Clinical Skills in Assessment

This chapter is dedicated to pertinent notes for clinical skills.

Listening and Relationship Development

These categories and descriptions are mostly taken from Somers-Flanagan & Somers-Flanagan. They include (1) Basic attending, listening, and action skills; (2) Directives - Questions and Action Skills; (3) Theoretically-supported and evidence-based relationships in clinical interviewing.

Basic attending, listening, and action skills

Nondirective listening responses:

• Attending behaviours (eye contact, body language, vocal qualities, verbal tracking)
• Silence
• Clarification
• Paraphrasing
• Sensory-based paraphrase (aligning with their primary sense modality they use in language)
• Nondirective reflection of feeling
• Summary

Directive listening responses:

• Interpretive reflection of feeling.
  • Statement indicating what feelings the interviewer believes are underlying the client's thoughts or actions. E.g., "You know, I also sense you have some other feelings about what your teacher did. Maybe you were hurt because she didn't trust you."
• Interpretation.
  • Statement indicating what meaning the interviewer believes a client's emotions, thoughts, or actions represent. Often includes references to past experiences. E.g., "So when you respond to your teacher's distrust of you with anger, it's almost like you're reacting to those times when your parents haven't trusted you."
• Question
• Feeling validation
  • This includes a judgment that it is okay or expected that the client is feeling that feeling.
• Confrontation
  • Statement that points out or identifies a client incongruity or discrepancy.

Directives: Questions and Action Skills

Questions

Therapeutic Questions

• The pre-treatment change question
  • E.g., "what changes have you noticed that have happened or started to happen since you called to make an appointment for this session?"
• Scaling questions
• Percentage questions
  • N.b. interviewer systematically keeps the client focusing on the appearance, sound, feel, and smell of success or improvement
• Unique outcomes or redescription questions
  • The counsellor selects for attention any experience, however minute and insignificant to the client, that stands apart from the problem story. These fragments of experience are the raw material from which the new story can be fashioned. By asking questions about these "unique outcomes", the counsellor inquires into the client's influence on the life of the problem.
  • E.g., "what did you do that helped you get yourself out of bed and in here for this appointment despite the depression?"
• Presuppositional questions
  • Questions that presuppose a positive change has already occurred and ask for a specific description of these changes.
  • E.g., "Who will be most surprised in your family when they hear that your grades have improved? Who will be the least surprised?"
  • E.g., "What do you imagine will have changed when you start staying calm even when other students try to make you mad?"
  • E.g., "Let's suppose two years have passed and now you're living your life completely free from alcohol. What exactly would you be doing every day to keep yourself busy and sober?"
• The Miracle Question
  • E.g. "Suppose you were to go home tonight, and while you were asleep, a miracle happened and this problem was solved. How will you know that the miracle happened? What will be different?
• Externalising questions
  • From narrative therapy. E.g., "who are you with when you feel lighter and happier and like you've thrown off the weight of that depression?"
• Exception questions
  • Exception questions seek minor evidence that the client's problem is not always huge and overbearing. Can be who, what, why, how, where, when questions:
  • E.g., Who: Who is present when the exception occurs? What are they doing differently? What would they say you are doing differently?
  • E.g., What: What is happening before the exception occurs? What is different about the behaviour during the exception period? What happens afterwards?
  • E.g., Where: Where is the exception occurring? What are the details of the setting that contribute to the exception?
  • E.g., When: What time of day does the exception occur? How often is the exception happening?
  • E.g., How: How are you making the exception happen? What strengths, talents, or qualities are you drawing on?

Guidelines In Using Questions

1. Prepare your clients for questions
2. Do not use questions as your predominant listening or action response
3. Make your questions relevant to client concerns and goals
4. Use questions to elicit concrete behavioural examples and positive visions for the future
5. Approach sensitive areas cautiously

Directive Action Responses

Directive action responses are used to encourage clients to change the way they think, feel, or act. Based on clinical judgment, directive action responses are used when interviewers believe that change should occur in the client's life, attitudes, or behaviour. Such responses require that interviewers take responsibility for determining what client changes might be desirable.

