THE DIFFERENCE BETWEEN COUNSELING AND

PSYCHOTHERAPY
o Both counseling and psychotherapy focus less on the
content of a specific decision than does guidance
(e.g guidance: vocational counseling)
o Instead, both counseling and psychotherapy focus on
helping a person reach the decision that fits best for
them with regard to their own values and desires.
o Shorter-term work focused on dealing with a specific
“difficulty in life” situation (marital breakup, loss of
job, etc.) is more likely to be called counseling than
therapy (but this is not always true).
o Persistent and pervasive patterns of maladaptive
behavior are likely to require longer-term service
provision, which is more likely to be called therapy.
o Therapy also assumes the need for greater expertise
by the provider
o Services provided by social workers, pastoral care
counselors, nurses, vocational guidance personnel,
and school psychologists are more likely to call their
treatment counseling than therapy. They are more
likely to use developmental psychology type models
(rather than DSM).
o Service providers who use diagnostic systems, such
as the DSM, are more likely to call their services
treatment. And those who view themselves as
providing treatment are more likely to call what they
do therapy (possibly because this fits with the
medical model).
PERSON VARIABLES
The Therapeutic Relationship
▫ The therapeutic relationship is an important
component of effective counseling
▫ The therapist as a person is a key part of the
effectiveness of therapeutic treatments
▫ Research shows that both the therapy relationship and
the therapy used contribute to treatment outcome
Age
- Results are mixed
- Some studies show a positive relationship between age
similarity and client satisfaction
- Others show that older therapists are seen as more empathic
and competent
- The issue might be more about ascribed credibility where the
client sees the therapist as someone who knows what he/she is
doing
Gender
- Results are mixed
- Gender socialization might affect therapeutic relationship.
- E.g. male/female power differences might be problematic for
a female client and male therapist.
- There might be transference and countertransference issues
between 2 females
- The problems the clients are addressing, plus their phase in
the life cycle must be considered when assessing the impact of
the therapist’s gender
THE THERAPIST’S VALUES
 Recognize that you are not value-neutral
 Be aware of value imposition
▫ How your values influence your interventions
▫ How your values may influence your client’s
experiences in therapy
 Your job is to assist clients in finding answers that are
most congruent with their own values
 Find ways to manage value conflicts between you
and your clients
 Begin therapy by exploring the client’s goals
Characteristics of an Effective Counselor

The Effective Counselor

The most important instrument you have is YOU, so you have

to take care of and be aware of the instrument that is YOU:

▫ Your ethnicity
▫ Your age
▫ Your gender
▫ Your values
▫ Your need for counseling

THERAPIST VARIABLES

Ethnicity

- An ethnic match showed significantly decreased attrition rate

- This is probably based on the ethnic/cultural sensitivity of
the therapist ascribed by client to therapist

