Helping Skills Ch 5 and 6 PDF

5 Overview of the Exploration Stage When one pours out oneʼs heart, one feels lighter. —YIDDISH PROVERB Kolmabd was feeling miserable, lonely, and worthless after his recent move to the United States. He desperately wanted to...

5 Overview of the Exploration Stage When one pours out oneʼs heart, one feels lighter. —YIDDISH PROVERB Kolmabd was feeling miserable, lonely, and worthless after his recent move to the United States. He desperately wanted to have a close friend with whom he could talk about his deepest feelings. His parents were concerned about him and suggested that he talk with a helper. During his first session with the helper, Kolmabd indicated that he felt like he was going to “burst from loneliness.” Since moving to this country, he had not talked to anyone other than his parents. He was hesitant to tell them how badly he felt because he worried that they would get too concerned, and he felt they could not really do anything to help him. The helper listened carefully and reflected Kolmabdʼs feelings of isolation, sadness, and rejection. Kolmabd began to cry and was able to talk about how he felt different from the other kids because he was from another culture. The helper let him talk and express all his feelings. She accepted him and listened nonjudgmentally, interested in understanding his experiences. At the end of the session, Kolmabd told the helper that he felt much better and had renewed energy to make friends, although he also felt a bit shamed from having cried. Talking to a caring, understanding person helped lift Kolmabdʼs burden and made him feel better. In the exploration stage, helpers work to establish rapport and encourage clients to talk about their innermost thoughts and feelings. They do this by listening attentively and nonjudgmentally, empathizing with their clients, placing themselves in their clientsʼ subjective realities, and using appropriate nonverbal and verbal skills (restatements, reflections of feelings, and open questions for thoughts and feelings). This overview chapter presents the theoretical background for and major goals of the exploration stage. Chapters 6 through 8 of this volume describe the major skills used to reach the goals of the exploration stage. Chapter 9 discusses how to integrate these skills when addressing clinical issues that new helpers face when implementing this stage. THEORETICAL BACKGROUND: ROGERSʼS CLIENT- CENTERED THEORY Much of what takes place in the exploration stage is influenced by Carl Rogersʼs client-centered theory of personality development and psychological change (see Rogers, 1942, 1951, 1957, 1959, 1967; Rogers & Dymond, 1954). Rogers had a profound influence on the field of psychology with his optimistic and hopeful assertion that all people have the potential for healthy and creative growth. His client-centered orientation was rooted in phenomenology, which places a strong emphasis on the experiences, feelings, values, and inner life of the person. Rogers believed that perceptions of reality vary from person to person, that subjective experience guides behavior, and that people are guided by their internal experience rather than by external reality. Similarly, he believed that the only way to understand individuals is to enter their private world and understand their internal frame of reference. In other words, to understand another person, one needs to suspend judgment and try to see things from that personʼs perspective. According to Rogers, the basic motivational force is the tendency toward self-actualization, which propels people to become what they are meant to become. He believed that each person has an innate blueprint, or set of potentialities, that can be developed. Just as plants and animals grow without any conscious effort provided that the conditions for growth are optimal, Rogers believed that people have an inherent ability to fulfill their potential. Furthermore, Rogers believed that people are resilient and can bounce back from adversity given this innate growth potential. Rogersʼs Theory of Personality Development According to Rogers (1942, 1951, 1967), infants have an organismic valuing process at birth that enables them to evaluate each experience in terms of how it makes them feel. Infants thus evaluate each experience as to whether it makes them feel better or worse. For example, if an experience (e.g., being fed, being held skin to skin) feels good, the infant will be satisfied and content. However, if an experience does not feel good (e.g., being hungry, being hot or cold, having a dirty diaper), the infant will be unhappy and will cry. Infants thus evaluate events by how they actually feel, not by how someone else tells them they should feel. They can accurately perceive experiences without distorting them. With the organismic valuing process, no experiences are more or less worthy; they just are. The organismic valuing process, then, is an internal guide that everyone has at birth, and it leads people toward trusting themselves and ultimately to self-actualization if this internal guide is followed. But problems arise because children depend on parental figures for their survival. In Rogersʼs terms, they have a need for unconditional positive regard (e.g., acceptance, respect, warmth, and love without conditions of worth). That is, they need to be loved for who they are and not because they meet certain standards or fulfill certain requirements. When children feel prized, accepted, and understood by significant others, they begin to experience self-love and self-acceptance and develop a healthy self-concept (i.e., sense of self) and have little or no conflict. Prized children are able to attend to their organismic valuing process and make good choices on the basis of inner experiencing. Significant others often, however, place conditions of worth on their children, demanding that children fulfill certain requirements to be loved. For example, parents may give messages such as “I will not love you unless you are a ‘good girl,’” “I will not love you unless you keep your room clean,” “You must be intelligent to receive my love,” or “You must be heterosexual or I will be ashamed of you.” Because parents communicate (through words or actions) that children are lovable and acceptable only when they behave in accordance with imposed conditions of worth, children come to believe that they must be and act in certain ways to earn their parentsʼ love.  Given the need for love, the conditions of worth, rather than the organismic valuing process, come to guide childrenʼs organization of their experiences. In other words, children sacrifice their organismic valuing process to receive love from their parents (e.g., children give up being spontaneous and playful to sit “properly” and be “good” to please their parents). When a child introjects (i.e., internalizes) parentsʼ conditions of worth, these conditions become a part of the childʼs self-concept. The more conditions of worth there are, the more distorted the person becomes from experiencing. For example, a mother may communicate to a young girl that it is not acceptable for her to hate her brother. The girl may feel that to be loved, she must be a good girl, and so she may disown the hate as not being part of herself. Hence, rather than learning that she may feel hate but cannot hurt her brother, she learns that her feelings are not acceptable. Another example is parents who punish or ridicule children for crying when they are hurt or need help with a difficult task. The children might repress feelings of pain and dependency and become extremely independent to maintain parental approval. As another example, a parent might shame a child for dressing in a way that does not fit the gender of birth, and thus the child might learn that it is not okay to express such preferences. These examples illustrate how externally imposed values can come to substitute for the organismic valuing process as the child needs to survive in the world. When feelings such as hate, dependency, or sexual preferences get aroused, these children must repress or deny these feelings and thus become out of touch with their inner experiencing. Children feel positive self-regard only when their experiences are consistent with feedback they receive from others (e.g., a child feels talented in playing the violin and others say that the child is talented). Feelings of self-worth become dependent on the conditions of worth that are learned in interaction with significant others. Children with too many conditions of worth will not be open to experience, accepting of feelings, capable of living in the present, free to make choices, trusting, capable of feeling both aggression and affection, and capable of creativity. They will have a conflicted sense of self. Obviously, children must become socialized to live in their families and society. Children cannot act on all their innate desires or get all of their needs met immediately because the world is not a perfect place and also because other people have needs that sometimes conflict with theirs. Parents, for example, cannot always immediately meet the infantʼs needs because they have other demands on their time. In addition, parents cannot allow a child to hurt a sibling or another child. The manner, however, in which