Explanation or Psychoeducation

The usual psychoeducational targets within an interview include three components:

• Explaining the counselling process. Aka role induction/ psychotherapy socialisation
  • Role induction consists of informing or educating clients about what to expect in therapy, especially regarding the respective roles of a therapist and client.
  • E.g., "A basic rule of counselling is that when you start wondering whether you should say something or not, you should just go ahead and say it and then we can decide together whether it is important to talk about in greater depth."
  • It's not unusual for clients to say, "I don't know if I should talk about this", or "I'm not sure what I'm supposed to say." When they do, it often signals that some psychoeducation (or role induction) is needed.
• The meaning or implications of a particular symptom. A second type of explanation is needed when clients are experiencing symptoms, but are puzzled about what their symptoms mean - e.g., "I'm going crazy". Some clients with panic disorder believe they are "crazy" and will eventually end up institutionalised, despite the fact that the prognosis for most anxiety disorders is positive. This should be explained to the client because symptom explanations, even diagnosis, can be reassuring for clients.
  • E.g., "I know you think there's something wrong with your mind, because what you're feeling is very frightening. But based on your personal history, family history, and the symptoms you have, it's clear that you're not going crazy. The problems you're experiencing are not unusual. They respond very well to counselling."
• Instructions on how to implement a specific piece of advice or therapeutic strategy. This information an interviewer decides to give is dictated, in part, by his or her theoretical orientation.

Suggestion

Although sometimes interchangeable, suggestion and advice are two distinct and different interviewer responses. Specifically, to suggest means to bring before a person's mind indirectly or without plain expression, whereas to advise is to give counsel to or offer an opinion or suggestion worth following.

Suggestion should be used with caution. Occasionally, it can be viewed as a sneaky or manipulative strategy.

Agreement/Disagreement

Using agreement has several potential effects:

• Can enhance rapport.
• If clients think you are a credible authority, agreement can affirm the correctness of their opinion (i.e., "If my therapist agrees with me, I must be right").
• Puts you in the expert role, and your opinion is sought in the future.
• Can reduce client exploration (i.e., "Why explore my beliefs any longer; after all, my therapist agrees with me")

The purpose of _disagreement _is to change client opinion. The problem with disagreement is that countering one opinion with another opinion may deteriorate into a personal argument, resulting in increased defensiveness by interviewer and client. Two basic guidelines apply when you feel like disagreeing with clients:

1. It is not your job to change the client's opinion but to help them with maladaptive thoughts, feelings, and behaviours.
2. If the client's belief is maladaptive, you may choose to confront the client and provide him or her with factual info designed to facilitate client change towards more adaptive beliefs.

Approval/Disapproval

Clients who seek their interviewer's approval may be feeling temporarily insecure or suffering from longstanding needs for approval. Strong needs for approval may stem from feeling rejected and disapproved of as a child. Giving approval can be a powerful therapeutic technique. Interviewer approval can enhance rapport and increase client self-esteem. It also fosters dependent relationships: When a client's search for approval is rewarded, the client is likely to resume a search for approval when or if the insecure feelings begin again.

In some cases it is difficult to avoid feeling disapproval toward clients. In these cases it is useful to keep in mind the following points:

• Clients who engage in deviant or abusive behaviour have been disapproved of before, usually by people who mean a great deal to them and sometimes by society. Nonetheless, they have not stopped engaging in deviant or abusive behaviour. This suggests that disapproval is ineffective in changing their behaviour.
• Your disapproval only alienates you from someone who needs your help to change.
• By maintaining objectivity and neutrality, you are not implicitly approving of your client's behaviour. There are other responses besides disapproval (e.g., explanation and confrontation) that show your client that you believe change is needed.
• If you cannot listen to your client's descriptions of his or her behaviour without disapproval, refer the client to another qualified professional.
• Disapproval is associated with reduced rapport, feelings of rejection, and early termination of counselling.

Giving Advice

Giving advice can be a helpful therapeutic change technique. It provides the client with ideas regarding new ways to act, think, or feel. However, if given prematurely, can be ineffective and can damage interviewer credibility. Recommended to start nondirectively, because you can always get more directive and provide advice later.

"So you haven't told anyone about the pregnancy. And if I understand you correctly, you're feeling that maybe you should be taking some particular action, but you're not sure what."

Some clients will push hard for advice and keep asking. In many cases, you should use an explanation and open-ended question when clients pressure you for advice. For example:

"Before we talk about what you should do, let's talk about what you've been thinking and feeling about your situation. Then we can talk together about options, but first, tell me what you've thought about and felt since discovering you're pregnant."

