99360_03_ch02_p039-082.indd - 1435499360_ch02.pdf



Thumbnails Document Outline HYPERLINK "" \l "page=1" \o "Page 1" HYPERLINK "" \l "page=2" \o "Page 2" HYPERLINK "" \l "page=3" \o "Page 3" HYPERLINK "" \l "page=4" \o "Page 4" HYPERLINK "" \l "page=5" \o "Page 5" HYPERLINK "" \l "page=6" \o "Page 6" HYPERLINK "" \l "page=7" \o "Page 7" HYPERLINK "" \l "page=8" \o "Page 8" HYPERLINK "" \l "page=9" \o "Page 9" HYPERLINK "" \l "page=10" \o "Page 10" HYPERLINK "" \l "page=11" \o "Page 11" HYPERLINK "" \l "page=12" \o "Page 12" HYPERLINK "" \l "page=13" \o "Page 13" HYPERLINK "" \l "page=14" \o "Page 14" HYPERLINK "" \l "page=15" \o "Page 15" HYPERLINK "" \l "page=16" \o "Page 16" HYPERLINK "" \l "page=17" \o "Page 17" HYPERLINK "" \l "page=18" \o "Page 18" HYPERLINK "" \l "page=19" \o "Page 19" HYPERLINK "" \l "page=20" \o "Page 20" HYPERLINK "" \l "page=21" \o "Page 21" HYPERLINK "" \l "page=22" \o "Page 22" HYPERLINK "" \l "page=23" \o "Page 23" HYPERLINK "" \l "page=24" \o "Page 24" HYPERLINK "" \l "page=25" \o "Page 25" HYPERLINK "" \l "page=26" \o "Page 26" HYPERLINK "" \l "page=27" \o "Page 27" HYPERLINK "" \l "page=28" \o "Page 28" HYPERLINK "" \l "page=29" \o "Page 29" HYPERLINK "" \l "page=30" \o "Page 30" HYPERLINK "" \l "page=31" \o "Page 31" HYPERLINK "" \l "page=32" \o "Page 32" HYPERLINK "" \l "page=33" \o "Page 33" HYPERLINK "" \l "page=34" \o "Page 34" HYPERLINK "" \l "page=35" \o "Page 35" HYPERLINK "" \l "page=36" \o "Page 36" HYPERLINK "" \l "page=37" \o "Page 37" HYPERLINK "" \l "page=38" \o "Page 38" HYPERLINK "" \l "page=39" \o "Page 39" HYPERLINK "" \l "page=40" \o "Page 40" HYPERLINK "" \l "page=41" \o "Page 41" HYPERLINK "" \l "page=42" \o "Page 42" HYPERLINK "" \l "page=43" \o "Page 43" HYPERLINK "" \l "page=44" \o "Page 44" CHAPTER 2Theories of Counseling: Application to Speech-Language Pathology and AudiologyCHAPTER OUTLINEIntroduction■Humanistic Approaches to Counseling■Interpersonal Approaches to Counseling■Behavioral Approaches to Counseling■Cognitive Approaches to Counseling■Family Systems Approaches to Counseling■Existential Approaches to Counseling■Multicultural Approaches to Counseling■Theoretical Integration■Concluding Comments■Discussion Questions■Role Plays■INTRODUCTIONMany exceptional practitioners have learned to integrate a number of theories of psy-chotherapy with their personal therapy experiences and over time have developed an in-dividual style of therapy (Corsini & Wedding, 2008; Gladding, 2009; Truscott, 2010). Meanwhile, most beginning therapists are working to master a particular theory and its applications. However, no one theory or therapy approach fits all situations, and a clini-cian may actually apply multiple therapy approaches with any one client, patient, or fam-ily. The theoretical and therapy approaches that an individual clinician selects and uses often depends on the clinician’s personal orientation (e.g., humanistic, behavioral, or mul-ticultural), what the clinician has learned in her training, and what has worked for the cli-nician in the past. There is no one “right” theoretical or therapeutic framework, although empirical research during the last couple of decades has provided more validation for some therapeutic approaches than for others (e.g., American Psychological Association, 2005; Hibbs & Jensen, 2005; Messer, 2004). As it is impossible to learn and use the over 400 99360_03_ch02_p039-082.indd 394/5/11 9:47:59 AM40■CHAPTER 2 counseling and psychotherapy approaches that are currently in the literature (Prochaska & Norcross, 2009), speech-language pathologists and audiologists can be most effective by learning about a few of the major theories that offer relevant concepts that can be applied to our professions. The theories presented in this chapter are among those that are consid-ered to form the conceptual and clinical bedrock of the fields of clinical psychology and counseling (Corsini & Wedding, 2008; Wachtel & Messer, 1997).There is much value in a clinician having multiple theoretical and therapeutic frame-works from which to draw. If a clinician only has one or two to select from, she is limited in ability to understand and help clients, patients, and families. (“If a person only has a hammer, then everything looks like a nail.”) Theoretical purity (i.e., following a singular approach) is seldom helpful with the vast variety of people and problems we work with. Lazarus and Beutler (1993) found that 60 to 70 percent of professional counselors identify themselves as eclecticin the use of theory and techniques. However, beyond a piecemeal eclectic approach we can use an integrativeapproach in which we tie together concepts and approaches that have commonalties or are complementary to each other. For further read-ing in the area of psychotherapy and counseling theories, the student or clinician may wish to refer to one of many excellent textbooks in the area, for example, Capuzzi and Gross (2003); Corey (2008); Corsini and Wedding (2008); George and Cristiani (1995); Gurman and Messer (2003); Prochaska and Norcross (2009). A personal favorite of the author (L.V. F.) is the Prochaska and Norcross text, which inspired the format for this chapter and the presentation of a case example seen through the lenses of various theoretical perspectives.This chapter begins with two therapy approaches that emphasize the clinician–client relationship: understanding how to use the relationship to promote therapeutic change. It then moves into therapies that emphasize helping people change their ways of thinking about particular issues and their problematic behaviors