Stress Management For Clients and Their Counselors

1. Stress Management For Clients and Their Counselors Michele D. Aluoch, PCC River of Life Professional Counseling LLC c.2013

2. The Client’s Stress

3. Area #1- Not Feeling Listened To Three Common Assumptions about Listening(Barker, L., & Watson, K., 2000) • Speakers control communication more than listeners. • We can wait to listen well when we really have to. • When someone starts talking people automatically listen.

4. Realities of Listening • Listeners control communication because they can open up communication by engaging or shut it down by tuning out. • Listeners use their will to tune in or out to a person. • The listener often is the one who puts his/her interpretation into things. • Listeners evaluate whether messages are important and valuable or not. • Listeners decide to follow through on what the speaker says or to not to that. • Listening is not automatic. Rarely can listeners answer more than 4 details of a conversation correctly. • Listening takes time and practice. • Listeners only remember a small portion of what has been said- 50% immediately after talk, 10% after 1 day.

5. Listening Pitfalls • Tuning Out or Halfheartedly Listening • Rehearsing Our Responses • Assuming Meanings From What the Speaker Says • Jumping to Conclusions

6. Four Listening Preferences People- Oriented Action Oriented Content Oriented Time Oriented

7. People Oriented Listening • Other focused • Demonstrates caring and warmth • Nonjudgmental • Clear verbal and nonverbals • Relates to where the other is coming from • Focuses on building relationships • Notices changes in other’s moods & incongruencies in them quickly

8. People Oriented Listening Problems • Becomes overinvolved in other’s feelings • Too empathic and may overlook faults • More prone to burnout because internalizes and adopts other’s feelings • Sometimes considered overly expressive by others • Nondiscriminating in relationships- nice to everyone • Exs: counselors, service professionals, teachers • Tell stories, use illustrations. • Use “we” and focus on teamwork. • Be personal.

9. Action-Oriented Listeners • Concentrate on the task at hand • Frustrated with disorganized people • Comes across as impatient to others • Focuses on expectations • Able to redirect others towards the most important points of things • Identifies inconsistencies in messages where things don’t add up

10. Action-Oriented Listeners Problems • Impatient with people who talk too long • Jumps to conclusions quickly • Distracted by disorganization • Too blunt- pushes people too far too fast in conversations • May ask blunt questions • Comes across as critical • Minimizes the importance of the emotional/feelings in communication because they are too task and thing oriented • Exs: Attorneys, financial analysts • Keep points to 3 or less • Be short and to the point. • Speak quickly.

11. Content-Oriented Listeners • Evaluate every angle of things • Likes digging below the surface to dissect problems • Value technical information • Wants people to back up what they say with examples and supports • Values complexities

12. Content-Oriented Listeners Problems • Overly detailed • May come across as intimidating because knows so much • Asks pointed questions • Devalues info. from people who don’t know their job • Takes time to make decisions after studying all the angles of things • Exs: scientists, mathematicians, engineers • Provide the data. • Quote experts and statistics. • Use charts and graphs.

13. Time Oriented Listeners • Sets time boundaries for conversations • Gives guidelines for conversation • Does not want “wasted” time • Tells others when they are “wasting” time

14. Time Oriented Listeners Problems • Impatient with time wasters as he/she see it • Interrupts others • Not good at concentrating and just hearing others in the moment • Rushes others by watches and clocks • Squelches creativity because so focused on time and clocks • Go under time limits if you can. • Avoid unnecessary exs. • Watch their impatience level.

15. Top Ten Listening Hindrances(Barker, L. & Watson, K., 2000) • Interrupting the speaker. • Not looking at the person who is talking. • Rushing the speaker and communicating thereby that his/her message is unimportant. Not letting the speaker tell the whole thing. • Showing interest in things other than the conversation at hand. • Getting head of the speaker and finishing or concluding what he/she is saying.

16. Top Ten Listening Hindrances(Barker, L. & Watson, K., 2000) • Not doing what the speaker requests. • Saying, “yes- BUT” which shows that the speaker doesn’t matter as much as what you want • Stopping the speaker by relating things to yourself. • Forgetting what the speaker talked about. • Asking too many questions about details. Not doing what the speaker requests.

