Chapter 02 - The Helping Relationship and the Values That Drive It PDF

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The Helping Relationship and the Values That Drive It...

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THE HELPING RELATIONSHIP AND THE VALUES THAT DRIVE IT

CHAPTER CONTENTS The Helping Relationship • The Importance of the Relationship Itself • The Relationship as a Means to an End • The Relationship as a Working Alliance • Getting Off to a Good Start • Keeping the Client’s Point of View and Preferences Center Stage • The Relationship as a Forum for Relearning • Relationship Flexibility The Values That Drive the Helping Relationship • Values as Tools of the Trade • Determining the Values Inherent to Successful Helping Respect as the Foundation Value • Behaviors Showing Disrespect • Behaviors Showing Respect Empathy as the Primary Orientation Value • A Brief Overview of Empathy • Empathy as a Two-Way Street • Empathy as Radical Commitment

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Proactive Appreciation of Diversity • Culture, Personal Culture, and Values • Helper Competencies Related to Client Diversity • Specific Multicultural Competencies Self-Responsibility as an Empowerment-Focused Value • Helping as a Social-Influence Process • Norms for Empowerment and Self-Responsibility • Conscientiousness • Self-Responsibility, Self-Regulation, Self-Control A Bias for Action as an Outcome-Focused Value • The Need for Behavioral Activation • Action and Discretionary Change • Real-Life Focus Shadow-Side Realities in the Helping Relationship • Helpers’ and Clients’ Flaws • Incompetent Helpers

THE HELPING RELATIONSHIP This chapter addresses how to behave toward clients. It contains many suggestions, but don’t get lost in the detail. One way of proceeding is to read this chapter thoughtfully but quickly. Then reread it as you move through Parts II and III of this book. Although theoreticians, researchers, and practitioners alike, not to mention clients, agree that the relationship between client and helper is important, there are significant differences as to how this relationship is to be characterized and played out in the helping process. Some stress the relationship itself, whereas others highlight the work that is done through the relationship. Some use the term “relationship,” while others prefer the term “working alliance.” Although different researchers define terms such as “relationship” and “alliance” differently, certain themes such as “collaboration” dominate. Even then what collaboration looks like differs from author to author. Recall the notion of “uncertainty” discussed in Chapter 1. The purpose of this section is not to reconcile differences but to give helpers a clinical “feel” for what a good relationship looks like together with some of the behaviors that contribute to the helping partnership. There is no one right way of developing a helping relationship. Even though there are fundamental principles, you and each client have to co-discover and co-develop the “right way” for that encounter. An enormous amount of research on the nature of the helping relationship has been done over the past ten years (Norcross, 2011a, 2011b), though, unsurprisingly, some of its findings are contradictory. The basic findings of an APA Task Force and the clinical principles that stem from it were alluded to in Chapter 1. No attempt is made in this chapter to dissect all that research and provide a critical review.

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Rather, this chapter tries to answer a few basic questions in light of all this research. What do helpers need to know about the relationship? What do clients need to know? How can counselors help clients enter a collaborative relationship? What needs to be done to make sure that the relationship serves life-enhancing outcomes for clients? In my view, the research findings often do no more than confirm common sense, which, admittedly, is not a “scientific” term. But clients certainly understand the term “common sense.” And if you think of the words related to the term—discretion, levelheadedness, practicality, prudence, sense, wisdom, street smarts, acumen, judgment, care, caution, circumspection, and the like—you get the idea. Admittedly, one person’s common sense need not be another’s. And common sense might be misnamed because, as some say, it isn’t that common.

THE IMPORTANCE

OF THE

RELATIONSHIP ITSELF

All of us establish relationships of one kind or another throughout our lives. One way of looking at any relationship, including a helping relationship, is to consider what each party “brings to the table,” as it were, and how these offerings interact. Both helper and client have a set of personality traits and personal cultures (discussed later in this chapter) that affect how they go about establishing and maintaining relationships. If helper and client had met at, let us say, a party or conference before therapy began, the relationship would be a result of what each would “bring to the party.” That is, neither would be acting from a role—the helper role or the client role. The point is that the helping relationship can be affected by the package of human elements each brings to the helping encounter. Norcross (2011a, 2011b) puts it simply: “Remember: The relationship is far broader and inclusive than the [working] alliance alone” (p. 120). It follows that the better both clients and helpers understand themselves in terms how they establish and maintain relationships, the better they might be in establishing a working alliance in therapy. The word “might” is important here. Most approaches to therapy affirm the importance of the helping relationship, but not in the same way. In a different mode, Carl Rogers (1951, 1957; Kirschenbaum, 2009), one of the great pioneers in the field of counseling, emphasized the quality of the relationship in representing the humanistic-experiential approach to helping (see Kelly, 1994, 1997). Rogers claimed that the unconditional positive regard, accurate empathy, and genuineness offered by the helper and perceived by the client were both necessary and often sufficient for therapeutic progress. Through this highly empathic relationship, counselors, in his eyes, helped clients understand themselves, liberate their unused resources, and manage their lives more effectively. Rogers’s work started the widely discussed clientcentered approach to helping (Rogers, 1965). On the other hand, in psychoanalytic or psychodynamic approaches, “transference” and “countertransference”—the complex and at first unconscious interpersonal dynamics between helper and client that are rooted in the client’s and even the helper’s past—are central. Resolving these often murky dynamics, some say, is intrinsic to successful therapeutic outcomes. Rogers considered the empathic helping relationship a facilitative condition, not a “problem” in itself to be explored and resolved.

