adolescents (see Tan, Passerini, & Stewart, 2007). This is especially true for minors with limited cognitive functioning and for mi-nors whose parents are involved in high-conflict divorce or separation (Shumaker & Medoff, 2013). Laws are of-ten unclear about whether adolescents should be treated as adults or as children when it comes to consent issues (Koocher, 2008; Shumaker & Medoff, 2013). An exam-ple of this was the New Hampshire Supreme Court's 2005 ruling In the Matter of Kathleen Quigley Berg and Eugene E. Berg that the medical (including therapy) records of minor children could be sealed when one parent demands access to the records for the purpose of litigation (see Wolowitz & Papelian, 2007). As a result of this ruling, it appears that in certain circumstances there could be “mature minors” who would be able to consent to mental health treatment without also having parental consent and that these same children could also claim client-therapist privilege (i. e., deny parental access to therapy information, including therapy records). Professional helper consultation (e. g., state laws, codes of ethics) and discernment is essential in these matters because age is an arbitrary indication of maturity, children and youth reach developmental milestones at different rates, and mental health and substance use concerns can affect a young per-son's decisional capacity (Belitz & Bailey, 2009). It is true that children and youth vary greatly in their capacity to provide truly informed consent. Soliciting a young person's assent or accepting the helper's invitation to participate in the therapeutic process (Belitz & Bailey, 2009) is encouraged by the American Medical Association (AMA, 2008), and the ACA Code of Ethics (2014) stipu-lates this in Standard A. 2. d. This means that although children and adolescents may not be able to provide legal consent, they are able to indicate whether or not they understand and agree to what is being proposed. Assent conveys that an individual is willing to accept recom-mended care after having the opportunity to express his or her own wishes, knowing that these wishes will be taken seriously although they will not be given the weight of full consent. Tan et al. (2007) explained that assent allows a young person to participate in decision-making without the burden or responsibility for making the choice alone. Koocher (2008) offered sample text that helpers may wish to consider for inclusion in an informed consent docu-ment when working with children and adolescents. Confidentiality Closely related to protecting client well-being is the issue of confidentiality. In many respects, confidentiality—or the promise to respect and honor another's privacy—is the foundation or cornerstone of all helping processes (Meer & Vande Creek, 2002). Donner, Vande Creek, Gonsiorek, and Fisher (2008) adamantly asserted that maintaining client confidentiality is our primary obligation as professional help-ers and is of a higher priority than risk management or the threat of litigation. Therapy and other forms of professional helping could not be conducted without the infrastructure or buttress of confidentiality, the assurance that both the content and the process of client-helper interactions will be “contained” within established parameters or boundaries of privacy. Helpers who breach client confidences can do seri-ous and often irreparable harm to the helping relationship. Practitioners generally are not free to reveal or disclose information unless they have first received written per-mission from clients. Exceptions to confidentiality vary from state to state but generally include Merideth's (2007) “Five C's” mnemonic for remembering the five generally recognized exceptions to confidentiality: Consent of client or legally authorized surrogate decision-maker (e. g., parent, guardian) Court order, which is issued by a judge and should not be considered equivalent to a subpoena, unless the latter is also issued by a judge Continued treatment that requires the clinician to commu-nicate with other professionals and health care agencies (e. g., insurance company) Comply with the law, which includes mandatory reporting (e. g., suspected child abuse or neglect) Communicate a threat, or warn specifically identifiable potential victims of a clear and imminent danger Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 59 Confidentiality and the Duty to Protect The last of Merideth's (2007) “Five C's” of exceptions to confidenti-ality is commonly known as the helper's duty to protect (sometimes referred to as the duty to warn). The duty to protect is based on the case of T arasoff v. Regents of the University of California (1976). There are at least 33 states that have adopted some type of duty to protect law (Bersoff, 2014) by which helping professionals in those states may not be subject to litigation if they take spe-cific action when a client threatens to cause imminent bodily harm to an identified victim. Depending on the state, these helper actions may include implementing a risk management plan after consulting with a supervisor (e. g., prioritizing the goal of anger management in the treatment plan), involuntarily hospitalizing the client, encouraging the client to be hospitalized voluntarily, and/or notifying legal authorities of the client's threat and identity, as well as the potential victim's identity and location. Notice that not all of these actions require the helper to breach client confidentiality, something Bersoff (2014, p. 465) contends is a helper's “last resort. ” He describes the dilemma between two forms of protective action: pro-tecting the client's privacy and protecting another person's safety from the actions of the client. He writes: The therapist must tread a thin line between protecting confidentiality and protecting the potential victim. An error on either side of this line can lead to liability—either for malpractice in unreasonably breaching confidentiality or for wrongful death for failure to warn in the face of a real threat. (p. 466) Prioritizing one form of protective action over the other requires consulting with a supervisor and possibly with legal counsel, as well as familiarizing yourself with your state's laws. Confidentiality and Communicable Health Conditions A complex issue involving the limits to confidentiality is whether the client who tests positive for a contagious, communicable, and potentially life-threatening disease (e. g., human immunodeficiency virus or HIV) is regarded as a danger to others. Consider the case example adapted from Alghazo, Upton, and Cioe (2011): “Mark” is a 36-year-old married bisexual man recently diagnosed with HIV. He applies for life insurance at work and routine blood work identifies him as HIV-positive, which he chooses to keep private. Following this diagnosis, Mark begins missing an excessive amount of work (at least 2 days per week) and he has difficulty interacting with the public. Both of these behavior changes are problematic because he is a customer service representative for a media provider. His supervisor notices these two work problems and suggests that Mark see a rehabilitation counselor. Mark agrees to remain employed and to address the grief process associated with his infection. While receiving services, Mark reports that he continues to have a sexual relationship with his wife and other unidentified male partners. He has not informed anyone about his recent diagnosis and does not intend to do so. He believes it is unnecessary because he says he is practicing safe sex (pp. 43-44). Take a moment to reflect on the following questions about Mark's case: 1. What are the issues involved in this case? 2. If you had been seeing Mark and his wife in couples counseling and he disclosed this information to you outside of her presence, would you be able to keep this information from her? 3. Whether or not you were meeting with Mark in indi-vidual or couples counseling, what options are there for intervention? 4. What are your ethical obligations as a professional helper in your work with Mark? Advances in science and technology have clearly in-fluenced certain policies and professional recommen-dations. For example, the Centers for Disease Control and Prevention (CDC) now consider HIV and AIDS (acquired immunodeficiency syndrome, the late stage of HIV) to be chronic conditions that can be treated (although not cured) with therapies that were not available 10 to 15 years ago, namely antiretroviral therapy (ART). Because of this, the CDC now recom-mends routine testing for HIV/AIDS for adults, adoles-cents, and pregnant women seen in health care settings in the United States (see www. cdc. gov/hiv/topics/testing). This also is the recommendation of the U. S. Preventive Services Task Force, an affiliate of the U. S. Department of Health and Human Services (see www. uspreventiveser-vicestaskforce. org). Furthermore, President Obama (who was tested for HIV in 2009) issued an Executive Order in 2013 establishing the HIV Care Continuum Initia-tive to improve testing, care, and treatment outcomes for those living with HIV, their partners, and other family members. Learning the results of a positive screen makes it pos-sible for infected persons to then access available thera-pies and to receive valuable information so that they can take steps to manage their health and to protect their sex or drug-use partners from infection. These steps in-clude learning about pre-exposure prophylaxis (or Pr EP, Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
60 Chapter 2 a medication intended to prevent HIV infection among HIV-negative persons who are at risk for HIV exposure) and learning that ART can significantly reduce HIV in-fection in newborns (Ergin, Magnus, Ergin, & He, 2002). Despite these treatments and recommendations, HIV and AIDS remain stigmatizing conditions. This may be due to the criminalization of certain behaviors of HIV-positive persons. Thirty-three states currently have one or more HIV-specific criminal laws, categorized as felonies in 28 of these states (Lehman et al., 2014). In 24 of the 33 states, persons who know they are HIV-positive are required to disclose their status to their sexual partners; in 27 states, criminal behaviors include those that pose a high-risk of HIV transmission (e. g., anal and vaginal sex, donation of blood). Although a majority of HIV-positive persons in two of these states (Michigan and New Jersey) who were aware of the disclosure law reported having disclosed their status to their sexual partners, Galletly and her colleagues (Galletly, Pinkerton, & Di Franceisco, 2012; Galletly, Glasman, Pinkerton, & Di Fanceisco, 2012) found that awareness of the law in these two states was not associated with an increased disclosure to all prospective sex partners, increased use of condoms, or in-creased sexual abstinence. Rather than punishing persons for nondisclosure, Galletly and her colleagues recommend helping to increase the comfort level of HIV-positive per-sons to disclose their status or to remain abstinent. Beauchamp and Childress (2013) refer to the Ameri-can Medical Association's (AMA) guidelines to physicians for preventing HIV-positive individuals from infecting third parties as “a responsible, albeit demanding, strategy” (p. 322). The AMA's Council on Ethical and Judicial Af-fairs (2010) revised the AMA Code of Medical Ethics (Sec-tion E-2. 23) so that physicians “honor their obligation to promote the public's health by working to prevent HIV-positive individuals from infecting third parties within the constraints of the law” (p. 5). Specifically, if a physician determines that “an HIV-positive individual poses a sig-nificant threat of infecting an identifiable third party, the physician should: (a) notify the public health authorities, if required by law; (b) attempt to persuade the infected patient to cease endangering the third party; and (c) if permitted by state law, notify the endangered third party without revealing the identity of the source person” (p. 5). We believe it is essential for all helpers (not just physi-cians) to do all they can to enlist the cooperation of HIV-positive individuals to notify their sex partners of their infection. This includes becoming familiar with your state's law, remaining current about appropriate methods to pro-tect against transmission of HIV, providing clients with information about medical interventions (e. g., ART, Pr EP), processing with clients the meaning and implications of their HIV-positive status (including their possible grief and anger), and engaging in specific skill-building practices, such as communication skills. Promoting client self-disclosure to partners is preferable to the helper doing so. Based on this additional information, we encourage you to revisit the case of Mark mentioned earlier. What decisions would you make in his case given the informa-tion you now know? Confidentiality in Addictions Treatment Although not often mentioned in mental health practice, federal regulations exist in the United States that govern the confidential-ity of client and patient records in alcohol and other drug treatment services. Known as 42 CFR (42 Code of Federal Regulations, Part 2), these regulations (Code of Federal Regulations, 2002) were introduced in the early 1970s at a time when treatment for drug addiction was separate from alcohol addiction treatment so that some-one contacting a drug treatment center would automati-cally be identified as having engaged in illegal activity. The intent of 42 CFR remains to protect the identity of persons inquiring about and receiving substance use treatment. Without such protections, law enforcement could use client records as a means of arresting clients (Manuel, Newville, Larios, & Sorensen, 2013). Geppert (2013, p. 625) claims that it is precisely because of the stigma attached to persons with addictive disorders that 42 CFR has the most “rigorous privacy protections” of all other types of health information, protections that Hughes and Goldstein (2015) describe as more stringent than the Health Insurance Portability and Accountability Act (HIPAA) of 1996, also known as 45 CFR. Professional helpers may think that 42 CFR does not apply to them because they serve only those clients with mental health concerns. However, numerous stud-ies indicate that the co-occurrence of mental illness and a substance use disorder is common worldwide (Jané-Llopis & Matytsina, 2006). From one study specific to the United States, 20 percent of those who sought treatment for a mood disorder also had a substance use disorder (Grant et al., 2004a) and approximately 29 to 48 percent of those with a personality disorder also had either an alcohol or a drug use disorder (Grant et al., 2004b). These prevalence data continue to support the view that “co-occurrence is the rule rather than the exception in psychiatric inpatient and substance abuse settings” (Brems & Johnson, 1997, p. 440). Therefore, 42 CFR confidentiality regulations are not restricted to chemical dependency treatment facilities; they potentially apply to all behavioral health care providers serving clients with substance use disorders. In an increas-ingly integrated U. S. health care service delivery system, 42 CFR may have a wider reach (Manuel et al., 2013). Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 61 Protecting the Confidentiality Rights of all Clients In an ef-fort to “reach for the ethical ceiling” by reprioritizing con-fidentiality, Fisher (2008) outlined a six-step model for protecting the confidentiality rights of clients. Although it was developed for psychologists, we believe this model is appropriate for all professional helpers. First, as a helper you are exhorted to be prepared to have honest conver-sations with prospective clients about the meaning and implications of confidentiality, as well as the exceptions to confidentiality. This entails doing some of your own homework, such as reviewing the codes of ethics of your profession, understanding the policies and procedures of your treatment setting, and consulting with a supervisor about how to proceed if a prospective adult client refuses to sign a release of information form, for example. Second, it is up to you as a helper to explain to prospective clients up front, and in language they can understand, the nature and limits to confidentiality. Fisher (2008) described this step as informing the consent of a prospective client. This practice is particularly important for persons whose primary language is not English and persons who are mandated to counsel-ing, such as by a court or judicial board or employer. The third step in Fisher's (2008) model for maintain-ing client confidentiality is to obtain the client's truly informed consent, meaning that the client conveys to you an understanding of confidentiality and its limits and you are able to document the client's consent prior to disclos-ing client information. The fourth step is to respond ethically to legal demands for client information, such as when a subpoena or a court order is served, to know when to contest such demands and when not to make premature disclosures. Fifth, avoid the avoidable breaches of confidentiality, such as talking to your supervisor about a client in the public waiting area of the treatment facility. The sixth and final step is to talk with colleagues about confidentiality and its corollaries, which may include the need to confront a colleague's unethical practice. Client Privilege A concept similar to confidentiality is that of client privilege. Privilege is the legal right that pro-tects the client from the forced disclosure of personal and sensitive information in legal proceedings. Merideth (2007) cited a colleague's helpful method for differentiat-ing confidentiality and client privilege: confidentiality is the clinician's obligation (or CO) not to disclose confiden-tial information about a client, whereas privilege deals with the patient's right (or PR) to exclude from a legal proceeding communications made to a treating clini-cian. Sometimes referred to as testimonial privilege, client privilege defines how confidentiality can and cannot be used in the judicial arena (Younggren & Harris, 2008). As mentioned, in the New Hampshire Supreme Court ruling in the 2005 Berg case (see Wolowitz & Papelian, 2007), this legal right may extend to certain “mature minors. ” In 1996, the U. S. Supreme Court ruled in the case of Jaffee v. Redmond that communications between a master's-level social worker and her client were privileged under federal law. Although the Court explained that important public and private interests are served by protecting confidential communications between “psychotherapists” and their clients, some see its practical impact as limited. For one thing, no state legislature licenses “psychotherapists,” and the Jaffee court did not define its use of the term. The ethical conflicts between duty to protect and duty to maintain confidentiality take many forms (see Werth, Welfel, & Benjamin, 2009). Because states vary regarding their laws about confidentiality, and because laws differ in what medical professionals and counseling or psycho-therapy professionals are allowed, it is important to be informed about laws in your state. There are complex ethical, legal, and therapeutic issues surrounding confi-dentiality. These issues can vary based on treatment setting (e. g., school, hospital, correctional facility) and geographic location (e. g., rural) as well as client demographics (e. g., minors, older persons) and additional client information (e. g., sex offense history). Given this complexity, it is not uncommon to encounter conflicting positions about how to interpret and apply legal criteria and ethical codes. Confidentiality and Cultural Values Meer and Vande Creek (2002) stated that the concept of confidentiality lends itself well to the Western value of individual rights to privacy and autonomy. Persons from cultural groups with a more collectivistic than individualistic orientation may struggle to fully grasp the meaning of this concept. Parents who recently immigrated to the United States from China, for example, may not understand why they cannot participate in all counseling sessions you will have with their 8-year-old son. Also, clients who have been victimized by persons they regard to be in positions of authority (e. g., women who have been repeatedly abused by their male partners), including members of minority or target groups who have experienced discrimination and trauma from members of the socially dominant group (e. g., a teen questioning his sexuality who has been bullied at school), may not be able to appreciate initially that they do have a voice in therapy and can make decisions for themselves. This includes not divulging to the therapist any information they choose not to, and limiting who the therapist can talk to about their case. It is worth repeating that the helper must clearly explain to clients the nature of his or her professional obligations so that, for instance, not initiating contact outside of therapy (e. g., during an inadvertent meeting in the gro-cery store) does not signal the helper's lack of respect for Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
62 Chapter 2 the client. Rather, it actually represents the helper's high-est respect for the client because it honors the client's right to acknowledge the counselor in public only if the client chooses to do so. See Chapter 7 for additional informa-tion on issues of confidentiality. Multiple Relationships Multiple relationships arise when the practitioner is in a professional helping relationship with the client and simul-taneously or consecutively has one or more other kinds of relationships with that same person, such as an administra-tive, instructional, supervisory, social, sexual, or business re-lationship. Multiple role relationships can be subtle and are significant sources of ethical complaints. Such relationships are problematic because they can reduce the counselor's objectivity, confuse the issue, put the client in a position of diminished consent and potential abandonment, foster discomfort, and expose the client and practitioner to nega-tive judgments or responses by others. Therefore, as much as possible, professional helpers should avoid becoming involved in dual or multiple relationships with clients. There are occasions, however, when engaging in mul-tiple relationships with clients is unavoidable. This is particularly true in smaller communities where profes-sional helpers are more likely to know clients in other contexts and are less likely to be able to refer clients elsewhere. For example, a male client may be employed as a physical trainer at the local health club where his therapist is a member. The client and helper also may at-tend the same church, have children who attend the same elementary school, and/or attend the same support group or fellowship, such as Alcoholics Anonymous. These and other examples illustrate only a few of the many ways in which our lives intersect with others. Werth, Hastings, and Riding-Malon (2010) encouraged mental health professionals in rural areas to become actively involved in the community to promote others' trust in them and the work they do to lessen the stigma associated with mental health concerns that is common in low-density, isolated areas. To do otherwise would suggest a helper who does not appreciate and is out of touch with com-mon, ordinary, and localized concerns, an insular, or at least a detached, professional who may not be able to establish meaningful connections with his or her clients. Interactions with clients outside of therapy, regardless of geographic setting, therefore may not only be inescapable but advisable. This makes the management of multiple relationships that much more sensitive and deliberate. Take, for instance, the client who recently accomplished what for her was the monumental task of earning a 4-year college degree as a single parent. Because she regards you as someone who has provided her with helpful professional assistance over the past 2 years, offering support and encour-agement to realize this goal, she invites you to her commence-ment ceremony and to her graduation party afterwards with family and friends. Declining her invitation on the grounds that such out-of-session contact would violate professional boundaries may actually strain the ongoing helping relation-ship you have with her. Any “nonprofessional interaction” with a client or former client must be initiated by the client, and the helper must document the rationale, potential ben-efit, and anticipated consequences of this interaction. This nonprofessional interaction is what Bridges (2005) characterized as a “boundary crossing,” an ex-ample of “enactments between the therapist and patient that may or may not be harmful to the therapeutic pro-cess” (p. 26). These types of interactions are differentiated from “boundary violations,” defined as “egregious and potentially harmful transgression[s] of the therapeutic contract and treatment frame that involve a breach of the fiduciary contract and abuse of the therapist's power” (p. 29). Engaging in a romantic or sexual relationship with a current or former client would be an example of a boundary violation that would not uphold the ethical value of nonmaleficence (i. e., do no harm), and would result in the helper's being subject to ethical and legal sanctions (e. g., revocation of the helper's state license). Obviously, sexual contact between practitioner and client is never warranted under any circumstance and is explicitly proscribed by all the professional codes of ethics and by state laws. In some states, initiating a romantic and sexual relationship with a client after therapy has concluded also is illegal. However, at least three professional associations allow for such relationships, but only after a required length of time elapses after termination and the therapist is able to document that the purpose of terminating services was not to initiate a post-therapy relationship. The APA's (2010) Ethics Code stipulates a 2-year interval after termination, whereas the ACA Code of Ethics (2014) and the CRCC's (2009) Code of Professional Ethics for Rehabilitation Counselors prohibit counselors and rehabilitation counselors, respectively, from engaging in a sexual or romantic relationship with a former client whose care was terminated or otherwise discontinued less than 5 years before the intimate relationship began. We strongly advise, however, that professional helpers not engage in such relationships with a former client at any time “because of the potential harm to the client,” as the NASW (2008) Code of Ethics stipulates (see Ethical Standard 1. 09(c)). Telepractice The ubiquitous use of many forms of communication technology in daily life explains the burgeoning use Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 63 of diverse forms of technology in health care, specifi-cally technology intended to enhance or make possible communication between clients and helpers, as well as among professionals. The increased sophistication of technology platforms in the past 20 years is reflected in the names assigned to this particular practice. Earlier references were to cybercounseling or cybertherapy, Internet-based or online counseling or online psycho-therapy, e-therapy, or simply distance therapy. More recent references use the prefix tele-, as in telehealth, telecounseling, and telemental health. This signifies a broader scope of technological devices that can be used (e. g., smart phones), as well as practice formats (e. g., video teleconferencing). The term telepractice captures this diversity and thus refers to any contact with a client (or patient) other than face-to-face or in the same room (Matthews, 2014). This includes synchronous (i. e., in real-time) and asynchronous (e. g., email, text) forms of communication. It is impor-tant to note, however, that as of this writing Medicare and Medicaid will only reimburse telehealth services that use real-time audio and video interactive telecommunica-tions systems between the client and helper (see Centers for Medicaid & Medicare, www. cms. gov). Telephones, fax ma-chines, and email therefore do not qualify as telehealth com-munication systems reimbursable by Medicaid or Medicare. There are five important developments that explain the rapid and expansive application of telepractice, specifi-cally telemental health (TMH), in the United States today (T urvey & Myers, 2013): 1. A growing shortage of mental health providers, specifi-cally in socioeconomically disadvantaged geographic areas. 2. Advances in the quality and availability of desktop and Internet videoconferencing applications. 3. Reimbursement for TMH services from Medicaid, Medicare, and private insurance companies. 4. Research attesting to the benefits of treating mental health disorders through TMH, comparable to in-person or same-room care. 5. Health care reform in the United States, specifically the Patient Protection and Affordability Care Act signed into law in March 2010 by President Obama that, among other provisions, allows for certain tele-health services. Onken and Shoham (2015) discuss several poten-tial benefits of participating in TMH and other forms of technology-based interventions for clients and help-ers. For clients, these include the increasing reach and availability of behavioral health care, affordability of treatment, and sense of anonymity that helps to allevi-ate stigma attached to having a mental health condi-tion. For helpers, one benefit of conducting TMH is increasing the potency of treatment, particularly when technology-based interventions are used in conjunction with standard care, such as the computer-assisted deliv-ery of cognitive-behavior therapy (CBT) for substance use disorders known as “CBT4CBT” (Carroll et al., 2008). Other potential benefits to helpers are the in-creasing reach and availability of online and other forms of technology-based training, affordability of training, and time available to invest in specific aspects of care (e. g., strengthening the therapeutic relationship) when skills-training, for example, is delivered via an interactive online program. It is understandable that with telepractice comes a new set of ethical considerations. Taylor, Mc Minn, Bufford, and Chang (2010) predicted that ethics committees would be unlikely to establish formal guidelines on the use of specific technologies in the near future because of the accelerating rate of technological change. Indeed, being able to practice TMH has “outpaced” the enact-ment of regulatory reforms needed to address the modi-fication of standards of practice to telepractice (Kramer, Mishkind, Luxton, & Shore, 2013). In the past 5 years, however, professional associations have published guidelines and codes of ethics specific to telepractice. For example, the APA (2013) adopted Guide-lines for the Practice of T elepsychology, and the most recent revision of the ACA Code of Ethics (2014) includes a new section (Section H) on Distance Counseling, T echnology, and Social Media. In addition, the American Telemedicine Association (2013) developed Guidelines for Video-based Online Mental Health Services that encompass clinical, technical, and administrative guidelines. The Tele Mental Health Institute (http://telehealth. org) maintains links to the guidelines and codes of conduct of other professional associations with respect to telepractice. Three Ethical Considerations in Telepractice There are at least three ethical considerations addressed in professional association guidelines and codes of ethics with respect to telepractice: (1) helper competence using technology; (2) informed consent; and (3) protection of client confi-dentiality. Each of these is discussed briefly in this section. It does not seem accidental that what is mentioned first in at least two professional association documents targeting telepractice is helper competence. Guideline 1 of the APA's (2013) eight Guidelines for the Practice of T ele-psychology states that “psychologists who provide telepsy-chology services strive to take reasonable steps to ensure Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