17. Nonverbal Listening • Body language= up to 93% • Words can hide secrets whereas body language gives more clues • 1st 10 seconds= most important • Cautions: defining things by a single gesture alone without context • Cultural background must be considered • First obtain baseline behavior • Factors to consider: • Status in society fashion subculture • The gaze of person- direction, length of gaze • What eyebrows do • Touch- spatial relations and how touch is used

18. Nonverbal Listening • Direct look • Lean slightly in • Smile gently • State the person’s name and shake hand • Take turns communicating • Angling your body toward the speaker • Use regular head nods • Reflect the speaker’s emotions

19. Issue #2- Client’s Expectations • Advertisements/Marketing of Your practice • Insurance panels Bios. • Your website • What they thought they gave consent for • Their understanding of what therapy is/is not • What they think your title or credentials are or mean • What they think your certifications, licenses or certificates are for • How they perceive the environment physically • How they perceive you, office staff, colleagues, other clients

20. Issue #3- Informed Consent • Extent and nature of services • Pros and cons (counseling in general, electronic counseling, phone counseling, techniques used, setting) • Limitations • In clear, understandable, non-technical language • Specified provider name • Therapist’s responsibility to make sure the client understands (e.g. if cannot read, blind, etc.) • Defines role of counselor (versus mediator, court guardian, expert witness) • Expectations of both therapist and client behaviors • Risks/benefits of therapy • Qualifications of the therapist • Financial considerations and responsibilities

21. Issue #4- Assessment/Diagnosis • Why we as the questions we do • What the diagnosis mean • s • Who knows what • Unethical- therapist as moral agent, client no longer autonomous person coming for help • Ethical- based on observation of concrete, observable or clients self reported behaviors compared to “norms” and researched and studies standards • with respect to client perspectives and worldview • with full information and informed consent • under a specific “contract” outlining terms of the clinical relationship

22. Issue #5- Treatment Planning • What goals the client will by into • Client desires • What client perceives to have worked/not worked so far • How involved client wants to get in the therapeutic process • How goals are measured • Operational definitions of measurable goals • How achievable goals are • Competing demands therapist’s hopes, clients’ hopes. Referring agency, insurance company, family/friends, employers/schools/physicians

23. Issue #6- Client’s Perceptions of your Competency • How the client defines competency • Board requirements regarding licensure, certifications, and disclosure statements in office • Client’s assumptions about your title and ability to clarify or correct these • Techniques used

24. Issue #7- Readiness or Resistance A) RESPONSE QUALITY RESISTANCE • Silence • Minimal talk • Incessant talk B) RESPONSE CONTENT RESISTANCE • Intellectualizing everything to avoid discussion of emotions • Preoccupation with symptoms • Small talk • Rhetorical questions bout the counselors decisions on hmwk, assumptions of Dx, etc.

25. Issue #7- Readiness or Resistance C) RESPONSE STYLE RESISTANCE • Discounting (yes BUT ____) • Limiting topics in session • Blaming others • Second guessing the counselor (“are you saying or meaning ___?”) • Reporting only positives • Seductiveness • Forgetting supplies or materials • Disclosure at last minute • Habitually breaking promises D) LOGISTIC MANAGEMENT RESISTANCE • Poor appointment keeping • Payment delay or refusal • Personal favor asking

26. Common Defense Mechanisms(Clark, A.J., 1991) • Outside awareness initially • Habitual • Useful (in client’s perception) Denial- rejecting responsibility • “I don’t have a problem.” • “Nobody ever told me.” • “I didn’t know.” Displacement- shifting responsibility to a vulnerable substitute • “I couldn’t control my behavior because of that stupid overbearing teacher.” • “A few drinks just cause me to do things I don’t expect.” Identification- acting like someone he/she admires • “I have a good heart just like my brother.” • “My family may have it’s flaws but we all are hard working.” • “I can be just as competitive as the next guy when things comes down to it.”

27. Common Defense Mechanisms(Clark, A.J., 1991) Undoing- Trying to reverse an unhealthy behavior by doing something opposite • “I drank all weekend but when I came to my senses I realized this isn’t me so I threw all the liquor in the house down the drain.” • “I know I mouth off and get out of control but I am the most gentle and apologetic person afterwards.”

28. Common Defense Mechanisms(Clark, A.J., 1991) Intellectualization- avoiding unpleasant feelings which are perceived as “negative” and make someone feel vulnerable • “Drinking on occasions is not like getting drunk, you know.” • “I just have a different way of getting things done than what my boss wants.” Projection-attributing unacceptable behaviors to others that are really characteristic of self • “It seems like you don’t want this counseling to help me. You disagree with me.” • “They said I didn’t perform on my job.” • “If that fool would have gotten out of the way I wouldn’t have hit him in the drunk driving incident anyway.

29. Common Defense Mechanisms(Clark, A.J., 1991) Rationalization-Justifying one’s behaviors • “Everyone lies to their parents.” • “All people steal some of the extra supplies on the job that aren’t being used.” • “Most parents get frustrated with their kids and lose control at times.” Reaction formation- Exaggerating claims of highly moral actions and attitudes • “I would never get tempted to do anything like that.” • “I organized the community fair against that kind of behavior.”

30. Common Defense Mechanisms(Clark, A.J., 1991) Regression-returning to an earlier stage of maturation and development • “I had these kids young. It is my time to live . What’s wrong with dressing in their clothes and going to clubs. I missed out.” Repression-Resisting discussing or approaching topics or barring self or others from certain topics • “I don’t recall anything like that.” • “I don’t ever remember disobeying my parents.”

