Helping skills clara hill 4th edition pdf

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Library of Congress Cataloging-in-Publication Data

Hill, Clara E., 1948- Helping skills : facilitating exploration, insight, and action / Clara E. Hill. — Fourth edition. pages cm

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Includes bibliographical references. ISBN-13: 978-1-4338-1678-9 ISBN-10: 1-4338-1678-4 1. Counseling. 2. Counseling psychology. 3. Helping behavior. I. Title.

BF636.6.H55 2014 158.3—dc23

2013033731

British Library Cataloguing-in-Publication Data A CIP record is available from the British Library.

Fourth Edition

http://dx.doi.org/10.1037/14345-000

http://dx.doi.org/10.1037/14345-000
To my husband, Jim Gormally, my fellow traveler in the process of learning helping skills;

to my children, Kevin and Katie, who have tested my helping skills; and to my students, who have taught me how to teach helping skills.

Contents

P R E F A C E

A C K N O W L E D G M E N T S

I Overview

Chapter 1. Introduction to Helping What Is Helping? Is Psychotherapy Effective? Facilitative Aspects of Helping Problematic Aspects of Helping When Do People Seek Help From Others? On Becoming a Helper Overview of This Book DVDs Concluding Comments What Do You Think?

Chapter 2. An Overview of the Helping Process Assumptions Underlying the Three-Stage Model The Three-Stage Model Facilitative Conditions A Model for the Process and Outcome of Helping Concluding Comments What Do You Think?

Chapter 3. Ethical Issues in Helping General Ethical Principles Ethical Issues for Beginning Helpers Working Through an Ethical Dilemma Concluding Comments What Do You Think?

Chapter 4. Self-Awareness Self-Knowledge and Self-Insight State of Heightened Self-Focus What Do You Think?

Chapter 5. Cultural Awareness Defining Culture Dimensions of Culture Cultural Issues in the Helping Process Ethical Behavior Related to Culture Becoming a Culturally Competent Helper Difficulties Helpers Have Related to Cultural Issues My Own Experiences of Culture

What Do You Think?

II Exploration Stage

Chapter 6. Overview of the Exploration Stage Theoretical Background: Rogers's Client-Centered Theory Goals for the Exploration Stage Exploration Stage Skills Concluding Comments What Do You Think?

Chapter 7. Skills for Attending, Listening, and Observing Overview of Attending, Listening, and Observing Cultural Issues in Attending, Listening, and Observing Relax and Be Natural but Professional Nonverbal Behaviors That Facilitate Attending Paraverbal Behaviors That Facilitate Attending Behaviors That Facilitate Active Listening and Observing Examples of Inappropriate and Appropriate Attending, Listening,

and Observing Difficulties Helpers Experience in Attending, Listening, and

Observing Concluding Comments What Do You Think?

Chapter 8. Skills for Exploring Thoughts and Narratives Rationale for Exploring Thoughts and Narratives Restatements and Summaries Open Questions and Probes for Thoughts Closed Questions About Thoughts Disclosures of Similarities A Comparison of Skills for Exploring Thoughts What Do You Think?

Chapter 9. Skills for Exploring Feelings Rationale for Exploring Feelings Cultural Considerations in Working With Feelings Reflection of Feelings Disclosure of Feelings Open Questions and Probes About Feelings Focusing A Comparison of Skills for Exploring Feelings What Do You Think?

Chapter 10. Integrating the Skills of the Exploration Stage Choosing Goals to Facilitate Exploration Choosing Skills to Match the Goals and Intentions Implementing the Skills of the Exploration Stage

The Process of the Exploration Stage Cultural Considerations Difficulties Implementing the Exploration Stage Coping Strategies for Managing Difficulties Example of the Exploration Stage What Do You Think?

III Insight Stage

Chapter 11. Overview of the Insight Stage What Is Insight? Theoretical Background: Psychoanalytic Theory Developing Conceptualizations About Client Dynamics Goals and Skills of the Insight Stage Concluding Comments What Do You Think?

Chapter 12. Skills for Challenging Clients and Fostering Awareness Rationale for Using Challenges Theoretical Perspectives on Challenges Types of Challenges Guidelines for Presenting Challenges Difficulties Helpers Experience Using Challenges What Do You Think?

Chapter 13. Skills for Facilitating Insight Open Questions and Probes for Insight Interpretations Disclosures of Insight What Do You Think?

Chapter 14. Skills for Immediacy Types of Immediacy Rationale for Using Immediacy Guidelines for Using Immediacy Example of Immediacy Difficulties Helpers Have in Using Immediacy What Do You Think?

Chapter 15. Integrating the Skills of the Insight Stage Steps for Integrating Insight Skills Caveats About Using Insight Skills Cultural Considerations Difficulties Helpers Might Experience in the Insight Stage Strategies for Overcoming Difficulties in Implementing the Insight

Stage Example of an Extended Interaction in the Insight Stage What Do You Think?

IV Action Stage

Chapter 16. Overview of the Action Stage Rationale for the Action Stage Deterrents to Action Philosophical Underpinnings Markers for Knowing When to Move to Action Theoretical Background: Behavioral and Cognitive Theories Goals of the Action Stage Skills of the Action Stage What Do You Think?

Chapter 17. Steps for Working With Four Action Tasks Relaxation Behavior Change Behavioral Rehearsal Decision Making What Do You Think?

Chapter 18. Integrating the Skills of the Action Stage Implementing the Action Skills Difficulties Helpers Might Experience in the Action Stage Strategies for Overcoming the Difficulties What Do You Think?

V Integration

Chapter 19. Putting It All Together: Working With Clients in the Three-Stage Model Session Management Dealing With Difficult Clients and Clinical Situations Example of an Extended Interaction Concluding Comments What Do You Think?

G L O S S A R Y

R E F E R E N C E S

A B O U T T H E A U T H O R

F E E D B A C K F O R M

Preface

My interest in training helpers has developed from teaching helping skills classes to undergraduate and graduate students for more than 40 years. When I first taught these courses, I felt frustrated in trying to find the right textbook that would embody my philosophy of helping and address the needs of my students. Few, if any, helping skills texts integrate the importance of affect, cognition, and behavior in the process of change. Some concentrate on feelings while disregarding the role of challenge and action in facilitating critical life changes, whereas others highlight insight at the expense of affective exploration and behavior change. Several popular texts focus solely on a problem-solving approach, which neglects the critical role of affect in helping clients express, understand, and alter that with which they are dissatisfied in their lives. Other books do not provide the crucial theoretical and empirical foundation for the helping skills. To address these limitations, I used the knowledge garnered from my experiences as a student, teacher, counselor, supervisor, and researcher to write a book that teaches helpers to assist clients in exploring their feelings and thoughts, gaining new insights about their problems, and moving toward positive behavior changes.

My Philosophy of Helping

This text introduces an integrated model that is grounded in practice, theory, and research. Grounding the model in practice and theory is important to take advantage of the work of accomplished clinicians and theoreticians who have articulated a rich theoretical knowledge base. Rogers, Freud, Bowlby, M. Erikson, Mahler, Skinner, Ellis, Beck, and others have provided brilliant insights into the nature of human beings, the mechanisms of change in counseling and therapy, and the techniques for assisting individuals to achieve their potential and accomplish their goals. The three-stage model is grounded in the contributions of these sage theorists, and readers are introduced to the salient aspects of their work.

The model involves three stages: exploration, insight, and action. The exploration stage is based on client-centered theory (e.g., Rogers, 1942, 1951, 1957, 1959). Psychoanalytic and interpersonal theories (e.g., Freud, 1940/1949; Teyber, 2006; Yalom, 1980) form the foundation for the insight stage. The action stage is based on behavioral (e.g., Goldfried & Davison, 1994; Kazdin, 2013; Watson & Tharp, 2006) theories. These major theories are integrated in this three- stage model because all have proven to be effective in helping clients (see Wampold, 2001).

The helping process can be conceptualized as involving moment-by-moment interaction sequences (Hill, 1992). Helpers develop intentions for how they want

to help clients. These intentions are based on what they know about clients and what they hope to accomplish with clients at a given time. With these intentions in mind, helpers select verbal and nonverbal skills with which to intervene. In turn, clients react to the interventions in ways that influence how they then choose to behave with helpers. Thus, helping involves not only the overt behaviors but also the cognitive processes of helpers (i.e., intentions) and clients (i.e., reactions). Awareness of intentions assists helpers in selecting effective interventions. In addition, attention to the clients’ reactions to the interventions can aid helpers in planning future interventions.

Finally, I sought to write a book that both supports students’ development as helpers and provides challenges to facilitate the development of helping skills. Becoming an effective helper is an exciting and challenging process. For some, this undertaking can be life changing. Many students are fascinated by the process of becoming helpers, and they pose thoughtful questions as they struggle to learn the skills and develop confidence in their ability to assist others. Because the focus of this book is on helpers (not clients), I pose many questions that relate to the helpers’ development and concomitant feelings and thoughts.

What This Text Does Not Provide

It seems necessary to clarify the focus of this book by also indicating what this text does not provide. It is beyond the scope of this book to provide information about counseling children, families, or clients who have serious emotional or psychological difficulties. Although the helping skills taught in this book are crucial and form the foundation for work with all these groups, helpers will need much more extensive and specialized training before they will be qualified to work with these groups.

Furthermore, I do not address the diagnosis of psychological problems or identify characteristics of psychopathology, which are two important topics that require extensive additional training. I encourage helpers to pursue additional training in assessment and psychopathology after developing a working knowledge of basic helping skills. I believe that all helpers, even those working with healthy populations, should be able to recognize serious psychological disorders. This level of knowledge aids helpers in making appropriate referrals and working only with clients they have been trained to assist.

Goals for This Book

I have several goals for this book. After reading it, students should be able to articulate the principles of the integrated three-stage model of helping as well as the theoretical and research foundations underlying this model. They should

demonstrate an understanding of the interactional sequences of helping, including the intentions that helpers have for interventions with clients, the helping skills that are commensurate with these intentions, the possible reactions and behaviors demonstrated by clients, and the means through which helpers evaluate the interventions used. In addition, readers should gain a better understanding of themselves in relation to becoming helpers, including their thoughts about helping as well as their strengths and areas for continued growth. Finally, I hope to instill enthusiasm for the process of learning to help others—an enterprise that is certain to provide countless challenges and rewards throughout a lifetime.

Changes in the Fourth Edition

I continue to modify the model as I teach and do research on helping skills. I have also obtained extensive feedback from students about what they find helpful. The model feels like a living thing because of how I continually find ways to improve it. The fourth edition of this book differs from the first three editions in several ways:

I have added a separate chapter on self-awareness. Although covered before, I wanted to highlight this topic given its importance for helper growth. I have also added a separate chapter on cultural awareness. Students have been hungry for more information about the role of culture in the helping process. Although we are at an early stage in terms of understanding culture, we need to be aware of its role and sensitive to different reactions of clients based on their cultural backgrounds. I have added a greater variety of methods that helpers can use to challenge in the chapter on that topic. I continue to try to make the action stage clearer and easier to use. A summary of a specific research study has been added to each chapter, with highlights about how the results enhance our understanding of the role of helping skills in the helping process. There is now a glossary of the key words so that readers can refer to it when confused by some of the jargon. Much of learning any new system involves learning the language, so we want to make this as easy as possible.