64 Chapter 2 their competence with both the technologies used and the potential impact of the technologies on clients/patients, supervisees or other professionals” (p. 7). Similarly, Sec-tion H. 1. A. of the ACA Code of Ethics (2014) stipulates that counselors who provide these services will develop knowledge and skills (i. e., competence) related to technol-ogy and ethical and legal considerations. Helpers are advised to be trained in certain technolo-gies, such as video teleconferencing (VTC), and then to initiate, explain, and coordinate their use; they must continuously evaluate the effectiveness of each method of telepractice. This includes attending to cultural factors and maintaining therapeutic boundaries. A TMH provider in Washington, DC, for example, who delivers primarily individual therapy to female U. S. military veterans on the east coast will need to adapt her method when asked to provide group-based TMH services to American Indian veterans in Alaska using VTC. In addition, it is recom-mended that helpers conduct VTC from a consistent en-vironment, be mindful of what appears in the camera's view (from the client's as well as the helper's view), and al-ways maintain professionalism (Drum & Littleton, 2014). With each new form of technology comes a unique set of communication challenges that may impact the develop-ment of the therapeutic relationship (Fitzgerald, Hunter, Hadjistavropoulos, & Koocher, 2010). Just because the technology is available (e. g., smart phones, tablet comput-ers) doesn't mean it is appropriate for use in telepractice. The second ethical consideration in telepractice is informed consent. This includes informing clients of the helper's physi-cal location, any time zone differences, and the helper's cre-dentials, including the state(s) in which he or she is licensed. Helpers are advised to contact their state licensing board and the licensing board of the state where the client is physically located prior to conducting TMH (American Telemedicine Association, 2013). Because licensure for a wide range of U. S. health care providers remains under the purview of the states and not the federal government, it is likely that TMH providers will need to obtain licensure in the state where the client is physically located (Kramer et al., 2013). Additional aspects of informed consent in TMH in-clude the helper clarifying methods for session cancella-tion and reviewing with the client procedures to follow in the event of a crisis (e. g., client suicidal thinking). This latter practice will require the helper to become familiar with resources in the client's location. Furthermore, the client will have to verify his or her age and establish means of payment for services. Adolescents have been found to easily engage in and also to benefit from various forms of TMH (Carlisle, 2013), but their participation in such services may remain contingent on a parent or guardian consent, as is true for same-room care. The third ethical consideration in telepractice is pro-tection of client confidentiality. This includes securing the transmission and storage of electronic records, and imple-menting encryption standards. Helpers who provide TMH must abide by a number of federal laws, including HIPAA (briefly described in this chapter), possibly 42 CFR (dis-cussed previously), and also those of the Federal Commu-nications Commission, which has established the mobile health (or mhealth) task force to offer recommendations for improving health care delivery using wireless health technologies (see Hughes & Goldstein, 2015). Laws gov-erning the use and safety of consumer products (regulated by the Federal T rade Commission), such as mobile health apps and Web-based services, also will need to be consulted. We invite you to place yourself in the shoes of a client who recently scheduled and then participated in an ini-tial telemental health visit using video teleconferencing (VTC). This is Learning Activity 2. 4 on pages 65-66. Please review the three ethical considerations in teleprac-tice before you do this activity, as well as link to one of the professional association guidelines or code of ethics related to telepractice that are mentioned in this section. Feedback to Learning Activity 2. 4 is provided on page 68. Out-of-Session Client Communication Zur (2009) noted that “the Internet has blurred the line between what is personal and what is professional, as well as between self-disclosure and transparency” (p. 24). This is particularly true of social networking, such as the use of Facebook, Twitter, You Tube, Linked In, and Instagram. Because the majority of young professional helpers and graduate students in a helping profession maintain a so-cial networking site (Harris & Kurpius, 2014), it is highly likely that you will encounter clients or client information while online. It is important to remember that, to your clients, you remain a professional helper whether in person/in the same room or online. Protecting your privacy and respecting their privacy remains essential, regardless of setting. Based on the ACA Code of Ethics (2014), this means that helpers clearly distinguish between their professional and personal virtual presence (Section H. 6. a. ), and that helpers do not view client information on social media without client con-sent (Section H. 6. c. ). Any contact with clients or encoun-tering client information online must be documented. The APA (2010) Ethical Principles stipulate that “Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium” (p. 7). Conducting online searches of clients—especially out of personal curiosity—is likely an unethical action because it violates the fundamental right of clients to privacy (Harris & Kurpius, 2014). Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 65 Learning Activity 2. 4 A Telemental Health Visit* For this activity, place yourself as the client in the follow-ing scenario. Once you have read through the scenario, respond to the two questions posed at the end. Feedback to Learning Activity 2. 4 is provided on page 68. Imagine that you have begun to experience anxiety in al-most all aspects of your life, especially at work. Dave, a co-worker and friend, suggested going to Twin Rivers, the local community mental health center near your home town of Rupert. Dave shared that he went there approximately 1 year ago and the therapist he met with was very helpful. With some reluctance, you call Twin Rivers and schedule an appointment. On the day and time of your appointment, you meet for ap-proximately an hour with Jackie, an intake professional. Once the intake session is completed, you are somewhat surprised when Jackie explains that you will be served best by meeting with Dr. Brown, a licensed clinical counselor who specializes in anxiety disorders and is located in another state. She reassures you that you will not be traveling to where he is; Dr. Brown will come to you. She explains that given the rural nature of Rupert and its low population, Twin Rivers applied for and received funding to become a video teleconferencing (VTC) clinic earlier this year. This means that Twin Rivers now has state-of-the art technology to offer a greater variety and more specialized care at its facility delivered by behavioral health care specialists from around the country, like Dr. Brown, using VTC. Jackie explains that she is the VTC coordinator for Twin Rivers. She adds that although this treatment modality is dif-ferent from traditional face-to-face or same-room counseling, current research indicates that telemental health counseling, including that delivered via VTC, can be equally effective. After reviewing the informed consent material, you de-cide that VTC counseling is acceptable because it will make it possible for you to be seen by a specialist. You tell Jackie to go ahead and schedule the initial appointment with Dr. Brown. She proceeds to ask Marissa, the office manager in charge of scheduling, to make the appointment. After comparing your work schedule to Dr. Brown's availability, you schedule your appointment for 9:00 a. m. next Tuesday. As you leave, Marissa reminds you to arrive 15 minutes early to complete the additional paperwork required for telemental health counseling. Fast-forward to Tuesday. Eager to finally work with a specialist to get some relief from your anxiety, you arrive at Twin Rivers half an hour early. Your eagerness quickly turns to frustration when you learn that Marissa forgot to account for time zone differ-ences. Dr. Brown is located in another time zone and is 1 hour behind your time zone, so he will not be available until 10:00 a. m. here in Rupert. Marissa apologizes pro-fusely, explaining that Dr. Brown is a new provider for Twin Rivers, and offers to reschedule for another day, promising that the mistake will not be made a second time. After tak-ing a moment to consider rescheduling, you decide that because you are already here and took the morning off from work, you might as well wait for the appointment. While waiting, you decide to re-read the informed con-sent material and VTC protocol sheets you were given by Jackie during your intake. This time you notice the protocols to follow if there is a technology failure during the session. Also included is a disclaimer about the risks and benefits of participating in VTC counseling. The disclaimer states that sessions will not be videorecorded or archived in any way without your consent. Also mentioned is that although Twin Rivers uses current legal standard encryption software, there is still a risk of unauthorized access to the session from an outside source. Despite some of the questions you still have about this VTC format, they don't prevent you from changing your mind. You're ready to get started. After a long wait in the lobby, Marissa calls your name and guides you over to the counseling room, although to you it looks more like a room where you would file your taxes than receive counseling. There is only one chair and it is positioned in front of a computer monitor with an audio/video camera attached to it. As you sit in the chair, Marissa makes adjustments to the camera to ensure it is centered at your eye level. She explains how to move the device yourself in case Dr. Brown requests it be adjusted once the session begins. In the corner of the room is a printer/fax machine, which, as Marissa explains, can be used to deliver various materials that Dr. Brown deems appropriate once the session begins, such as assessments or therapy-related exercises. On the desk is a landline telephone that can be used in case there is a technical problem with the camera, or if the Internet connection is lost. Before leaving the room, Marissa explains that the room is sound-proof and if you need her help with anything once the session starts, she or Jackie can be reached by dialing *1 on the telephone. As the door shuts, the blank computer screen is replaced by the image of an office. A moment later a smiling man appears on the screen who introduces himself as Dr. Brown. During his introduction, you notice someone moving around behind Dr. Brown, in what appears to be the corner of Dr. Brown's office. As if reacting to the concerned look on your face, Dr. Brown explains that his baby sitter is ill and therefore he had to work from home today. He adds that his children are too young to understand the conversation, so there is no need for you to worry. He also informs you that because he is working from home he does not have a copy of his credentials to show you, but refers you to the informed consent materials you signed earlier at Twin Rivers. The session proceeds without any technical difficulties and it feels good to finally be able to talk with a specialist about your anxiety. (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
66 Chapter 2 Documentation, Electronic Records, and Federal Laws Documenting or recording the provision of professional services and also carefully managing those documents and records are ethical issues that speak to helper competence. According to Mitchell (2007), helpers must keep timely and accurate records for three primary reasons: fiscal, clin-ical, and legal accountability. Entering and maintaining electronic health records or electronic medical records specifically has now become the standard tool for billing, keeping track of client progress, and easing the process of client transition from and to other providers. Increasingly, for both government-funded agencies and private health maintenance organizations, Mitchell (2007) pointed out that if you don't have records to verify ser-vices rendered, both government-funded sources and insur-ance companies may not pay, or if they do, they may want their money returned until verification of services can be provided. Maintaining records for legal and ethical reasons therefore can help to resolve disputes regarding the nature of care provided, fee arrangements, or the effects of treatment (Drogin, Connell, Foote, & Sturme, 2010). The American Psychological Association's (2007) record-keeping guidelines can serve as a useful decision-making tool for all profession-als concerning issues of documentation and record keeping. Health Insurance Portability and Accountability Act (HIPAA) Record-keeping gained prominence with the 1996 enact-ment of the Health Insurance Portability and Account-ability Act (HIPAA) in the United States. It is the primary federal law protecting the privacy and security of health information (Hughes & Goldstein, 2015). Specific infor-mation about HIPAA is available at the website www. hhs . gov/ocr/hipaa, and most professional organizations also have HIPAA-related information on their websites. The U. S. Congress intended HIPAA to ensure the portability of health insurance between jobs for American workers (Robles, 2009). In a nutshell, HIPAA means that helpers must protect the confidentiality of health information they collect, maintain, use, or transmit about clients. There are two basic components to HIPAA: the Privacy Rule and the Security Rule. The Privacy Rule relates to all protected information in any form—oral, written, and elec-tronic. Under the Privacy Rule, clients are entitled to a written notice about the privacy practices of the helping setting, to review their record, to request a change of information in that record, and to be informed about to whom information has been disclosed. The Privacy Rule is designed to manage intentional releases of protected health information (referred to as PHI) by safeguarding and controlling when, under what circumstances, and to whom PHI is released. The Security Rule, by contrast, is designed to man-age electronic protected health information (referred to as EPHI) from unintended or unauthorized disclosure either through security breaches such as computer hackers or through unintended losses such as a natural disaster or a stolen laptop. The Security Rule means that service settings must develop policies and procedures to ensure that appro-priate privacy procedures are followed and that potential risks to security are identified. Safeguards are to be imple-mented particularly in electronic client records and infor-mation transmitted or accessed on websites and by email, mobile or hand-held devices, pagers, and fax machines. In March 2013, the U. S. Department of Health and Human Services (DHHS) issued further HIPAA mandates intended to strengthen the confidentiality, integrity, and se-curity of patients' PHI in electronic health/medical records, including behavioral health information. Businesses that now must comply with HIPPA privacy and security rules include information technology firms such as cloud server Learning Activity 2. 4 (continued) When the session ends, though, you leave the counseling room still unnerved by the schedule time mistake, and also that Dr. Brown was working from home. As you approach the reception desk, Marissa asks if you would like to go ahead and schedule your next session. You respond by asking if it would be possible for you to remain at home for the next session. “If Dr. Brown can work from home, ” you explain, “why should I have to drive all the way here for each session?” You inform Marissa that you have Skype, you use it regularly to talk with family, and you think you could use it for any further counseling sessions with Dr. Brown. You add some-what sarcastically, “If this video counseling is supposed to be convenient, it seems it's only convenient for the counselor. ” Marissa apologizes again for the scheduling mistake, and politely informs you that to be accredited, their VTC software must meet encryption guidelines. She adds that not only does Skype not meet those encryption standards, the Internet connection at Twin Rivers must also meet en-cryption standards that most personal connections do not meet. With a reluctant grimace, you proceed to schedule the next appointment, but only after confirming that the sched-uled time is correct for both you and Dr. Brown this time. Questions to Consider A. What ethical concerns are present in this vignette?B. How could the ethical concerns present have been avoided? * With thanks to Robert Bradley for his development of a draft of this Learning Activity. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 67 providers and Amazon Web Services. Wang and Huang (2013) contend that these new rulings demonstrate that “a delicate balance between protecting patient privacy and unleashing the power of [technology] innovation” remains elusive. Because HIPAA is constantly evolving, we encour-age you to consult the HIPAA website for updates. Patient Protection and Affordable Care Act (PPACA) The Pa-tient Protection and Affordable Care Act (PPACA) was passed by the U. S. Congress in March 2010 during Presi-dent Obama's first term in office, and parts of it were upheld by the U. S. Supreme Court in October 2011. The PPACA has transformed health care in the United States. This in-cludes the provision of mental health care and substance use services, collectively known as behavioral health care. The fundamental goal of the PPACA is to ensure that all Americans have health care insurance (Nilsen & Pavel, 2015). This will involve curtailing the spiraling costs of health care and improving the overall quality of health care. To accomplish this, the PPACA has two priorities: preventive care and integrated care. Prevention practices include screening for the early detection of health con-ditions and the use of health information technology, such as self-monitoring of symptoms or behavioral targets (e. g., physical exercise) using Smartphone technology. In-tegrated care means that all health care professionals work collaboratively so that care is coordinated and compre-hensive. This includes accessing shared electronic records. Features and Content of Documentation It should go without saying that all forms of documentation must be completed in a timely and accurate manner, conform to confidentiality requirements and guidelines, and be clear and understand-able. Swartz (2006) reminds us that documentation is “in-stitutional memory for cases passed from one practitioner to another, and indeed as memory for practitioners needing to check detail with each returning client” (p. 429). Carefully worded reports are therefore essential to ensure ongoing and collaborative care. Furthermore, all signatures obtained must be authentic—that is, they cannot be forged. Although these are basic practices and should not require a reminder, it is not uncommon for helpers in the throes of hectic schedules, emergency situations, stress, and exhaustion to overlook ad-herence to some of these practices from time to time. Mitchell (2007) likened record-keeping to a “logical, short story” (p. 13) that begins with an assessment, and then moves to a plan, notes, case reviews, and termination. Identifying data about the client are recorded initially, as well as appointment times, cancellations, and so on. The intake or the initial history-taking session is recorded next. When writing up an intake or a history, avoid labels, jar-gon, and inferences. If records were court-ordered, such statements could appear inflammatory or slanderous. Don't make evaluative statements or professional judgments with-out supporting documentation. For example, instead of writing, “This client is homicidal,” you might write, “This client reports engaging in frequent (at least twice daily) fantasies of killing an unidentified or anonymous victim. ” Instead of “The client is disoriented,” consider writing, “The client could not remember where he was, why he was here, what day it was, and how old he was. ” The informa-tion collected in all of the assessment interviews is reflected in the intake report. Following the intake report, a written treatment plan is prepared. Although the specific format of this written plan can vary, it always includes the elements of treatment goals and objectives, interventions designed to achieve such objectives, and diagnostic codes. The process of constructing treatment goals is discussed in Chapter 9. It is important to keep notes of subsequent treatment sessions and of client progress. These likely will be entered according to a standardized form or template of an elec-tronic health records program. Generally, treatment notes are brief and highlight only the major activities of each session and client progress and improvement (or lack of it). These notes usually begin during intakes, and information from the assessment interviews is added. As the number of sessions increases, notations about goals, intervention strat-egies, and client progress are included. Again, labels and inferences always should be avoided in written notes and records. Remember that as long as you are being supervised, your supervisor needs to sign off on all progress notes and on treatment plans, too. If there are multiple clients, such as a parent and child, or two parents or partners, keep in mind that separate reports, treatment plans, and progress notes must be written for each person. If one party discusses a related party in the session, do not identify the discussed person by name in the progress note. For example, instead of writing “Kyle said he wants to break things off with Melissa,” write “Client disclosed desire to end relationship with girlfriend. ” Notice the more formal and objective lan-guage used in this alternative statement. The following list, adapted from the Quin Curtis Center for Psychological Service, T raining, and Research of the West Virginia University's Department of Psychology, sug-gests a model for a progress note that we especially like: ● ●Session number, start and stop times, diagnostic and procedure codes ● ●Relevant assessment, current status, dangerousness, current stressors ● ●Progress toward treatment goals ● ●Interventions ● ●Plan ● ●Assignment ● ●Signature by clinician and supervisor ● ●Supervisor note/consultation Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
68 Chapter 2 Notice that several key components of this kind of progress note are essential for quality control reviews and insurance company reviews. These include the session number, start and stop times, diagnostic and procedures codes, current assessment, and progress or lack of prog-ress toward the achievement of the identified treatment goals. As Mitchell (2007) stated, the most helpful prog-ress notes are ones that connect interventions to the treatment plan. Under HIPAA, progress notes are defined as PHI (protected health information). PHI becomes part of the client's record or official clinical record. PHI includes ● ●Medication prescription and monitoring ● ●Counseling session start and stop times ● ●Modalities and frequencies of treatment provided ● ●Results of clinical tests ● ●Summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date HIPAA also permits practitioners to keep a second set of notes (recorded in any medium) that are separate from the PHI or the clinical record. These are referred to as psychotherapy notes and are defined as process notes ( not progress notes; see Robles, 2009) because they include the helper's impressions about clients and the therapeutic process (see De Lettre & Sobell, 2010) and exclude information contained in the PHI or the clini-cal record (as listed). De Lettre and Sobell (2010) found that 46 percent of the 464 psychologists they surveyed reported using psychotherapy notes, but another 21 per-cent reported not knowing about the option of keeping psychotherapy notes. HIPAA requires that clients have access to their PHI, but not to their helper's psycho-therapy notes. There are provisions, however, for client access to psychotherapy notes, and these vary from state to state in the United States. Because psychotherapy notes may be ordered into a court of law, Mitchell (2007) and others have discouraged practitioners from keeping a separate set of psychotherapy notes. Whether or not to maintain psychotherapy or process notes is a topic of discussion for you and your supervisor or clini-cal director. Feedback to Learning Activity 2. 4 A Telemental Health Visit* A. There are at least four ethical concerns evident in the telemental health visit scenario: 1. You were given an incorrect time for your first visit with Dr. Brown, one that did not account for time zone differences. 2. Because Dr. Brown was working from home, the security of his Internet connection is unclear. As Marissa explained, most home connections fail to meet proper encryption protocols. 3. Dr. Brown did not inform you right at the start of the session that there was someone else in his office. 4. Even though Dr. Brown's credentials were listed on the informed consent materials you received prior to your session, he did not show them to you during your session. B. With reference to relevant practice guidelines and codes of ethics, these four ethical concerns could have been avoided by: 1. According to the ACA Code of Ethics (2014), Section H. 2. A., it is the responsibility of the provider to ac-count for time zone variations. Although the time zone scheduling mistake was that of Twin Rivers of-fice staff and likely due to Dr. Brown being a new pro-vider for the agency, it is incumbent upon providers of telemental health services to ensure that time zone discrepancies are resolved. From this scenario, clients also may need to clarify times. 2. Dr. Brown conducting the session from his regular counseling office where Internet connection secu-rity is established. This is addressed in Guideline 5 of APA's (2013), Guidelines for the Practice of Tele Psy-chology. 3. Dr. Brown should have announced at the very begin-ning of the session that there was someone else in his office, regardless of age. This type of information should be announced immediately and the client should not have to ask. See Guideline D of the Ameri-can Telemedicine Association's (2013), Practice Guide-lines for Video-based Online Mental Health Services. 4. Most opening protocols for telehealth services rec-ommend that professionals identify themselves, display their credentials, and state their geographic locations. When providing services across state lines, telemental health providers must verify that they are licensed in the state where they are located as well as the state where the client is receiving services. Sec-tion H. 3. of the ACA Code of Ethics (2014) states that counselors who provide distance counseling are to take steps to verify client identify. This can include requesting some form of photo identification. Also see Guideline A of the American Telemedicine As-sociation's (2013), Practice Guidelines for Video-based Online Mental Health Services. * With thanks to Robert Bradley for developing a draft of this feedback. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 69 It is important to document in detail anything that has ethical or legal implications, particularly facts about case management. For example, with a client who reports depression and suicidal thinking, it would be important to note that you conducted a suicide assessment and what its results were, that you consulted with your supervisor or another professional, and the outcome of consultations conducted, including whether or not you did anything else to manage the case differently, such as seeing the client more frequently or constructing a safety contract with the client. The release of information pertaining to client involve-ment in therapy is possible only when the client has pro-vided written consent. Obtaining client consent at times can be a challenge in itself, particularly when the client questions the need for a release of information and may be skeptical of your motives. Completing a detailed release-of-information form is therefore essential, and how it is explained to the client may determine whether the client will grant consent and invest in the process of helping. To be certain that necessary pieces of information have been addressed, Fisher and Harrison (2013) itemized the 10 “ingredients” of a standard release-of-information form, based on 42 CFR. These are presented in Box 2. 4. When the client terminates therapy, there also is a written record about termination. The termination or dis-charge report becomes the final piece in the written “short story” about the client. Such closing reports are very important in the event the client returns for additional services and in the event of any future litigation. A typical termination report includes the reason for termination, a summary of progress toward the treatment goals, a final diagnostic impression, and a follow-up plan (Mitchell, 2007, p. 75). Practitioners also need to be concerned about retention of client records. All professional organizations, all states in the United States, and many other countries have regu-lations about the length of time that practitioners must retain client records. HIPAA requires that records be kept for a minimum of 6 years, many of the states in the United States specify 7 years or longer, and professional organiza-tions often have longer lengths of record retention than these. Retention of records applies to electronically or digitally stored information as well as paper records. The records we keep about clients are reviewed by a number of entities, including internal review boards, ac-crediting bodies, and insurance companies. Regardless of whether you keep electronic or written records, or both, bear in mind Mitchell's (2007) seven assumptions of record-keeping (p. 46): 1. The counseling record may be subpoenaed, and the court will need to be able to understand what occurred. 2. The client may present for treatment at a time when you are sick or on vacation and one of your colleagues will need to read your record. 3. The client may read your record. 4. The accuracy of your record is compromised if you wait more than a day to complete it. 5. The record should be the best possible reflection of your professional judgment. 6. Nothing you do with a client is considered a profes-sional service until you enter it in the record. 7. Your record may be selected for an audit to verify a legally reimbursable service. Referral Referring a client to another practitioner may be necessary when, for one reason or another, you are not able to provide the service or care that the client requires or when the cli-ent requests another helper. If client symptoms persist and worsen, another level of care, such as hospitalization, may be indicated. Similarly, if a client's needs become increas-ingly complex and surpass your level of competence, then it will be necessary to refer the client to a practitioner whose ● ●Name of program making the disclosure ● ●Name of individual or organization receiving the disclosure ● ●Name of client ● ●Purpose or need for the disclosure ● ●How much and what kind of information will be disclosed ● ●A statement that the client may revoke the disclosure at any time● ●The date, event, or condition on which the disclosure expires ● ●Signature of client and/or authorized person ● ●Date the consent was signed ● ●Statement prohibiting redisclosure of information to any other party Source: Fisher & Harrison, 2013. BOX 2. 4 Required Contents of a Standard Release-of-Information Form Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
70 Chapter 2 expertise is likely to address the client's needs. Referrals are mandated when your services are interrupted by cer-tain events in your life: illness, death, relocation, financial limitations, or any other form of unavailability on your part (ACA, 2014). As discussed in this chapter, a referral is an act of last resort (Kaplan, 2014) and should not be made simply based on a conflict in personal values between helper and client (or a helper's perceived conflict in values). This is par-ticularly important given that many clients may not follow through with a referral. For example, of the 25 percent of clients seen for at least two sessions in a university counsel-ing center over 1 year and who were referred to another provider off campus, almost 42 percent were not success-ful in connecting with the referral, the majority of whom (57%) were clients of color (Owen, Devdas, & Rodolfa, 2007). With respect to the client's sexual orientation, John-son and Buhrke (2006) indicated that the practitioner's “homonegative or heterosexist values and attitudes should never serve as an excuse for failing to render competent clinical services to [LGBTQ clients]” (p. 96). This form of discrimination could be especially debilitating to the client because its source is a professional helper viewed by the cli-ent as someone committed to caring for persons in distress. Johnson and Buhrke (2006) recommended that all re-ferrals be made “cautiously and collaboratively” (p. 96) to minimize the risk of perceived rejection or abandonment by the client. This underscores for us that referral is a process, and one that necessarily involves a supervisor or colleague. Indeed, the decision to refer is not that of the helper who is in training or who continues to receive clini-cal supervision (e. g., graduate working toward licensure). Walker and Prince (2010) developed a case study to assist counselor educators and supervisors in their supervision of counseling students who have been assigned a client who identifies as LGBTQ. They described a faculty su-pervisor who reassigned a gay client to another counseling student who was further along in her LGBTQ compe-tency level so that the counseling student to whom the client was originally assigned and who claimed discomfort working with LGBTQ clients because of deeply held religious beliefs could improve her LGBTQ competency. The supervisor assigned reading to the first student and, despite this student's religious convictions, also required her to demonstrate her efforts in improving her LGBTQ competency before assigning her other LGBTQ clients. Careful referral involves more than just giving the client the name of another person or agency. Ethical Standard 2. 