Or, in this case, simply an open ended question might be appropriate:

"What options have you thought of already?"

When you do agree to offer advice, it should almost always be advice about how to obtain the resources or information the client needs to make a decision. Rather than advising someone to get an abortion, initiate an adoption process, or to leave an unfulfilling relationship, advice can centre on how to weigh options and make a decision. Additionally, solution-oriented interviewers often emphasise client skills and resources and get clients to generate their own advice by asking questions like, "How did you manage to change things around?" or "What's the longest you've gone without being in trouble with the law? How did you do that?"

Self-Disclosure

Self-disclosure is a complex and flexible interviewing response that can be used for many purposes. Hill (2004) encourages helpers to use self-disclosure to lead clients toward greater insight. She suggests a brief self-disclosure focused on the client's central issue, followed by a check-in with the client. E.g. "Yes, I do that too. I notice that I have a tendency to regress to being dependent unless I'm careful. I wonder if that's true for you?" As you can see from the example, self-disclosure can be very leading. In this case, the interviewer is suggesting a pattern that might be common to both interviewer and client. This strategy not only implies commonality, but it also implies that the way the interviewer thinks about or handles her own life may be a model for the client. Obviously, there are many problems with this presumption - especially when it comes to working with clients with different cultural identities than your own.

Using self-disclosure with culturally diverse clients

Most approaches to multicultural work recommend that interviewers use self-disclosure when working with clients from different cultures. In these situations, self-disclosure is viewed as making you more human and real and therefore potentially more trustworthy. However, as with virtually all interviewing responses, the effectiveness of self-disclosure depends on how (and why) you use it.

• Self-disclosure with the purpose of joining or connecting is generally very appropriate.
• In contrast, when used as a means of providing advice or suggestions, self-disclosure to culturally diverse clients is more risky and can damage the therapeutic relationship.
  • Imagine, for example, an interviewer from the dominant culture noting to an African-American male that sometimes he feels invisible in the workplace and goes on to wonder if the client feels the same. Given the depth and the pain associated with the invisibility complex among Black men, this disclosure could further the client's belief that his interviewer really has no idea of what it's like to be a Black man in the workplace.
• Generally, any cross-cultural self-disclosure that implies that someone from a dominant cultural group knows the inner feelings and struggles of someone from a less-dominant cultural group is ill-advised. Instead, interviewers are better off to cite research or to quote other individuals from the culture when exploring client issues. For example, instead of relying on his own personal experiences in feeling invisible, the interviewer would likely be more effective if he simply notes the research and writing of Anderson Franklin about invisibility experiences of Black Americans and then checks to see if the client has had similar experiences.

Some writers refer to self-disclosure that focuses on the interviewer's current thoughts about or feelings toward the client as immediacy or metacommunication (Hill, 2004). Self-disclosure as immediacy is, of course, a here-and-now communication that can facilitate therapy process or increase client defensiveness. Consequently, we consider it a high-risk or high-stakes interviewer response and recommend devoting class discussion and supervision time to explore appropriate and inappropriate uses of immediacy.

Urging

Urging is a step beyond advice giving. It involves pressuring clients to take a specific action. When interviewers urge clients to take a specific action, they are using a direct power approach to facilitating change. Urging is not common during clinical interviews, but there are situations when urging is more appropriate. These situations involve primarily crisis (e.g., when the client is in danger or dangerous). For example, in child abuse cases, if you are interviewing the abuser, you may urge him to report himself to the local agency responsible for protecting children. By urging the client to make the report with you present for support and encouragement, you might facilitate a better child protection investigation process.

Theoretically supported and evidence-based relationships in clinical interviewing

Carl Rogers's Core Conditions

1. Congruence
2. Unconditional positive regard
3. Accurate empathy

Congruence means that a person's thoughts, feelings, and behaviour match. Congruent interviewers think, feel, and behave in a consistent and integrated manner and are described as genuine, authentic, and comfortable in their interactions with clients. Congruence implies spontaneity and honesty. Rogers (1961) was clear that congruence requires expression of "various feelings and attitudes which exist in me" (p. 33). He also emphasised that congruent expression is important even if if consists of attitudes, thoughts, or feelings that do not, on the surface, appear conductive to a good relationship.

