Helping skills clara hill 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.