06 of the NASW (2008) Code of Ethics states that helpers who refer a client to another professional “should take ap-propriate steps to facilitate an orderly transfer of responsi-bility. ” “Appropriate steps” include explaining to the client the need for the referral, anticipated benefits to the client of such a referral, and providing the client with a choice of service providers who are competent and qualified to deal with the client's concerns and circumstances. In your recommendations and reasoning, you should respect your client's interest and self-determination. If a client declines your suggested referrals and you determine that you are no longer able to be of professional assistance to that client, the ACA Code of Ethics (2014) states that counselors are to discontinue the relationship (see Standard A. 11. b. ). Additional steps to take in the referral process include ob-taining written client permission before discussing the case with the new service provider. Meeting jointly or participat-ing in a conference call with the client and the professional to whom you have referred the client is recommended, espe-cially if a client is having difficulty understanding the need for the referral or is reluctant to follow through. Throughout the transfer process, the helper should be prepared to assume the role of advocate for the client and engage in the practice of resource brokering (Crimando, 2009). This means that be-cause the client's welfare is the first priority, the helper may need to link the client to specific resources in the commu-nity (e. g., transportation, child care) to facilitate the client's access to the new professional's services. To protect against abandonment, the practitioner should follow-up with the client to determine if impediments were encountered and if assistance is needed for the client to meet with and establish a connection with the referral source. Ethical Decision-Making Models Professional codes of ethics provide one set of guid-ance about ethical expectations, roles, and responsibilities. When grappling with specific ethical dilemmas, however, they should not serve as “one-stop shopping” or the sole reference point. Said in another way, practitioners should not regard ethical codes as the only clearing house or the final answer to very specific and difficult ethical situations. The NASW (2008) stipulates that its Code of Ethics “does not provide a set of rules that prescribe how social work-ers should act in all situations” (p. 6). Furthermore, the ACA Code of Ethics (2014) directs counselors “to engage in a carefully considered ethical decision-making process” and “to use a credible model of decision making that can bear public scrutiny of its application” (p. 3). Several such models exist, including Welfel's (2016) 10-step model for ethical decision-making, and Garcia, Cartwright, Winston, and Borzuchowska's (2003) transcultural integrative model for ethical decision making. Garcia et al. 's (2003) model incorporates specific cultural strategies such as reviewing potential discriminatory laws or institutional regulations LO2 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 71 in processing an ethical dilemma, consulting with cultural experts if necessary, and ensuring that potential courses of action reflect the diverse perspectives of all parties involved. Although there is not a “right” model for every prac-titioner and many ethical decision-making models share common steps, we have elected to highlight the Tarvy-das integrative decision-making model of ethical behavior (Tarvydas, 2012). An earlier version of the Tarvydas model was used as the basis for Garcia et al. 's transcultural integra-tive model, and the current version of the Tarvydas model extends its application beyond the (micro) clinical counsel-ing level to the levels of clinical multidisciplinary team, agency or institution, and society or public interest (the macro level). In this way, the Tarvydas Integrative Model can be applied to a range of ethical dilemmas and contexts. We feature it here because of its integrative foundation, wide applicability, emphasis on practitioner reflection and col-laboration, and consistency with a multicultural approach. The Tarvydas integrative decision-making model of ethical behavior (Tarvydas, 2012) is based on the work of several ethicists in the mental health and counseling communities. Summarized in Table 2. 1, this model en-courages practitioners to adopt four attitudes and corre-sponding behaviors: (1) reflection; (2) pursuing balance among issues, people, and perspectives; (3) attending to context; and (4) participating in collaboration. The model then offers four primary steps or stages, each with specific components, to help the practitioner care-fully walk through the decision-making process with the best interests of the client in mind. Notice in particular the reflection that is called for once again in stage III, specifically with respect to the helper's personal values (e. g., social harmony, expediency) that might compete with the moral values or qualities of being a professional helper (e. g., autonomy, integrity). Engaging in deliberate reflection at this particular stage serves to guard against the helper acting on his or her blind spots or prejudicial views, such as cultural encapsulation or a privileged frame of reference. For example, the heterosexual helper may need to pause to consider whose values are being honored and whose interests are being served by discouraging a 16-year-old from coming out as gay to her conservative Christian parents—the client's? the parents'? the helper's? The course of action taken after this further reflection may uphold the ethical course of action selected at the end of stage III, or it may be a modified course of action, consistent with a culturally affirmative approach. At each stage, however, we recommend peer consultation, and for those helpers whose practice is supervised (e. g., counselor trainees), following supervisor directives is imperative. Upon reviewing the Tarvydas integrative decision-making model of ethical behavior (Tarvydas, 2012), you may decide to return to the case of Mark (adapted from Alghazo et al., 2011, pp. 43-44) described previously in the chapter (see page 59). How might this model be used to further clarify the actions to be taken in his case? What additional consid-erations has this ethical decision-making model raised? As has been emphasized throughout this chapter, a commitment to ethical practice is critical, complex, and difficult. It involves high levels of abstraction about val-ues, principles, and duties. A proven how-to manual for resolving ethical dilemmas does not exist and often the process involves nonrational influences, such as intuition and cognitive errors or biases (e. g., maintaining initial im-pressions despite more recent information to the contrary; Rogerson, Gottlieb, Handelsman, Knapp, & Younggren, 2011). Because ethical decision-making and practice in-volves these and other nonrational influences, it is impera-tive that helpers consult colleagues and supervisors on a routine basis and also enlist the services of an ethics com-mittee chairperson and/or legal counsel when questions remain on a specific dilemma. We hope that the Tarvydas integrative decision-making model of ethical behavior (Tarvydas, 2012) can serve as a helpful tool as you prac-tice your critical decision-making skills and continue to develop and hone ethical competence. Remaining attentive and responsive to these multiple considerations is not an easy task. Balancing our many roles and responsibilities is a perpetual challenge. Managing complexities and navigating our way through changes in our professional lives may not be too unlike the challenges faced by our clients in their personal lives. We can therefore gain further appreciation for what our clients experience and empathize with their circumstances. In addition, as persons who have selected a profession committed to hu-man growth and development—that is, to change!—it is rather unlikely that we would be content with perpetual stability, predictability, and routine in the work that we do. Actually, being fascinated with change, attuned to its intricacies and the array of possibilities for evolution and transformation, is probably what attracted us to a helping profession in the first place. Living a life without encoun-tering and responding to challenges to the status quo, therefore, would be mundane and boring for us. CHAPTER SUMMARY Part of being an effective helper is knowing your-self well so that you can engage as a creative, critical thinker who can work with clients toward meeting their goals. This self-awareness includes insight into your val-ues, strengths, and challenges but also extends to a fuller awareness of how you as an individual helper and change LO2 LO2 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
72 Chapter 2 agent are part of the process of change for clients. Each of us brings a somewhat unique set of connections among knowledge, skills, commitments, diversity, and collabora-tive effectiveness. Ideally, awareness of these connections enables you to respond to each client as a unique person, to develop understanding of clients who have values dif-ferent from yours, and to work in adaptive, collaborative ways with clients whose heritage may differ from your own in one or more significant ways. Finally, your self-awareness and context awareness should foster an appre-ciation of the balances to be struck in applying an ethical code of behavior and pursuing an active role as a lifelong learner to contemporize and strengthen practice. When lived authentically and intentionally, the lifestyle of a professional helper can be extremely rewarding. This line of work affords us the privilege of being part of the lives of many different individuals and their families at a level of intimacy extended to few. We are in many ways their guests; they extend to us an invitation to witness and share in their struggles and accomplishments. Participat-ing in what may be characterized as sacred conversations with our clients is not something we should ever take for granted or otherwise minimize. It is something to always value and protect. We do this by learning from and with our many and diverse clients, honoring their experiences and stories, and upholding ethical guidelines as profes-sional helpers. This critical work requires critical commit-ments on our part. We trust that as you continue to make and uphold your critical commitments to the helping profession and to your identity as a professional helper that you will be able to realize the many professional and personal benefits of this line of work. Visit Cengage Brain. com for a variety of study tools and useful resources such as video exam-ples, case studies, interactive exercises, flash-cards, and quizzes. TABLE 2. 1 The Tarvydas Integrative Decision-Making Model of Ethical Behavior Themes or Attitudes Maintain an attitude of reflection. Address balance between issues and parties to the ethical dilemma. Pay close attention to the context(s) of the situation. Utilize a process of collaboration with all rightful parties to the situation. Stages and Components Stage I: Interpreting the Situation through Awareness and Fact Finding Component 1 Enhance sensitivity and awareness. Component 2 Determine the major stakeholders and their ethical claims in the situation. Component 3 Engage in the fact-finding process. Stage II: Formulating an Ethical Decision Component 1 Review the problem or dilemma. Component 2 Identify existing ethical codes, laws, ethical principles, and institutional policies and procedures that apply to the dilemma. Component 3 Generate possible and probable courses of action. Component 4 Consider potential positive and negative consequences for each course of action. Component 5 Consult with supervisors and other knowledgeable professionals. Component 6 Select the best ethical course of action. Stage III: Selecting an Action by Weighing Competing Nonmoral Values, Personal Blind Spots, or Prejudices Component 1 Engage in reflective recognition and analysis of competing nonmoral values, personal blind spots, or prejudices. Component 2 Consider contextual influences on values selection at the collegial, team, institutional, and societal levels. Component 3 Select the preferred course of action. Stage IV: Planning and Executing the Selected Course of Action Component 1 Ascertain a reasonable sequence of specific actions to be taken. Component 2 Anticipate personal and contextual barriers to effective execution of the plan of action and establish effective countermeasures for them. Component 3 Perform, document, and evaluate the course of action as planned. Source: The Professional Practice of Rehabilitation Counseling, Maki/Tarvydas, 2012, Springer Publishing Company, LLC. Used with permission. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 73 Critical Commitments 73 2 Knowledge and Skill Builder Part One According to Learning Outcome 1 listed at the beginning of this chapter, you will be able to identify attitudes and behaviors about yourself that could help or interfere with es-tablishing a positive helping relationship. Here, we present a Self-Rating Checklist that refers to characteristics of effective helpers. Use the checklist to assess yourself now with respect to these attitudes and behaviors. If you haven't yet had any or much contact with actual clients, try to use the checklist to assess how you believe you would behave in actual interac-tions. Identify any issues or areas you may need to work on in your development as a helper. Discuss your self-assessment in small groups or with an instructor, colleague, or supervisor. There is no written feedback for this part of the Knowledge and Skill Builder. Self-Rating Checklist Check the items that are most descriptive of you. A. Openness to Learning Assessment 1. I already have learned a lot of life lessons, and I be-lieve clients will benefit from hearing my own story of recovery. 2. I invite clients to comment on their experiences in therapy and how my work has either helped or hin-dered the process. 3. I am a member of a professional association that publishes a scholarly journal for its members. 4. I think that taking notes in supervision is not necessary. 5. I am considering participating in therapy as a cli-ent to learn more about my own developing style of helping. 6. I routinely solicit feedback from my supervisor and trusted colleagues. 7. I have attended a professional workshop or confer-ence in the past 6 months. 8. I think I've already learned what it is that I need to work on to provide good care to my clients. Review-ing audio or video recordings of my counseling ses-sions therefore is no longer necessary. B Competence Assessment 1. Constructive negative feedback about myself doesn't make me feel incompetent or uncertain. 2. I tend to put myself down frequently. 3. I feel fairly confident about myself as a helper. 4. I am often preoccupied with thinking that I'm not going to be a competent helper. 5. When I am involved in a conflict, I don't go out of my way to ignore or avoid it. 6. When I get positive feedback about myself, I often don't believe it's true. 7. I set realistic goals for myself as a helper, ones that are within reach. 8. I believe that a confrontational, hostile client could make me feel uneasy or incompetent. 9. I often find myself apologizing for myself or my behavior. 10. I'm fairly confident I can or will be a successful helper. 11. I find myself worrying a lot about “not making it” as a helper. 12. I'm likely to be a little apprehensive about clients who idealize me. 13. A lot of times I will set standards or goals for my-self that are too difficult to attain. 14. I tend to avoid negative feedback when I can. 15. Doing well or being successful does not make me feel uneasy. C. Power and Values Assessment 1. If I'm really honest, I think my helping methods are a little superior to others. 2. A lot of times I try to get people to do what I want. I might get pretty defensive or upset if the client disagrees with what I want to do or does not fol-low my direction in the interview. 3. I believe there is (or will be) a balance in the interviews between my participation and the client's. 4. I could feel angry when working with a resistant or stubborn client. 5. I can see that I might be tempted to get some of my own ideology across to the client. 6. Allowing the client to make certain decisions and not telling him or her what to do is a sign of weak-ness on the helper's part. 7. Sometimes I feel impatient with clients who have a different way of looking at the world than I do. 8. I know there are times when I would be reluc-tant to refer my client to someone else, espe-cially if the other counselor's style differed from mine. 9. Sometimes I feel rejecting or intolerant of clients whose values and lifestyles are very different from mine. 10. It is difficult for me to avoid getting into a power struggle with some clients. (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
