Friday, November 6, 2015

The Basic Counseling Skills

     A word of caution: No good therapist exists who does not have basic counseling skills. Why do I bring this up? I realize that I have recently been focusing overmuch on the higher-level therapy skills, having not really strengthened my core skill set yet. I guess what I want to illuminate here are the skills that a therapist needs to be successful, were any kind of orientation stripped away. It is on this foundation that a good practice can be built. What are these elementary skills?

  1. Listening skills
  2. Empathy
  3. Positive regard
  4. Appropriate silence
  5. The "go on" skill
  6. Unpacking
  7. Appropriate self-care
  8. Introduction
  9. Gaining feedback
  10. Balance self versus clinician
     I'm going to comment on these ten items. I think that they are a good beginning, but are also nowhere near what any good therapist needs to be successful and helpful.
     The first three items are very Rogerian. It is my belief that Rogers was a good practitioner of basic counseling skills. Listening - specifically active listening - is a much-needed skill because it pushes the clinician not only to really hear what the client is saying, but to react in an appropriate way. Both of these skills allow the client to feel comfortable telling a stranger some of their darkest truths. Listening should start from day one in order to accustom the client to that level of deep interpersonal acknowledgment. This skill is difficult because it takes a high level of composure and compartmentalization on the part of the counselor to ensure that such listening can occur. Because every counselor is still a person with his or her own hopes, dreams, thoughts, beliefs, motivations, prejudices, loathes, etc, we must all ensure that our outside (or inside) stuff does not preclude us from this most basic and important of techniques. 
     Now let us talk bout empathy. I find myself with much internal conflict about this, specifically as to the ability to develop it versus being born with it. The reason I waiver has both to do with my own personal level of empathy and neurological science behind empathy and personality. I think, for myself, that I have a certain amount of empathy inherent in me, but that there could be more (but who couldn't say that?). It is better in this business to have more empathy, as it is the main connection of caring between the client and the clinician, though too much may lead to a difficulty in engaging in appropriately high-level self-care. The other argument, to get back on track, is saying that brain structure decides empathy. To take it to an extreme, those diagnosed with anti-social personality disorder are said to have no empathy. Taking it a step further, we can say that to this population, empathy cannot be taught; perhaps put differently, empathy cannot be "bought into," meaning that it might be taught and understood academically or mechanically, but cannot be truly believed in by that person. So what does all this mean for the therapist? Empathy is something that, at best might be taught and developed in someone that has the seed for it. Empathy, being one of these core criteria for a counselor, is something that a good counselor MUST have. 
     This next subject is one that I don't quite agree with Rogers on. Rogers touted unconditional positive regard. This seems very difficult and tiresome to me, as, like empathy, it almost seems to be something one must be born with. I also think that unconditional positive regard is almost a lie to the self and unrealistic in practice. I will talk about the latter first. Unconditional positive regard is not something that exists naturally in the world. It seems to me that everyone has an internal list of things that, if violated, would break this type of positive regard. Also, we need to make sure that we are reality testing here with our clients . . . Now that I am thinking about it, I guess that there really is a difference between unconditional positive regard for the client and unconditional positive regard for the client's actions and choices. The latter does not deserve such regard, whereas the former is difficult, but perhaps possible. The reason I changed my mind is that a client will not work with a therapist who thinks that he or she is a scumbag or a dumbass. I guess this one is both an interpersonal issue as well as one that could effect the clinician's case conceptualization. 
     Appropriate silence can be a difficult topic. I think that it can be every new counselor's instinct to fill in the conversation completely. A problem here is that frequently such dialogue is inane chatter, which only serves to confuse the client and tire the clinician. Sometimes clients must sit with a problem and think about it, while in the presence of a therapist. In these moments, it is not therapeutic to tell the client an answer or a philosophy. Rather, allowing them to piece out a problem might be exactly what they need in that moment. Silence is also a guard measure taken against over-functioning. Of course, there are some clients who disallow silence, so for those cases a clinician must be able to act in the opposite way in order to be effective.
     The next skill is a difficult one to make sound genuine for me. Frequently clients stop their dialogue, looking for something. From my own time in therapy, I would say that clients stop in order to ensure that the clinician is still with them, that they are not sounding crazy or stupid, that they started to hit on a topic that they would rather not talk about, or that they are looking for more encouragement to continue (for whatever reason). it is in this case that the clinician employs this skill to "allow" the client to continue. The therapist needs to give some kind of verbal or non-verbal cue to the client. Sometimes, a simple nod of the head will do. Frequently, a vocalization is fine (such as "mhm" or "hmm" or such). Now and then something like "yeah, "yup," "I hear you," or some such can be used. I think that this skills is quite dramaticized and romanticized in movies and books, to the point that the clinician says something like, "Talk/Say more about that," or, "Tell me more." For the reason that these terms are used so frequently in major media, I myself feel awkward in using such lines. Still, they might be useful.