Resources

As with the previous editions, this fourth edition of Helping Skills offers a Web- based “Instructor and Student Resource Guide” (http://pubs.apa.org/books/supp/hill4), the student portion of which features a

http://pubs.apa.org/books/supp/hill4
dozen Web Forms (in downloadable PDFs) that are referred to throughout this text to assist students in evaluating their helping skills and helper–client sessions. The Web Forms page also includes an Emotion Words Checklist—a downloadable version of this edition’s Exhibit 9.2 (see Chapter 9)—that students have found helpful to have handy in a printed format for easy reference during the exploration stage of a helper–client relationship. In addition, the student resources section of the Helping Skills Web site includes downloadable versions of the Labs for various chapters, as well as Practice Exercises for each of the skills chapters of the book.

In addition, two DVDs are available to demonstrate the model. Helping Skills in Practice: A Three-Stage Model was created to illustrate the three stages of working with a client struggling with concerns related to childhood, eating, and self-esteem. Dream Work in Practice was created to illustrate the three stages with a client who had a troubling recurrent dream. Both DVDs are available from the American Psychological Association.

Acknowledgments

I am grateful to the following students who worked with me extensively in researching different aspects of the different editions of this book: Jennifer Dahne, Judith Gerstenblith, Jennifer Jeffery, and Eric Spiegel.

I am also grateful to the many people who have read selected chapters or all of the book and provided valuable feedback on at least one of the editions: Rebecca Adams, Margaret Barott, Kevin Cramer, Elizabeth Doschek, Jessica England, Lisa Flores, Suzanne Friedman, Judy Gerstenblith, Melissa Goates, Julie Goldberg, Jim Gormally, Allison Grolnick, Kelly Hennessey, Beth Haverkamp, Jeff Hayes, Debby Herbenick, Pamela Highlen, Merris Hollingworth, Gloria Huh, Skyler Jackson, Ian Kellems, Kathryn Kline, Sarah Knox, Misty Kolchakian, Jim Lichtenberg, Rayna Markin, John Norcross, Kathy O’Brien, Sheetal Patel, David Petersen, Jennifer Robinson, Missy Roffman, Katherine Ross, Pat Spangler, Jessica Stahl, Nicole Taylor, Barbara Thompson, Linda Tipton, Terry Tracey, Jonathan Walker, Heather Walton, and Elizabeth Nutt Williams. There are also numerous anonymous reviewers who have read and reviewed the book for the American Psychological Association and provided invaluable feedback.

I have profited considerably from the editorial feedback, guidance, and encouragement of Beth Beisel, Dan Brachtesende, Amy Clarke, Beth Hatch, Phuong Huynh, Linda McCarter, Peter Pavilionis, and Susan Reynolds—all from the American Psychological Association Books program—on the various editions of the book.

I am most indebted to the many students in my undergraduate course in helping skills and graduate course in theories and strategies of counseling over the past several years. They have taught me a tremendous amount about how to teach helping skills with their willingness to challenge my ideas, offering thoughtful perspectives on the process of becoming helpers and providing examples for the text. I tried out all the chapters and the lab exercises on many classes before including them in the book. Finally, and with much gratitude, I recognize and acknowledge my therapists, professors, and supervisors, who served as wonderful models for how to use helping skills and provided much encouragement throughout my process of becoming a helper. I particularly want to acknowledge Bill Anthony (who studied with Robert Carkhuff), from whom I first learned helping skills many years ago in graduate school. I clearly recall the heady times of coming to believe that I could help clients if I applied the helping skills.

Nothing in life is achieved without effort, daring to take risks, and often some suffering.

—Erich Fromm

Angeli was a stellar student and athlete. She was president of her high school class and had been accepted into an elite eastern university. By any standard, she was an exceptional and talented individual with much promise. However, after arriving at college, Angeli began to feel sad. Much to the dismay of her family, teachers, and friends, she lost interest in interacting with others, studying for her classes, and attending track practice. Angeli’s track coach encouraged her to meet with a helper, who helped Angeli explore her feelings and gain understanding of the issues underlying her sadness and inactivity. Angeli felt supported, cared for, and challenged by her helper. The helping relationship enabled her to express, understand, struggle with, and overcome the feelings of inadequacy, loneliness, and loss that emerged when she left home for college.

As you read about Angeli and think about what it would be like to be her helper, you may have contradictory thoughts and feelings. You may feel confident that you could help someone like Angeli because you have listened to and advised friends and family members about similar problems. But you may also feel anxiety about knowing how to help her explore her feelings, gain understanding, and work to get back her confidence.

If you are interested in learning more about the skills that would help you work with someone like Angeli, you have come to the right place. The first purpose of this book is to provide you with a theoretical framework that you can use to approach the helping process. The second purpose is to teach you specific skills to use in sessions with clients to help them explore, gain insight, and make

changes in their lives. The third purpose is to get you started in the process of coming to think of yourself as a helper.

This chapter provides an introduction to the helping process, defines helping, and reviews facilitative and problematic aspects of helping. I talk about what makes people seek out professional helpers, and that leads naturally to a discussion about the effectiveness of helping. Next, I introduce the idea of becoming a helper, specifically exploring the healthy and unhealthy motivators for helping other people. Finally, I describe the organization of the book and discuss how it can best be used.

Welcome aboard! I hope you enjoy learning and using helping skills as much as I have.

What Is Helping?

Helping is a broad and generic term that includes the assistance provided by a variety of individuals, such as friends, family, counselors, psychotherapists, and human service providers. I use this broad term (rather than the more specific terms counseling and psychotherapy) because not everyone learning these skills is in a program that offers training and credentialing to become a mental health professional. Of course, these same skills are used by counselors and psychotherapists, but you cannot call yourself a counselor or psychotherapist until you have had further training, practice, and supervision and pass a credentialing examination.

Throughout this book, then, the term helper refers to the individual providing assistance, and the term client refers to the person receiving support. Helping can be defined as one person assisting another in exploring feelings, gaining insight, and making changes in his or her life. Helpers and clients work together to achieve these outcomes, with helpers guiding the process and clients deciding what, when, and how they want to change.

When I talk in this book about trainees who are learning helping skills practicing with each other or with volunteer clients, I refer to the process as helping. In contrast, when I talk about clients seeking help from professionals, I use instead the terms counseling (or counselor) and psychotherapy (or therapist or psychotherapist).

Students often ask about the differences between counseling and psychotherapy. At times, the two are differentiated by length of treatment (counseling may have fewer sessions than does psychotherapy), by clientele (counseling is more often used with relatively “healthy” individuals who have issues with adjustment, whereas psychotherapy serves those who have more serious pathology or unresolved conflicts), by qualifications of the provider (counselors may have master’s or doctoral degrees, whereas psychotherapists tend to be doctoral-level practitioners), and by types of problems presented in sessions

(counseling may deal with development and life transition issues, whereas psychotherapy may address more serious psychological disturbances). However, in fact, I know of no empirical evidence that counseling and psychotherapy can be distinguished in terms of the processes or outcomes.

Is Psychotherapy Effective?

Investigators have overwhelmingly concluded that psychotherapy is generally helpful. Most clients improve by the end of psychotherapy. Specifically, Wampold (2001), in his review of the literature, found that the average client who was in psychotherapy was psychologically healthier than were 79% of untreated individuals. Wampold concluded that “psychotherapy is remarkably efficacious” (p. 71).

Once researchers established conclusively that psychotherapy in general is indeed helpful, they began to examine the relative effectiveness of different types of therapy. To date, hundreds of studies have compared different types of treatment (e.g., client-centered, psychodynamic, cognitive–behavioral, experiential), but no one type of therapy has been found to be more effective than others (Lambert, 2013; Wampold, 2001; Wampold et al., 1997). Wampold noted, however, that the treatments studied were all sanctioned forms of treatment rather than fringe or quack forms of treatment, so these results may not hold for nonmainstream treatments. Similarly, no differences have been found between individual and group treatments (Piper, 2008; M. L. Smith, Glass, & Miller, 1980). The findings from this area of research have been humorously summarized using the dodo bird verdict from Alice in Wonderland: “Everyone has won and all must have prizes” (Carroll, 1865/1962, p. 412).

It is probably hard to understand how therapies that are so different can all lead to the same outcomes. Many different reasons have been proposed for the lack of differences across approaches. The most currently popular explanation is that factors involved in all types of mainstream approaches (i.e., common factors) lead to positive outcomes. Frank and Frank (1991) discussed six factors that are common across psychotherapies: the therapeutic relationship, instillation of hope, new learning experiences, emotional arousal, enhancement of mastery or self- efficacy, and opportunities for practice. Thus, although therapists from different orientations espouse different philosophies and use somewhat different skills, the most important factor may be what therapists do in common.

Another explanation for the lack of differences among psychotherapeutic approaches is that client and therapist factors explain more of the variance than do treatment types (again, see Wampold, 2001). Thus, differences among therapists and clients may be more important than the approach used.

Yet another explanation (and one that I personally prefer) is that our research is still at a rather primitive state and that our tools for examining the process and

outcome of therapy are not sophisticated enough to pick up the differences between approaches. It is quite possible that all approaches can be helpful and lead to similar outcomes but do so through different mechanisms. For example, experiential therapy might heal through allowing deep immersion into feelings, which then leads the client to change thoughts and behaviors. By contrast, cognitive–behavioral therapy might begin with changes in thoughts and behaviors, which in turn lead to a change in emotions. Furthermore, different therapists and clients may prefer approaches that fit with their worldviews and personality styles.

Another interesting line of research involves how many psychotherapy sessions are needed to reduce psychological distress and return the client to normal psychological functioning (e.g., Grissom, Lyons, & Lutz, 2002; Howard, Lueger, Maling, & Martinovich, 1993; Kopta, Howard, Lowry, & Beutler, 1994). In their reviews of a large number of studies, these researchers proposed three phases of the psychotherapeutic recovery process. In the first phase, clients change rapidly in terms of feeling subjectively better. In the second, slower phase, there is a remediation of symptoms such as depression and anxiety. In the third and slowest phase, there is rehabilitation of troublesome, maladaptive behaviors that interfere with life functioning in areas such as family and work. Clients with minimal distress improve fairly quickly, whereas clients with chronic characterological problems (i.e., innate, severe, ongoing, and difficult-to-treat disorders) require the greatest number of sessions to return to normal functioning.

In his review, Lambert (2013) found that 50% of clients who were in the dysfunctional range at the beginning of therapy achieved clinically significant change after 20 sessions of therapy. He noted, however, that it takes more than 50 sessions for 75% of initially dysfunctional clients to reach clinically significant change. It is interesting that positive mental health is rarely mentioned in these studies but is an important index of outcome.

Facilitative Aspects of Helping

There are a number of ways in which helping can be facilitative. For people in emotional pain, helping can provide support and relief. For example, Jillian and Jesse went to couples counseling because Jillian had been involved in a sexual relationship with a colleague. Both Jillian and Jesse were extremely hurt and felt angry with each other. Positive changes in their relationship came after months of working on communication skills, receiving assistance in exploring feelings, understanding the factors related to the affair, and learning how to work proactively to improve their relationship. After several sessions, Jillian and Jesse were able to communicate their feelings more openly, grieve the loss of trust in their relationship, and move toward rebuilding their lives as a cohesive and caring couple. They felt that their therapist had been supportive, and they felt relief from the problems for which they sought therapy.