74 Chapter 2 2 Knowledge and Skill Builder (continued) Part Two According to Learning Outcome 2 for this chapter, you will be able to identify issues related to values, diversity, and ethics that could affect the development of a therapeutic relation-ship. Here we present seven written case descriptions and a list of seven types of issues. Read each case description care-fully; then, on the line preceding each case, write the letter of the major kinds of issue reflected in the case description. (More than one type of issue may be reflected in each case. ) When you are finished, consult the feedback for this part of the Knowledge and Skill Builder. Type of Issue A. Values conflict B. Values stereotyping C. Ethics—breach of confidentiality D. Ethics—client welfare and rights E. Ethics—referral F. Ethics—inappropriate disclosure G. Diversity Case Description 1. You are counseling a client who is in danger of fail-ing high school. The client states that he feels like a failure because all the other students are so smart. In an effort to make him feel better, you tell him about one of your former clients who also almost flunked out. 2. During a break from the therapy group you co-facilitate, you overhear a member of the group describe you to another client as “really hot in a pink bikini. ” You immediately remember the photo-graph you recently posted on your boyfriend's so-cial networking site of you in your new pink bikini. 3. A 58-year-old man who is having difficulty adjust-ing to life without his wife of 36 years who recently died comes to you for counseling. He has difficulty discussing his concern with you, and he appears to not understand what your role is as a counselor and what counseling might do for him. He seems to feel that you can give him a tranquilizer. You tell him that you are not able to prescribe medication, and you recommend that he be evaluated by a physician. 4. A fourth-grade girl is referred to you by her teacher. The teacher states that the girl is doing poorly in class yet seems motivated to learn. After working with the girl for several weeks, including giving a battery of tests, you conclude that she has a severe learning disability. After obtaining her permission to talk to her teacher, you inform her teacher of this and state that the teacher might as well not spend too much more time working on what you believe is an “unfortunate case. ” 5. You are counseling a couple who are considering a trial separation because of constant marital prob-lems. You tell them you don't believe separation or divorce is the answer to their problems. 6. A Euro-American helper states in a staff meeting that “people are just people” and that he does not see the need for all this emphasis in your treatment facility on understanding how clients from diverse racial/ethnic/cultural backgrounds may be affected differently by the therapy process. 7. A racial minority client comes into a mental health center and requests to meet with a helper of his own racial group. He also indicates that he would consider seeing a helper who is not a member of his racial group but who shares his values and per-spective and also who has some idea of his cultural struggles. He is told that it shouldn't matter whom he sees because all the therapists on the staff are culturally sensitive. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Critical Commitments 75 Critical Commitments 75 2 Knowledge and Skill Builder Feedback Part Two This feedback is to assist you in fulfilling Learning Outcome 2 for this chapter. 1. C: Ethics—breach of confidentiality. The helper broke the confidence of a former client by revealing his grade difficulties without his consent. 2. F: Ethics—inappropriate disclosure. The helper made what Zur (2009) might describe as an accidental self-disclosure that was inappropriate. To avoid further inappropriate self-disclosures on social networking sites or anywhere on the Internet, we strongly ad-vise that helpers limit any self-disclosures to strictly professional information, select the highest level of security options on such sites, disguise their iden-tity when engaging in online activities, or avoid participating altogether in social networking sites. 3. E: Ethics—referral. The helper did not refer in an ethi-cal or responsible way, because of failure to give the client names of at least several physicians or psychi-atrists who might be competent to see the client. 4. B: Values stereotyping. The helper is obviously stereo-typing all kids with learning disabilities as useless and hopeless (the “label” is neither helpful nor in the client's best interest). 5. A: Values conflict. Your values are showing. Although separation and divorce may not be your solution, be careful about persuading clients to pursue your views and answers to issues. 6. F: Diversity. The Euro-American helper is ignorant about the importance and influence of racial/eth-nic/cultural factors and is not able to see beyond his white privilege of power. 7. B and G: Values stereotyping and Diversity. The helper ignores the client's racial identity status and also responds in a stereotypical way to his or her request. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
76 Ingredients of an Effective Helping Relationship The quality of the helping relationship remains the foun-dation on which all other therapeutic activities are built. Gelso and Samstag (2008) define a helping relationship as “the feelings and attitudes the therapy participants have toward one another and the manner in which these are expressed” (p. 268). The past several years have brought renewed acknowledgment of the significance of the most important components of that relationship. The compo-nents in the helping relationship that seem to be consis-tently related to positive therapeutic outcomes include the following and form the focus of this chapter: 1. Facilitative conditions—empathy, genuineness, and posi-tive regard. These three therapist qualities, particularly empathy, represent conditions that, if present in the therapist and perceived by the client, contribute a great deal to the development of the relationship. 2. A working alliance—a relationship in which helper and client collaborate and negotiate their work together to-ward particular goals and outcomes on an ongoing basis. The working alliance is characterized by a cognitive component, in which both parties agree to the goals and tasks of counseling, and by an affective compo-nent, or emotional bond between the helper and cli-ent, characterized by mutual regard and trust. Regard for the client involves acceptance and caring; trust in-cludes principled behavior, credibility, and reliability. 3. Transference and countertransference—issues of emo-tional intensity and objectivity felt by both client and helper. These issues are usually related to unfinished business with one's family of origin, yet they are trig-gered by and felt as a real aspect of the therapy relation-ship. T ransference and countertransference enactments form the basis of relationship ruptures. A repair of these ruptures is a central task of the helper. The Importance of the Helping Relationship The helping relationship is as important to the overall outcome of the helping process as any particular change or intervention treatment strategy. The power of the help-ing relationship is acknowledged in nearly all theoretical orientations of psychotherapy. What makes the helping relationship so powerful for clients? Many believe that the power lies in the helper's potential to be healing. Healing is a word derived from a term meaning “to make whole. ” Comas-Díaz (2006) speaks of the universality of healing, noting that “the archetype of the healer is present in many societies” (p. 95). It is through the helping relationship and the interpersonal interactions with the practitioner that clients learn to be whole or integrated. In the rela-tionship clients can experience a healing of the broken-ness that often leads them into the helping process in the first place. Yalom (2009) explains the healing process in the therapeutic relationship this way: connection is para-mount, and because all human beings are hardwired for Learning Outcomes After completing this chapter, you will be able to 1. Communicate the three facilitative conditions (empathy, genu-ineness, and positive regard) to a client in a role-play situation. 2. Identify issues related to transference and countertransference that might affect the development of the helping relationship, given five written case descriptions. chapter 3 Out beyond ideas of wrongdoing and rightdoing, there is a field. I'll meet you there. (Rumi) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Ingredients of an Effective Helping Relationship 77 connection, the connection fostered by the therapeutic relationship helps to heal. Empirical Support for the Helping Relationship In recent years, there has been an explosion of empirical support for the helping relationship. Harmon, Hawkins, Lambert, Slade, and Whipple (2005) conclude that “em-pirical support for the importance of the therapeutic re-lationship in outcome spans more than four decades and hundreds of published research studies” (p. 178). Client ratings of the therapeutic relationship are significantly re-lated to and good predictors of outcomes of therapy, lead-ing these researchers to conclude that when clients respond to treatment negatively, “therapists need to be particularly alert to the client's level of comfort and satisfaction with the therapeutic relationship” (Harmon et al., 2005, p. 179). In a qualitative study of what clients find helpful in therapy, the therapeutic relationship also emerged as an important component of effectiveness (Levitt, Butler, & Hill, 2006). In this study, clients spoke of their therapeu-tic relationship “in excess of any other factor” of perceived helpfulness (Levitt et al., 2006, p. 322). This finding was echoed in an outcome study with chronically depressed patients. In this study, the single best predictor of out-come was the overall degree of emphasis therapists placed on discussing the client-therapist relationship (Vocisano et al., 2004, p. 263). This study also highlighted the im-portance of the relationship as a key component of change in cognitive behavioral therapy (Vocisano et al., 2004). Additional empirical support for the therapeutic relation-ship comes from the Interdivisional Task Force on Evidence-Based Therapy Relationships established by the American Psychological Association. The most recent findings of this task force are published in a book by Norcross (2011). In important ways, the evidentiary strength required for the re-search/evidence forming the basis of these conclusions is rigor-ous. In lieu of relying on only one or two studies, the evidence for relationship elements was drawn from comprehensive meta-analyses of many studies spanning various treatments and research groups (Norcross & Wampold, 2011). Norcross and Wampold summarize the empirical sup-port for the helping relationship (2011, p. 423): 1. The therapy relationship “makes substantial and con-sistent contributions to psychotherapy outcome” re-gardless of the specific type of treatment used. 2. The therapy relationship accounts for “why clients improve (or fail to improve)” as much as the particular treatment method being used. 3. Efforts to promulgate best practices or evidence-based practices (EBPs) without including the relationship “are seriously incomplete and potentially misleading. ” 4. The therapy relationship “acts in concert with treat-ment methods, patient characteristics, and practitioner qualities in determining effectiveness. ” 5. Adapting or tailoring the therapy relationship to spe-cific patient (in addition to diagnosis) enhances the effectiveness of treatment. In the helping relationship, there is no “one size fits all” approach. Data are increasingly showing that the thera-peutic relationship needs to be adapted or tailored to the individual client. Using an identical therapy relationship (or, for that matter, an identical treatment intervention) for all clients is not supported by data, is inappropriate, and, in certain cases, is unethical (Norcross & Wampold, 2011). Tailoring the therapeutic relationship to each cli-ent is now the better standard of practice. A recent special issue of Psychotherapy Research (2014) explored various innovative practices in the therapeutic relationship. What in the Helping Relationship Heals? The results of the interdivisional task force point to spe-cific elements of the helping relationship that are power-fully healing and that work. These include the following elements that we discuss in this chapter and are listed in order of the weight of the existing evidence base: The alliance Empathy Positive regard Congruence Managing countertransference In addition, the evidence points to adapting or tailoring the helping relationship to specific client characteristics that enhance the overall effectiveness of therapy. These cli-ent characteristics, again listed by weight of the evidence, include the following: Reactance/Resistance level Preferences Culture Religion and spirituality Stage of change Coping style There is no single adaptation from any of these client characteristics that is best; many adaptations are possible, much like getting a multiflavor instead of a single-flavor ice cream cone. As an example of this, consider the data summarized by Smith, Rodriguez, and Bernal (2011) on Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
78 Chapter 3 the many possible adaptations of culture within the thera-peutic relationship. These authors found that multiple cultural adaptations, such as the use of culturally relevant language, metaphors, content, tasks, and goals, were more effective than only one or two cultural adaptations. What Does Not Heal/Help in the Relationship? Just as there are helpful practitioner relational behaviors and practices, there are also ones that are not helpful, per-haps even damaging. Here are some of the main ones to avoid as cited by Norcross and Wampold (2011): Confrontational Style We include confrontation in Chapter 5 as an influencing response but add some caveats there. As an individual response, the confrontation or challenge response can be helpful when used judiciously and infrequently, but as a style this modus operandi is ineffective, especially when working with substance abuse and addiction issues. In these situations in particular, motivational interviewing, which we describe in Chapter 10, is a more helpful style. Criticism, Blame, Attacks on Clients It should go without saying that avoiding comments and behaviors that are judgmental, hostile, pejorative, critical, or demeaning is important in the helping process, but consider this a friendly reminder! Rigidity Inflexibility and excessive structuring of the help-ing process or “dogmatic reliance on particular relational or therapy methods” seem to damage the helping process and outcomes. Adhering to an identical therapy approach for all clients or using a singular matching treatment protocol for all clients are further examples of therapeutic rigidity. Again, customizing or tailoring the helping relationship to the individual client is a way to guard against rigidity. Cultural Variables in the Helping Relationship All helping relationships can be considered cross-cultural (Comas-Díaz, 2006, p. 82). Comas-Díaz asserts that an effective helping relationship is one that varies from culture to culture. In a ground-breaking article on cultural variations in the therapeutic relationship, she summarizes some of the ways in which the helping relationship is impacted by culture. For example, she notes that some clients from Eastern cultures often expect their helper to conform to a sort of “cultural hierarchy” and regard their helper as an “authority figure” (p. 90). As a result, the nondirective relationship approach of many practitioners can be unsettling to these clients, who prefer a relationship that is more hierarchical (p. 90). Another way in which some ethnic/racial minority clients may be impacted by the therapeutic relationship has to do with notions of family and extended family. As Comas-Díaz (2006) points out, some clients expect the therapeutic rela-tionship to extend beyond the therapy session and into the structure of the families or their extended support network. Further, clients from indigenous and collectivist cultures may rely on nonverbal communication and pay greater attention to contextual cues in the relationship to maintain a harmo-nious relationship with their helpers. Such clients may feel “put off” by an interpersonal style of relating that is “direct, explicit, and specific” (p. 93). An important variable that shapes the helping relation-ship has to do with microaggressions—brief, common intentional and unintentional verbal, behavioral, and envi-ronmental indignities that convey derogatory slights and in-sults to the client—often based on some cultural dimension of difference such as race, sexual orientation, disability, and gender (Sue, 2010, p. 5). According to Sue, practitioners often are unaware of their microaggressions—characterized by this distinguished author as microassaults, microinsults, and microinvalidations—in their interactions with clients of color or with clients who differ on other cultural dimensions such as sexual orientation, gender, citizenship, religion, and disability. As a result, the helping relationship is likely to be impaired in some way(s) when microaggressions occur. Part of the surrounding distress and the resulting power of such microaggressions lies in their invisibility to the practitioner and sometimes to the recipient as well. For example, in the case of racial microaggressions, although the practitioner may find it hard to believe he or she has engaged in an act of racism, discrimination, or prejudice, the recipient of the microaggressive act faces loss of self-esteem, loss of psychic and spiritual energies, and increased levels of anger and mistrust (Sue, 2010). As Sue (2010) notes, any singular mi-croaggression may be “minimally impactful, but when they occur continuously throughout a life-span, their cumulative nature can have major detrimental consequences” (p. 7). Sue and colleagues observe that a “failure to acknowledge the significance of racism within and outside of the therapy session contributes to the breakdown of the alliance between therapist and client. A therapist's willingness to discuss racial matters is of central importance in creating a therapeutic al-liance with clients of color” (Sue et al., 2007, p. 281). Comas-Díaz (2006) also emphasizes the importance of recognizing and validating sociopolitical factors to so-lidify the multicultural therapeutic relationship (p. 99). Additionally, she notes the ways in which the relationship conditions that we call “facilitative conditions” are also impacted by culture. We explore this topic in greater de-tail in the following section. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Ingredients of an Effective Helping Relationship 79 Facilitative Conditions Facilitative conditions have roots in a counseling the-ory developed by Rogers (1951) called client-centered or person-centered therapy. Because this theory is the basis of these fundamental skills, we describe it briefly here. The first stage of this theory (Rogers, 1942) was known as the nondirective period. The helper essentially at-tended and listened to the client for the purpose of mirror-ing the client's communication. The second stage of this theory (Rogers, 1951) was known as the client-centered period. In this phase, the therapist not only mirrored the client's communication but also reflected underlying or implicit affects or feelings to help clients become more self-actualized or fully functioning people. (This is the basis of the current concept of empathy, discussed in the next section. ) In the most recent stage, known as person-centered therapy (Meador & Rogers, 1984; Raskin & Rogers, 1995), therapy is construed as an active partner-ship between two persons. In this current stage, the em-phasis is on client growth through experiencing himself or herself and experiencing the other person in the relation-ship. Evidence-based support for person-centered therapy in general is summarized in meta-analyses conducted by Elliott (2002) and Elliott and Freire (2008). Cur-rent descriptions of person-centered theory are described by Kirschenbaum and Jourdan (2005) and by Raskin, Rogers, and Witty (2014). Although person-centered therapy has evolved and changed, certain fundamental tenets have remained the same. One of these is that all people have an inherent ten-dency to strive toward growth, self-actualization, and self-direction. This tendency is realized when individuals have access to conditions (both within and outside therapy) that nurture growth. In the context of person-centered therapy, client growth is associated with high levels of three core, or facilitative, relationship conditions: em-pathy (accurate understanding), genuineness (congruence), and positive regard (respect) (Rogers, Gendlin, Kiesler, & T ruax, 1967). If these conditions are absent from the therapeutic relationship, then clients may fail to grow and may deteriorate (Carkhuff, 1969a, 1969b; T ruax & Mitchell, 1971). Presumably, for these conditions to en-hance the therapeutic relationship, they must be commu-nicated by the helper and perceived by the client (Rogers, 1951, 1957). Clients have reported that these facilitative conditions are among the most helpful experiences for them in the overall helping process (Paulson, T ruscott, & Stuart, 1999). It is important to note that although we (and other authors) discuss each of these three conditions separately, in reality they are not isolated phenomena but in fact interrelated ones (Wickman & Campbell, 2003). In recent years, various persons have developed con-crete skills associated with these three core conditions. This delineation of the core conditions into teachable skills has made it possible for people to learn how to communicate empathy, genuineness, and positive regard to clients. In the remainder of the Facilitative Conditions section, we describe these three important relationship conditions and associated skills. Empathy or Accurate Understanding Empathy may be described as the ability to understand people from their frame of reference rather than your own. Responding to a client empathically may be “an attempt to think with, rather than for or about the cli-ent” (Brammer, Abrego, & Shostrom, 1993, p. 98). For example, if a client says, “I've tried to get along with my father, but it doesn't work out. He's too hard on me,” an empathic response would be something like, “You feel discouraged about your unsuccessful attempts to get along with your father. ” In contrast, if you say something like “You ought to try harder,” you are responding from your frame of reference, not the client's. As described in the first Chapter Objective, our goal is to help you learn enough about empathy to be able to communicate this facilitative condition to clients. The evidence base on empathy suggests that client per-ceptions of feeling understood by their helpers relate fa-vorably to helping outcomes (Elliott, Bohart, Watson, & Greenberg, 2011; Watson, Steckley, & Mc Mullen, 2014). Elliott et al (2011) conclude from their meta-analyses on empathy that it is a general predictor of helping outcomes across theoretical orientation of the helper, treatment for-mats, and severity levels of client problems. Moyers and Miller (2013) have found that empathy seems to exert an even larger effect on successful addiction treatment than in psychotherapy in general. The Neuroscience of Empathy and Emerging Evidence Empathy has received a great deal of attention from both researchers and practitioners over the years. We now know that there is even a brain connection with empathy! As El-liott and colleagues (2011) note, the emergence of active scientific research on the biological basis of empathy has been the most important development in the construct of empathy in the past two decades. In 1996, a team of neuro-scientists discovered brain neurons called mirror neurons. Mirror neurons are tailor-made to mirror the emotions and LO1 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
80 Chapter 3 bodily responses of another person. According to Siegel (2010), these mirror neurons help us create actual body sen-sations that allow us to resonate with the experiences of the other person. This forms the foundation of the empathic experience in therapy, which is based on the recognition of the self in the other. The resulting potential for empathic at-tunement with our clients is profound. This empathic mir-roring helps clients feel understood, and ultimately it leads to brain changes in clients through the establishment of new neural firing patterns and increased neural integration (Cozolino, 2010; Pfeifer & Dapretto, 2009; Siegel, 2010). Some recent research has postulated that empathic ac-curacy is associated with two specific areas of the brain: the inferior frontal gyrus (IFG) and the dorsomedialpre-frontal cortex (dm PFC). Moreover, this research found that training individuals in compassion-oriented medita-tion not only increased brain activity in these two regions but also improved empathic accuracy in the meditation group of participants compared to the control group (Mascaro, Rilling, Negi, & Raison, 2012). In addition to the discovery of the mirror neurons and their role in empathic communication, additional neu-roscience research also points to a range of affective and perspective-taking components of empathy in people (De-cety & Lamm, 2009). The results of this body of research suggest that empathy involves three interlinked processes with corresponding areas of brain activation (Decety & Ickes, 2009): Affective simulation—the mirroring of emotional elements of the client's bodily experience with brain activation in the limbic system. Perspective taking—understanding the client's experiences and how things feel and what they mean to the client with brain activation in both the prefrontal and temporal cortexes. Self-regulation of one's own emotions—the ability to self-soothe one's own feelings or distress as the helper with brain activation in the frontal, prefrontal, and right inferior parietal cortexes. Current concepts of empathy thus emphasize that it is far more than a single concept or skill. Empathy is believed to be a multistage process consisting of multiple elements, including affective and cognitive components (Bohart, Elliott, Greenberg, & Watson; 2002; Clark, 2010; Wat-son & Greenberg, 2011). The affective component refers to emotional connectedness between the practitioner and the client, and it involves the helper's ability to identify and contain the feelings and emotions or affective ex-perience of the client. Affective empathy is based on emotional neural circuits activated by the client's expres-sion of emotions and the helper's own understanding of specific situations that might stimulate various emotional responses (Watson & Greenberg, 2009, p. 133). Cogni-tive empathy comprises a more intellectual or reasoned understanding of the client. Cognitive empathy is thought to operate independently of emotional neural networks and involves mirror neurons and the neural systems that facilitate perspective taking (Watson & Greenberg, 2009, p. 133). As Elliott and colleagues conclude, “empathy is best understood as a complex construct consisting of a variety of different acts used in different ways” (2011, p. 133). It is important to note, however, that most cur-rent constructs of empathy are based on Western culture because client perceptions of counselor empathy have rarely been explored with non-Western clients. Cultural Empathy Currently there are multiple explanations for what occurs in the empathic process between helper and client. Here we describe the cultural view of empathy, the person-centered view of empathy, and the self-psychology view of empathy. In our opinion, all three of these views are im-portant for practitioners to be aware of and to incorporate into their therapeutic and relational style. Ivey, Gluckstern, Packard, and Ivey (2007) distinguish between individual and multicultural empathy, saying that the concept of multicultural empathy requires that we understand different worldviews from our own. The culturally empathic helper responds not only to the cli-ent's verbal and nonverbal messages but also to her or his historical/cultural/ethnic background. Cultural empathy is important because it is considered one of the main foundations of prosocial behavior and of a justice orien-tation (Hoffmann, 2000). Moreover, empathy (and also positive regard) is an important component in culturally adapted therapies (Smith, Rodriguez, & Bernal, 2011). Empathic accuracy is, to some extent, impacted by many aspects of social context. Recent research found that one contextual variable, that of social class, was associated with empathic accuracy (Kraus, Cote, & Keltner, 2010). In this study, lower-class individuals who were university students and employees obtained higher scores on a test of empathic accuracy and judged the emotions of an interac-tion partner more accurately than upper-class individuals (Kraus, Cote, & Keltner, 2010). In an ethnographic study of empathy with Chinese cli-ents, some evidence suggested that the clients in this study viewed empathy as a different phenomenon linguistically and conceptually (Ng & James, 2013). Using the literal Chinese translation, these clients described empathy as “having the heart to help” or “the heart of feeling the same. ” For the subjects in this qualitative study, this meant that helpers are responsible and are willing to engage in tasks beyond the pre-scribed duties, in other words, to “go the extra mile. ” Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Ingredients of an Effective Helping Relationship 81 Comas-Díaz (2006) asserts that the practitioner in a multicultural helping relationship may be able to empa-thize cognitively or intellectually with the culturally di-verse client but may not be able to empathize affectively or emotionally. As an example, consider a practitioner who encounters a client who is an African refugee. The helper may be able to study the client's culture and consult with others who have firsthand knowledge of the client's cul-ture and historical experiences. However, the practitioner may not be able to relate emotionally either to the client's experiences as a refugee or to the practitioner's own emo-tions that are stirred up in working with this particular client. When affective empathy is missing, cultural mis-understandings abound. Misunderstandings or breaches of empathy are often a function not just of miscommunications but also of dif-ferences in understanding styles, nuances, and subtleties of various cultural beliefs, values, and use of language (Sue & Sue, 2013). Smith and colleagues (2011) de-scribed the example of a U. S. mental health practitioner who volunteered in Haiti following the January 12, 2010, earthquake. The practitioner was working with a Haitian woman who, during the earthquake, had lost her child, her home, and one of her legs. While the client was most upset about losing her leg, the U. S. practitioner insisted that the client should be more upset about the loss of her child. In doing so, the U. S. practitioner privileged his or her own cultural understanding of what the client's traumatic experiences were instead of attempting to understand the client's frame of reference (Smith, Rodriguez, & Bernal, 2011). In an empathic misunderstanding, the helper should acknowledge it and take responsibility for it. Comas-Díaz (2006) concludes that misunderstandings or “missed empathetic oppor-tunities” are prevalent but also subtle in cross-cultural relationships because clients from other cultures fre-quently communicate indirectly to test and assess the practitioner (p. 84). Person-Centered and Self-Psychology Views of Empathy Rogers's theory of person-centered therapy and his view of the role of empathy in the therapeutic process assume that at the beginning of counseling, a client has a distinct and already fairly complete sense of himself or herself—in Rogers's terms, a self-structure. This is often true of clients with more “neurotic” or everyday features of presenting problems—that is, they bring problems of liv-ing to the helper and at the outset have an intact sense of themselves. Rogers believed that clients come to the help-ing process as a complete person and become more whole through the unconditional acceptance of the helper. In contrast to the Rogerian view of the function of empathy—which is to help actualize the potential of an already established self-structure—is the view of empathy offered by the self-psychology theory of Kohut (1971b). Self-psychology theory assumes that many clients do not come into therapy with an established sense of self, that they lack a self-structure, and that the function of empa-thy in particular and of therapy in general is to build on the structure of the client's sense of self by completing a developmental process that was arrested at some time, re-sulting in an incomplete sense of self. Kohut believes that the client comes to the helping process as an incomplete person who becomes whole through therapeutic correc-tive experiences such as empathic understanding. Both Rogers (1951, 1957) and Kohut (1971b) have had an enormous impact on our understanding of the role that empathy plays in the development of a posi-tive and authentic sense of self, not only in the normal developmental process but also in the helping relation-ship. Rogers's emphasis on understanding and acceptance helps clients learn that it is acceptable to be real, to be their true selves. Kohut's emphasis on empathy as a corrective emotional experience allows clients to discover parts of themselves that have been buried or split off and that in counseling can be integrated in a more holistic way. Both Rogers and Kohut stress the importance of a nonjudg-mental stance on the part of the helper. It is our position that the views of both of these persons, even though dispa-rate, can be used together in a pragmatic fashion to create and sustain a facilitative helping relationship. These views of empathy were corroborated in a recent empirical study in which clients' perceived therapist empathy decreased clients' negative views and treatment of themselves and increased their levels of secure attachment in interper-sonal relationships, leading the authors to conclude that “therapist empathy is multifunctional in psychotherapy” (Watson, Steckley, & Mc Mullen, 2014, p. 296). We discussed the various processes involved in empathy. Similarly, there are different manners of expression of empa-thy to clients. For example, a study that validated a nine-item therapist empathy scale found expression of therapist em-pathy ranged from an expressive vocal tone, an attunement to the client's inner world, and an understanding and ac-ceptance of the client's cognitive and affective experiences (Decker, Nich, Carroll, & Martino, 2014). We discuss two ways of expressing empathy to clients: validating responses and the provision of a safe-holding environment. Empathy and Validation of Clients' Experiences: Kohut and Linehan Both Rogers and Kohut developed their views on empa-thy from their work with various clients. For Kohut, the Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