The Helping Relationship and the Values That Drive It

THE RELATIONSHIP

AS A

MEANS

TO AN

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END

Some see the helping relationship as very important but still as a means to an end. This makes sense because life-enhancing client outcomes, as noted in Chapter 1, are what helping is all about. The cognitive-behavioral tasks of the helping process are accomplished, as Tursi and Cochran (2006) have noted, in a person-centered relational framework. In this view, a good relationship is practical because it enables client and counselor to do the work called for by whatever helping process is being used. Practitioners using cognitive and behavioral approaches to helping such as the manualized treatments discussed in Part III, although sensitive to relationship issues, tend toward this means-to-end view. Overstressing the relationship, they say, is a mistake because it obscures the ultimate goal of helping: managing problem situations and developing life-enhancing opportunities. This goal won’t be achieved if the relationship is poor, but if too much focus is placed on the relationship itself, both client and helper can be distracted from the real work to be done.

THE RELATIONSHIP

AS A

WORKING ALLIANCE

“The alliance refers to the quality and strength of the collaborative relationship between client and therapist” (Norcross, 2011, p. 120). Although the term “working alliance” has a long history and a number of different interpretations (Horvath et al., 2011), it can be used to bring together the best of the empathicrelationship-in-itself and relationship-as-means-to-achieving-desired-outcomes. Bordin (1979) defined the working alliance as the collaboration between the client and the helper based on their agreement on the goals and tasks of counseling. Horvath and his associates (2011) add a dynamic-process touch: “The alliance represents an emergent quality of partnership and mutual collaboration between therapist and client…. Its development can take different forms and may be achieved quickly or nurtured over a longer period of time …” (p. 11) In the working alliance, helpers and clients are collaborators. Helping is not something that helpers do to clients; rather, it is a process that helpers and clients work through together (Frankel, 2007). Helpers do not “cure” their patients. Both have work to do in the problem-management and opportunity-development stages and tasks, and both have responsibilities related to outcomes. Outcomes depend on the competence and motivation of the helper and the client, and on the quality of their interactions. Helping is a two-person team effort in which helpers need to do their part and clients theirs. If either party refuses to play or plays incompetently, then the entire enterprise can fail. Bachelor, Laverdière, Gamache, and Bordeleau (2007), digging down into the heart of collaboration, found three different types of client collaboration—active, mutual, and therapist-dependent, though the last of these three might better be called cooperation rather than collaboration. Active clients see themselves “as playing a significant role, or at least as making a difference, as to whether the work moves forward or not” (p. 181). The mutual-type client “acknowledges her or his role in the work of therapy and positive change but also views (and in some cases explicitly expects) the therapist to play an equally active role” (p. 183). As to The collaborative nature of helping

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dependent-collaborative clients, “collaboration refers to change-inducing or otherwise beneficial therapist interventions” (p. 184). The researchers found that a third of clients fall into this last category. The Skilled Helper will provide plenty of grist for the mill of your mind to determine what precisely collaboration means and the role it plays in the helping process. Because the term “working alliance” is a concept, an abstraction, it takes on life and clinical significance through the behavioral principles that make it a reality. Here are some alliance-focused principles:

Guiding Principles for Alliance Behavior

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Alliances emerge. Don’t try to build an alliance. Rather make sure that everything you do in using, for instance, the problem-management process briefly mentioned in Chapter 1 and described in detail in Part III or any other approach to treatment contributes to a spirit of collaboration and partnership. When Karl and Laura interact constructively, say, in exploring Karl’s tendency to run away from closer interpersonal relationships, the alliance “emerges” and grows. Track the client’s evolving needs and wants. Make an effort to understand the client’s preferences and modulate accordingly. Remember that both of you are on a collaborative search for the right relationship. When Karl summarily rejects the survey approach to monitoring the helping process and outcomes, Laura doesn’t push the issue. There are other ways to get feedback. And some clients need to get comfortable with the relationship before adding what they might see as “extras.” Focus on resources. Make sure that you are getting in touch with not just the client’s problems and concerns but also the resources and expectations the client brings to the helping endeavor. Effective helpers begin focusing on the client’s strengths right from the beginning. Right from the start Laura says to herself, “This guy seems to have a lot going for him, but I’m not sure if he is in touch with his considerable resources.” Don’t be surprised at differing views of the relationship. Your view of how the relationship is evolving may not be the same as the client’s view especially in the early stages of the relationship. Look for cues indicating the state of the relationship throughout the helping endeavor. Ups and downs are common. Do not be surprised about ups and downs in the relationship. That happens in everyday life. For example, a client might get an insight that is upsetting (“I’ve really be acting like a jerk in my family life”). You might think that you’ve done something wrong. Even when you’re the cause of some kind of negative reaction, this does not mean that the relationship is in trouble. When Laura invites Karl to look at the consequences of being “out of community,” Karl sulks. Both of them have to work at reestablishing equilibrium. Horvath and his colleagues see these ups and downs as “normal” variations, which, if “attended to and resolved, are associated with good treatment outcomes” (p. 15). Expect and deal with client negativity. Therapy is hard work for clients. When they get frustrated, they often enough lash out at their therapists. When Karl is frustrated by the fact that he keeps dreaming about the attack in which his buddies were killed, he interrupts Laura, “Laura, you know nothing, I mean