To evaluate and use congruence, we should view it from Carl Rogers's perspective. When engaged in counselling, Rogers became deeply connected with clients and could feel what it was like to live in their world, which is partly why he named his approach "client-centred" and later "person-centred." This focus greatly reduced his need to express negative feelings towards clients or excessively self-disclose. Rogers clearly stated that therapy was not for interviewers to talk about their own feelings:

"Certainly the aim is not for the therapist to express or talk about his own feelings, but primarily that he should not be deceiving the client as to himself. At times he may need to talk about some of his own feelings (either to the client, or to a colleague or superior) if they are standing in the way. (pp. 133-134)

This statement illustrates how Rogers believed good judgment should be used when using self-disclosure. Discussing your feelings with peers or supervisors is usually more appropriate than discussing feelings directly with your client. A good question to ask when thinking of whether to be expressive with a client is to consider, "who is it for?"

Since the 1960s, feminist therapists have strongly advocated congruence, or authenticity, in interviewer-client relations: "To be involved, to use myself as a variable in the process, entails using, from time to time, mimicry, provocation, annoyance, analogies, or brief lectures. It also means utilising my own and others' physical behaviour, sensations, emotional states, and reactions to me and others, and sharing a variety of intuitive responses. This is being authentic."

Unconditional Positive Regard. Rogers (1961) stated, "the safety of being liked and prized as a person seems a highly important element in a helping relationship" (p. 34). An important question for interviewers is: "How can I express or demonstrate unconditional positive regard?"

Expressing unconditional positive regard directly to clients is not recommended. Direct expressions may be interpreted as phony or inappropriately intimate. So, how might we do this?

• First, by keeping appointments, by asking how your clients like to be addressed and then remembering to address them that way, and by listening sensitively and compassionately, you establish a relationship characterised by affection and respect.
• Second, by allowing clients freedom to discuss themselves in their natural manner, you communicate respect and acceptance.
• Third, by demonstrating that you hear and remember specific parts of a client's story, you communicate interest in your client's life and experiences. This usually involves using paraphrases, summaries, and sometimes interpretations.
• Fourth, by responding with compassion or empathy to clients' emotional pain and intellectual conflicts, you express concern and acceptance. This is what Othmer and Othmer (2002) mean when they say that finding the suffering and showing compassion are rapport-building strategies.
• Fifth, clinical experience and research both indicate that clients are sensitive to an interviewer's intentions.

Remembering what your client says requires deliberate attentiveness. Using intellect, intuition, and empathy to mirror the client's inner world communicates a deep respect that is the very essence of unconditional positive regard.

Accurate empathy or empathic understanding is a central concept in clinical interviewing, counselling, and psychotherapy. Rogers (1980) defined empathy as:

"...the therapist's sensitive ability and willingness to understand the client's thoughts, feelings, and struggles from the client's point of view. [It is] this ability to see completely through the client's eyes, to adopt his frame of reference, (p. 85)... It means entering the private perceptual world of the other ... being sensitive, moment by moment, to the changing felt meanings which flow in this other person ... it means sensing meanings of which he or she is scarcely aware. (p. 142).

The "empathy question" may be helpful to enhance empathy: "how would I feel if I were in [client]'s situation?"_ _But this question is also limited in that it oversimplifies the empathic process in at least two ways.

• First, it assumes that the interviewer (or helper) has an accurately calibrated affective barometer within, allowing for objective readings of client emotional states. The fact is, clients and interviewers may have had such different personal experiences that the empathy question produces completely inaccurate results; just because _you _would feel a particular way if you were in the client's shoes doesn't mean the client feels the same way.
• It is generally helpful to not only focus on what you would feel if you were in your client's shoes, but also to reflect intellectually on how other clients (or other people you know) might feel and think in response to this particular experience.
• Rogers (1961) also emphasised that feeling reflections should be stated tentatively so clients can freely accept or dismiss them.

Keep in mind that you should express empathy not only for what your client is saying, but also his/her defensive style (e.g., if they're using defense mechanisms such as rationalisation or denial, show empathy for those). For example.

• Client: "I don't know why my dad wants us to come to therapy now. We've never been able to communicate. It doesn't bother me anymore. I've accepted it. I wish he would."
• Interviewer: "Coming into therapy now doesn't make much sense to you. Maybe you used to have some feelings about your lack of communication with your dad, but it sounds like you're pretty numb to the whole situation now."
• Client: "Yeah, I guess so. I think I'm letting go of my relationships with my parents. Really, I don't let it bother me."
• Interviewer: "Maybe one of the ways you're protecting yourself from how you felt about your lack of communication with your dad is to distance yourself from your parents. Otherwise, it could still bother you, I suppose."
• Client: "I, yeah. I guess if I let myself get close to my parents again, my dad's pathetic inability to communicate would bug me again."