parents socialize their children is crucial. For example, parents can empathize with young children but still place limits (e.g., “I know you are angry at your brother, but you cannot hurt him”). Children may feel frustrated at not getting to do what they want but do not learn to deny their feelings. Instead, they learn to experience the feelings but channel them in a more socially acceptable direction. In contrast, when parents humiliate a child (e.g., “Real men donʼt cry,” “Shut up, or Iʼll give you something to cry about”) or deny that the child has feelings (e.g., “You donʼt hate your teacher,” “You donʼt feel hurt”), children become confused about their feelings. They may feel sad or feel hatred, but the parents say they do not have these feelings. Should child trust their inner experience or what parents tell them to feel? If children do not pay attention to their parents, they risk losing parental approval and love. If they do not pay attention to their own inner feelings and instead try to please others, they lose their sense of self. One can easily see how children come not to trust their inner experiences. Children must survive, so they often choose parentsʼ attention and “love” over inner experiencing. When conditions of worth are pervasive and the organismic valuing process is disabled, the sense of self is weakened to the point that the person is unable to experience or recognize feelings as belonging to the self. For example, people might not even be aware of feeling angry and hurt when being verbally and physically abused by their partners because they think they deserve the abuse. When people cannot allow themselves to have their feelings, they often feel a sense of emptiness, phoniness, or lack of genuineness. This lack of genuineness about oneʼs feelings reflects a split or incongruence between the real and ideal self and is the source of anxiety, depression, and defensiveness in relationships. There is considerable evidence for Rogersʼs developmental theory. For example, dismissive reactions to childrenʼs emotions (e.g., yelling) can deter self-reflection of emotions and create barriers to gaining emotional knowledge (Denham, Mitchell-Copeland, Strandberg, Auberbach, & Blair, 1997). In contrast, parental support for childrenʼs emotions predicts greater emotional knowledge (McElwain, Halberstadt, & Volling, 2007), and parents who engage in “emotion talk,” such that they focus on helping children label and articulate emotions as well as understand why they are feeling a particular emotion produce children who are emotionally knowledgeable (Denham & Kochanoff, 2002). When mothers explained emotions, showed positive emotions, and responded positively to their preschool childʼs emotions, their children had greater emotional understanding (Denham, Zoller, & Couchoud, 1994). Defenses Rogers (1957) suggested that when there is an incongruence between who one is and who one thinks one ought to be (which Rogers called a split between the real and ideal self), the person feels threatened. For example, people who pretend to be pleasant and happy (“Smile!”) but are actually feeling grumpy and depressed are in danger of losing touch with their inner self. If they were to accurately perceive their depression, their self would be threatened because they have built an image of self as always happy. When people feel such a threat, they typically respond with anxiety, a signal that the self is in danger. People reduce the anxiety by invoking defenses to reduce the incongruity between experience and sense of self. One major defense is perceptual distortion, which involves altering or misinterpreting oneʼs experience to make it compatible with oneʼs self- concept. By distorting experiences, clients avoid having to deal with unpleasant feelings and issues and can maintain their perceptions of themselves. For example, a man may perceive himself as being of average weight even though he is quite overweight and no longer fits into chairs. He might tell himself he does not eat any more than other people. As another example, a person with a sense of worthlessness who is promoted at work might misinterpret the reason for the promotion to be congruent with a negative sense of self. A person might say she got the promotion because “the boss had to give it” or “no one else wanted the job.” A second defense is denial, which involves ignoring or denouncing reality. In this situation, people refuse to acknowledge experiences that are inconsistent with the images they have of themselves. By denying their experiences, clients avoid anxiety. For example, a transgender woman who is treated unfairly at work might ignore their anger at their boss because they have internalized their parentsʼ belief that anger is bad and that they will not be loved if they express anger. Rather than allow themselves to experience the anger, they may say they are not trying hard enough or are not smart enough for the job. Defenses block incongruent experiences from full awareness and minimize threats to oneʼs sense of self and thus allow the person to function and cope. A certain level of defenses is necessary for coping, but excessive use of defenses can take a toll on the self in at least three ways. First, the subjective reality (what one allows oneself to experience) can become incongruent with the external reality (the world as it is). At some point, the person may no longer be able to distort or deny the experience, which could lead to overwhelming feelings of threat and anxiety and disintegration of the self. For example, a child might struggle to maintain the illusion that things are fine between his parents despite hearing their nightly battles. However, when his mother leaves without warning, the boy may not be able to handle the loss and may stop attending school and talking to others. In another example, a person might partition off parts of self that are unacceptable and exclude them from awareness (e.g., deny to oneself that sexual abuse occurred). Second, people might develop a rigidity of perception in areas in which they have had to defend against perceiving reality. For example, a man might have such a strong need to believe in the curative effects of a quack medicine for cancer that he does not listen to any disconfirming evidence, resulting in not seeking proven strategies for treating the cancer. Third, the real self can become incongruent with the ideal self, suggesting a discrepancy between who one is and who one wishes to be. A woman might be average in intelligence but feel a need to be super smart (particularly if she has internalized parental conditions of worth that she should be extremely intelligent). If the discrepancy between the real and the ideal is large, the person may feel dissatisfied and become maladjusted (e.g., depressed, anxious). Reintegration According to Rogers (1957), to overcome disintegration, rigidity, or discrepancies between real and ideal selves, a person must become aware of the distorted or denied experience. In other words, a person must allow the experience to occur and accurately perceive the event. The woman just described must acknowledge to herself that she has average intelligence and accept and value herself rather than distort or deny her feelings.  Rogers theorized that for reintegration to occur, the person must (a) reduce the conditions of worth and (b) increase positive self-regard by obtaining unconditional positive regard from others. Conditions of worth lose their significance and ability to direct behavior when others accept the person as they are. In effect, individuals return to the organismic valuing process and begin to trust the inner self, thus becoming more open to experience and feelings. A person can reintegrate without unconditional positive regard from another person if there is minimal threat to the self and the incongruity between self and experience is minor. Typically, however, individuals respond to years of having conditions of worth imposed on them by becoming increasingly defensive. Once developed, defenses are difficult to let go because the person anticipates being vulnerable and hurt again. In effect, defenses are adaptive to help children cope, but fear and habit make them difficult to shed when they are no longer needed. A helping relationship, then, is often crucial for overcoming defenses and allowing the person to return to trusting the organismic valuing process. A helping relationship allows the individualʼs self-actualizing tendency to overcome the restrictions that were internalized in the conditions of worth. In a helping relationship, the helper attempts to enter the clientʼs subjective world and understand the clientʼs internal frame of reference. The helper also tries to provide an experience in which the client is accepted and cared for without conditions of worth. Thus, genuine acceptance from helpers begins to enable clients to accept themselves. This helping relationship does not necessarily need to be from a professional helper, and in fact, people often seek healing relationships from supportive people in their environment (e.g., friends, relatives, rabbi, minister, priest, imam). Rogers (1951) believed that the helping relationship, in and of itself, can produce growth in the client. He said, “I launch myself into the therapeutic relationship having a hypothesis, or a faith, that my liking, my confidence, and my understanding of the other personʼs inner world, will lead to a significant process of becoming” (p. 267). Rogerian helpers believe that most clients benefit greatly from being listened to, understood, and accepted. The power of this kind of relationship can be highly therapeutic and constructive. In the Rogerian approach to helping, the helper enters the therapeutic relationship with the facilitative attitudes of congruence (genuineness), unconditional positive regard, and empathy.  Rogers (1957) postulated six conditions that he considered to be necessary and sufficient for change to occur. 1. The client and helper must be in psychological contact. A therapeutic relationship or emotional connection between the helper and client is essential. 2. The client must be in a state of incongruence. There must be a discrepancy between self and experience that leads the client to feel vulnerable or anxious. If clients feel no anxiety, they are unlikely to be motivated enough to engage in the helping process. 3. The helper must be congruent (genuine) or integrated in the relationship. Helpers must be open to their own experiences and genuinely available to clients. The helper cannot be phony in the helping relationship. 4. The helper must feel unconditional positive regard for the client. The helper must value all feelings (although not necessarily all behaviors) and places no judgment on the feelings of the client. Essentially, a helper is trying to understand a clientʼs feelings and experience but is not trying to judge whether the person “should” or “should not” have the feelings or whether the feelings are “right” or “wrong.” 5. The helper must experience empathy for the client. Helpers should try to immerse themselves in the clientʼs feeling world and understand the clientʼs inner experiences. The understanding comes out of the helperʼs experiencing of the clientʼs feelings, using the helperʼs inner processes as a referent. Helpers not only experiences clientsʼ feelings but also have their own reactions to clientsʼ feelings; helpers are thus able to go beyond words to understanding clientsʼ implicit feelings (Meador & Rogers, 1973). Helpers try to feel as if they are the client and temporarily live in the clientʼs life, without ever losing the awareness that they are separate individuals. Helpers try to sense and uncover feelings of which the client is unaware because of the threatening nature of these feelings. Rogers emphasized that empathy is not passive but requires thinking, sensitivity, and understanding. He described empathy as follows: It means entering the private perceptual world of the other and becoming thoroughly at home in it. It involves being sensitive, moment by moment, to the changing felt meanings which flow in this other person, to the fear or rage or tenderness or confusion or  whatever that he or she is experiencing. It means temporarily living in the otherʼs life, moving about in it delicately without asking judgments. (Rogers, 1980, p. 142) 6. The client must experience the helperʼs congruence, unconditional positive regard, and empathy. If the client does not experience the facilitative conditions, they do not, for all practical purposes, exist for the client. Thus, the helper must experience the facilitative conditions, communicate these conditions to the client, and the client must experience the facilitative conditions. The lack of empathy could be caused by problems at any one of these steps (the helper not feeling the facilitative conditions, the helper not expressing the facilitative conditions, or the client not experiencing the facilitative conditions). Rogers (1951) stated that a facilitative attitude (being genuine, unconditionally positive in regard, and empathic) on the part of helpers is the most beneficial component of the helping process for clients. He indicated that skills were important but that the facilitative attitude served as the basis for the skills. According to Rogers, skills without a facilitative attitude might not only be unhelpful but might actually be harmful. In summary, Rogers speculated that if helpers can accept clients, clients can come to accept themselves. When clients accept themselves, they can allow themselves to experience their real feelings and accept that the feelings come from themselves. Hence, the organismic valuing process is unblocked, and people become open to their experiences. Clients can begin to experience love, lust, hatred, jealousy, joy, competitiveness, anger, pride, and other feelings; accept the feelings; and come to accept the self. It is important to remember that acceptance of feelings is distinct from decisions about what to do about those feelings. Allowing oneself to have the feelings provides a basis for making decisions about what to do because the actions are then based on inner feelings rather than on “shoulds.” Other humanistic and existential theorists also place great value on helpers being authentic (see Cooper, 2015; Yalom, 1980). For example, Buber (1958) encouraged an “I–Thou” relationship in which helpers put their whole selves into therapy and withhold nothing from clients. Buber encouraged helpers to incorporate all aspects of themselves—including their vulnerabilities, strengths, cognitions, emotions, wisdom, and humor— into their work. Buber, who also theorized that healing takes place through the therapeutic relationship, strongly endorsed being genuine and interacting with clients as a “human” rather than as an expert or professional. Current Status of Client-Centered Therapy Meta-analyses have shown that client-centered therapy and humanistic therapy are indeed effective and that they are just as effective as other approaches to psychotherapy (Elliott, Greenberg, Watson, Timulak, & Freire, 2013). In addition, reviews of the empirical literature have confirmed the importance of the facilitative conditions, particularly of empathy, in leading to positive outcome of therapy (e.g., Elliott, Bohart, Watson, & Murphy, 2019). It appears that the facilitative conditions are important for allowing clients to feel safe and supported, to help clients have a positive relationship experience, to promote exploration, and to support clientsʼ active self-healing efforts. Relationship of Rogersʼs Theory to the Helping Skills Model Rogersʼs theory is the foundation for the exploration stage and informs the insight and action stages. I agree with Rogers that helpers should maintain an empathic stance of trying to understand the clientʼs experience as completely as possible with as little judgment and as few prior assumptions as possible throughout all three stages. Empathy, compassion, and a therapeutic relationship can be effective in helping clients begin to accept themselves and trust their experiences. I also agree with Rogers about the importance of client experiencing and becoming aware of feelings, which is why we place so much importance on the exploration stage for facilitating client awareness and acceptance of repressed feelings, thoughts, and memories. In contrast to Rogersʼs assertion that a facilitative attitude is more important than the specific skills, I believe that a facilitative attitude and skills are inseparable (Hill, 2005b, 2007). Skills are used to express a facilitative attitude, and a facilitative attitude is needed to express the skills well. In addition, as articulated in Chapters 3 and 4, awareness (including self-knowledge, in-the-moment awareness, and cultural awareness) is also crucial because without awareness, the helper is likely to act out unconscious impulses in ways that could damage clients. Client involvement is also important because unless the client is willing and motivated to work, nothing happens. And client involvement enables the helper to be more effective and facilitative. Thus, a facilitative attitude, self- awareness, skills, and an involved client are all important components of the helping process. I agree with Rogers that, for some clients, being understood and encouraged to express their feelings is enough to get them back to a self- healing mode so that they can function again and make needed changes. Others, however, need more assistance in learning how to deal with feelings and experiences, many of which may be new to them. Furthermore, some clients need to be assisted in moving toward insight and action. In addition to experiencing and communicating the facilitative conditions, then, I posit that helpers need to be able to facilitate insight and action when their clients are ready. Additional theories (psychoanalytic, cognitive, and behavioral), to be covered in later chapters, are thus needed to assist some clients in moving beyond exploration of thoughts and feelings. Furthermore, I do not completely agree with Rogers that people are inherently good and striving for self-actualization. My belief is that people are neither inherently good nor bad at birth but rather develop depending on temperament, genetics, the environment, parenting, and early experiences (see Chapter 2, this volume). Despite these differences in beliefs about human nature and biological contributions, though, I agree with Rogers about the importance of the facilitative conditions for establishing the therapeutic relationship and helping clients explore concerns and achieve self-acceptance. And I agree with the notion of that clients are self-healing and the active agents of change (Bohart & Tallman, 1999). Finally, Rogers did not attend closely to cultural considerations in his theory, probably because the United States was not as diverse then as it is now. Culture certainly fits into Rogersʼs theory, however, in that being truly empathic and compassionate assumes a major interest in the person, awareness of who the person is, and an acceptance of the person. Thus, I would assert that multicultural awareness is important to genuinely being Rogerian. GOALS FOR THE EXPLORATION STAGE The goals for the exploration stage involve establishing rapport and a trusting relationship, attending and listening, helping clients explore their thoughts and narratives, facilitating emotion, and learning about clients. Here I provide an overview of these goals, but they are presented in greater detail in the other chapters in Part II of this book (see also Exhibit 5.1). EXHIBIT 5.1 Skills for Facilitating the Goals of the Exploration Stage Goal Skills To attend and listen Eye contact Facial expression Head nods Body posture Body movements Space Grammatical style Silence Minimal interruptions Minimal touch Approval–reassurance Self-disclosure of similarities To explore thoughts and narratives Restatement Open question or probe for thoughts To explore feelings Reflection of feelings Disclosure of feelings Open question or probe about feelings Establishing Rapport and Developing a Therapeutic Relationship Helpers establish rapport (i.e., an atmosphere of understanding and respect) with their clients to help clients feel that it is feel safe to explore. Rapport sets the stage for development of the therapeutic relationship, which is important in helping (see Chapter 2 for more about the therapeutic relationship). Clients generally need to feel safe, supported, respected, cared for, valued, prized, accepted as individuals, listened to, and heard in their interactions with helpers. In everyday relationships, people often do not fully listen to others, so it is a gift to clients for helpers to listen attentively to them without rushing to say something next (e.g., telling a competing story, as friends often do). During the exploration stage, helpers strive to understand their clients from the clientsʼ frame of reference. They aspire to “walk a mile in the clientʼs shoes” and view the world through their clientsʼ eyes. Helpers try to understand clientsʼ thoughts and feelings without imposing their thoughts or values on the clients. They attempt not to judge clients and figure out whether they are “right” or “blameworthy,” but instead have compassionate concern and curiosity about how clients came to be the way they are. Helpers also try to align or attune themselves (i.e., feel what it is like to be the client) so that they can understand the clientʼs feelings.  If helpers can assist clients in becoming aware of their inner experiencing, clients can begin to trust and then to heal themselves. Rogers (1957) hypothesized that clients typically need to feel accepted and prized by others before they can begin to accept and value themselves. To do this, helpers need to accept clients as they are as much as possible and provide them with the facilitative conditions of empathy, unconditional positive regard, and genuineness. Helpers need to listen and understand clients without judging them. In addition, having knowledge of helping skills, being competent in using the skills, and being aware of feelings and motivations enables helpers to be grounded, present, and have a therapeutic attitude. Helpers should not think that they can simply establish a relationship at one point in time and ignore it thereafter. They need to be aware of maintaining the relationship throughout the helping process. At any time throughout the process, the relationship can, and often does, rupture and need repair (see Hill, Nutt-Williams, Heaton, Thompson, & Rhodes, 1996; Rhodes, Hill, Thompson, & Elliott, 1994; Safran, Muran, Samstag, & Stevens, 2002). In fact, relationships are often stronger after a rupture and repair. We spend a lot of time talking about resolving problems in the therapeutic relationship in Chapter 13. Beginning helpers often worry about the possibility of not liking clients or being unable to establish rapport with them. For example, many beginning helpers think they could never work with rapists or child abusers because they would be repulsed and horrified. However, the goal of being a helper is not to make friends with clients. Helpers do not need to “like” clients in the same way they like or choose to spend time with close friends. Rather, helpers have a responsibility to understand and assist clients and try to feel compassion for the human beings underneath the exterior presentations. Often, if helpers can gain insight into how clients got to how they are, they can begin to have compassion for these clients. For example, the greatest challenge for one helper was working with women in a prison. The crimes committed by the women made it difficult for the helper to empathize with and respect these clients. However, after getting to know the women and their life circumstances, the helper became aware of some similarities with them (e.g., a desire to be loved, hurt at being rejected). Even though the helper had not experienced the same exact life events as the prisoners, the helper had experienced many of the same emotions and thus could empathize with the clientsʼ feelings, even while not condoning their behaviors. We often like to think of people who make us anxious and defensive (e.g., prisoners, dictators) as evil and “other,” as a different species than we are so that we do not have to encounter our own negative impulses, but in fact, it is important to remember that we are all human and have similar feelings. Attending and Listening The major way that we as helpers establish rapport and build a therapeutic relationship is through attending and listening. We orient ourselves nonverbally toward clients so that we are receptive to listening to whatever they say. We listen intently to what they say rather than assuming we know anything about them. We observe carefully to see how they are feeling and reacting to everything that happens in the session. In addition, helpers monitor their reactions to clients, as described in Chapters 2 and 3. Helpers need to know what is going on internally as they work with clients and make a determination about whether the reactions are due to their own issues, due to what clients are eliciting from them, or some combination of the two. PREEXPLORATION EDUCATION Helpers working with clients from cultures who do not value the three-stage model may need to spend some time with clients educating them about the model and making sure they “buy in” to participating in this type of helping process (Joo, Hill, & Kim, in press). For example, Joo et al. (in press) found that Korean therapists modified the Hill model by educating clients initially about what the expectations were about the helping process. Given that many Koreans have been raised not to express their feelings and reactions, they need to have a rationale and believe that it is appropriate to explore thoughts and feelings, or the helping process will not be effective. Helping Clients Explore Nonaffective Content, Thoughts, Narratives, and Stories Clients need a chance to talk about their problems. It often helps to talk out loud about what is going on inside. All too often, people just continue with their ordinary routines without exploring their problems in any depth. As Frank and Frank (1991) noted, “How can I know what I think until I have heard what I have to say?” (p. 200). Having a forum to express their thoughts allows clients to hear and think about the content of what they are saying. Clients need to realize what they are thinking and have a chance to express these thoughts out loud. This talking is similar to telling oneʼs story or narrative. Furthermore, by realizing what one is thinking, one has a better chance to hear the inconsistencies and logical fallacies. Talking about oneʼs thoughts provides clients the opportunity to think about whether they really believe what they are saying, especially when they know someone else is listening. In addition, the process of talking to a helper about a problem is useful because it allows the client to think about it, take it out and examine it, put thoughts into words, and get another personʼs reactions. Then, during the insight stage, clients can reevaluate what they are thinking, rewrite the script, and perhaps change the narrative. Encouraging Expressions and Experiencing of Feelings Emotions are a key element in the helping process because they represent fundamental experiencing and are connected integrally to cognitions and behavior. In fact, mental health could be defined as allowing oneself to have a whole range of feelings and expressing these feelings in an appropriate manner (e.g., laughing when happy, crying when sad). One major goal of the exploration stage is for helpers to assist clients in experiencing feelings they suppressed earlier in life. Clients often had to distort or deny their actual feelings to survive and gain approval from parents or other significant persons, so many clients are not aware of their feelings. For example, if clients cannot allow themselves to feel hurt, they limit their range of emotions and might feel hollow or empty inside. Some clients feel that their “inner cores” are rotten or nonexistent. Clients might not know who they are and might rely on other people to tell them how they feel. In significant relationships, they might ignore their feelings and feel distant without knowing why. Hence, being able to feel their true feelings and put words onto the feelings can be liberating for clients and help them develop a clearer and more coherent sense of self. Sometimes the content of what the client says is not as important as the feelings about the topic, particularly if there is a discrepancy between content and feelings. Helpers need to listen to the “music” (i.e., the underlying message) in addition to listening to the words. They thus need to try to hear both the content and what the client feels. In addition, clients need to be helped to focus on what they are feeling in the present moment. Experiencing immediate feelings is often not comfortable, so clients may want to run away and avoid their feelings. Through support and encouragement from helpers, clients often can begin to tolerate the anxiety and discomfort of exploring immediate feelings. For example, Joel spent much of the session telling the helper about events that occurred during the week. When the helper gently encouraged him to explore his feelings in the present regarding these past events (e.g., “How do you feel right now about the event?”), Joel talked about his feelings, and the session became more intense and productive than it previously had been. Helpers sometimes need to be assertive and ask about feelings that clients are not discussing. For example, clients might need to be invited to talk about difficult feelings such as shame or being depressed or suicidal. In friendships, people often do not probe beyond what their friends choose to reveal because they feel that would be overstepping implicit boundaries. In helping relationships, by contrast, helpers encourage clients to explore painful feelings that are hard to express. However, helpers need to respect the rights of clients not to go any deeper than they choose. Helpers thus walk a fine line between inviting clients to disclose feelings and not forcing them into unwanted disclosure. Another reason for encouraging clients to talk about feelings is that emotional arousal seems to be necessary for change to occur (Frank & Frank, 1991). Without emotional arousal, clients typically are not involved in the helping process and are not motivated to change. Many times, people deny or defend against their feelings because they do not want to deal with the overwhelming or painful nature of their feelings. In contrast, when people have strong emotional arousal (e.g., fury, despair), they are most aware of feelings and more likely to change. CONCLUDING COMMENTS The exploration stage is important to facilitate the development of the helping relationship, gives clients a chance to explore concerns and immerse themselves in their immediate experiencing, and provides helpers with an opportunity to learn about clientsʼ presenting issues and assess the appropriateness for what helpers can offer. For Rogerians, the exploration stage is all that is needed for helping. Rogerians believe that the facilitative attitudes of empathy, unconditional positive regard, and genuineness allow clients to begin to accept themselves, which releases the inner experiencing and unblocks the potential for self-actualization. Indeed, some clients need only a listening ear to get them back to their own self-healing processes. Hence, I generally suggest that helpers spend considerable time in the exploration stage to ensure that clients feel heard and have the opportunity to experience and express their thoughts and feelings. Because many clients cannot make progress with exploration alone, however, insight and action are often necessary to help them change. In this case, exploration sets the stage for everything that follows. In addition, exploration skills are used throughout all three stages. Thus, even when helpers move to insight and action, they continue to use exploration skills to help clients feel safe and to facilitate exploration as they are confronted with new things. An important caveat throughout the exploration stage (and the rest of the helping process) is that there are no absolute “right” interventions to use. Although there are general guidelines, it is not possible to provide a cookbook to tell helpers exactly what to do in different circumstances with different clients. Individual clients require different things at different times from helpers. It is up to helpers to determine which interventions are productive and which are not useful by paying attention to the individual clientʼs reactions and responses (refer back to Chapter 2 for a review of the moment-by-moment process). We practice the individual skills so that we can become competent in them and then be ready to use whatever in needed at the time. I describe more about integrating the skills in Chapter 9. WHAT DO YOU THINK? Rogers has been criticized for being too optimistic about human nature and as reflecting American culture in the mid-20th century (compared with the pessimistic view of Europeans such as Freud).  Debate whether Rogersʼs view is too simplistic and optimistic. Debate the merits of each of Rogersʼs six conditions. Do you think the therapistʼs facilitative conditions, the relationship between the helper and client, therapist awareness of needs and motives, or client involvement is the most crucial for the success of the exploration stage? How well do the tasks of the exploration stage fit your personal style? Discuss whether establishing a relationship is more a matter of facilitative attitudes or of implementing helping skills. Describe the challenges you would face in developing a relationship with someone you believe has wdone awful and despicable things (e.g., rape, murder). Do you believe that it is necessary for clients to “tell their stories”? KEY TERMS blueprint chair work client-centered theory defenses (or defense mechanisms) emotion-focused therapy narratives RESEARCH SUMMARY Therapist Skills and Innovative Moments Citation: Cunha, C., Gonçalves, M. M., Hill, C. E., Mendes, I., Ribiero, A. P., Sousa, I.,... Greenberg, L. S. (2012). Therapist interventions and client innovative moments in emotion-focused therapy for depression. Psychotherapy, 49, 536–548. http://dx.doi.org/10.1037/a0028259 Rationale: Narrative theorists suggest that the major change clients make in therapy involves how they talk about or tell their stories. They measure this change by identifying innovative moments (IMs) in client speech. Five types of IMs have been identified: action (the client acting in ways that are discrepant with the problematic self-narrative), reflection (new understandings that undermine the dominance of the problematic self-narrative), protest (challenging the problematic self-narrative), reconceptualization (a shift between two positions and a transformation process), and performing change (new activities or experiences that become possible because of changes). Previous studies have found more IMs in successful than unsuccessful therapy—in particular, with more occurrences of reconceptualization and action IMs. Cunha et al. (2012) wondered whether specific therapist skills facilitated IMs. Therapist skills were conceptualized as exploration (includes approval–reassurance, closed questions, open questions and probes, restatements, reflections of feelings), insight (includes challenges, interpretations, self-disclosures, and immediacy), and action (includes information and direct guidance). Method: Three good-outcome and three poor-outcome cases of emotion- focused therapy for depression were selected based on examination of a number of outcome measures. The first two sessions, two middle sessions, and the two final sessions of these six cases were coded for therapist skills and client IMs. Interesting Findings: Exploration skills were used more often, whereas insight skills were used less often, in good- compared with poor-outcome cases across all three phases of therapy. Action skills were used more often in initial phases of good- than poor-outcome cases but more often in the final sessions of poor- than good-outcome cases. IMs more often followed skills in the good- than poor-outcome cases. In good- outcome cases, the connection between skills and IMs increased from the initial  to middle phase of therapy and was maintained in the final phases. In poor- outcome cases, the connection between skills and IMs increased from the beginning to middle but then decreased in the final phase. In the initial and middle phases of the good-outcome cases, all helping skills were associated more with easier IMs (action, reflection, protest) than with more advanced IMs (reconceptualization, performing change). In the final phase of good-outcome cases, exploration and insight skills were more often associated with easy IMs than with the more advanced IMs. In the final phase of poor- outcome cases, all skills