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nothing, about war and you never will. So stop pretending.” Laura has been responding empathically to what Karl has been saying, but her empathy is seen as ignorance. But, given the fact that their relationship has been growing stronger, she does not internalize Karl’s remarks. Rather she tries to learn from them. The communication and relationship building skills essential to all the above are outlined and illustrated in Part II.

GETTING OFF

TO A

GOOD START

Miller, Duncan, et al. (2006, p. 5) noted that “research has found that client change occurs earlier rather than later in the treatment process, and that the client’s subjective experience of meaningful change in the first few sessions is critical. If improvement in the client’s subjective sense of well-being does not occur in the first few sessions, then the likelihood of a positive outcome significantly decreases.” They go on to review the evidence for this finding. If that is the case, then helpers in collaboration with their clients need to establish the kind of alliance that supports such change relatively quickly, if possible. DeFife and Hilsenroth (2011), in reviewing the evidence on effective therapeutic relationships, identified three areas related to helping clients and therapists get off to a good start. First, help clients develop positive expectancies related to both the helping process and its outcomes. How can helpers do this? •

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By using all the relationship-building skills presented in Part II. For instance, Laura comes across as attentive, honest, and flexible. This helps Karl say to himself, perhaps subconsciously, “I think that I can work with her.” By providing a framework that helps clients understand the problems they are facing. Early on Laura gives her take on the PTSD framework, but humanizes it by tailoring it to Karl’s version of this syndrome. By sharing the problem-management process detailed in Part III of this book, but describing it in terms of some of the issues Karl has highlighted. For instance, she helps him explore some of the issues from a different perspective. “It seems that sometimes your thinking gets a bit twisted. It’s you, but it’s not really your kind of thinking.” By suggesting that there are specific ways of handling his symptoms. Laura says, “There are ways of helping you deal with both anxiety and depression, but we, you and I, need to find the programs that are best for you.” By helping patients develop confidence in the treatment process. The fact that Karl agrees to try the “buddy” approach is a positive sign. He says to himself, “Here’s a guy who has been through it all and has come out the other side.” By discussing the kind of commitment and work that is needed both in the sessions themselves and in everyday life. Laura says, “I can’t say that all of this will be easy. You will have to be convinced that the payoff it worth it.” By “normalizing” the client’s problems and concerns. Karl needs to see that, given what he has seen and gone through in both Iraq and Afghanistan, the problems that are plaguing him can be expected. No one escapes unscathed. It is a question of degree.

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Second, help clients understand and move into the role of a proactive and committed client. How do you help them do that? •

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By helping clients understand the essential details of the helping process, including frequency of meetings, meeting length, work between sessions, and the like. Laura does this and adds, “But remember, you can ask any kind of question you want. If you have any objections, bring them up. If you think we are headed in the wrong direction, say so. What we are doing has to make sense to you.” By providing a brief overview of what it the sessions could be like. The overview should be simple, but not simplistic, and clear. Continue to reinforce the notion that Karl is in the driver’s seat. For instance, after describing what sessions could look like, Laura adds, “I can help you see the options, but you will be making the decisions as we move along. This isn’t a cookie cutter process.” By making sure that the client understands the collaborative nature of that role. Laura says, “Notice that I use ‘we’ a lot. During the time we spend together you will probably make any number of decisions. My role is to help you make choices that are best for you.” By providing some idea of the issues to be discussed. Laura says, “My job is to help you explore issues that will make a difference in your life. I’ll help you, but you’re the agenda setter.” In summary, Laura wants to find ways of helping Karl move into the driver’s seat right from the start.

Third, emphasize goal formation and highlight its collaborative nature. Lifeenhancing outcomes chosen by the client constitute the goal of helping. Collaborative goal setting is addressed in detail in Part II of this book. There are a lot of things in these lists. Which ones are the most important? The answer is simple: the ones that make a difference in the client’s life. It is impossible to predict which ones will make a difference in this client’s life. Client and helper have to work that out together. It is extremely important in all of this not to dump too many decisions on the client right from the start. Simplicity helps.

KEEPING THE CLIENT’S POINT CENTER STAGE

OF

VIEW

AND

PREFERENCES

Bedi (2006) has suggested that the research community has given too much attention to therapists’ views of the helping relationship to the neglect of clients’ views. There are two key questions: First, what kind of relationship does the client want? Clients can differ widely in this regard. Second, what does the therapist need to do to help the client become a collaborating partner in the helping process? Ackerman and Hilsenroth (2003) presented a comprehensive examination of therapists’ personal attributes and in-session activities that positively influence the therapeutic alliance. These at...