Obviously, this client still has feelings about her father's poor communication. _Accurate _empathy facilitates the exploration of feelings or emotions and may help the client to begin admitting her underlying feelings.

• A second way in which the empathy question is simplistic is that it treats empathy as if it had to do _only _with accurately reflecting client feelings. Certainly, accurate feeling reflection is an important part of empathy, but, as Rogers (1961) and others have discussed, empathy also involves _thinking _and _experiencing _with clients. This is why empathic acknowledgement of client's defensive styles is important to empathic responding. Clients protect themselves from emotional pain through defense mechanisms. Consequently, to be maximally empathic, interviewers need to address not only feelings, but also the way clients shield themselves from feelings.

The empirical data on empathy

Meta-analysis (Greenberg et al., 2001) reported a correlation of .32 between empathy and treatment outcome. Although this is obviously not a large correlation, they noted, "empathy... accounted for almost 10% of outcome variance" and "Overall, empathy accounts for as much and probably more outcome variance than does specific intervention" (p. 381). Based on their meta-analysis and an analysis of various theoretical propositions, Greenberg et al., identified four ways in which empathy contributes to positive treatment outcomes.

1. First, they noted that empathy improves the therapeutic relationship.
2. Second, empathy contributes to what is referred to as a corrective emotional experience. A corrective emotional experience occurs when the client expects more of the same pain-causing interactions with others, but instead, experiences acceptance and understanding. When clients feel understood they are more likely to also feel worthy and to shed old feelings and behaviour patterns associated with negative, critical, and rejecting early childhood experiences. Negative, critical, and rejecting interpersonal interactions tend to cause clients to shut down and become far less interactive, while empathic understanding tends to foster deeper and more trusting interactions and disclosures.
3. Third, empathy facilitates client verbal, emotional, and intellectual self-exploration. In a very basic way, because feeling understood helps clients feel safe, it also helps them engage in personal exploration. From an assessment perspective, empathy elicits information. Rogers (1961) emphasised: "It is only as I see them (your feelings and thoughts) as you see them, and accept them and you, that you feel really free to explore all the hidden nooks and crannies of your inner and often buried experience." (p. 34) The research appears to support these claims.
4. Fourth, empathy moves clients in the direction of self-healing. Partly because empathy contributes to self-acceptance and self-respect, clients become more capable of establishing their own "empathic workspace" where they can independently examine their thoughts, feelings, behaviours and motivations. Miller and Rollnick (2002) clearly articulate how important it is for clients to take the lead in their own personal change - based on a deeper understanding of their own motivations: "All of this points towards a fundamental dynamic in the resolution of ambivalence: It is the client who should be voicing the arguments for change.

Often when a client comes up with a maladaptive belief or thought, gentle, open questioning might help deepen the interviewer's understanding of the client's unique personal experience and help her to begin exploring other feelings, like anger, that she might have felt in response to her mother's abuse. For example, the interviewer could ask:

"I hear you saying that maybe you felt you deserved to be hit by your mother in that situation, but I also can't help but wonder... what other feelings you might have?"

Or, the interviewer might use a third-person or relationship question to help the client view her experience from a different perspective:

What if you had a friend who experienced something like what you experienced? What would you say to your friend?

From a nondirective perspective, sensitive nondirective responses that communicate empathy through voice tone, facial expression, and feeling reflection are usually more advantageous than open support and sympathy. There is always time for open support later, after the client has explored both sides of the issue.

Empathy is also complex, and different clients can respond in different ways:

Certain fragile clients may find expressions of empathy too intrusive, while highly resistant clients may find empathy too directive; still other clients may find an empathic focus on feelings too foreign. Therapists therefore need to know when - and when not - to respond empathetically. Therapists need to continually engage in process diagnoses to determine when and how to communicate empathic understanding and at what level to focus their empathic responses from one moment to the next. (Greenberg et al., 2001, p. 383).