     This next skill is a pretty advanced one for this list, but is one that requires a lot of work on the part of the therapist. I think that "unpacking" can lead to a clinician getting to know themselves better as a therapist, to a point that they might be able to learn their own theoretical orientation. Anyway, unpacking is the ability to break apart what a person is saying into different parts, consisting of narrative, problems, thoughts, feelings, complexes, etc (or the lack of any of these attributes), in order to highlight the important aspect to a client that can be explored during therapy. As previously mentioned, what a clinician chooses to unpack - or perhaps better put - what a clinician chooses to discuss after unpacking is a good indicator of that clinician's end "theoretical orientation." Unpacking is important because a clinician can gain much information from one sentence. At this time, I do not have a great example of such a sentence. While unpacking, a clinician can make connections and hypotheses that will allow them to continue a conversation if it starts to stall later on in therapy. My level of unpacking at this point is still somewhat basic, meaning that it takes me longer to do it and that it is difficult for me to do it in my head - meaning that I frequently have to be writing things down. This can get in the way of truly active listening and engaging with the client, but it is a positive for good and accurate case conceptualization. This is a skill that must be continually used and perfected if the clinician has a hope of being a master therapist in the future.
     Good self-care is essential to any therapist. Not engaging in proper self-care leaves one open to "psychic viruses" such as sarcasm in the office, compassion fatigue, a grand case of the fuck-its, and depression or anxiety. Good self-care can take the form of pretty much anything - being as changing as the subjective person.
     The next two skills frequently occur at the beginning (for the first) and at the end (for the second) of the relationship. The first is the introduction. I have elaborated on this portion many times, especially when discussing the documentation that occurs at the beginning. I will most liley be updating that section soon. This has more to do with how one acts at the beginning of a clinical relationship and at the start of all sessions. Confidence is key here, as it starts the relationship off on good footing and allows the client to see the clinician as someone who might actually help them. It is important in the first introduction to talk about fees, credentials, past history in psychotherapy, experience, orientation, and any paperwork that must be completed. It is important to ask for questions and concerns throughout, as airing these might allow for good discussion topics and make the client as comfortable as possible. That work - comfort - is very much something that is highly important in the first session. I think that making the client as comfortable as possible can only echo well throughout the rest of therapy. Every session also has some kind of introduction, which can change very much based on the clinician and their therapeutic approach. A clinician could create a set agenda or start out with a general question, such as "So, what's going on?" or "What would you like to talk about?" I guess comfort is just as important to the clinician, but in a different sense. The clinician is supposed to be relatively comfortable in the chair, so the introduction is just as much for him or her as it is for the client to ensure that there is a good fit or match between the two parties.
     This next one seems to, again, be an issue that is frequently regulated based upon theoretical orientation. This is unfortunate, as feedback is good for both parties and very good for future discussion and planning. Oddly, I think that most theories could easily accept the feedback rule and integrate it into themselves. Bringing the conversation back to the present with a feedback question is very existential-focused. I think that a behaviorist can get behind this question as well in their constant search for feedback and numbers-based results. Feedback allows the client to give their thoughts on the conduct of each party as well as the discussion and give good insight for the clinician as to what is important in current therapy to them and figure out what they are getting from therapy. Clinicians are on the receiving end of this and use the feedback to alter their own case conceptualization and change now they are engaging in therapy with the client. I'm not sure that it must be a rule as to when the feedback question is asked. I can see wisdom in sometimes asking the question during the middle of the session, especially to check whether an intervention has landed, though I would say that ending the session with the question might be a good idea to write good notes and track milestones in the client's treatment.
     The last point that I will mention here is a sometimes difficult balance that any counselor has to make between showing self and not showing self in session. This can be better said. Many counselors have to deal with this question: How much of myself do I show in session versus showing a more generic therapist self? This is a very good question that can easily affect how a clinician behaves in session. Some therapists have an innate ability to add themselves genuinely into the conversation. They can highlight their own behaviors subtly and model what a healthy individual might act like. Some clinicians use the role of clinician as a foundation or base to act in a way that they find appropriate. I can't say that one is necessarily better than the other, though I do think that there should be a balance because clients can tell when a clinician is hiding things and/or not being up-front with their feelings. 

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