MULTICULTURAL COUNSELING
▫ Become aware of your biases and values
▫ Become aware of your own cultural norms and
expectations
▫ Attempt to understand the world from your client’s
vantage point
▫ Gain a knowledge of the dynamics of oppression,
racism, discrimination, and stereotyping
▫ Study the historical background, traditions, and
values of your client
▫ Challenge yourself to expand your vantage point to
explore your client’s ways of life that are different
from your own
▫ Develop an awareness of acculturation strategies
MULTICULTURAL ISSUES
Biases are reflected when we:
▫ Neglect social and community factors to focus
unduly on individualism
▫ Assess clients with instruments that have not been
normed on the population they represent
▫ Judge as psychopathological – behaviors, beliefs, or
experiences that are normal for the client’s culture
▫ Strictly adhere to Western counseling theories
without considering its applicability to the client’s
diverse cultural background
VICARIOUS TRAUMATIZATION
 Vicarious trauma is the emotional residue of exposure
that counselors have from working with people as
they are hearing their trauma stories and become
witnesses to the pain, fear, and terror that trauma
survivors have endured.
 “Vicarious trauma is what happens to your
neurological, physical, psychological, emotional and
spiritual health when you listen to traumatic stories
day after day or respond to traumatic situations while
having to control your reaction” (Vicarious Trauma
Institute, 2013)
 VT is pervasive because it not only affects a helper’s
effectiveness in his occupation, it also invades other
aspects of his life.
 The effects are cumulative and repeated exposure to
trauma survivors not only puts helpers at greater risk
of developing VT, but may also intensify their own
symptoms.
It is important to note:
 VT is a normal reaction to doing the difficult work
of trauma therapy.
▫ It can happen to anyone.
▫ It should NOT be considered as an inadequacy
on the part of the helper.
▫ It can be seen as an occupational hazard of sorts
that comes with the helping profession.
Symptoms of VT are similar to trauma
 Intrusions
 Avoidance
 Hyperarousal and hypervigilance
Should a counselor be a client?
In your experience of being a client you can:
▫ Consider your motivation for wanting to be a
counselor
▫ Find support as you struggle to be a professional
▫ Increase self-awareness
▫ Have help in dealing with personal issues that are
opened through your interactions with clients
▫ Awareness of values system, needs, attitudes, and
experiences
▫ Be assisted in managing your countertransferences
▫ Experiential frame of reference (we can now relate
with client’s view AND experience a particular
strategy/mode)
Corey believes that “...therapists cannot hope to open doors
for clients that they have not opened for themselves.”
Staying Alive – It’s a Prerequisite
 Take care of your single most important instrument –
YOU
▫ Develop self-care strategies and a plan for
renewal
 Know what causes vicarious traumatization, burnout,
compassion fatigue, etc.
 Know how to recognize and remedy these issues
 The importance of self-care
SIMILAR/OVERLAPPING CONSTRUCTS
Professional Burnout
- “Emotional exhaustion” from being overloaded with the
demands of work in general.
Secondary Traumatic Stress
- “Results from knowing about a traumatizing event
experienced by a client and the stress resulting from helping or
wanting to help that client”
Compassion Fatigue
- Results from frequent use of empathy when interacting with
clients who suffer.
- can also be understood as the “emotional exhaustion” from
the demands of the helping profession in general
Individual Level
Self Education - Understand the trauma on both sides
Self Awareness - Setting professional boundaries
Self-Care - Sleep, diet, exercise; Engage in fun activities
Peer Level
Professional Supervision
- Practicing in front of an expert
- Get insights from another perspective
Healthy Support System
- Have somebody to talk to regarding your personal problems
CLIENT VARIABLES
Sociodemographic Variables
Socio Economic Status
▫ Lower SES has been associated with early
termination
▫ Education, correlated with SES, has also been
positively correlated with longer therapy
▫ Certain basic physiological needs need to be met
before some clients can benefit from therapy
▫ But in terms of outcomes, results are
inconclusive.
Gender
▫ Women are more likely to seek therapy, but there are
little significant differences in terms of outcome
Marriage
▫ Those who are married usually stay in treatment
longer, but kind of treatment should also be
considered (married did better receiving CBT, while
singles/cohabitating did better receiving person
centered therapy)
Personality Characteristics
▫ There are few findings that connect trait dispositions
with outcome
▫ But psychologists argue that clinicians should
consider
▫ Looking at what dispositions/characteristics would
work best with particular treatment modes
▫ Acknowledging the basic tendencies/temperaments
Psychopathology symptoms
▫ Severity is related to poorer outcomes
▫ Age of onset is less significantly related to outcome
▫ Kind of psychopathology is related to kind of
treatment:
▫ Clients low in initial rates of psychiatric disturbance
did better with psychoanalytic therapy than those
who started high on psychiatric disturbance
▫ BUT behavioral therapy is equally efficacious with
those initially high and low on psychiatric
disturbance.
ETHICS IN COUNSELING AND PSYCHOTHERAPY
PROFESSIONAL ETHICS