Evidence-based psychoanalytic and interpersonal relationship concepts

Transference

Freud (1949) defined transference as a process that occurs when "the patient sees in his analyst the return - the reincarnation - of some important figure out of his childhood or past, and consequently transfers on to him feelings and reactions that undoubtedly applied to this model". Transference is characterised by inappropriateness; the client responds to the interviewer by acting, thinking, or feelings in an inappropriate manner. Freud (1958) stated that transference "exceeds anything that could be justified on sensible or rational grounds". Like many relationship variables, transference is often abstract, vague, and elusive. To notice it, you have to pay attention to idiosyncratic transactions clients initiate with you; for example, clients may subtly respond to you in ways that are more emotional than the situation warrants, they may make assumptions about you that have little basis in reality, and they may express unfounded and unrealistic expectations regarding you or therapy.

A fairly common old map on new terrain is the clients' unspoken beliefs that you, like others in their lives, will evaluate them, find them lacking, and reject them. Transference reactions may become self-fulfilling prophecies: once the client is looking for signs of rejection, negative evaluation, or lack of empathy, he starts seeing them everywhere, and the interviewer may eventually unconsciously respond to this with a genuine negative reaction if she is not conscious of the transference pattern.

As Freud (1949) stated, "Transference is ambivalent" (p. 66). Transference may manifest itself in positive (e.g., affectionate, liking, or loving) or negative (hostile, rejecting, or cold) attitudes, feelings, or behaviours. Each can be a productive area to work through with the client as therapy progresses. However, during initial stages, the wisest course for interviewers is to be astute observers, noticing responses and behaviours that seem to come from old terrain and past relationships in the client's life, but not commenting on these patterns. Interpretation of transference early in therapy is generally avoided. Adequate rapport and a working relationship should always precede interpretation. Further, working with transference as part of therapy requires advanced skills and firm theoretical grounding that should be obtained from specialised texts and professional supervision. However, it doesn't mean that interviewers should ignore transference. The interviewer can simply respond by asking, "When are some times you've felt similar feelings in the past?" or "I've noticed you seem to get angry at me whenever we talk about your father. What do you make of that?" These questions deflect the comment back to the client and reduce the chances that the interviewer might respond defensively or accusingly by stating, "Well, you make me nervous, too" or "Sounds like an old problem from your past."

Countertransference

Guidelines for interviewers to cope with countertransference reactions:

• Recognise that countertransference reactions are normal and inevitable. If you experience strong emotional reactions, persistent thoughts, and behavioural impulses toward a client, it does not mean you are a "sick" person or a "bad" interviewer.
• If you have strong reactions to a client, consult a colleague or supervisor.
• Do some additional reading about countertransference. It is especially useful to obtain reading materials pertaining to the particular type of client you're working with (e.g., eating disorders, depression, antisocial behaviour).
• If your feelings, thoughts, and impulses remain despite efforts to deal with them, two options may be appropriate: Refer your client to another therapist, or obtain personal psychotherapy to work through the issues that have been aroused in you.

Originally, Freud (1949) identified countertransference solely as a reaction to client transference. This is certainly the case sometimes. However, many therapists go beyond Freud's definition of countertransference and define it more broadly as interviewer unconscious feelings, attitudes, or behaviours that are prompted by the interviewer's own needs. In other words, countertransference may begin with the interviewer's (rather than the client's) unconscious agenda. Additionally, more recent formulations of countertransference acknowledge that, although unplanned and compelling, countertransference reactions may be well within the interviewer's conscious awareness.

Freud originally considered transference an impediment to psychotherapy, but later modified his position, suggesting that the analysis of transference, conducted properly, is a crucial therapeutic tool. In contrast, Freud always considered countertransference to be an impediment to psychotherapy. However, many contemporary psychoanalysts and object relations therapists have broken with Freud's negative view of countertransference and believe there is much to be gained from an interviewer's countertransference reactions. For example, if a client provokes strong and unusual feelings of fear, disappointment, or sexual attraction, it may be worthwhile to scrutinise yourself to determine if your emotional response is from your own personal issues. Only after scrutinising yourself can you assume that your client's behaviour is an indicator of the client's usual effect on people outside psychotherapy. Countertransference is now widely considered a natural phenomenon and useful source of information that can contribute to therapy process and outcome.

Identification and Internalisation

Identification and internalisation are terms that come primarily from psychoanalytic and object relations theory. However, concepts that share very similar meanings can be found in other schools of thought, a fact that underscores the importance of these two concepts and their central role in therapeutic relationship development and treatment outcomes. For example, behaviourists have long emphasised the importance of modelling in behaviour therapy.