Through the process of helping, clients can also gain insight, such that they come to understand themselves in new ways. For example, in her book about serving as a psychologist in Iraq, Kraft (2007) described the process of therapy working with a soldier who could not walk even though the medical doctors found no physiological reason for this inability (a condition called conversion hysteria). After establishing a good relationship with the soldier, Kraft was able to help the soldier talk about losing a friend who died trying to shield him from danger. Once the soldier gained insight into the reason for his symptom, he was able to walk again. It is interesting to note that many of Freud’s first patients similarly had conversion hysteria and were healed through catharsis and insight.

In addition, helping can assist individuals in dealing with existential concerns (i.e., who am I, where am I going, and what do I want out of life?). As Socrates said, “The unexamined life is not worth living.” Helping can promote proactive involvement in life when these questions are asked, reflected on, and answered. For example, Max was referred for helping because of failing grades, poor peer relationships, and generalized sadness. After several sessions, Max began to address critical questions regarding how he might live his life, the fears he often confronts within himself, and the salience of his relationships with others. Helping provided him with an opportunity to look within himself, discover what was important, and then make decisions about how to change his unhealthy behaviors.

Moreover, clients can learn skills needed to live more effectively and reach their potential. These skills may include learning how to communicate with others, practicing ways to resolve conflicts, becoming more assertive, identifying decision-making strategies, studying more effectively, learning to relax, or changing unhealthy habits (e.g., rarely exercising; having unprotected, anonymous sex). Often, these skills can alleviate the powerlessness that individuals feel when they are unable to communicate their emotions directly and can assist clients in engaging more fully in their lives.

Helping can also assist individuals in making decisions about the direction of their lives. The most effective helpers have the ability to assist individuals in determining goals that are consistent with their dreams, values, and abilities. For example, Mai Lin came to counseling because she was uncertain about whether she should move far away from her family and end her relationship with her live-in boyfriend. She described her current situation and asked the helper to tell her what the best path for her would be. After dealing with her anger and frustration at the helper for not providing the answers, Mai Lin was able to explore her unwillingness to take responsibility for the direction of her life and her reluctance to address the questions that plagued her. She contemplated her fear of taking action and of making wrong decisions and connected this with feelings of helplessness she had experienced as a child of a battered woman. Further exploration of thoughts, feelings, and behaviors provided her with the desire to make small decisions (with the support and encouragement of her helper). Soon, Mai Lin was able to progress to more challenging decisions (e.g., ending her romantic relationship, moving across the country alone to explore her

independence and to understand herself better). An additional facilitative aspect of helping involves helpers providing

feedback about how clients appear to others, information that others might hesitate to provide. For example, a client who is having difficulty maintaining relationships may be able to hear (from the helper) that he appears dependent and needy in sessions and may want to examine whether these behaviors are present in other relationships. When phrased in a gentle manner, honest feedback can sometimes be extremely helpful in motivating individuals to change.

Helping also can enable a client to experience a healthy, nondamaging, intimate relationship with another person. Sometimes the helping process involves a corrective relational experience (something like reparenting) in that a caring relationship with a helper alleviates some of the hurtful and unhealthy interactions experienced with important figures early in life. For example, Kondja came to helping because she felt depressed and lacked direction in her life. She believed that her mother did not want her as a child, and she cried when she saw mothers and daughters who were connected and loving with one another. Kondja had been in a series of relationships in which she felt ignored, alone, uncared for, and discounted. During the helping process, Kondja experienced the helper as unconditionally accepting, actively listening, and genuinely caring. The development of a supportive relationship with a helper assisted Kondja in healing past wounds, drinking less alcohol to numb her feelings, and developing healthy relationships in which she valued herself enough to ensure that her needs were met.

Finally, effective helping teaches clients to function on their own. Similar to the way children grow up and leave their parents, clients also need to leave their helpers after engaging in the helping process. Perhaps some of you have tried to teach another person to skate: You hold the person up, and she or he hangs on while making a first attempt at skating. In time, the person begins to skate alone. The steps that the learner makes on his or her own are rewarding not only for the learner but also for you as the teacher. The same is true with helping: Providing the initial support and teaching the skills are most effective when individuals internalize the messages and take off on their own.

Problematic Aspects of Helping

Although helping is usually beneficial, there are a few potentially problematic aspects. Sometimes helping can provide just enough relief to enable people to stay in maladaptive situations or relationships. For example, battered women’s shelters provide needed safety and security to abused women and their children. However, some shelter workers have observed that occasionally they provide just enough assistance to enable women to return to the abusive situation. When the workers in one shelter confronted this “enabling” in themselves and discussed these behaviors with the residents, some of the battered women were able to

identify their pattern of seeking shelter during the abusive periods and returning home in the “honeymoon” period. Without this insight, helping could have enabled some of the women to continue in a potentially deadly cycle.

Another potential problem is that helping can create dependency if clients rely too much on their helpers for support and feel unable to explore feelings or make changes in their lives without assistance from the helper. For example, Kathleen might decline a spontaneous invitation to join her new partner’s family on Cape Cod for a week because her helper is on vacation and unavailable for consultation. Helpers sometimes facilitate dependency by providing clients with “the answers” to their problems (e.g., if her helper told Kathleen not to go to Cape Cod). Effective helpers understand that providing the answers does not typically help clients; rather, most clients need to participate actively in a process whereby they uncover new insights and discover which actions feel best for themselves. This strategy works because only clients fully know the situations, experience the associated feelings, and have the best answers to the presenting problems. In addition, advising others may be problematic when the solution does not fit with what they want or think they need. Many of us have made suggestions to family members or friends about how to handle difficult situations, only to find that our advice was not exactly what they wanted to hear. For example, a helper advised a client to stay away from her boyfriend who broke up with her because he was not good enough for her. Although the client was eager at the time to hear about how rotten the boyfriend was, she resented the helper’s critical words about her sweetheart when they later got back together.

In addition, helpers’ personal issues sometimes place them at risk for encouraging dependency in those they assist. For helpers who are lonely and isolated, their clients’ dependency may fulfill personal needs that are not being met elsewhere. Helpers who have not developed a network of social support and personal relationships may be at special risk of encouraging their clients to rely extensively on them.

Another problematic aspect of helping emerges when helpers unduly impose personal or societal values on their clients (McWhirter, 1994). Although all of us have values that shape who we are, the goal of helping is to encourage clients to explore and choose their own values. Examples of undue influence are when a helping professional attempts to alter the sexual orientation of people who are lesbian, gay, or bisexual (Haldeman, 2002); advises parents to raise their children in a certain religion because the helper believes that problems in families result from children not having a strong religious foundation; or states that women should not work outside the home because they take jobs away from qualified men who have families to raise. These examples all involve the helper attempting to force his or her values on the client.

Values can also be imposed at a more subtle level. In an investigation of Carl Rogers providing therapy, Truax (1966) found that in fact Rogers was more reinforcing of some client behaviors than others. For example, Rogers responded with more empathy and warmth when the client expressed insight, but with less

empathy and warmth when the client was ambiguous. In other words, even Rogers, who worked hard to be accepting and empathic, demonstrated that he valued certain client behaviors over others. These results show that it is difficult to leave our biases behind.

It can also be problematic when helpers work outside their areas of competence (e.g., working with someone who has substance abuse but not having knowledge about that area). Similarly, helpers sometimes try to force clients to explore difficult topics, such as sexual abuse, without making sure that clients feel safe and have the necessary emotional regulation skills to explore such topics. Finally, it can be difficult when helpers are paired with clients with whom they do not “click.” As in friendships, one needs to have a certain “clicking” with one’s helper to feel comfortable enough to talk about one’s problems. Without that matching, clients can become discouraged and actually feel more distressed because they might feel that no one can understand and help them.

When Do People Seek Help From Others?

Two factors seem to be necessary for people to seek help (Gross & McMullen, 1983). First, a person must become aware that she or he is in pain or is facing a difficult situation and then must perceive her or his feelings or situation as being problematic. Obviously, the perception of pain varies from person to person, such that what is unbearable for one person is easily tolerated or ignored by another person.

Second, the pain must be greater than the perceived barriers to seeking help. Sometimes the barriers involve practical considerations, such as the time or money required to obtain help; but often the obstacles are emotional and can include fears about exploring problems deeply or concerns about the opinions of others regarding people who seek therapy.

Many people hesitate to seek professional help (Gross & McMullen, 1983) because they feel embarrassed or ashamed about asking for assistance or believe that seeking help constitutes emotional weakness or inadequacy (Shapiro, 1984). Many Americans, for example, believe that individuals should rely solely on themselves and that all problems should be solved individually. Given these beliefs, it is not surprising that researchers have found that people seek help first from friends and family members and only last from professionals (Snyder, Hill, & Derksen, 1972; Tinsley, de St. Aubin, & Brown, 1982; Webster & Fretz, 1978).

Some people are concerned about talking with others because they feel that no one else can possibly understand their situation (e.g., Thomas thought that no one could understand his experience growing up in a religious cult). Others fear a punitive response or a value judgment regarding their thoughts, feelings, or actions (e.g., Candace felt that she would be judged for having had two abortions). Furthermore, some people may be concerned that they will be labeled mentally ill

and thus be subject to the many negative stereotypes and stigma associated with this label (Hill et al., 2012; D. Sue, Sue, & Sue, 1994). Some clients may be hesitant to seek therapy because they rely on their insurance companies to pay for therapy: They may be concerned that the stigma associated with receiving therapy could have negative ramifications for obtaining insurance or employment in the future.

For example, Conchita came to her first session of psychotherapy because she was experiencing multiple stressors: Her mother had committed suicide 3 years earlier, her sister had been diagnosed with depression, she was failing all of her courses (previously, she had been an A student), her first serious boyfriend had broken up with her, and she was pregnant. For some time, Conchita had felt that she should handle her problems by herself because she feared what others might think of her if they knew that she needed to see a therapist. Moreover, she was on a limited budget and was reluctant to pay for therapy. However, Conchita had begun to feel that she could no longer cope with her problems by herself. Her brother had gone to a therapist and felt better, so she thought that going to a therapist might work for her. Thus, Conchita sought help because she perceived herself as having problems and she believed that the potential benefits associated with therapy (e.g., emotional support, assistance with coping) outweighed the costs (e.g., financial expense, perceived stigma).

Individuals in considerable pain who are able to admit their need for psychological assistance have made significant progress toward obtaining the help they need. Support from friends and family can provide the encouragement these individuals need to contact trained helpers (Gourash, 1978). For example, Joe was reluctant to seek help after his wife of 40 years died. His friends and children encouraged him to attend a support group for adults who had lost their partners. Although initially reluctant, Joe was so upset about his loss that he agreed to participate in the group sessions if his daughters would accompany him. The support his family and friends provided enabled Joe to access the help that he needed.