82 Chapter 3 turning point was a client who came to each session with bitter accusations toward him. As he stopped trying to explain and interpret her behavior and started to listen, he realized these accusations were her attempts to show him the reality of her very early childhood living with incapacitated caregivers who had been unavailable to her. Kohut surmised that clients show us their needs through their behavior in therapy, giving us clues about what they did not receive from their primary caretakers to develop an adequate sense of self and also about what they need to receive from the helper. It is important to remember that when a childhood need is not met or is blocked, it simply gets cut off but does not go away; it remains in the person in an of-ten primitive form, which explains why some grown-up clients exhibit behaviors in therapy that can seem very childish. When these needs are chronically frustrated or repressed, the child grows up with poor self-esteem and an impaired self-structure. Also, the self is split into a true self, the capacity to relate to oneself and to others, and a false self, an accommodating self that exists mainly to deny one's true needs to comply with the needs of the primary caregivers (Winnicott, 1958). Invalidating Environments Linehan (1993a; 2015) has extended the work on the dis-cussion about empathy and environments in her seminal work on dialectical behavior therapy in the treatment of individuals diagnosed with borderline personality disorder (BPD), a disorder characterized by emotional dysregulation. She notes that most persons with an initial temperamental vulnerability to emotion dysregulation do not go on to develop symptoms of BPD unless they are exposed to a particular developmental/social environment that she terms “invalidating. ” Neacsiu & Linehan (2014) note that invali-dating environments, which can be immediate or extended family, school, work, or community, are characterized by the tendency to “negate, punish and/or respond erratically and inappropriately to private experiences, independent of the validity of the actual behavior. Private experiences, and es-pecially emotional experiences and interpretations of events, are not taken as valid responses to events by others; are punished, trivialized, dismissed, or disregarded” (p. 414). In more optimal developmental environments, the individual's private, internal experiences are validated, giving rise to a stable identity and coherent sense of self. In invalidating environments, however, the individual “learns to mistrust his/her internal states, and instead scans the environment for cues about how to act, think, or feel. This general reli-ance on others results in the individual's failure to develop a coherent sense of self” (Neacsiu & Linehan, 2014, p. 415). Corrective Emotional Experiences Both Linehan (2015) and Kohut (1984) have discussed the role of empathy in response to the disrupted sense of self experienced by clients in these sorts of invalidating environments. Kohut (1984) believes that empathy—the therapist's acceptance of the client and his or her feelings—is at the core of providing a “corrective emo-tional experience” for clients. It means avoiding any sort of comment that may sound critical to clients. Because the lack of original empathic acceptance by caregivers has driven parts of the client's self underground, it is important not to repeat this process in helping interac-tions. Instead, the helper needs to create an opposite set of conditions in which these previously buried aspects of the self can emerge, be accepted, and be integrated (Kahn, 1991, pp. 96-97). The way to do this is to let clients know that the way they see themselves and their world “is not being judged but accepted as the most likely way for them to see it, given their individual history” (Kahn, 1991, p. 97). This is known as a validating response or an empathic affirmation (Elliott et al., 2011). Validating Responses Validating responses are usually verbal messages from the helper that mirror the client's experience (notice the emphasis on experience rather than on words) and validate the client's perspective. Validation can occur nonverbally as well through helper behaviors that communicate un-derstanding and acceptance. This sounds remarkably easy to do but often becomes problematic because of our own woundedness. Too often we fail to validate the client be-cause a button has been pushed in us, and we end up vali-dating or defending ourselves instead. This reaction forms the basis of countertransference, which we discuss later in this chapter. The key to being able to provide validating responses is to be able to contain our own emotional reactions so that they do not get dumped out onto the client. Recall from our earlier discussion on the processes in empathy that one such process—that of self-regulation of our own affective experiences—is what helps us manage feelings that get stirred up in our work with clients. This is especially difficult to do when a client pushes your own buttons, and this is why working with yourself and your own “stuff” is so important. For Linehan (1993a; 2015), validation is at the core of her dialectical behavior therapy (DBT) approach and forms the basis of acceptance. Linehan (1993b) describes validation in DBT in the following way: The essence of validation is this: The therapist com-municates to the client that her responses make sense and are understandable within her current life context Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
Ingredients of an Effective Helping Relationship 83 or situation. The therapist actively accepts the client and communicates the acceptance to the client. The therapist takes the client's responses seriously and does not discount or trivialize them. Validation strategies require the thera-pist to search for, recognize, and reflect to the client the validity inherent in her response to events (p. 222). Linehan further delineates six levels of empathic validat-ing responses. Note that each level is more complete than the prior one and each level depends on one or more of the prior levels as well. Brief summaries of these six validation levels as described in Neacsiu and Linehan (2014) are as follows. Level 1: Listening and Observing (V1)* The helper listens and pays attention to the client—not only the client's words but also the client's nonverbal behavior, expressions, and experiences. The key in Level 1 is that the helper is inter-ested in the client and is showing that interest in both ver-bal and nonverbal responses. This occurs through helper behaviors such as verbal prompts of understanding (“Yes, I see,” “Go on,” “Tell me more about that”) and also non-verbal activity, such as head nods, eye contact, and body posture, that shows the helper is engaged with the client. You probably can see that this level of empathic validation involves one of the processes of empathy we discussed previously, that of affective simulation, or mirroring of the emotional elements of the client's experience. Level 2: Accurate Reflection (V2) Level 2 validation builds on Level 1 and extends it by accurately reflecting back to the client what the helper has heard and understood. “Val-idation at Level 2 sanctions, empowers, or authenticates that the individual is who he or she actually is” (Linehan, 2015, p. 89). For example, the client says, “I feel sure that my boss hates me. ” The helper responds at this level with an accurate reflection by saying something in response like, “Your experience tells you that your boss does not like you. ” Note that validation responses do not create “validity”—you do not have to agree or disagree with the client's perceptions. One way to do this is to remember that basically all realities are subjective anyway! We discuss reflections further in Chapters 4 and 10. Level 3: Articulating the Unverbalized (V3) In Level 3 of vali-dation, the helper extends levels one and two and “commu-nicates understanding of aspects of the client's experience and response to events that have not been communicated directly by the client” (Neacsiu & Linehan, 2014, p. 433). In essence, in this level of validation, the helper articulates something about the emotions and meanings the client has not yet explicitly expressed but are inferred implicitly (Linehan, 2015). How does the helper accomplish this? It is accomplished by the use of perspective taking that we dis-cussed in this section as one of the processes of empathy. In the previous example about the client who feels like her boss hates her, the implicit assumption is that she wishes the boss wouldn't hate her. A validation response at Level 3 would be something like, “You don't think your boss likes you and you wish she (he) would. Then, you would have a different and more positive experience at work. ” Note that at Level 3 there is a fine balance between taking the perspective of the client and defining the client's subjective reality, so it is best to check out the accuracy of your validating response. Level 4: Validation in Terms of Past Learning or Biological Dysfunction (V4) In Level 4, the client's behavior is validated in terms of its causes, As Neacsiu and Linehan suggest, “Validation here is based on the notion that all behavior is caused by events occurring in time; thus, in principle, it is understandable... even though information may not be available to determine all the relevant causes, the client's feelings, thoughts, and actions make perfect sense in the context of the client's current experience, physiology, and life to date” (2014, p. 433). In the example with the client, a Level 4 validation response might be something like this: “Given the fact that this boss even reminds you of your last one, and that your last one was sort of a nightmare for you, I can see why you could feel the way you do about his (her) reactions to you. ” Level 5: Validation in Terms of Present Context or Normative Functioning (V5) At this level of validation, the helper's task is to communicate that the client's behavior is “justifiable, reasonable, well grounded, meaningful, and/or efficacious in terms of current events, normative biological functioning, and/or the client's ultimate life goals” by looking for “the wis-dom or validity of the client's response” (Neacsiu & Linehan, 2014, p. 433). Here the helper accomplishes this task by communicating understanding of the client's response and by finding relevant facts in the client's current context that support the client's behavior. In the example with the client, a sample validating response at Level 5 would be something like this one: “It makes sense to me that you would be feeling put off and discouraged by your boss's response to you given what is happening to you with this person at work. ” Level 6: Radical Genuineness (V6 ) We describe genuineness in a later section in this chapter as one of the three core facilitative conditions described by Carl Rogers in person-centered therapy. Linehan describes genuineness in her model in the following way: “In Level 6, the task is to recognize the person as he/she is, seeing and responding to his/her *Source: From Linehan and Dexter Mazza, “Dialectical behavior therapy for borderline personality disorder,” in Barlow, Clinical Handbook of Psychological Disorders, 4e. Copyright (c) 2009 by Guilford Press. Reproduced by permission of Guilford Press. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf
84 Chapter 3 strengths and capacities, while keeping a firm empathic understanding of his/her actual difficulties and incapaci-ties. The therapist believes in the client and his/her capac-ity to change and move toward ultimate life goals just as the therapist may believe in a friend or family member. The client is responded to as a person of equal status, due equal respect” ( Neacsiu & Linehan, 2014, p. 434). At this highest level, the validation is, in essence, the validation of the client sitting in front of you “as is. ” Rather than being a specific response that builds on prior responses sequen-tially as we have seen in Levels 1-5, Level 6 is a sort of stance, an attitudinal response to clients that conveys your belief in them (see Learning Activity 3. 1). Teyber and Mc Clure (2011) note that validating re-sponses are especially important when working with clients of color, LGBT clients, low-income clients, physically challenged clients, and any other clients who may feel different. “These clients will bring issues of oppression, prejudice, and injustice into the therapeutic process, and their personal experiences have often been invalidated by the dominant culture. These clients in particular will not expect to be heard or understood by the therapist” (p. 65). We believe that Linehan's six levels of validation can be extended to foster cultural empathy as well. Consider, for example, the scenario below. Learning Activity 3. 1 Validating Empathy Part One Consider the following case descriptions of clients. What might be the effect on you of hearing each client's issue? What might you try to defend about yourself? How could you work with this to give a validating response to the cli-ent instead? Provide an example of such a response. For our feedback on this activity, see page 86. 1. The client expresses a strong sexual interest in you and is mad and upset when she realizes you are not in love with her. 2. The client wants to be your favorite client and repeatedly wants to know how special he is to you. 3. The client is a man of Roman Catholic faith who wants to marry a Jewish woman. He is feeling a lot of pressure from his Latino parents, his priest, and his relatives to stop the relationship and find a woman of his own re-ligious faith. He wants you to tell him what to do and is upset when you don't. Part Two In this part of Validating Empathy, match a client descrip-tion/helper response with one of Neacsiu and Linehan's (2014) corresponding six levels of helper validation. Feed-back is given on page 86. Levels of Validation V1 Listening and Observing V2 Accurate Reflection V3 Articulating the Unverbalized V4 Validation in Terms of Past Learning V5 Validation in Terms of Present Context V6 Radical Genuineness Client Descriptions/Helper Responses 1. The client thinks it is unfair that she does all the errands in her relationship with her partner. You say to the client, “You feel like it is unfair that you are shouldering all the responsibility for the er-rands in your relationship with your partner. ” 2. The client is very upset about the death of her beloved pet. The helper responds by listening attentively and being nonverbally engaged with the client. 3. The client believes that people do not like her at work because she is a lesbian. As the helper, you say something like, “Your experience at work tells you that your coworkers do not like you and you feel like this is because of your sexual orientation. Because you have been responded to quite negatively by others in the past due to your sexual orientation, I can see why you feel like this is happening to you once again. ” 4. The client had been expecting a bonus at work and is quite upset and angry that the expected bonus was not given to him. The helper says, “You are really angry about not getting that bonus you thought you would get. Given your existing workload, it sure makes sense that you would be feeling really upset about this situation. ” 5. The client is the only international student in a study group and feels constantly like she does not really fit into the group and that her partici-pation is not that welcomed. As the helper, you acknowledge her experience of marginalization in this group and comment on her coping and resilience in response. 6. The client expresses sadness and frustration about her recent discovery that her partner in life has betrayed her. The helper responds by say-ing, “You are sad and upset about the discovery of your partner's betrayal; you wish this had not happened to your relationship and that things could just be the way they used to be with the two of you. ” Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf