Helping skills facilitating exploration insight and action 4th edition

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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.