Helpers can work to change negative attitudes about seeking professional psychological assistance in our society. We can begin by seeking help ourselves and encouraging others to seek help when needed. We can also work to initiate and support legislation for additional mental health benefits. In addition, we can work to educate the public by publicizing information about mental health treatments. Finally, we can do research to discover more about the process and outcome of helping endeavors and disseminate these research findings to the public.

On Becoming a Helper

The model I promote in this fourth edition of Helping Skills describes three components to being a successful helper: helping skills, self-awareness, and a

facilitative attitude. See Figure 1.1 for the connections among these three components.

FIG U R E 1 . 1

Components needed for effective helping.

I propose first of all, however, that the “wannabe helper” begins with a natural inclination toward helping. She or he has taken on a helping role in many situations early in life, friends and family find him or her to be helpful, and she or he has emotional intelligence along with a passion for helping others. As a part of helping others, the wannabe helper has naturally learned communication skills that are helpful, although the person may not be aware of how she or he comes across to others and can sharpen the skills.

This natural inclination is augmented by learning and practicing helping skills until they become an integral part of who we are, even when those behaviors initially feel awkward and forced. Many effective helpers have stories about their initial attempts at assisting others. For example, when one person first started studying helping behaviors, her father was undergoing heart surgery. She spoke with him every day and asked him how he was feeling. After weeks of this, he asked her whether she really wanted to know how he was feeling. “Finally!” she thought, “he’ll share his innermost feelings with me.” Her father said he was feeling as though he liked her a lot more before she began studying helping skills.

Many of your friends and family may have similar reactions as you begin to learn helping skills. This may initially be discouraging, but it may help to know that most effective helpers practice these behaviors for many years before comfortably integrating them into their interactions with clients. In fact, some helpers discover that during the process of becoming a helper, their helping skills and confidence get worse before they get better. This down-and-up pattern makes sense given that trainees learn that not all of their old communication styles work,

and they feel temporarily awkward until the new patterns become integrated into their own personal style. Similarly, Goldfried (2012) talked about how, when learning a new behavior, people move from unconscious incompetence (i.e., they are not aware of what they do not know or cannot do) to conscious incompetence (i.e., they become aware that they are not very good at the skills and thus their confidence dips) to conscious competence (i.e., they become skilled but behave in a self-conscious manner) to unconscious competence (i.e., the skills recede into the background, and they have increased self-efficacy).

In addition to the natural inclination and knowledge of skills, helpers must have self-awareness. Chapter 4 describes self-awareness as both a trait (i.e., self- knowledge and self-insight about general personality characteristics or motivations) and a state (i.e., an in-the-moment understanding of what one is feeling and perceiving). Self-awareness is crucial so that helpers know what is going on inside themselves and can then separate out how they are reacting to clients. Otherwise, helpers might act out on impulses and reactions of which they are unaware and harm clients. Hence, self-awareness seems to be a foundation for effective interventions.

Similarly, having a facilitative attitude toward the specific client in the specific moment is a necessary foundation. Facilitative attitudes include empathy, warmth, genuineness, compassion, and nonjudgmentalness. These facilitative conditions are not something that helpers possess generally but rather are something that helpers feel in the moment toward specific people. These facilitative conditions naturally fluctuate across and within clients.

This model suggests that some people are more oriented than others toward becoming helpers. These people then work to gain general self-knowledge about who they are as people and as helpers, and they work to become more skilled as helpers. And then within a specific session with a client, they work to become aware of feelings and perceptions, and they strive to have a facilitative attitude.

In other words, it is not enough just to know the skills, because skills implemented without self-awareness and facilitative attitudes would be noxious and unhelpful. Likewise, having just self-awareness and a facilitative attitude would be nice, but it would not be very helpful, because the person would not know how to communicate and intervene with clients. Thus, helpers need to be self-aware so as not to inappropriately use clients, they need to genuinely care about the client, and they need to know how to use helping skills to help clients.

Overview of This Book

ORGANIZATION The second chapter in Part I of this book provides an overview of the helping process in terms of the three-stage model and a description of the components of helping. Chapter 3 provides an overview of ethical issues involved in helping.

Chapter 4 involves a discussion of self-awareness (including both self-knowledge and in-the-moment awareness). Chapter 5 introduces the important topic of cultural awareness.

Parts II, III, and IV present more description of the exploration, insight, and action stages, respectively. In each part, an overview chapter highlights the theoretical foundation and the goals of the stage. The chapters that follow the overview chapter focus on skills that can be used to accomplish specific goals within the given stage. At the end of each part, a chapter addresses the integration of the skills taught for that stage and presents clinical issues that arise in implementing the stage. Finally, Part V involves integrating the skills into ideas for how to conduct sessions with clients. Issues that arise in helping sessions (e.g., beginning a session, termination) are discussed.

Please note that a lot of examples are used throughout the book to make the points come to life. Some examples are based on real people (names have been changed to protect the identities of those involved); other examples are completely fictitious, created to illustrate a given point.

RESEARCH SUMMARIES In each of the chapters, there is a special section summarizing the results of an applicable research investigation. Given the importance of an evidence base for helping, some knowledge of research studies is valuable. I encourage readers to study these research summaries carefully and think about the evidence. In addition, given that the establishment of an empirical foundation is in its infancy, I strongly encourage readers to conduct research of their own so that we can have evidence about how to modify psychotherapy and training.

EXPERIENTIAL COMPONENT Reading about helping skills is important, but reading alone will not make you an effective helper. Many students have said that when they did the reading, the skills sounded easy, but when they tried to actually practice doing the skills, they came to realize how difficult it is to use them and use them effectively.

Acquiring extensive knowledge about helping, although important, is only the first step in your journey toward helping others. Probably the best way for you to learn the skills is first to read and study the text and then try to apply what you have learned by answering questions about the material and by participating in practice helping exercises and lab experiences. The following sections describe the ways in which you can use this book to maximize your growth as a helper.

What Do You Think? Several questions are provided at the end of each chapter to stimulate your thinking about the text material. I strongly feel that it is important for students to debate the issues raised in this book rather than slavishly accepting everything written here.

There are few hard-and-fast “truths” or rules related to helping skills; rather, many of the issues are matters of taste, style, or art, and trainees need to think for themselves about how they want to be as helpers. I encourage you to contemplate each question and discuss your answers with your classmates.

Practice Exercises Practice exercises provide readers with the opportunity to think about and formulate responses to hypothetical client situations before practicing the skills in the lab setting. You can practice by downloading the PDF of the practice exercise from the student resources area of the Helping Skills (4th ed.) website (http://pubs.apa.org/books/supp/hill4), writing down an intervention for each client situation on the Practice Exercise sheet, and then comparing your answers with the suggestions for possible responses (remembering that these are just suggestions).

Laboratories The companion website for this book (http://pubs.apa.org/books/supp/hill4) contains downloadable lab exercises so that beginning helpers can practice helping skills in dyads or small groups. These labs are ones that I have used over the years in both my undergraduate- and graduate-level helping skills classes, so they have been tested and seem to work (although of course, instructors should feel free to modify these labs to fit their own preferences and situations). You can download the labs from the student resources area of the website.

During labs, helpers are asked to practice the skills with peers who act as clients presenting real or role-played problems. Observers take careful notes and attend to the helper’s ability to deliver a particular skill, so that they can provide feedback to the helper. Thus, everyone has an opportunity to experience the roles of helper, client, and observer for each skill. At the end of each lab in the personal reflections section, students are asked to think about their ongoing development as helpers.

Disclosure During Lab Exercises The success of the lab experiences depends partly on the participants’ willingness to reveal information about personal topics. It is preferable for participants to discuss personal topics for two reasons. First, helpers have difficulty learning what is effective when “clients” are not responding genuinely. Second, “clients” often are unable to provide useful feedback to helpers about what is helpful and how the interventions feel if they are not discussing real problems. When role- playing, “clients” are often more involved in trying to think of how the person they are pretending to be might feel or behave than in immersing themselves in the immediate experience.

As clients, however, students should disclose only about easy, safe topics.

http://pubs.apa.org/books/supp/hill4
http://pubs.apa.org/books/supp/hill4
Students should never disclose about deep topics, even if they are comfortable disclosing, because their classmates will not be comfortable trying to help them, and it takes the focus too much off the helper learning helping skills and on the helper trying to help the client. At times, students might start talking about an issue they think is safe but then become uncomfortable, either because of the depth of the topic or because they do not feel comfortable with the helper. I stress that students always have the right (without jeopardy or prejudice) to indicate that they choose not to explore a particular issue further.

At this point, it may be helpful to note that the “Ethical Principles of Psychologists and Code of Conduct” (American Psychological Association, 2010, Standard 7.04) indicates that

psychologists do not require students or supervisees to disclose personal information in course- or program-related activities, either orally or in writing, regarding sexual history, history of abuse and neglect, psychological treatment and relationships with parents, peers and spouses or significant others except if (1) the program or training facility has clearly identified this requirement in its admissions and program materials or (2) the information is necessary to evaluate or obtain assistance for students whose personal problems could reasonably be judged to be preventing them from performing their training- or professionally related activities in a competent manner or posing a threat to the students or others. (p. 9)

This guideline was established to educate people about the perils of requiring disclosure. Thus, although I recommend easy, safe, nondeep disclosure because it typically facilitates the training process, I urge both instructors and students to be alert for possible negative effects.

If students are not willing to disclose personal information, they can role-play a hypothetical client. In such cases, they should not reveal whether the problem is role-played or real—in this way no one ever knows whether the person is actually disclosing or whether the problem is role-played, thus preserving confidentiality.

Exhibit 1.1 provides topics that students have discussed. Although a topic may be “safe” for many people, it may not be comfortable for an individual student, so trainees must think about what they want to discuss. Students may want to refer to this list throughout the semester when a topic is needed for the lab exercises.

E XHIB IT 1 . 1 Topics for Volunteer Clients to Talk About in the Labs

Ideal Topics Anxieties about learning helping skills Worries about performance of helping skills Academic issues (e.g., studying, test anxiety) Career; future plans Choosing a major or graduate program Pets Problems at work Public-speaking anxiety Roommate issues Romantic relationships Feelings about technology Happy childhood memories Hobbies and extracurricular activities Problems with health

Relatively Safe Topics Depending on Client Minor family issues Autonomy–independence struggles Minor relationship concerns High school experiences Personal views on alcohol and drugs Existential concerns (e.g., Who am I? What is the meaning of life, death?) Financial difficulties Problems with physical appearance Moral dilemmas

Topics to Be Avoided Substance abuse Fears about going crazy Traumas (e.g., sexual or physical abuse, rape, victimization, child abuse, serious medical

condition) Serious problems in romantic relationships Shameful feelings Serious family disputes Sex Sexual abuse Suicidal thoughts Murderous thoughts

Confidentiality During Lab Exercises Although practice sessions might seem somewhat artificial, the information shared

is personal and should be treated in a confidential manner. Helpers should not disclose information shared in practice sessions without the permission of the client. Specifically, helpers should only discuss the material presented in helping sessions with their supervisors and classmates, and then only when it relates to developing their helping skills. When one respects clients, they typically respond by sharing personal information and delving into their thoughts and feelings. Confidentiality of shared information thus provides a foundation for respectful interactions with others (see extended discussion of ethical issues related to confidentiality in Chapter 3).