Ethics codes are a fundamental component of effective
counseling: Guidelines that outline professional standards of
behavior and practice
▫ Codes do not make decisions for counselor.
▫ Counselors must interpret and apply ethical codes to
their decision-making
Types of ethics to consider:
Mandatory Ethics: deals with the minimum level of
professional practice
Aspirational Ethics: deals with doing what is in the best
interest of the client (ethics is more than a list of things to
avoid for fear of punishment)
Positive Ethics: wanting to do what is best for client and not
simply with complying with minimum standards
ETHICAL DECISION MAKING
The principles that underlie our professional codes
▫ BENEFIT OTHERS, DO NO HARM, RESPECT
OTHER'S AUTONOMY, BE JUST, FAIR AND
FAITHFUL
The role of ethical codes:
▫ They educate us about responsibilities; are a
basis for accountability; protect clients; are a
basis for improving professional practice
MAKING ETHICAL DECISIONS
Identify the problem:
Is it ethical, legal, professional, clinical, moral? What are
the rights and responsibilities of all those involved?
Review relevant codes:
Are your values, ethics and behaviors consistent with the
guidelines?
Seek consultation
▫ Brainstorm on all options; include other
professionals; include client
▫ Enumerate consequences and reflect on
implications on your client
▫ Decide and document the reasons for your
actions
▫ To the degree it is possible, include your client in
your decision making process
INFORMED CONSENT
What should we inform our client about?
o Therapy Procedures
o Risks, Benefits and Alternatives
o Right to withdraw from treatment
o Costs of treatment
o Supervision
o Privileged communication
o Dimensions of Confidentiality
o Clients need enough information about the
counseling process to be able to make informed
choices.
o We are empowering them and building a trusting
relationship
o The challenge is striking a balance about giving
too much or too little
o Educate clients about their rights and
responsibilities
Dimensions of confidentiality
▫ It is essential for developing a trusting and
productive relationship
▫ Confidentiality is essential but not absolute
▫ Confidentiality issues must be discussed with
client.
Exceptions:
Duty to Warn
▫ The client poses a danger to self or others:
▫ A client under the age of 16 is the victim of abuse
▫ A dependant adult or older adult is the victim of
abuse
▫ The client needs to be hospitalized
▫ The information is made an issue in a court action
▫ The client requests a release of record
DUAL RELATIONSHIPS
Dual Relationships are not deemed inherently unethical
in the ethics codes of the APA.
Multiple relationships must be managed in an ethical
way to eliminate nonprofessional interactions and protect
client well-being.
Some helpful questions:
Will my dual relationship keep me from confronting and
challenging the client?
Will my needs for the relationship become more important
than therapeutic activities?
Can my client manage the dual relationship?
Can my client still see me as a someone he/she can trust?
Can my client still see me as a professional
Whose needs are being met--my client's or my own?
Can I recognize and manage professionally my attraction to
my client?
Ethical issues in assessment and diagnosis
Can I diagnose that a person has anti-social personality
disorder?
▫ Both can help in treatment: planning a
framework for conceptualization, understanding
and research
▫ Both require cultural sensitivity
Diagnosis is the process of identifying pattern of
symptoms which fit the criteria for a specific mental
disorder defined in the DSM-5
▫ Can be a detriment in understanding the client's
subjective world
▫ Can make it difficult to see the client as a person,
with his unique strengths and individuality; can
result in a self-fulfilling prophecy
Assessment is an ongoing process designed to help the
counselor evaluate key elements of a client's psychological
functioning
▫ Assessment practices are influenced by the
therapist's theoretical orientation
Ethics and evidence-based practices
Ethically, we should use the intervention that has been
proven to work well.
Strengths
▫ Counselors use treatments that have been
validated by empirical research
▫ Treatments are usually brief and are
standardized
▫ Fits well with accountability among mental
health professionals who can operationalize
effective treatments
Criticisms
▫ Some counselors believe this approach is
mechanistic and does not allow for individual
differences and phenomenological understanding
in clients
▫ Is not well-suited for helping clients with
existential concerns
▫ It is difficult to measure both relational and
technical aspects of
BASIC SKILLS IN COUNSELING PRACTICE
LISTENING WELL
Listening to patients (trying to understand their thoughts
and feelings) is crucial to effective communication.
Patients' feelings must be accepted without judgment as to
being "right" or "wrong."
Success of listening depends on all 4 elements:
▫ Hearing: Physiological process
▫ Filtering out distractions: to focus, concentrate
on message
▫ Interpreting: Assigning meaning, decoding
(includes verbal and nonverbal cues).
▫ Recalling: Remembering the information later
Factors that impact listening
Some communication habits can interfere with your ability
to listen well:
▫ Multi-tasking: to do two things at once (it evident
to patients that they don't have your full
attention).
▫ Planning ahead to what you will say next:
Planning next point.
▫ Jumping to conclusions before patients have