as they relate to our professions. Additional therapy approaches are discussed that help expand our way of seeing the client or patient’s world as well as our own.HUMANISTIC APPROACHES TO COUNSELINGCarl Rogers (1951, 1957, 1961, 1980) developed in the 1940s and 1950s what is known today as humanistic therapy and client-centered (person-centered) therapy. Rogers empha-sizes that people are rational and inclined toward positive growth or self-actualization(re-alizing one’s potential). This viewpoint is considered the central assumption of humanistic therapy. Healthy personality development occurs if the person receives sufficient uncondi-tional positive regard, that is, love and acceptance from parents or significant others for her unique, individual self. Often times the best example of unconditional positive regard is the love and acceptance a parent has for her child. For example, the parents of a child with hearing impairments who show consistent love and acceptance help the child to grow and develop feelings of self-worth. The child learns congruence, that is, to be in touch with her own thoughts and feelings, and to communicate with facial expressions and body language that mirrors (i.e., is consistent with) verbal or sign language.Unhealthy personality development occurs when an individual experiences conditions of worth, repeatedly receiving messages from parents that she will be loved and accepted 99360_03_ch02_p039-082.indd 404/5/11 9:48:01 AMTHEORIES OF COUNSELING: APPLICATION TO SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY ■41only if certain conditions are met; for example, the child must never cry or show anger and, instead, must be compliant, studious, and easy to get along with. As a result of these experiences, the child learns to conceal her real self and present a fa?ade that is incongru-ent (discrepant with what the child thinks, feels, and expresses verbally or nonverbally) with her genuine feelings. In presenting a fa?ade, the child sacrifices natural tendencies toward positive growth in order to receive conditional love and approval. For example, a child with a hearing loss may not feel accepted by parents when she observes that they give more attention and love (“regard”) to siblings. The child with a hearing impairment may try to conceal from parents that she could not hear or understand them in order to appear more like her siblings.SLPs or Auds using humanistic or person-centered techniques attempt to promote the client’s natural positive striving and growth. The clinician’s role is nondirective(not try-ing to influence; being primarily reflective) and supportive. The clinician avoids engaging in confrontation or direct attempts to change the person’s behavior.Conditions Necessary and Sufficient for Therapeutic ChangeRogers (1957) discussed therapeutic conditions that he regards as necessary and suf-ficient for therapeutic change, which are outlined in the following sections.GENUINENESSThe genuine clinician presents herself in an open manner and is not showing a fa?ade. The clinician behaves in a way that is congruent (consistent and genuine) with her real feelings. For example, if a client comments to the clinician, “You look tired today,” the clinician may say, “Yes, you’re right, I am a little tired today.” In this response, the clinician validates the client’s (correct) perceptions.Presenting a congruent response is challenging when how we feel toward a client is not congruent with how we think we should feel toward the client. For example, we may feel irritated with a client who has not followed through with exercises or comes late to ses-sions. Yet we are striving to respond respectfully and therapeutically. If we are not careful, what the client may experience is a mixed message based upon our real feelings “leaking out.” Our behavior may be polite on the surface but contain undertones of anger or resent-ment. Another example of incongruence may occur when the clinician is not aware of how angry or annoyed he actually is with the client.In either case above, the clinician focuses on presenting a positive and warm response to the client. However, the client may perceive both levels of the clinician’s response: the polite surface behaviors and the angry, irritated undertones. The incongruence between the two levels of communication will likely cause discomfort in the client, and the client may respond negatively. The clinician, unaware of the client’s perceptions, may view the client as uncooperative, unappreciative, or difficult. In order to work with this challenging situation, the clinician first needs to become aware of any tendency toward an incongruent response, and work through the negative feelings toward the client rather than just trying to conceal them. The clinician also may choose to express feelings to the client in a non-threatening manner using “I-messages” (e.g., “When you do . . . , I feel . . .” ) As we have 99360_03_ch02_p039-082.indd 414/5/11 9:48:01 AM42■CHAPTER 2 seen in the above example, trying to conceal negative feelings often does not work and can impair the clinician’s working relationship with a client.Working through negative feelings towards a client involves trying to better under-stand the client’s viewpoint (empathy). The clinician may want to ask herself some ques-tions, such as, “What stops the client from coming on time?” or “What is the client afraid of?” Usually if the clinician can better understand the client’s fears, behaviors, and life circumstances, she will feel more empathic and less annoyed with the client. The point is that the clinician needs to reflect on her own behavior toward the client and not simply blame the client. By taking these steps the clinician will be better able to develop or return to a stance of unconditional positive regard toward the client. It is important to note that Rogers’ (1957) concept of clinicians’ genuineness has sometimes been misunderstood as a license for clinicians to talk about themselves or engage in excessive self-disclosure. This was not Rogers’ intention; he was primarily concerned with the idea that clinicians should not feign interest or caring, as this fa?ade is likely to be detected by clients and damage the therapeutic relationship.EMPATHYEmpathyinvolves “being with” the person and his experiences on a moment-to-moment basis. It involves a personal encounter, not simply an objective appraisal of the person’s problems. In order for the clinician to experience and show empathy, she must understand not only the communication disorder (e.g., stuttering), but how the commu-nication disorder is affecting the person’s self-image and life. Although we can never truly feel what the client is experiencing, we can try to get a sense of what the person must cope with almost every time he tries to talk.In striving to be empathic, clinicians should take care not to go overboard. Sometimes excessive efforts to appear friendly, caring, and empathic, especially in the early stages of the working relationship, can appear phony and disingenuous to the client. This is a dif-ferent kind of incongruence than discussed above. In this case the clinician is trying to appear warmer and more empathic than she is truly feeling. The clinician may have good intentions, for instance, to help the client feel understood and valued, but a saccharine (i.e., too sweet and overly caring) presentation may be viewed negatively by clients.UNCONDITIONAL POSITIVE REGARDWhen SLPs and Auds communicate genuine respect and caring in a consistent manner toclients they are demonstrating unconditional positive regard. This allows clients to ex-perience a nonjudgmental environment in therapy, which may encourage them to be more honest with the clinician, such as when they cannot (or will not) perform therapy tasks with maximum involvement or effort.In humanistic therapy there is an emphasis on providing a positive relationship rather than on therapeutic techniques. As the person expresses himself, however, the clinician is alert for statements pertaining to the self (for example, “I haven’t felt like doing my exercises lately” or “I don’t understand how these exercises will help”). The clinician also attends to the person’s nonverbal communications that are incongruent with verbal com-munications (e.g., smiling while discussing a negative feeling or personal loss).99360_03_ch02_p039-082.indd 424/5/11 9:48:01 AMTHEORIES OF COUNSELING: APPLICATION TO SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY ■43In order to help both the client and clinician understand the client’s feelings, the clini-cian may provide reflections that paraphrase the statements or, when needed, point out discrepancies in the communications (these skills, rooted in Rogers’ theory, are expanded in Chapter 4). To provide a simple reflection the clinician should let the person know she has been heard and that the clinician is interested in hearing more. The clinician’s reflec-tions should, however, not simply mimic or parrot the client’s last words. For example, a patient may mention symptoms that suggest penetration of food or liquid into the larynx (e.g., episodes of coughing or choking), and then deny that they are a problem. The clini-cian may reflect on both of these statements and then ask about the person’s feelings. The patient may be feeling embarrassment or have fear around meal times. For example, the clinician might say, “You say you are doing some coughing and choking while eating, but that it’s not really a problem for you. Are you sometimes a little embarrassed about cough-ing and choking, or are you a little afraid that you won’t be able to continue eating regular food?” While it is important not to force a particular interpretation on a client or to as-sume what he is feeling, the clinician can ask questions such as these which express empa-thy for the client’s probable experiences. Providing an environment where all of the client’s feelings and experiences are respected and validated is central to humanistic therapy and can maximize disclosure in therapy sessions.COUNSELING SKILLS IN ACTIONReflecting Empathy to a Child Who StuttersA 13-year-old boy was brought to therapy by his parents because of the child’s stutter-ing problem.Clinician: “Tell me what it’s like to talk in different situations.”Child: “I don’t talk much at school. It makes me nervous.”Clinician: “You don’t talk much because it makes you nervous.”Child: “Yeah, and I get reallynervous about speaking out in front of the class.”Clinician: “Speaking out in front of the class. Is that one of the hardest things for you to do?”Child: “Uh huh, especially if the teacher wants me to read from the science book.”Clinician: “You don’t like to read out loud from the science book.” (The clinician is staying very close to what the child says, but not sounding like a mechanical parrot.)Child: “Yeah, the words are tough and I get stuck on them and I make a fool of myself.”Clinician: “So you are afraid of stuttering or making a mistake and being embar-rassed about that.” Child: “The guys will laugh at me.”99360_03_ch02_p039-082.indd 434/5/11 9:48:01 AM ................
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