Psychoanalysts and object relations theorists use the concepts of identification and internalisation to describe what learning theorists consider modelling. Specifically, individuals identify with others whom they love, respect, or view as similar. Through this identification process, individuals come to incorporate unique and specific ways in which that loved or respected person thinks, acts, and feels. In a sense, identification and internalisation result in the formation of identity; we become like those we have been near but also like those whom we love, respect, or view as similar to ourselves. Identification is enhanced when clients feel understood at the point where their values run deepest or their distress is most poignant. If identification is achieved, superficial dissimilarities do not detract from the counselling relationship. In other words, empathy enhances identification and reduces the importance of surface differences.

Identification is the precursor to internalisation. Object relations theorists hypothesise that as we develop we internalise components of various caretakers and others in our early environment. These internalisations serve as the basis for how we feel about ourselves and how we interact with others. If we internalise "bad objects" (i.e., abusive parents, neglectful caretakers, vengeful siblings), we may experience disturbing self-perceptions and interpersonal relationships. Psychotherapy involves a relationship that can replace maladaptive or bad internalisations with more adaptive or good internalisations, derived from a relatively healthy psychotherapist.

Resistance

Resistance is a multifaceted concept that frequently exerts influence in the therapy relationship. It is usually framed as something the client engages in to avoid talking about core issues, or to avoid change or healing. There are many ways to work with resistance. General advice is to view resistance as an interesting component of the client's presentation. It most likely serves a function that was once adaptive in the client's life, and, in fact, might still be serving protectively. It is not directed at you personally, and you cannot simply make it go away and get down to work. In fact, in many cases, working with the resistance will be central to the therapeutic process.

Working Alliance

Psychoanalytically-oriented clinicians believe therapy involves the simultaneous development of three different relationships between therapist and client. These three relationships are (a) the transference relationship, (b) the real (human) relationship, and (c) the working alliance or therapeutic relationship. Strupp (1983), among others, has pointed out that a client's ability to establish a therapeutic or working alliance is predictive of his or her potential to grow and change as a function of psychotherapy. In other words, if clients cannot or will not engage in a working alliance with the interviewer, there is little hope for change.

Ainsworth's (1989) and Bowlby's (1969, 1988) work on attachment has been applied to components of the psychotherapy process. Similar to a caretaker, a therapist provides a safe base from which clients explore can explore and to which they can return.

Research has also indicated that therapists vary in their ability to form a working alliance. Ackerman and Hilsenroth's (2003) meta-analysis found that therapists who were able to form and sustain the alliance had personal attributes that included warmth, flexibility, experience, and trustworthiness. They also used techniques that facilitated emotional expression, that were reflective, affirming, and focused on their client's experiences.

Evidence-based behavioural and social psychology concepts

Expertness (credibility)

Attractiveness

Trustworthiness

The following interviewer behaviours are associated with trust:

• Initial introductions that are courteous, gentle, and respectful.
• Clear and direct explanations of confidentiality and its limits.
• Acknowledgement of difficulties associated with coming to a professional therapist.
• Manifestations of congruence, unconditional positive regard, and empathy.
• Punctuality and general professional behaviour.

With clients who are very resistant to counselling, it is often helpful to state outright that the client may have trouble trusting the therapist. For example:

"I can see you're not happy to be here. That's often true when people are forced to attend counselling. So, right from the beginning, I want you to know I don't expect you to trust me or like being here. However, because we'll be working together, it's up to you to decide how much trust to put in me and in this counselling. Also, I might add, just because you're required to be here doesn't mean you're required to have a bad time."

Clients will periodically test their interviewers trustworthiness. For example, children who have been sexually abused often behave seductively when they meet an interviewer; they may sit on your lap, rub up against you, or tell you they love you. These behaviours can be viewed as blatant tests of interviewer trustworthiness (i.e., the behaviours ask, "Are you goin to abuse me, too?"). It is important for interviewers to recognise tests of trust and respond, when possible, in ways that enhance the trust relationship.

Evidence-based feminist relationship concepts

Feminist theory and psychotherapy emphasise the importance of establishing an egalitarian relationship between client and interviewer. The type of egalitarian relationship preferred by feminist interviewers is one characterised by mutuality and empowerment. While sharing common ground with the core relationship components identified by Carl Rogers, feminists take into account the social location, gender, and power differentials that impact the way clients experience themselves and their worlds.