completed their messages (only hearing parts of
messages).
▫ Selective listening: Focusing only on content-
listening with ears only. (judging the person or the
message).
▫ Faking interest.
▫ Perceptions.
▫ Stereotyping.
Listening well involves understanding both the content of
the information being provided and the feelings being
conveyed.
There are Skills that are useful in effective listening,
include:
1. summarizing,
2. paraphrasing,
3. empathic responding "reflection of feeling": statements
that verbally convey your understanding of the essence or
emotional meaning of another person's communication.
SUMMARIZING
When a patient providing information, summarize the
critical pieces of information.
Importance of summarizing:
▫ Allows you to understand accurately the
information conveyed by the patient.
▫ Allows the patient to add new information that
may have been forgotten.
▫ It serves to identify misunderstandings that may
exist, especially when there are barriers in
communication, such as language barriers.
PARAPHRASING
Paraphrasing condenses aspects of content as well as some
superficial recognition of the patient's attitudes or feelings,
convey back to the patient the essence of what he or she
has just said.
Example of paraphrasing:
Patient #1: I don't know about my doctor. One time I go to
him and he's as nice as he can be. The next time he's so
rude I swear I won't go back again.
Counselor #1: He seems to be very inconsistent.
EMPATHIC RESPONDING
Empathy: can be defined as an ability and willingness to
understand the client's thoughts, feeling & struggling from
client's point of view. In other term entering private
conceptual world of other. Empathy serves primarily as a
reflection of the patient's feelings rather than focusing on
the content of the communication.
▫ Putting yourself from their own shoes.
Empathy and Effective Communication
Empathy has many positive effects on a counselor's
relationships with patients. It helps patients:
▫ To trust you as someone who cares about their
welfare (interest).
▫ To understand their own feelings more clearly.
▫ To alleviate (relieve) the patient's sense of
isolation, which often accompanies an illness
experience.
▫ To facilitate the patient's own problem-solving
ability.
A number of less helpful responses are frequently used in
communication with others.
1. Judging response
2. Advising response
3. Placating or falsely reassuring response
4. Generalizing response
5. Quizzing or probing response
6. Distracting response
JUDGING RESPONSE
▫ We tend to judge or evaluate another's feelings.
▫ Any message from you that indicates you think
patients are "wrong" or "bad" or that they
"shouldn't" feel the way they do, will indicate that
it is not safe to confide (trust) in you.
Patient: "I've been feeling so down lately, like I just can't
snap out of it."
Therapist (judging response): "Well, you shouldn't let
yourself get so down. There are people who have it much
worse, you know."
ADVISING RESPONSE
▫ That is part of our professional responsibility
when patients do want advice and are looking for
help with their problems.
▫ However, the advising role may not be
appropriate in helping a patient deal with
emotional or personal problems.
Patient: "I've been feeling really anxious about my
upcoming job interview."
Therapist (advising response): "You should try practicing
some deep breathing exercises before the interview. It
might help calm your nerves."
PLACATING OR FALSELY REASSURING RESPONSE
▫ This response may seem to be helpful, but is
really conveying that the person "shouldn't" feel
upset.
▫ We often use this kind of response to try to get a
patient to stop feeling upset or to try to change a
patient's feelings, rather than accepting the
feelings as they exist.
“Ayaw lang kabalaka... mahuman ra gyud ninga kalbaryo!”
“Everything will be ok.”
GENERALIZING RESPONSE
▫ Another way in which we try to reassure patients
is by telling them, "I've been through the same
thing and I've survived." this response may take
the focus away from the patient's experience
onto your own experience, before patients have
had a chance to talk over their own immediate
concerns.
▫ This can lead you to stop listening because you
jump to the conclusion that, since you have had
an experience similar to the patient's, the patient
is feeling the same way you felt? ..... This may not
be true.
Patient: "I'm having trouble coping with my recent
breakup.”
Therapist (generalizing response): "Breakups can be
tough, but trust me, with time, you'll start feeling better."
QUIZZING OR PROBING RESPONSE
▫ Asking questions when the patient has expressed
a feeling can take the focus away from the feeling
onto the "content" of the message.
“Ayyy tinuod ka??? Kinsa man nang maestroha???”
DISTRACTING RESPONSE
▫ Many times we get out of situations we don't
know how to respond by simply changing the
subject to stop or change their feelings.
▫ Changing the subject (distracting); is trying to
show them that things are not as bad as they
seem; or we may direct the communication to
subjects we feel comfortable with.
EMPATHY
Attitudes Underlying Empathy
Empathic attitude means that:
1. You want to listen and try to understand a person's
feeling and point of view.
2. You are able to accept feelings as they exist without
trying to change them, stop them, or judge them.
3. An empathic response implies neither agreement nor
disagreement with the perception of the patient.
4. You should not be afraid of a patient's emotions and not
necessarily do anything except listen.