31. Dealing With Defense Mechanisms Relationship stage • Identify specific defenses for that client • Generally will be the same ones they use with you • Use advanced empathy to understand and help them understand why they habitually relied on them • Sentence completion exercises help Integration stage • Distortions are confronted • Lack of congruency is brought to the client’s attention Accomplishment stage • Productive actions and alternatives are highlighted • Client is encouraged to act differently as he or she would like to be • Alternative behaviors are maintained • A strengths-based approach is used

32. Issue #8- Perceptions of Process Variables • Still critical foundations for success • Empathy • Non possessive warmth • Genuineness • Whose are these? (Counselor Versus Client?) • Hypothesis #1: Good counselors enhance treatment when they have high levels of these variables. • Hypothesis #2: Clients determine the levels of variables. Good clients elicit high variables but poor clients elicit low variables. • NON-POSESSIVE WARMTH- mutual function • EMPATHY/GENUINENESS- under control of the therapist

33. Client’s Perceptions of What Predicts Therapeutic Alliance (Duff, C.T., & Bedi, R.P., 2010) • Therapeutic alliance=most robust predictor of outcome than techniques • Three critical factors: making encouraging statements, making positive comments about the client, greeting the client with a smile • Others listed: • Asked me questions • Identified and reflected back feelings • Was honest • Validated my experience • Made eye contact with me • Referred to details discussed in previous sessions • Sat still and did not fidget • Sat facing me • Told me about similar experiences he/she had • Let me decide what to talk about • Kept the administration outside of our sessions

34. Mattering To Others (Rayle, A.D., 2006) • Internal need to feel significant: • A) general mattering • B) interpersonal mattering • Why do I exist? What difference do I make? • Do others notice me? • Are my interactions with others different because of me? • Do I have the social supports I desire? *** Counselors can have a significant role in shaping mattering.***

35. Issue #9- Successful Intervention • Elements of Helpful Counseling Interventions(Miller, G., 1997) • Promote empathy, encouragement, and positive approach to addressing problems • Assist clients in attending to previous unattended areas • Shifts clients from a problem focus to a solution focus • Plants the seed that there will be a time where the issue does not have to have a negative hold on the client (Getting the client to imagine not having the problem anymore) • Shift from constructing problems/analysis to constructing solutions • Reinforcing how the client manages to get by • Emphasis on increasing the frequency of healthy behaviors

36. Issue #10- Confidentiality/Privacy • Has to do with private information being protected through reasonable expectation that it will not be further disclosed except for the purpose for which it was provided Areas Protected: • Whether or not a person has been a client • The frequency and intervals of appointments • Types of treatment or services received • Reasons for treatment • Specific words, behaviors or observations during treatment • Client diagnosis • Course and prognosis of treatment • Summaries and recommendations

37. Confidentiality/Privacy • Requires informed consent- specifying what consenting to, with discussion to client about advantages and disadvantages and potential limitations of disclosure • Should be in your policies and procedures about confidentiality, possible breaks of confidentiality and how this is should be handled • Should be in writing and signed by all parties

38. Confidentiality/Privacy • Information cannot be disclosed in court proceedings unless both: 1) a subpeona has been issued 2) a court order has disclosure. Then court must find that the need for information outweighs the public policy for confidentiality (42 CFR 2.61-2.65 and 45 CFR 164,512 (e) (1) (ii) • By law confidentiality continues even after the death of the patient, death of the therapist or sale of the practice to others • “When in doubt don’t give it out.”

39. Issue #11- Therapist Openness/Disclosure Reasons to Disclose • Fostering therapeutic alliance • Modeling freedom for clients to disclose • Reducing client’s sense of being alone in his/her problems • Increasing sense of realness in the counselor • Sidney Jourard’s idea of “dyadic effect”: “disclosure begets disclosure”- people are more likely to be open with interviewers who themselves are open than with interviewers who express little or nothing of themselves” Reasons against Disclosure • Shifting focus off the client • Using counseling time • Role confusion

40. Therapist Openness/Disclosure What May Be Disclosed: • Professional identity/credentials • Educational background • Professional experiences • Professional Successes or failures • Counselor Cognitions and emotions related to the client life Experiences • Personal Feelings • Personal Life Successes or Failures • Personal Values • Personal Beliefs • Personal Attitudes on Topics • To Be individualized to each client

41. Three Dimensions of Self Disclosure(Jeffrey, A., & Austin, T., 2007) • The amount of disclosure • The intimacy of information shared • The duration of disclosure • Within each there are the issues of where the disclosure is positive or negative, personal or demographic, similar or dissimilar, past or present.