Mutuality

_Mutuality _refers to a sharing process; it means that power, decision-making, goal selection, and learning are shared. The underlying framework of the interviewer-client relationship being built in mutuality-oriented therapies contrasts sharply with traditional frameworks. The client is not excluded from the interviewer's emotional reactions. She is not given the message that she is the bearer of problems and the interviewer is the bearer of insights or cures. Instead, the groundwork is laid for a relationship that includes honest self-disclosure on the interviewer's part and that may, later in therapy, even include times when the client observes and comments on patterns in the interviewer's behaviour. In a mutuality-oriented relationship, interviewers and therapists are ready to respond to such offers from clients in a genuine manner that neither merely reflects client statements nor interprets them as coming from client pathological needs.

When interviewers engage in mutuality, they usually do so for the ultimate purpose of empowering clients. Their clients see therapy as a working relationship in which they are equal members rather than subordinates. Although mutuality does not entirely alter the fact that a certain amount of authority must rest with the counsellor, the feminist interviewer actively works to teach clients to respond to authority with a sense of personal worth and with their own personal authority. Feminist therapists believe respectful, reciprocal interactions can result in a growing sense of personal power in clients and the empirical data supports this claim.

Empowerment

Most therapies have as underlying goals the development, growth, and health of clients. However, therapies vary in the routes they take to reach these goals; and therefore, different approaches inevitably leave clients with different beliefs as to how they "got better." The interviewer who begins therapy with an emphasis on authenticity and mutuality usually hopes that clients attribute their gains, growth, and life improvements to their own efforts and to the strength and potential residing within them. Rather than set up relationship rules that separate client from therapist along the lines of dependency/neediness versus authority/expertise, the interviewer interested in empowerment affirms that both participants in the therapy process are human and therefore more similar than different. Interviewers have skills and knowledge that clients may not have; in feminist therapy, these skills are viewed as tools clients can avail themselves of to help themselves grow.

Interviewers interact in ways that validate their client's life experiences and attempts at solving their own problems. Interviewers recognise that often people come to therapy in part because of the pressures, discrimination, and mistreatment we all experience in varying degrees as we interact in society. These experiences of powerlessness are acknowledged for what they are rather than interpreted as something inherently wrong within the client. Beginning in 1911, Alfred Adler established himself as an early feminist theorist and spoke articulately about issues associated with empowerment:

"All our institutions, our traditional attitudes, our laws, our morals, our customs, give evidence of the fact that they are determined by privileged males for the glory of male domination." (Adler, 1927, p. 123)

Adler's assertion points out a key issue in feminist theory. That is, pathological conditions among women (and men, I'd say) are often constructed and sustained by social-political factors. Consequently, the concept of empowerment for a feminist involves consciousness raising among oppressed groups (especially women) and encourages them to stand up and claim their personal power, starting by understanding the forces at play in the society around them. Brown and Bryan (2007) write:

Feminist therapy uses analysis of gender, power, and social location as a means of understanding the emotional distress and behavioural dysfunctions that trouble people who enter psychotherapy. (p. 1122)

Evidence-based solution-focused and constructive relationship concepts

In contrast to cognitive-behavioural therapy, solution-focused and constructive interviewers consistently emphasise that it is the client who is the expert on his or her life and thus, the best source for personal solutions. These positions are a paradox or dialectic in that the interviewer's role becomes that of someone who leads the client to discovering his or her own solutions or toward rewriting a more adaptive and empowered personal narrative. In this process, solution-focused and constructive interviewers emphasise relationship variables.

Collaboration, Cooperation, and Co-Construction

The nature of solution-focused, constructive therapy relationships is characterised by collaboration, cooperation, and co-construction (or reconstruction) of old and new solutions and narratives. These relationships are described as "collegial" and "cooperative" and as involving a process known as "leading from behind". To establish this relationship, interviewers are explicitly positive, compliment their clients for movements forward, and nudge or encourage clients toward doing more of what is working in their lives.

The Client is the Expert

"It is rare for a SFBT therapist to make a suggestion or assignment that is not based on the client's previous solutions or exceptions. It is always best if change ideas and assignments emanate from the clients, at least indirectly during the conversation, rather than from the therapist, because the client is familiar with these behaviours." (Shazer & Dolan, 2007, p. 5)