▫ Establishing eye contact while talking to patients
▫ Leaning toward them slightly with no physical
barriers
▫ Having relaxed posture
▫ Head nods and encouragements to talk.
▫ Tone of voice
▫ Conveying that you have time to listen.
If we don't have time to listen. It may be necessary to tell a
patient that you do not have time right now to discuss an
issue in detail, but will telephone or set an appointment for
when you are not so busy.
▫ The fact that you were direct and honest about
your limits will probably do less to harm the
relationship than if you had said, 'Im listening,"
while nonverbally conveying hurry or impatience.
▫ The discrepancy (conflict) between what we say
and how we act sets up barriers that are difficult
to overcome.
Problems in establishing helping relationships
Certain counselors attitudes and behaviors are damaging
in establishing helping relationships with patients.
These include:
Stereotyping
Depersonalizing
▫ Communication problems may exist because of
negative stereotypes held by health care
practitioners that affect the quality of their
communication.
If you hold certain stereotypes of patients, you may fail to
listen without judgment.
What might the patient response be to these counselors'
perceptions?
▫ loss of personal control
▫ Increase dependency of the healthcare provider
resentment
DEPERSONALIZING
Depersonalizing - Perceiving the patient as a case or
number- Impersonal;
Ex. "Just please allow me to call you Patient 3-B. You are
my third Badjao patient. Well you have the reputation of
not paying your counseling sessions... so Patient 3-B, what
seems to be the problem this time?"
BASIC ATTENDING SKILLS
Purpose:
▫ To help client tell story
▫ Draw out appropriate background and contextual
information
▫ Communicate understanding
▫ Facilitate deeper level of exploration make
connections
▫ Demonstrate empathy
▫ Provide emotional support to the client
Skill: Minimal Encourages
o Prompts
o Verbal (uh huh, go on, yes, hmmm,)
o Nonverbal (bodily movement, gestures, nods)
Skill: Probes
▫ Probes should be used to help keep clients
engaged in dialogue and provide client with
enough structure to achieve concreteness and
clarity while providing an opportunity to get
necessary details of story.
▫ Probes can also help clients get a balanced view
of problem situations and opportunities.
▫ Probes help clients get deeper into issues, move
forward, and help in exploration of issues.
▫ Probes can also challenge clients.
Skill: Questions
When to ask questions:
▫ Initially. "Where would you like to begin today?"
▫ When you need specific information
▫ For clarification (but you could always do a
paraphrase)
▫ To get things back on track. "Earlier you said...
what is... To bring it in the here and now
▫ When you want to make a point or a connection.
"What were you thinking just now when you heard
me say that?"
▫ When you want to define goals.
▫ When you want to motivate the client into action
Problems with Questions
▫ Bombarding client
▫ Too many questions in a row
▫ Using questions effectively
If you can make it a statement it's better!
Tell me....
Explain that...
I wonder....
Talk more about that....
▫ Good idea to mix probes, statements, reflections
▫ Avoid “Why”
Open and Closed
Open questions:
▫ help elaborate and enrich the client story help
bring out the concrete specifics of the client's
world what would an example be?
▫ Closed gives basically a yes/no response
Fluff:
▫ If you are trying to fill "space", it's probably not a
useful question
▫ If you can reflect or use another skill, it's always
better
Skill: Clarifying and Summarizing
This is not restating or parroting, but summarizing. This
shows the client you are paying attention.
What is important?
▫ Listen to what your heard
▫ Ask yourself what is underlying message
Mini-summarization:
▫ A sentence stem: "I hear you say..." or "In your
point of view..." or "Looks like..."
▫ Use key words of clients
▫ Stay true to client's ideas.. they will correct if you
are wrong (and that's okay!)
▫ Summarize themes of long dialogue
▫ Summarize at beginning of new session
▫ Summarize at end of session
▫ Clarify/Summarize when situation seems to not
be going anywhere or client is rambling
▫ Clarify/Summarize when client gets stuck or
when clients needs new perspective
Skill: Nonverbals
Both client and counselor nonverbals can communicate
volumes.
▫ Client nonverbals can give context to the
information the client is sharing, can support or
discredit the validity of what the client is
 expressing, and can serve to provide additional
understanding to words the client is using.
▫ Counselor nonverbals also give clients clues
about counselor confidence, degree to which
counselor is listening to them, relationship
trustworthiness.
Nonverbal information can be gained through observation
of:
▫ Facial expressions
▫ Eye Contact (*consider cultural differences)
▫ Appearance (clothing, grooming)
▫ Gestures/Body movements (i.e., fidgety)
▫ Spatial behavior (how did client position
him/herself)
▫ Posture
Skill: Non-Verbal Attending
What information can be gathered from nonverbals?
▫ Assessment of general mood
▫ Clues to inner states
▫ Mental status
▫ Verbal and nonverbal congruency
▫ Signals of distress Unconscious reactions

Skill: Counselor Nonverbals

So, what nonverbal behaviors indicate interest and caring?
SOLER (sit squarely, open posture, lean in, eye contact, and
relax
▫ Also, your facial expression will show appropriate
response Minimal encouragers: head nods, uh
huhs...