42. What Clients Said Was Helpful Disclosure • Acceptance and Encouraging • Ensuring Attention • Body Language • Silence (Listening) • Open and Closed Ended Questions • Reflection of the Content of Sessions • Disclosure of Feelings • Reflection of Feelings • Self Disclosure • Confrontation • Key- developing an understanding of what each operationally means to a given client

43. How Clients Judged if Disclosure Was Helpful • It built my confidence. • It helped me share more. • I felt relieved afterward. • I had more respect for the therapist and/or the clinical relationship.

44. Frequency of Reasons to Self Disclose(Simone, D.H., McCarthy, P., & Skay, C.L., 1998, p.179) • Promote feelings of universality-85 • Encourage client and instill hope- 81 • Model coping strategies- 71 • Build rapport and foster alliance-68 • Increase awareness of alternative views- 67 • Provide reality testing-38 • Decrease client anxiety-37 • Prevent client idealization of counselor-36 • Increase self disclosure through modeling/reinforcement-31 • Increase counselor authenticity-29 • Decrease client resistance-8 • Dilute transference near termination-7 • Challenge the client-4 • Decrease general transference-3 • Prevent transference with clients who have poor reality testing-3 • Provide counselor satisfaction-1 • Decrease counselor anxiety-0

45. Frequency of Reasons Not to Self Disclose(Simone, D.H., McCarthy, ., & Skay, C.L., 1998, p.179) • Avoid blurring boundaries- 107 • Stay focused on the client-99 • Prevent concern about counselor welfare-67 • Prevent merging-54 • Prevent premature closure-45 • Avoid information overload and confusion-40 • Prevent client feeling burdened by counselor problems-39 • Avoid interfering with transference-28 • Prevent client demoralization by counselor success/failure-25 • Avoid giving client information to manipulate counselor-20 • Avoid counselor discomfort-14 • Prevent client questioning counselor’s ability to help-11 • Avoid questions about counselor’s mental helath-9 • Prevent client communicating information about counselor-4 • Avoid losing credibility as an expert-3

46. Questions to Consider Regarding Disclosure • Have I paused to evaluate this potential disclose beforehand? • Why am I disclosing? • How will this help the client’s goals in counseling? • Are there conditions which necessitate this disclosure? If so, what? • Are there other ways of approaching the client’s issue that may be as effective as disclosure? • Is there any potential harm or danger to the client from this potential disclosure? • Does the client have the ego strength for this disclosure? • Will this disclosure blur professional boundaries? • How will this disclosure help the client emotionally (instilling hope, moving toward counseling goals, feeling less alone)? • Could the client end up feeling demoralized by my disclosure? • Will this disclosure help with reality check? • Possibly test out a lower level disclosure first (e.. an obvious topic the client may be wondering about) versus a more detailed deliberate disclosure

47. Self Disclosure With Children/Teens(Capobianco, J., & Farber, B.A., 2005 & Gaines, R., 2003) • Children/teens require a higher degree of self disclosure. • Children may elicit and require a higher level of therapist disclosure • All information on you is a type of disclosure for a child/adolescent (mannerisms, dress, décor, word you use/don’t allow, etc.) • Children/teens generally less rigid than adults. • Find the meaning for the child (what is the symbolism behind it?) • Keep in mind age, maturity level, culture, an individual variables unique to this child/teen. • Our reactions to the child’s behaviors disclose something to (e.g. how we handle misbehaviors, how to set boundaries, how we handle parent/child interactions, play allowed

48. Issue #11: Cultural Sensitivity • Counseling is culture infused so the working alliance must be culture infused when necessary • The worldview, orientation, race, ethnicity, identity factors, abilities, religion, socioeconomic status, language, music, hobbies, traditions, beliefs, etc. • Three areas of competency: • Domain I: Self: active awareness of personal assumptions, values, and biases • Domain II: Cultural awareness: Other- Understanding the worldview of the client • Domain III: Culturally Sensitive Working Alliance: (respect, goal formation, collaboration throughout)

49. Discursive Empathy(Sinclair, S.L. & Monk, G., 2005) • Also called “discursive” empathy Not only 1) perceiving the client’s view • Or 2) communicating this to the client • But also … 3). incorporating the culture framework and backdrop • 4). while keeping our separateness • Involves “deconstruction”- exploring assumptions and what they are made up of to reinforce or challenge them What this achieves: • 1. clarifies the client’s position and values • 2. helps the clients become more reflexive • Increases client’s ability for choice, freedom and self-development • “no study found that showed that empathy is harmful”

50. Issue #12: Doing Confrontation • Open, Honest identification of self defeating thoughts or behaviors • identify the cycle • help client increase awareness of thoughts and behaviors which keep the unhealthy cycle going Functions • bringing contradictions to light • helping develop congruency • admit personal needs • keys: • timing • genuineness and empathy of counselor • foundations of rapport and trust built