were more associated with the easy than advanced IMs. Conclusions: Therapists used the skills more effectively in good- than poor-outcome cases (i.e., all three types of skills led to more IMs in good- than poor-outcome cases). Experiential therapists used mostly exploration skills, which fits with this theoretical perspective as being client centered. However, exploration skills did not lead to more IMs than did insight skills. Insight skills were used more often in poor- than good-outcome cases. The authors speculated that therapists were trying to engage clients when their preferred exploration skills were not working. Exploration and insight skills led mostly to the easier IMs in the initial and middle phases of therapy, whereas they led mostly to the more advanced skills later in therapy. It appears that the foundation must be set early in therapy with the easier IMs before the complex IMs can occur. Action skills were used more in the beginning and middle phases of good- outcome cases, which the authors speculated was because therapists were engaging in in-session experiential activities such as chair work. They speculated that action skills were used less in the final phase because therapists were helping clients consolidate gains. In contrast, in poor-outcome cases, action skills increased steadily across phases, perhaps because therapists continued to try to engage clients in therapeutic tasks even when they were not working. Action skills led more often to the easier than the more complex IMs. Implications for Therapy: Therapists should observe the immediate effects of their interventions. Therapists can use both exploration and insight skills to promote easy IMs in the early and middle phases of therapy and the more complex IMs in the final sessions of therapy. Therapists can use action skills (remember that these were usually the in- session directives) to promote the easy IMs throughout therapy. LEARN MORE Students and instructors will find practice exercises, labs, and other resources for study and teaching at the companion website: http://pubs.apa.org/books/supp/hill5. 6 Skills for Providing Support The one who listens is the one who understands. —AFRICAN (JABO) PROVERB The students in one class prearranged to manipulate their professorʼs behavior through nonverbal responding. Whenever the professor moved to the right, they looked up, paid rapt attention, and smiled encouragingly. Whenever the professor moved to the left, they looked down, rustled their papers, coughed, and whispered. The professor soon had moved so far to the right, he fell off the stage! This example illustrates the power of attending skills. The skills covered in this chapter rarely show up on transcripts of helping sessions because they are mostly nonverbal rather than verbal. They are what have been called the “back channel” of communication, similar to the oil that greases the mechanism to make a machine run smoothly or the glue that holds the elements of a collage together. Helpers attend and listen to clients to provide support. These attending skills help clients feel safe and comfortable, which allows them to explore their thoughts and feelings. Helpers do not usually think consciously about and are not aware of these skills, but they can have a big impact on clients. OVERVIEW OF ATTENDING AND LISTENING Attending refers to helpers orienting themselves physically toward clients. The goal of attending is for helpers to communicate to clients that they are paying attention to them so that clients feel safe to talk openly about their thoughts and feelings. In effect, attending lays the foundation for the implementation of the verbal helping interventions. Clients feel they are valued and worthy of being listened to when helpers attend to them. Attending can also encourage clients to verbalize ideas and feelings because they feel helpers want to hear what they have to say. Furthermore, attending can reinforce clientsʼ active involvement in sessions. Attending is communicated mostly through nonverbal and paraverbal (i.e., how we say the words) behaviors, which help convey both what helpers are trying to express and what they do not intend to express (or might be trying to hide). For example, although helpers might try hard to be empathic and look concerned, they might feel bored and irritated with a client, which might be expressed through foot tapping or stifled yawns. Attending orients helpers toward clients, but listening goes beyond just physically attending to clients. Listening refers to capturing and understanding the messages that clients communicate (Egan, 1994). Listening involves trying to hear and understand what clients are saying. Reik (1948) talked about listening with a third ear, or trying to hear what clients really mean, not just what they say overtly. In effect, helpers puts the verbal and nonverbal messages together and hear what clients are thinking and feeling at a deep level. Attending behaviors set the stage for allowing helpers to listen, but attending does not necessarily ensure listening. Helpers could attend physically but not listen (e.g., they could be thinking about dinner that night and not hear what clients are saying). Listening provides the raw material from which helpers develop their verbal and nonverbal interventions, but listening sshould not be confused with the ability to deliver helpful interventions. Helpers could listen without being helpful, but it would be difficult to be helpful without listening. Thus, from watching sessions, one could not actually tell whether helpers were listening; however, one could infer that they were listening if they were able to produce statements that reflected what they heard. Clearly, there is a lot of overlap between the attending and listening skills, which is why they are presented together in this chapter. As a helper, you will want to pay attention to these skills to build a relationship with clients. Exhibit 6.1 lists the attending and listening skills reviewed in this chapter, along with guidance for when they are appropriate to use and common mistakes to avoid. EXHIBIT 6.1 Helper Behaviors That Enhance Attending and Listening Overall Caveat: Depends on Client Behavi or Appropriate use Inappropriate use Eye Maintain eye contact while speaking Too much can feel dominating; too little contact to convey empathy can appear uninterested Facial Best to have a natural appearance Too much animation can take attention expressio of calm and attentiveness to client away from client and onto the helper; n too little can appear rigid and unnatural Smiling Occasional smiles can support and Too much smiling can seem fake and reinforce client inhibit clients talking about negative emotions; too few can feel cold and distant Head Can convey understanding or Too many can be distracting; too few nods agreement can feel cold and distant Body Leaning slightly toward client in a Leaning too far toward client can make posture natural pose client pull away; leaning away in a slouching position can appear uninterested Gestures Can be useful when used in Too many can be distracting; too few conjunction with verbal statements can make the helper seem rigid Spacing 45–55 inches between the middle of Too close can feel like an intrusion into between chair seats is ideal; good not to have personal space; too distant can feel chairs a table in between helper and client awkward Touching To be avoided other than perhaps a Touching can be misinterpreted so it is handshake at the beginning if best to avoid culturally appropriate Tone of Soft, slow, inviting; match to client Too dissimilar from client; too strident; voice too soft Grammat Natural but similar to client Too much jargon; language that is too ical style dissimilar from the client Minimal Typically at the end of a phrase or Too many minimal encouragers can encourag sentence to indicate that client convey a lack of genuineness; too few ers should continue can make for a stilted conversation where the client does not know if the helper is listening Approval Occasional if client is needing Too many can minimize clientʼs feeling; – specific support too few can feel unsupportive reassura nce Behavi or Appropriate use Inappropriate use Disclosur Occasional if client is needing Too many can minimize clientʼs e of specific support and to feel like experience; too few can make client similaritie others have been in a similar feel isolated s situation Interrupti To be avoided generally to allow Talking over the client and not allowing ons client space to talk; if, however, client time to think is problematic client talks nonstop and does not allow the helper to talk at all, the helper can gently interrupt Silence Can be useful to allow client time to Can be inappropriate if client is think anxious CULTURAL RULES FOR NONVERBAL COMMUNICATION Each culture develops rules for nonverbal communication (Harper, Wiens, & Matarazzo, 1978). An example of such a rule is the pattern of greeting that might take no more than one third of a second. This pattern involves looking at the other person, smiling, lifting the eyebrows, and nodding the head. These behaviors act as a releaser in that they elicit the same response from another person. Another example is turn- taking: when one person speaks and then indicates nonverbally that it is the