Benefits of Being a Volunteer Client The primary focus of the lab experiences is on the helper learning the helping skills. However, students often report that it is beneficial to talk about their concerns when they participate in the client role and that the experience of being a client provided them with firsthand exposure as to how it feels to receive the various helping skills. Moreover, students often develop empathy with their clients after having experienced what is involved in being a client. Being a participant in counseling allows students to experience “the other side” of helping and to gain respect for the courage clients exhibit when they share their concerns with their helpers. In addition, beginning helpers often report that watching their helpers provide helping skills can teach them about effective (and ineffective) helping techniques.

I stress, though, that being a client in practice helping sessions should not be used as a substitute for seeking counseling or therapy. Students experiencing personal distress should seek help from a trained and qualified counselor or therapist. University counseling centers or health services often provide counseling services for college students at little or no cost and offer an excellent opportunity for students to learn more about themselves and address salient issues.

Problems Related to Practicing Skills With Friends During the Labs Another important issue involves the recognition that problems can occur when practicing helping skills with classmates who are friends or acquaintances. During helping sessions with friends, it is a good idea for helpers to pretend that they know nothing about their friend and respond only to what the “client” actually reveals during the helping session. Although it is challenging to discount relevant information, students in my classes have found the lab exercises easier to perform if they consider only information provided in the practice helping session. For example, Nancy was practicing her helping skills with her friend, Katrina, who was bemoaning the fact that her partner had not called her in 2 weeks. Although Nancy knew that Katrina’s partner had not called because Katrina had dated someone else, she focused only on Katrina’s expressed feelings related to not

having contact with her partner. In Chapter 3, I focus more on ethical issues related to using helping skills with friends outside the lab setting.

Providing Feedback to Peers Providing feedback is an essential component of training. Helpers appreciate positive feedback because learning helping skills is challenging, and they appreciate encouragement when they are on the right track. However, they also need and want feedback that helps them change and improve their helping skills. It is enjoyable to have people tell us that we are doing a terrific job as helpers, but we also need observers to provide concrete recommendations for how we might improve our skills. Students often feel cheated if they consistently receive only positive feedback yet also feel wounded if they receive too many critical comments.

Claiborn, Goodyear, and Horner (2002) recommended providing positive feedback first and then providing only one piece of constructive feedback. It is less overwhelming and more feasible to focus on making one change in a given lab experience rather than trying to fix everything at once. For example, the observer might say,

You used good attending and listening skills; I particularly liked that you had good steady eye contact, leaned forward while you were listening, and did not interrupt. One thing I noticed though that you might think about is that you asked a lot of questions in one speaking turn, making it hard for the client to know which one to respond to.

Note that the feedback should be stated in behavioral terms (e.g., “You were looking away a lot and playing with your hair”) rather than in broad and nonspecific terms (e.g., “You did not connect with the client”). Having clear, concrete feedback gives the helper specific ideas for how to change.

The best source of feedback is the client who experienced the helper’s interventions firsthand and experienced whether or not these interventions were helpful. The next best source of feedback is from observers who have watched the practice session and see from the outside what was happening. It can be beneficial for helpers to hear that different people have different responses to the same intervention, thus emphasizing that there is no one right way to intervene.

DVDs

A new feature of the third edition of the book was an accompanying DVD, Helping Skills in Practice: A Three-Stage Model. For this fourth edition, we have also produced a DVD of the helping skills model applied to dream work, Dream Work in Practice. These DVDs can be used to illustrate the three stages of the helping- skills model. Modeling has been shown to be an effective training tool (see review by Hill & Lent, 2006), probably because it brings the written word to life. It is important to remember though that the DVDs provide only two examples of how to

do the three stages. How you implement the three stages will depend on your style and the needs of the particular client.

Concluding Comments

You are about to embark on an exciting and challenging journey toward becoming a helper. Although learning helping skills takes time, knowledge, and a lot of practice, the rewards for integrating helping skills in your personal and professional repertoire are plentiful. I hope to help you reach your destination of learning helping skills by focusing on the development of these skills while providing a theoretical and research foundation for helping behaviors, as well as by providing exercises to practice these skills.

Effective helping requires practice, and even experienced helpers often return to the basics to review and refresh skills. To become a good helper, you will need to continue practicing after this course. It takes many years to become an expert counselor or therapist (see also Orlinsky & Ronnestad, 2005; Skovholt & Jennings, 2004), so I encourage you to pursue professional training, and practice, practice, practice.

I want to end this section by giving a metaphor that a Korean student used. She likened this book to a Korean bowl of bibimbap, a dish of rice with various sautéed and seasoned vegetables and meats that is made by each person as everyone sits around the table. Each person at the table may construct a slightly different bowl of bibimbap, but all might be delicious. Similarly, as you go through each chapter of the book, you will throw different skills and ideas into your bowl of bibimbap. You may agree more with some skills and ideas than with others, and so you will throw more of these into your bowl (theory). Ingredients that you do not like, you will not throw in, but you might consider them more at some other time when you are again constructing your theory. At the end, you mix all the ingredients together, and you have the beginnings of a cohesive theory of helping.

I hope this book assists you in learning helping skills and exploring your potential for, and interest in, becoming an effective helper. Good luck! And enjoy constructing and sampling your bowl of bibimbap.

What Do You Think?

Think of a time when you felt helped by someone. What did that person do that was helpful to you? Now remember a time when you needed help and the person you turned to was not at all helpful. What did she or he do to make this experience unhelpful? Describe how society perceives those who seek professional help.

How could you help decrease the stigma attached to help-seeking in our society? Write a brief job description for a helper. Include personal characteristics, required training, and job responsibilities. Now, evaluate yourself in comparison with the description that you developed. What would it take for you to seek professional help? Address the benefits and costs you associate with seeking assistance. Debate why people want to become helpers. Identify several current situations in your life in which helping skills could be used. In your opinion, what are the top three characteristics of an effective helper?

R E S E A R C H S U MMA RY Effects of Helping Skills Training Citation: Hill, C. E., Roffman, M., Stahl, J., Friedman, S., Hummel, A., & Wallace, C. (2008). Helping skills training for undergraduates: Outcomes and predictors of outcomes. Journal of Counseling Psychology, 55, 359–370.

Rationale: We need to know if helping skills training is effective. Do students actually learn the skills? What predicts who benefits most from training?

Method: Undergraduate students from three semester-long helping skills classes (involving weekly 2-hour lecture/skills demonstrations along with weekly 2-hour labs where students practiced skills) participated. Students completed ability measures (self-rated empathy, self- rated perfectionism, and grade-point average) at the beginning of the class so that we could use these as predictors of who would benefit from training. After every weekly lab, students completed measures of their confidence in using the helping skills effectively. At the beginning of the semester and two thirds of the way through the semester, students completed 20-minute helping sessions with classmates and also completed postsession measures assessing the helpfulness of these sessions. At the end of the semester, students reported their current self-efficacy as well as how they felt about their self-efficacy for using helping skills at the beginning of the semester.

Interesting Findings: Students reported an increase in confidence about using the helping skills across the course of the semester, although there was a dip in confidence during the time they were learning insight skills. As helpers in the helping sessions, students used more exploration skills (e.g., restatements, reflections of feelings) and rated the quality better in the second helping session than in the first helping session. Similarly, as volunteer clients, students indicated that their helpers used more exploration skills, rated the quality of sessions higher, and rated helpers as more empathic in the second helping session than in the first helping session. On the basis of codings of transcripts, helpers used more exploration skills and fewer words in the second session than in the first session. At the end of the semester, helpers rated themselves as having higher self-efficacy for using the helping skills than they had at the beginning of the semester. Self-rated empathy, self-rated perfectionism, and grade-point average were not associated with outcome of training.

Conclusions: Helping skills training appears to be effective in terms of students learning exploration skills, becoming more empathic, talking less in sessions, conducting better sessions, and feeling a sense of self-efficacy for using the skills. Insight skills are more challenging to learn than are exploration and action skills. We were not able to predict who benefited from training on the basis of the self-report measures used. Performance-based measures (e.g., ratings of how prospective helpers behave in helping- like settings) might be better predictors.

Implications for Training: It seems justified to train students in helping skills.

BONUS MATERIALS

Practice exercises, labs, and other resources for students and teachers are available on the companion website: http://pubs.apa.org/books/supp/hill4.

http://pubs.apa.org/books/supp/hill4
We ought to respect the effect we have on others. We know by our own experience how much others affect our lives, and we must remember that we in turn must have the same effect on others.

—George Eliot

A theoretical foundation is important for providing an overall picture of the goals of helping. It also enables helpers to make decisions about how to conduct helping sessions.

We all have theories and philosophies that guide our behavior, although we are often not aware of these theories because we have not explicitly examined them. In this chapter, I present the personal philosophy of human development and the helping process that I have developed over the years. I hope this presentation will help each of you think through your beliefs and thus help you continue to develop your personal philosophy.

The theoretical foundation that I propose in this book is based on an integration of several major approaches. Given that no differences have been found among the major theoretical orientations in terms of their effects on outcome (see Wampold, 2001) and because I find value in all the approaches, I integrate the best of these approaches in a philosophically consistent way that fits with my personal style and values. Thus, the three-stage model moves from exploration (based on client-centered therapy) to insight (based on psychoanalytic therapy) to action (based on behavioral therapy).

Assumptions Underlying the Three-Stage Model

I believe that people are born with varied potential in the psychological,

intellectual, physical, temperamental, and interpersonal domains. Thus, some people are genetically more intelligent, attractive, physically strong, active, verbally articulate, and mechanically adept than are other people. In terms of temperament, some people are by nature more active, whereas others are more phlegmatic or slow to warm up. In terms of morality, I do not believe that people are either inherently good (as Carl Rogers postulated) or inherently governed by instinctual urges (as Sigmund Freud postulated) at birth. Instead, once again, I believe that people have certain biological predispositions at birth and have a tendency toward fulfilling these potentials. How they are developed depends largely on the environment, to which I turn next.

The environment can enhance or thwart the innate movement toward survival and development. Healthy environments provide basic biological needs (e.g., food, shelter) and emotional needs (e.g., relationships characterized by acceptance, love, support, encouragement, recognition, and appropriate challenges). No environment is perfect, but the environment needs to be “good enough” to allow children to grow and develop. In contrast, when negative things happen in a child’s environment, the child’s development is thwarted. A child growing up in the midst of war and terrorist attacks has a different view of life than does a child growing up during peace. Furthermore, either too much gratification or too much deprivation stunts children’s growth, but an adequate good-enough amount of support allows children to develop naturally to fulfill their potential. So resiliency, or the ability to adapt, is both biologically and environmentally determined.

Early experiences, particularly in terms of attachment to caregivers, are crucial in laying the foundation for personality. Infants need to be nurtured by caretakers to have a firm foundation for interpersonal relationships and self- esteem. If these attachment needs are not met, children become anxious or avoidant of human contact (Bowlby, 1969, 1988).

People develop defenses to cope with anxiety, particularly during childhood, when they have less control over their personal destinies (e.g., a child might learn to withdraw to defend against dominating parents). A moderate level of defenses is adaptive because one needs strategies to cope with life. These defenses become problematic, however, when the individual cannot discriminate when it is appropriate to use defenses. For example, if a child who was abused avoids all adults, she or he cannot form benevolent relationships with caring people.