other personʼs turn to talk. Rules for nonverbal behaviors are typically outside of conscious awareness. Most people probably could not articulate the nonverbal rules in their own culture because they learn these rules as young children through social interactions rather than by explicit verbal instruction. Nonverbal behaviors that are appropriate in one culture might not be appropriate in another. A whole industry has developed to teach diplomats and travelers about nonverbal rules of other cultures. For example, in Asia, it is important for people not to praise themselves and instead to appear humble (Maki & Kitano, 2002). Therefore, an American who acts boastful might not be well received in Asian countries. If you are involved in interpersonal interactions in which another person does not follow your rules for nonverbal behaviors, you might feel intense discomfort. You might not be able to understand or articulate why you feel uncomfortable, but you probably know that something does not feel right. For example, if someone stares at you, you might feel uncomfortable because it is inappropriate in your culture to stare for a long time. If someone stands too close and grabs your arm when you are talking, you might feel an urge to move away because the person has violated your personal space. Helpers need to adapt their style to fit clientsʼ nonverbal styles rather than expect clients to adapt to their culture. Helpers can take cues from their clients as to what makes them feel comfortable. For example, if a client acts nervous when the helper initiates eye contact, the helper might look away and observe whether the client responds differently. We cannot stereotype that clients from certain cultures will behave in specific ways; rather, we have to observe to see how each individual client responds. When clients from another culture do something nonverbally that is different from the helperʼs custom (e.g., using eye contact differently), some helpers judge these clients according to their own cultural standards. It is important to become aware of this tendency and try not to judge clients using your own cultural standards. I want to again emphasize that there are no “right” nonverbal behaviors. The key is figuring what helps the client relax and explore. Within the bounds of looking professional, each helper needs to determine which attending behaviors feel comfortable and natural to use. For example, sitting in an uncomfortable but technically correct counselor posture will probably communicate discomfort rather than professionalism to the client. NONVERBAL BEHAVIORS THAT FACILITATE ATTENDING Helpers typically communicate much of their attending and listening through nonverbal behaviors. Indeed, some researchers (e.g., D. Archer & Akert, 1977; Haase & Tepper, 1972) have suggested that people communicate true emotions more through nonverbal than verbal expressions and that nonverbal behaviors are more reliable indicators of true emotion when there is a discrepancy between verbal and nonverbal behaviors. In my opinion, there is not enough empirical evidence to indicate the relative importance of verbal and nonverbal behaviors; however, enough evidence exists to suggest that helpers should pay attention to what they and their clients communicate nonverbally as well as verbally. So let us examine the different kinds of nonverbal behaviors. Kinesics refers to the relationship of bodily movements (arm and leg movements, head nods) to communication. Bodily movements can be categorized into several types, each of which has a different function (Ekman & Friesen, 1969). Emblems are substitutes for words (e.g., a wave is a universal greeting). Illustrators accompany speech (e.g., measuring the size of a fish with the hands). Regulators (e.g., head nods, postural shifts) monitor the conversation flow. Adaptors are habitual acts that are often outside awareness and have no communicative purpose (e.g., head scratching, licking oneʼs lips, playing with a pen). Helpers can use emblems, illustrators, and regulators to accompany verbal messages, but they should avoid using adaptors that detract from the helperʼs effectiveness and can turn the focus away from the client to the helper (e.g., the client might be distracted if the therapist is twitching or playing with a pencil or hair). Too many adaptors or an inappropriate use of emblems, illustrators, or regulators is often a sign of “nonverbal leakage” (i.e., the person tries to hide or not communicate, but the feelings leak out through nonverbal channels). In the next sections, I review several nonverbal behaviors that are important for enabling the helper to attend to the client. Obviously, these nonverbal behaviors all operate together, and sometimes one nonverbal behavior can compensate for another, but here I break them apart to describe how each one operates. Importantly, each of these behaviors can be used too much or too little by any given helper with any given client. There is typically an optimal level that the helper and client have to negotiate, often implicitly. Eye Contact Do an exercise in which you try keeping eye contact with another person. See how long you last before it becomes completely uncomfortable. Alternatively, try to keep eye contact for 2 minutes and see how it feels. Think about what conditions make it more or less comfortable. Looking and gaze aversion are typically used to initiate, maintain, or avoid communication. With a gaze, one can communicate intimacy, interest, submission, or dominance (Kleinke, 1986). Eyes are used to monitor speech, provide feedback, signal understanding, and regulate turn-taking (Harper et al., 1978). One could say we meet people with our eyes or that “the eyes are the windows into the soul.” In contrast, gaze avoidance or breaking eye contact often signals anxiety, discomfort, or a desire not to communicate with the other person. A person who violates the rules of eye contact will have a hard time communicating with others. In typical interactions, people make eye contact with each other (i.e., mutual gaze) in 28% to 70% of their interactions (Kendon, 1967), although usually for no more than 1 second at a time. Dyads typically negotiate when and how much to look at each other, although this is not a conscious negotiation and takes places at a nonverbal level. When eye contact is good and appropriate, people feel comfortable with each other. When there is too much or too little eye contact, people feel vaguely uncomfortable and anxious, although they cannot always identify the problem. Too little eye contact can also make one feel the listener is uninterested in the conversation and is avoiding involvement. By contrast, too much eye contact can make the other person feel intruded on, dominated, controlled, and even devoured. Likewise, staring can feel rude, insulting, and threatening. Norms for eye contact differ among cultures. In White, middle-class North America, people tend to maintain eye contact while listening but look away when speaking, checking back from time to time to get feedback. In some Native American groups, sustained eye contact is considered offensive and a sign of disrespect, especially if by a younger to an older person (Brammer & MacDonald, 1996). Several cultural groups (e.g., some Native American tribes) avoid eye contact, especially when talking about serious topics (Ivey, 1994). And, as noted in Chapter 4, a lack of eye contact signifies respect for an authority figure in some cultures. Facial Expression Darwin (1872) speculated that before prehistoric people had language, they communicated threats, greetings, and submission through facial expressions. He believed that this shared heritage explains why all humans express basic emotions through similar facial expressions. He wrote, The movements of expression in the face and body, whatever their origin may have been, are in themselves of much importance for our welfare. They serve as the first means of communication between the mother and her infant; she smiles approval, and thus encourages her child on the right path, or frowns disapproval. The movements of expression give vividness and energy to our spoken words. They reveal the thoughts and intentions of others more truly than do words, which may be falsified.... These results follow partly from the intimate relation which exists between almost all the emotions and their outward manifestations. (p. 366) The face is perhaps the body part most involved in nonverbal communication because people communicate so much emotion and information through facial expressions (Ekman, 1993). People pay attention to facial expressions because they give clues about the meaning of the verbal message. In Shakespeareʼs (1603/1980) Macbeth, Lady Macbeth says to her husband, “Your face, my thane, is a book whereon men may read strange matters” (Act 1, Scene 5, p. 17). The following are some common facial expressions and possible meanings (remember that these are only possible meanings), according to Nirenberg and Calero (1971): A frown might indicate displeasure or confusion. A raised eyebrow may suggest envy or disbelief. An eye wink might indicate intimacy or a private matter. Tightened jaw muscles may reflect antagonism. Eyes squinted might reflect antagonism. Upward rolling of the eyes may imply disbelief or