Although I strongly believe in the influence of early experiences, I also believe that we look toward the future in determining what we want out of life. Thus, we have existential goals, such as figuring out the meaning of life and determining what we want to accomplish during our lives, that guide our behavior.

I also believe that people have some degree of control over their lives and over their choices about how they behave. Within limits of what is available, one makes choices that alter the course of one’s life. For example, although friendliness is influenced by personality (e.g., introversion vs. extroversion) and previous experiences with meeting people, a person still has some range of

choices about how she or he acts with others in a new situation. Thus, determinism is balanced by free will. Furthermore, I believe that free will can be enhanced if individuals gain insight into their background, needs, and desires. Understanding enables one to have more control over one’s fate. One can never have complete control over fate, but one can have some influence through awareness and conscious effort.

In the United States, there is a strong emphasis on individualism and self- determination, which often works to the detriment of people who have limited control over their lives. In that regard, I cringe to hear the phrase that if people just work hard, they can be successful. From my many years of working in psychology, I know that most people cannot become wealthy, beautiful, and successful because of many factors in their biology, upbringing, and environmental constraints. We can work hard but cannot always achieve everything we want to because of internal and external constraints.

I also propose that emotions, cognitions, and behaviors are all key components of personality that are intertwined and operate in combination with one another. Mind and body cannot be separated. How people think influences how they feel and behave (e.g., if a person thinks that others are out to get him, he will feel afraid and back away when another person approaches). How people feel has an impact on how they think and behave (e.g., if a person feels happy, she is likely to seek out other people and think that they will like her). Finally, how people behave affects how they think about themselves and how they feel (e.g., if a person studies hard and gets good grades, he or she is likely to feel efficacious and have high self- esteem). Thus, any treatment approach must focus on all three aspects of human existence (emotions, cognitions, and behaviors) to help people change.

In summary, I believe that people are influenced by both their biology and their environment, particularly early experiences that contribute to the development of attachment to others and self-esteem. Furthermore, although people are influenced by past experiences, they have some choice and free will and an impetus to make a difference and have meaning in their lives. It is also important to recognize that people develop defenses as strategies for coping with the demands of the world.

I believe that people can change within limits. They cannot discard past learning or biological predispositions, but they can come to understand themselves more, live with themselves, have self-compassion, and accept themselves. They can develop more adaptive behaviors, thoughts, and feelings. People can adjust to their inner potential, make the best of what they have, and make choices about how they want to live their lives within the limits imposed by biology, early experiences, and external circumstances. These assumptions lead to an optimistic, but cautious, view about the possibility of change.

I should emphasize that my philosophy and assumptions are clearly influenced by my culture. I was born and raised in the United States, where there is a strong emphasis on individualism and determinism. Had I been born and raised in another culture, I might well have put more emphasis on harmony and collectivism.

Readers from other cultures should be aware of my biases and think carefully about the components of this model that fit for them given their cultural context.

The Three-Stage Model

In this section, I focus on the skills taught in this model. But recall that I outlined in Chapter 1 that the skills must be intertwined with self-awareness and facilitative attitudes to yield a productive helping process.

The helping process involves taking clients “down and into” understanding themselves more and then “up and out” into the world, better able to cope with problems (Carkhuff, 1969; Carkhuff & Anthony, 1979). Thus, as Figure 2.1 illustrates, the helping process involves beginning with exploration, moving to insight, and then moving to action. In the next section, I list the goals and skills relevant to each stage and then describe what occurs in that stage. See Exhibit 2.1 for an overview of the stages, goals, and skills.

FIG U R E 2 . 1

The three-stage model of helping.

E XHIB IT 2 . 1 Goals and Skills for the Three Stages

It is important to state early on that the stages are not rigid. Helpers do not need to spend a specific amount of time in each stage, and in fact, in actual helping, the stages often blur together such that it is hard to know what stage a helper is in. For training purposes, however, it is useful to think about the different goals that we have at different times during sessions. Thus, the three-stage model is a useful philosophical framework to use in understanding the goals of the overall process, but one need not strictly adhere to a set structure in using this model.

EXPLORATION STAGE In the exploration stage, one goal is to attend nonverbally to clients and listen carefully to everything they say. Helpers attend to and listen through nonverbal behaviors (e.g., appropriate eye contact, head nods), minimal encouragers (e.g., “mm-hmm”), paying attention, and not interrupting. Another goal is to encourage clients to explore thoughts, which helpers implement through questions/probes for thoughts and restatements. A third goal is to encourage exploration of feelings, which helpers do through questions/probes for feelings, reflections of feelings, and disclosures of feelings.

Exploration is crucial to give clients an opportunity to express their emotions and to think through the complexity of their problems. Having another person act as a sounding board or mirror is often helpful because it allows clients to open up; it is much easier to examine one’s concerns when another person is actively listening. When clients think about issues by themselves, they often become blocked by their defenses and anxieties rather than gaining insight and making changes.

The exploration stage also provides helpers an opportunity to learn more about their clients. Helpers cannot assume that they know clients’ feelings or

problems, even when they are similar in age, race, gender, religion, or sexual orientation. For example, Jennifer—who was similar in age, race, and gender to her helper—disclosed that she had just become engaged. The helper had just recently gotten married and was very happy in her relationship, so she assumed that Jennifer felt similarly and started congratulating her. Jennifer, however, broke down in tears and ran out of the room. Fortunately, the helper realized her mistake, called Jennifer and apologized, and asked her to return for another session. It turned out that Jennifer felt pressured to get engaged and, in fact, felt quite ambivalent about the relationship. When the helper could listen without assumptions, she was able to learn how Jennifer truly felt.

INSIGHT STAGE The first goal of the insight stage is to foster awareness, which helpers do primarily through challenges. The second goal is to facilitate insight, which helpers do through questions/probes for insight, interpretations, and disclosures of insights. The final goal is to work on the therapeutic relationship, which helpers do through immediacy (talking in the here-and-now about the therapeutic relationship).

In the insight stage, helpers collaborate with clients to help them achieve new understandings about themselves, their thoughts, their feelings, and their behaviors. They also work to help clients attain new awareness of and take responsibility for how they perpetuate their problems. Insight is important because it helps clients see things in a new light and enables them to take appropriate responsibility and control over problems.

In contrast to the purely client-centered stance in the exploration stage, helpers work more actively with clients in the insight stage to construct meaning together. In addition, helpers provide clients with feedback about their behaviors in sessions and assist clients in understanding how these behaviors have developed and the function they now serve. By understanding how they are perceived by their helpers, clients are often better able to understand how other people react to them. Helpers and clients also sometimes work through problems that arise in the therapeutic relationship, helping clients have a corrective relational experience, modeling how to interact with others more effectively, and working together to attain insight into relationships. Thus, the relationship itself can be a focus of learning in the insight stage.

ACTION STAGE The overall goal of the action stage is to help clients explore the idea of changing and then implement action plans. The major skills for this stage are open questions/probes for action, giving information, process advisement, direct guidance, and disclosure of strategies. More important, there are four major types of action plans (relaxation, behavior change, behavioral rehearsal, and decision making), each of which is implemented through several steps and several skills.

When clients have some understanding, it is usually easier for them to change. For example, it was easier for Jacques to take a chance on getting involved in another relationship once he understood that he became scared of getting close to others because of his punitive relationship with his mother. Thus, understanding, however imperfect, guides future behavior. Insight may also lead to long-lasting change because it provides clients with a template for making sense out of events and helps them make better choices.

Together, helpers and clients explore the idea of changing, determine whether or not clients want to change, and explore the meaning of change. They also might consider possible changes and help the client make decisions about which changes to pursue. In some cases, helpers teach clients skills needed to make changes. They also might help clients develop strategies for trying new behaviors and asking for feedback from others outside the helping relationship. In addition, helpers and clients continually evaluate the outcome of action plans and make modifications to assist clients in obtaining the desired outcomes. As in the first two stages, the process is collaborative. Helpers continue to ask clients to talk about their feelings related to changing. Again, helpers are not experts but are guides who assist clients in exploring thoughts and feelings about action and about making positive changes in their lives.

Psychoanalytic theorists have often assumed that insight naturally leads to action and thus that helpers do not have to be concerned with encouraging clients to think about making specific changes. For some clients, this may be true. However, clients often do not have the skills to behave differently, have defenses that block them from making changes, and have obstacles in the real world that make it hard to change. Therefore, they may need help to make the changes occur. By putting their new ways of thinking into practice, clients are able to consolidate the changes in their thinking that occurred in the exploration and insight stages. Without action, changes in thinking (insights) are typically short-lived.

RELATIONSHIP AMONG THE THREE STAGES The exploration stage lays the foundation for clients to understand their motivations and take responsibility for changing. Both helpers and clients need an adequate understanding of the scope and dynamics of the clients’ problems before developing an action plan. Unlike radio and television talk show psychologists who listen for three sentences and then advise clients, helpers rely on careful, thoughtful listening and probing to help clients fully explore their problems and gain new insights.

Thus, each of the stages in the model is important in the helping process. Thorough exploration sets the stage for the client to gain insight, and deep insight prepares the path for the client to make good decisions about action. Furthermore, making changes encourages the client to begin exploration of other problems.

It is important to note that all the skills are used in all three stages but to varying degrees. Figure 2.2 shows that exploration skills are used most in the

exploration stage but are also used quite frequently in the other two stages. Insight and action skills are used mostly within their own stages but are sometimes used in the other stages.

FIG U R E 2 . 2

Approximate amount of skills used in each stage of the model.

Although it sounds straightforward to move from the exploration stage to the insight stage and then to the action stage, the process rarely flows so smoothly with real clients, and stages are not always as differentiated and sequential as they seem to be when reading about them (Figure 2.3 shows some of the variations on the basic model). Within sessions, helpers and clients sometimes move back and forth among the stages. For example, helpers often have to return to exploring new facets of a client’s problem during the insight and action stages. Furthermore, attaining insight often forces a client to explore newly recognized feelings and thoughts. Realizing that a client is reluctant to change in the action stage might necessitate more exploration and insight about obstacles.

FIG U R E 2 . 3

Alternate paths for the three-stage model of helping.

Sometimes action needs to be taken after minimal exploration. For example, a client may be in crisis and need specific help immediately (e.g., discuss plans for the next 24 hours, have the number of a hotline). Or a client who has medical problems caused by anorexia might first need to learn to eat in a healthy manner and only later might be ready and able to explore motives underlying his or her eating disorder. In other cases, clients cannot really explore until they have been taught to relax. Other clients cannot handle insight and are resistant to having anyone “poke around in their heads”; they only want guidance about specific problems. With such clients, helpers may need to move more quickly to the action stage. However, I caution helpers to explore enough to make sure they know what is going on, what actions have been tried, and what help is needed, and also make sure it is for the client’s needs rather than for the helper’s comfort or preference before they rush to generate possible actions.

In summary, the three-stage model provides an overall road map for the helping process, but helpers must attend to individual needs of clients and environmental pressures before determining how to respond at any given moment. This book is not meant to be a simplistic “cookbook” or manual of what to do at every specific moment in helping. That would not be possible, given the infinite number of situations that could arise with different helpers and clients. Instead, helpers need to think about what they are trying to accomplish at each point in the helping process, become skilled at delivering the various possible skills, and then observe the client’s reactions to help devise better interventions for that particular client.

Facilitative Conditions

I postulate that helpers must not only use skills well but must also convey an attitude of empathy, feel compassion, and collaborate with their clients. Empathic collaboration and compassion are major features of all three stages of the model. Because of the importance of these facilitative conditions, I describe each in more detail.

EMPATHY Helpers need to try to understand their clients as much as possible, while at the same time recognizing that it is never possible to fully understand another person. Empathy involves understanding clients at both a cognitive level (their thoughts and expressions) and an affective level (their feelings; Duan & Hill, 1996). Empathy also includes genuinely caring about the client, nonjudgmentally accepting the client, being able to predict the client’s reactions, and communicating one’s experience to the client in a sensitive and accurate manner.

Although helpers sometimes feel the same emotions as their clients, empathy requires that they recognize that the pain, anger, frustration, joy, or other emotions belong to the client and not to the helper. Empathy is sometimes confused with a certain way of responding to clients (e.g., using reflections of feelings), but empathy is not a specific response type or skill; rather, it is an attitude or manner of responding with genuine caring and a lack of judgment. Empathy involves a deep respect for clients and for the clients’ willingness and courage to explore their problems, gain insights, and make changes. This empathic attitude is experienced and also implemented through a variety of helping skills, depending on what helpers perceive clients as needing at specific times.

As mentioned earlier, we can never fully understand other people. We can try to empathize and imagine how the other person feels, but we can never fully remove ourselves from our own experiences to understand another person completely. Similarly, although we might try to have unconditional positive regard (i.e., caring about, understanding, and appreciating clients for who they are, regardless of how they behave), our regard for clients is usually conditional (e.g., that they allow us to help them, that they talk openly about their problems, that they not get angry at us). Unfortunately, we are not always fully aware of all of our personal issues and the conditions that we place on clients. As helpers, we need to do our best to form positive therapeutic relationships with clients; but when we are not able to establish good relationships, we need to examine our own issues as well as think about how client dynamics might be influencing the interaction.

COMPASSION Compassion involves feeling aware of and open to suffering without judgment (Vivino, Thompson, Hill, & Ladany, 2009). Compassion goes beyond empathy and

understanding by genuinely allowing oneself to feel the pain and suffering and desire to relieve it. Another way to think of compassion is loving kindness, of genuinely caring about the other person because of who they are, not because they deserve it or not. Often, we sit in judgment of ourselves and others, and trying to think about empathy and gaining compassion can help us shift into a more open and caring posture toward self and others. I have found it enormously helpful when supervising student therapists to ask them to try to find their compassion for clients; this exercise allows them to feel into where the client is hurting.

COLLABORATION Furthermore, the whole helping process is collaborative in that helpers guide or coach clients in working through problems. Helpers are not experts in how clients ought to live their lives, but helpers can be experts at facilitating the process of helping clients explore feelings and values, achieve understanding, and make choices and changes. Rather than giving answers to clients, helpers try to teach clients how to think through problems, make decisions, and implement changes. This whole model is essentially client-centered in that helpers work with clients to choose their solutions to the problems they face. A good metaphor is the parable about teaching a hungry person to fish: Giving someone a fish feeds the person for one meal, whereas teaching her or him to fish enables the person to eat for a lifetime.

BEING EMPATHIC, COMPASSIONATE, AND COLLABORATIVE Although empathy, compassion, and collaboration are crucial components of the helping process, they are not specific skills that can be taught directly. Rather, they are outcomes of the successful implementation of helping skills and a reflection of an attitude that the helper feels toward the client. As helpers, we can be knowledgeable about our implementation of verbal and nonverbal behaviors, aware of how we come across when using these interventions, aware of our intentions for using different interventions, and aware of client reactions to these interventions. However, we cannot always control the outcome of the helping session. We can strive toward empathy and collaboration, but we cannot always attain these goals because much depends on clients and how well we “match” or “click” with them. Even so, through knowledge, self-awareness, and a genuine desire to understand, respect, and work with another person, empathic collaboration is likely to emerge and to be experienced by clients.

A Model for the Process and Outcome of Helping

Much of what happens in helping situations is so complex that it is often difficult

for helpers, especially beginning helpers, to have a full awareness of the process. Furthermore, the helping process occurs at many different levels (e.g., conscious awareness, unconscious processing) and at lightning speed, which does not give helpers much time to give conscious thought to every component and decision that accompanies interactions. Helpers must learn to react quickly because clients constantly present new needs and challenges.

By looking at the individual components of the process and outcome, helpers can begin to understand their reactions and responses in different situations and learn about possible client reactions to interventions. Analyzing each part of the helping process and outcome initially feels uncomfortable and cumbersome because beginning helpers are not used to breaking down their interactions and examining them so carefully. Furthermore, most beginning helpers are not used to thinking about their reasons for doing things and are not used to examining the reactions of others. With continued practice, however, beginning helpers can become more comfortable taking apart and analyzing the process and then putting it all together again to function in sessions. So let’s turn to some of the variables that go into the moment-by-moment process.

BACKGROUND VARIABLES Clients and helpers bring unique ways of viewing the world to the helping process. They contribute their personalities, beliefs, assumptions about the world, values, experiences, and cultural and demographic characteristics.

In addition, helpers bring their theoretical orientation (beliefs about how to help) and their previous experiences in helping (both informal and formal). For example, one could imagine that an introverted, young, European American female helper with a psychodynamic theoretical orientation would have a very different impact on the helping process than would an extroverted, middle-aged, Iranian American male helper with a cognitive–behavioral theoretical orientation. Moreover, helpers have preferences and biases related to clients, which undoubtedly influence their behavior. In Chapter 4, we spend a lot of time talking about the importance of self-awareness and self-care for helpers.

Similarly, client background variables greatly influence the process. A young, bright, attractive college student who is away from home for the first time and is feeling lonely and homesick is very different from a substance-abusing, older man who has been ordered by the court to attend counseling sessions because he batters his wife.

It is also important to be aware that clients are at various stages of readiness for change. Some are reluctant to participate in any form of helping; others are eager to learn more about themselves; and yet others are ready to make changes in their behaviors. Prochaska, Norcross, and DiClemente (1994, 2005) identified five stages of change:

In the precontemplation stage, clients are unaware of the need to change or have no desire to change. Precontemplators lack information about their problems, engage in denial about their problems, and often blame other people or society for their problems. Other people are typically more bothered by the precontemplator’s behavior than is the precontemplator. In the contemplation stage, clients are aware of and accept responsibility for their problems. They are beginning to think about changing but have not yet actively decided to change. Fear of failure often keeps clients stuck in this stage. Clients in this stage spend time thinking about the causes of their problems and ponder what it would be like to change. In the preparation stage, clients have made a commitment to change and are preparing themselves to begin the change process. Some clients make public announcements that they plan to change (e.g., “I plan to lose 30 pounds”). Some clients prepare themselves mentally for how their lives will be different (e.g., “When I lose weight, I will feel healthier and be more attractive, and it will be easier to exercise”). In the action stage, clients actively begin to modify their behaviors and their surroundings. They might stop smoking cigarettes, begin studying at regularly specified times, start taking more time for themselves, or decide to get married. The commitment and preparation accomplished in the contemplation and preparation stages seem to be crucial for success in this stage, in that prepared clients are more aware of what they are striving for and why. In the maintenance stage, clients have changed and are trying to consolidate their changes and deal with lapses. The process of change does not end, then, with the action stage. It takes several weeks or years for change to become incorporated into one’s lifestyle, and people often return to earlier stages in the process of change, suggesting that it is not easy to make lasting changes. This stage is very challenging because permanent change is difficult and often requires major lifestyle alterations.

Clients sometimes go through these stages linearly. But more often clients are at one stage for one problem and at a different stage for other problems (e.g., a client could be in the maintenance stage for stopping smoking but in the precontemplation stage for resolving spiritual issues in his life). Clients might also bounce around among the stages (e.g., on a good day a client may have a lot of insight but then regress to the precontemplation stage when scared).

Working with precontemplative clients can be difficult (but not impossible) because they often come to helping under duress (e.g., court referral) rather than because they genuinely want to change. One can compare working with precontemplative clients to trying to push carts with square wheels: It is more difficult to push a cart with square wheels than to push a cart with round wheels. In

contrast, working with clients in the later stages tends to be easier because these clients are more eager to work on themselves. The process works better when clients are interested in, rather than resistant to, change.

THERAPEUTIC RELATIONSHIP Gelso and Carter (1985) defined the therapeutic relationship as “the feelings and attitudes that counseling participants have toward one another, and the manner in which those are expressed” (p. 159). Researchers have consistently found that the therapeutic relationship is a major predictor of the outcome of therapy (Gelso & Carter, 1985, 1994; Horvath & Bedi, 2002). Clients typically report that the most helpful aspect of therapy is feeling understood and supported. For some people, the relationship itself is curative, and they need nothing else from the helper; others need the therapeutic relationship as a foundation for other interventions. We can think of the therapeutic relationship as being made up of three parts: the real relationship, the working alliance, and transference/countertransference (Gelso & Carter, 1985, 1994).

The real relationship is the genuine, authentic nondistorted connection between the helper and client. This part of the relationship is similar to relationships you would have with other people in your life.

The working (or therapeutic) alliance is the part of the relationship focused on the therapeutic work and consists of the bond (i.e., the connection between the helper and client), an agreement on goals (a consensus about changes the client needs to make), and an agreement on tasks (a consensus about what is to take place during the helping process to meet the goals). Interestingly, different types of working alliances may fit better for different types of clients. For example, Bachelor (1995) found that some clients prefer helpers who are warm and supportive, whereas others are put off by too much warmth and prefer helpers who are objective and businesslike.

Transference and countertransference involve distortions based on experiences in previous significant relationships. Transference involves client distortions of the helper, and countertransference involves helper distortions of the client. Transference and countertransference are thus like lenses or filters through which one views the world. For example, a female client may expect that the helper will be bored with her because her parents ignored her (transference). Likewise, the helper may react poorly to client anger because anger was not an acceptable emotion in her or his family (countertransference).

Although most researchers agree that a good therapeutic relationship facilitates the helping process, they are much less clear about how to establish good relationships with clients. I postulate that helpers establish good therapeutic relationships by attending and listening carefully to clients, using the appropriate helping skills at the right times, treating clients according to their individual needs, being aware of feelings and limitations, being aware of clients’ reactions to their interventions, being open to feedback from clients, and being willing to change

(see also Hill, 2005b). I propose that the therapeutic relationship works as follows. Clients often

come to helpers feeling that no one listens to them or cares about them. Helpers attend to their clients and communicate an understanding of clients’ feelings and experiences. Helpers are empathic and nonjudgmental and accept clients as they are, which allows the clients to feel safe enough to express deep feelings. Finally, helpers are skilled in their interventions, helping clients explore, gain insight, and make decisions about action and building clients’ confidence that they can be helped. Within the context of the helping relationship, clients begin to feel that if their helpers accept them for who they are, they must be okay. It also allows clients to see that not all people are like those with whom they have experienced difficulties. Furthermore, working with helpers facilitates clients in reducing their anxiety and thus increases their capacity for facing interpersonal pain and anxiety. Clients slowly begin to build self-esteem and gain hope that they can change.

Helpers cannot establish relationships with all clients, even though we would all like to think that we can. Some dyads just do not “click.” Some clients are not motivated or ready to be helped. For example, an adolescent girl might be forced by her parents to go for helping but not want to be there. Moreover, some clients have been so hurt and their capacity to trust so seriously impaired that they cannot benefit from a facilitative relationship. Clients who have been seriously damaged in relationships often have difficulty attaching to therapists. The problem sometimes lies with the helpers, however. Similarly, all helpers have limitations related to their backgrounds (e.g., dysfunctional families) and personal problems.

Furthermore, some matches between helpers and clients are not ideal and do not result in positive therapeutic relationships. For example, a female client who was raped recently might not be able to talk to a male helper no matter how kind he is because she is terrified of all men. An alcoholic client might not want to see a helper who has never had problems with alcoholism because he fears that such a helper could not understand his struggle to stay sober. Similarly, helpers who have not resolved their own experiences of traumatic sexual or physical abuse might not be able to hear a client’s story of abuse without having strong emotional reactions or being distracted by their own pain.

MOMENT-BY-MOMENT INTERACTIONAL SEQUENCE Figure 2.4 shows a graphical representation of the helping process. Given the background variables and context, helpers formulate intentions and decide on specific helping skills. In turn, clients react to the helpers’ interventions, which lead them to reevaluate their needs and goals and decide how to behave with the helpers. Helpers then assess clients’ reactions and reevaluate what to do next. The process thus continues with each person reacting both overtly and covertly, trying to determine the intentions of the other and deciding how to interact. Let’s slow down the process and look at each piece.

FIG U R E 2 . 4

Factors influencing the helping process.

Helper Intentions Helpers develop intentions (i.e., goals, plans) by thinking about everything that has previously occurred and what they would like to accomplish next. Through asking therapists about why they did what they did, Hill and O’Grady (1985) developed a list of the intentions. Therapists indicated that they often had intentions to set limits, get information, and give information. In addition, they wanted to provide support, focus, clarify, instill hope, and encourage catharsis. Other goals related to exploration include intent to identify maladaptive cognitions, identify maladaptive behaviors, encourage self-control, and identify and intensify feelings. Related to insight and action, therapists wanted to promote insight, promote change, reinforce change, deal with resistance, challenge, and deal with the therapeutic relationship. Last, one nontherapeutic intention was revealed: to relieve helper’s needs. The definitions for these intentions are listed in Web Form D (found at http://pubs.apa.org/books/supp/hill4).

Helpers are not always aware of their intentions at the time of delivery (Fuller & Hill, 1985). For example, helpers sometimes inadvertently self-disclose to make themselves feel better rather than to be helpful to clients. Reviewing audio- or videotapes after sessions (alone or with a supervisor) and thinking about or writing down intentions for each intervention is an excellent way to increase

http://pubs.apa.org/books/supp/hill4
awareness of what one was trying to accomplish. Helpers are typically able to identify intentions pretty easily when they review tapes within 24 hours of the session and recall how they were feeling and reacting at a given moment in the session (rather than indicating how they currently feel about their interventions). By slowing down the process and examining it piece by piece, helpers can discover the different layers of feelings, thoughts, and actions. After gaining experience with examining intentions during videotape replays, helpers are often able to obtain more awareness of intentions while they are in sessions with clients. I encourage beginning helpers to become intentional in their interventions and to think about what they are trying to accomplish during each intervention.

Helper Helping Skills For each intention, the helper could use a few different helping skills (see the Helping Skills System, Web Form E). For example, to facilitate the client talking about feelings, the helper might reflect feelings, disclose about feelings, or ask open questions/probes about feelings. All of these might be quite appropriate but subtly move the client in different directions.

In addition to matching the skill to the intention, helpers should bear in mind that the same intervention can have a different impact depending on the manner of delivery. If the helper says, “You seem to be feeling anxious” in a supportive, gentle tone, the client will probably have a different reaction than if the helper uses a critical, judgmental tone.

Client’s Reactions A helper intervention is met by one or more client reactions (see the Client Reactions System, Web Form G). When a helper is successful, the client’s reactions match the helper’s intentions and helping skills. For example, if the helper’s intention is to provide emotional support and the helping skill used is an encourager such as “I understand what you’re going through,” the client’s reaction might be to feel understood and supported. However, if the intervention is not successful, the client might feel that the helper did not really hear what was being expressed or that the helper made incorrect assumptions.

Clients are sometimes consciously aware of their reactions, although at other times they might be unaware of their reactions to helpers. In addition, clients sometimes have difficulty admitting to reactions that are not socially acceptable (e.g., feeling angry at a helper’s intervention). Admitting negative feelings about helpers can be difficult if clients respect and depend on the helpers or if clients cannot allow themselves to have negative emotions. For example, a client might react negatively to something a helper says because it is similar to something her parents said, but the client might not allow herself to express these negative feelings for fear of hurting the helper. Instead, the client might smile politely but feel somewhat distant and unengaged, not understanding why she withdrew from the interaction. Research suggests that clients often hide negative reactions from

their therapists out of fear of retaliation or out of deference to the helper’s authority (e.g., Hill, Thompson, Cogar, & Denman, 1993; Hill, Thompson, & Corbett, 1992; Rennie, 1994). For example, clients who feel angry at or misunderstood by their helpers are not likely to reveal those feelings if they feel unsafe in the therapeutic relationship. And even if they feel safe, they might feel uncomfortable expressing negative feelings because of cultural prohibitions against offending others.

A number of factors influence the reactions that clients have to helper interventions. First, clients’ reactions are influenced by their needs at the time. For example, clients in severe crisis might tolerate almost any intervention because they are desperately in need of help. In contrast, high-functioning clients might be more demanding that helpers be competent and knowledgeable about how to specifically help them.

Second, client reactions are moderated by the therapeutic relationship. In generally positive relationships, clients might tolerate some mistakes from helpers without an adverse reaction because they feel that helpers are genuinely trying to be helpful. If the relationship is problematic or rocky, however, anything helpers do might elicit negative reactions from disgruntled clients.

Third, clients’ reactions seem to be influenced by their impressions of the helper’s intentions. For example, if clients think that their helpers were acting out of their own personal needs rather than in the best interest of the clients (regardless of what the helpers’ actual intentions were), they might have negative reactions. If clients think that therapists want to extend therapy to make more money rather than because their clients need help, clients might become angry and uncooperative. In contrast, if clients think that their helpers are beginners who are just learning to be helpers, they might feel sympathetic and have positive reactions. Clients’ perceptions, then, even though they might not match the “reality” of helpers’ intentions, seem to influence clients’ reactions.

Clients’ Needs or Goals Clients react according to what they need and want from the interaction with the helper, and determine what is possible to obtain from helpers at a particular time. Thus, rather than being passive recipients of helpers’ interventions, clients are actively involved in trying to get what they need from interactions. For example, one client might feel a need to retreat to avoid further confrontation. Another client might decide that he wants to reveal more because his helper is accurate in understanding him and can be trusted with secrets.

Clients also want to have an impact on their helpers. For example, Sam wanted to please his helper and so kept telling her what a good job she was doing. Other clients might decide not to reveal shameful secrets because they do not want to tarnish the helper’s opinion of them.

Clients do not typically consciously plot the reactions they want to elicit from their helpers. Rather, they act on the basis of their past experiences in ways that

maximize the probability of getting their needs met (e.g., to feel close to or distant from the helper). Some of these client goals are influenced by transference, which occurs when clients project how significant people in their lives (e.g., parents) behaved onto how they expect their helpers to behave (see Gelso & Hayes, 1998; Gelso, Hill, Mohr, Rochlen, & Zack, 1999). For example, if Sue feels that no one listened to her as a child, she might not be able to believe that anyone could possibly want to listen to her now. Hence, even though the helper is attentive, Sue might want the helper to “prove” that he really wants to listen to her, or she will not talk in the session. Rather than being aware that the helper is silent because he is trying to give her space to talk, Sue might perceive the silence as occurring because the helper is bored by her.

Clients’ Behaviors Clients engage in specific behaviors (e.g., resist, agree, make an appropriate request, recount, engage in cognitive–behavioral or affective exploration, come to insight, or discuss therapeutic changes; see Client Behavior System, Web Form H) on the basis of their reactions, feelings about the therapeutic relationship, needs in the interaction, and goals (intentions) for a desired impact. Clients’ behaviors are determined not only by the interaction but also by their communication ability, awareness of needs, level of pathology, and personality structure. Hence, one client might be very articulate and insightful about describing the causes of his pain, whereas another client might be unskilled at communicating feelings and be unaware of what she is feeling in the moment.

Helpers’ Assessment of Client Reactions and Reevaluation of Goals Helpers, in turn, try to assess clients’ reactions to their interventions. They observe how the client reacted to the intervention (e.g., whether the client felt supported and understood, felt confused and misunderstood, or had no reaction). Unfortunately, helpers are not always accurate in perceiving clients’ reactions. In fact, research suggests that helpers are not particularly adept at perceiving negative client reactions to their interventions, but they are more accurate at perceiving positive reactions (Hill et al., 1992). The diminished ability to perceive negative client reactions might occur because, as noted earlier, clients hide negative reactions from helpers. People often learn as young children not to show negative reactions for fear of evoking displeasure or being punished (e.g., imagine what would happen if an elementary school student told her teacher that she did not like what the teacher said). Hence, helpers cannot assume that clients feel positively just because the clients are not displaying negative reactions.

In addition, helpers might be reluctant to recognize when clients have negative reactions. For example, many helpers have a hard time with clients’ anger directed at them (Hill, Kellems, et al., 2003). Because they want clients to like them, having clients get angry at them feels scary and upsetting. These helpers worry that clients will drop out. When clients are angry, helpers might misinterpret the anger as a

personal rejection. Other helpers might have difficulty allowing clients to become upset and cry because they feel obligated to make everything better and have all clients be happy.

Unfortunately, not all helpers have learned to examine the effects of their interventions on clients, so they use interventions that feel comfortable (e.g., giving advice) rather than ones that match the client’s needs in the specific situation (e.g., empathy, listening). In addition, there is a danger that over time, helpers can become insensitive to the influence of their behavior on clients and assume that they know how the clients are reacting internally. Helpers, even when they are experienced, can strive to be aware of the impact of their interventions on clients. Rather than making assumptions, helpers might ask the clients how they are feeling or reacting.

On the basis of their perceptions of the client’s reactions (whether accurate or not) and observation of the overt behaviors, helpers reevaluate what they are trying to accomplish and thus come up with new intentions and accompanying skills for the next intervention. If a helper perceives that the last intervention was successful and thinks that a similar intervention would be appropriate, she might continue with the same intention–skill combination. For example, if a reflection resulted in the client talking about sadness, the helper might use another reflection to help the client delve even deeper into these feelings. If a helper perceives that the last intervention was helpful but that something new is needed, he might choose a different intention–skill combination. For example, if a helper had reflected feelings and the client responded by talking in depth about a variety of feelings, the helper might decide to use an open question/probe to shift the focus to other aspects of problems.