exasperation. Both eyebrows raised may denote doubt or questioning. Ekman and Friesen (1984) showed photographs of facial expressions to people around the world and found that several facial expressions had the same meaning across cultures. People around the world cry when distressed, shake their heads when defiant, and smile when happy. Even blind children who have never seen a face use the same facial expressions to express emotions as sighted people (Eibl-Eibesfeldt, 1971). In addition, fear and anger are expressed mostly with the eyes and happiness mostly with the mouth (Kestenbaum, 1992). Although people in different cultures share a universal facial language, they differ in the manner and depth of expression of their emotions. For example, emotional displays are often intense and prolonged in Western cultures, whereas Asians display emotions of sympathy, respect, and shame but rarely display self-aggrandizing or negative emotions that might disrupt communal feelings (Markus & Kitayama, 1991; Matsumoto, Kudoh, Scherer, & Wallbott, 1988). We learn at a very young age, even in American culture, to control our facial expressions. Imagine showing in an elementary school classroom that you are uninterested in what the teacher is saying. No, we learn to keep those feelings to ourselves, and sometimes even force ourselves not to be aware of the feelings. Some people use the lack of facial expression to an advantage, such as in having a “poker face” so that no one knows their cards. Important facial features used in helping are smiling and laughter (see Gupta, Hill, & Kivlighan, 2018), which seem to have evolved as a survival strategy. Imagine young parents who are frustrated about the lack of sleep with a newborn. The babyʼs smiling, gurgling, and laughter form a powerful bond that helps the parents feel connected. Some research on laughter has shown that it rarely occurs in private but rather is a mode of communication between people (Provine, 1993, 2001). Although smiling makes a person look friendly and can encourage exploration, too much smiling on the part of the helper can be perceived as ingratiating or inappropriate when clients are talking about serious concerns. Helpers who smile excessively could be seen as not genuine, mocking the depth of clientsʼ problems, or uninvolved. Head Nods The appropriate use of head nods, especially at the end of sentences, can make clients feel helpers are listening and following what they are saying. Indeed, verbal messages are sometimes unnecessary because helpers communicate through head nods that they are “with” clients and that clients should continue talking. Too few head nods could make clients feel anxious because they might think that helpers are not paying attention; too many head nods could be distracting. Body Posture An often-recommended body posture is for helpers to lean toward clients and maintain an open body posture with the arms and legs uncrossed (e.g., Egan, 1994). This leaning, open body posture often effectively conveys that the helper is paying attention, although helpers can appear rigid if they stay in this position too long. Also, if the open, leaning position is uncomfortable, it can be hard for helpers to attend to clients. Body Movements Bodily movements provide information one often cannot obtain from either verbal content or facial expression. As Freud (1905/1953a) eloquently stated, “He that has eyes to see and ears to hear may convince himself that no mortal can keep a secret. If his lips are silent, he chatters with his fingertips, betrayal oozes out of him at every pore” (p. 94). Van den Stock, Righart, and de Gelder (2007) found that body expressions were particularly important in addition to those of the face and voice in helping responders recognize emotions. Similarly, Beattie and Shovelton (2005) suggested that spontaneous hand gestures enabled people to get their messages across more clearly. Ekman and Friesen (1969) noted that leg and foot movements are the most likely sources of nonverbal leakage because they are less subject to conscious awareness and voluntary inhibition. The hands and face are the next best sources of clues for nonverbal leakage. Hence, if helpers find themselves repeatedly tapping their feet, they might look inward to reflect on what they are feeling. Gestures often communicate meaning, especially when they are used in conjunction with verbal activity. According to McGough (1975), the following are some possible meanings (again, remember that these are just possible meanings): Steepling of fingers might suggest that a person feels confident, smug, or proud. Touching or rubbing the nose tends to be a negative reaction. Putting a hand to oneʼs mouth often occurs when a person has blurted out something that should not have been said. Finger wagging or pointing implies lecturing or laying blame. Tugging at the collar suggests that the person feels cornered. Pinching the bridge of the nose implies that the person is deep in thought. Locked arms or crossed legs can be a defensive or critical position. A clenched fist is sometimes a defensive or hostile gesture. A hand over the eyes can be a gesture of avoidance. Sitting back in chair with hands behind the head may communicate confidence or superiority. Furthermore, it appears that synchrony in body movements between the therapist and client is related to relationship quality and outcome (Ramseyer & Tschacher, 2011). I suspect this is at the unconscious level because therapists rarely mimic the nonverbal movements of clients. Rather, it suggests that there is some mirroring between them when they are in tune with other. Space The term proxemics refers to how people use space in interactions. Hall (1966) described four distance zones for middle-class Americans: intimate (0–18 inches), personal (1.5–4 feet), social (4–12 feet), and public (12 feet or more). If rules for prescribed distances are not followed, people can feel uncomfortable, although they are not usually aware of what is making them uneasy. Hall noted that once these patterns for space are learned, they are maintained largely outside of conscious awareness. Typically, the personal to social distance is considered appropriate for seating arrangements in helping relationships, although individuals vary in the amount of distance that feels comfortable for them. Some helpers place chairs close together, whereas others, when they have control over the arrangements, place the chairs far apart. Some helpers place a number of chairs in their offices and allow clients to choose where they sit; where the client sits then provides information that the helper can later use in speculating about the clientʼs needs (e.g., to be close or to be distant). Space is used in different ways in different cultures (Hall, 1963). American and British people generally prefer to be relatively distant from other people and rarely touch. In contrast, Hispanic and Middle Eastern people generally prefer less distance. For example, Arabs and Israelis often stand close, touch, talk loudly, and stare intently. In their review of the literature in work environments, Ayoko and Hartel (2003) found consistent evidence that space violations triggered conflict for people from different cultural backgrounds. In addition, Norman (1982) noted that space is a specialized elaboration of culture. He claimed that space reflects status, power, and expressions of personality. Thus, helpers need to take cultural considerations into account rather than just reacting unconsciously to someone who uses space differently. Avoid Touch Touching is a natural inclination when helpers want to indicate support to their clients. In fact, clients can feel understood and involved in a human relationship if there is some touch (Hunter & Struve, 1998). Montagu (1971) noted that touch is a natural physical need and that people can hunger for touch if they do not receive enough physical contact. Unfortunately, touch can also sometimes have negative effects. Clients can feel that their space has been invaded. Furthermore, if the touch is unwanted or if clients have a history of unwanted touch, touch can be frightening and make clients feel unsafe. A survey of practicing therapists indicated that about 90% never or rarely touched clients during sessions (Stenzel & Rupert, 2004). The only type of touch that was used much at all was a handshake, typically before or after a session. Some therapists, however, were reluctant to even shake hands due to concern that any touch could be misinterpreted as sexual or exploitative and could thus result in harm or litigation. Furthermore, therapists indicated that they were more likely to accept a hug or handshake than to initiate such behaviors. Given the potential benefits, misunderstandings, and harm related to touch, it clearly requires clinical judgment to know when to use touch. It is probably better for beginning helpers to refrain from touching to avoid ethical and clinical problems that may arise. General guidelines for touch for more advanced helpers, as suggested by Kertay and Reviere (1998) and E. W. L. Smith (1998), are to seek consent from the client before touch, explain the use of touch to the client, and discuss the experience with the client afterward. PARAVERBAL BEHAVIORS THAT FACILITATE ATTENDING In addition to nonverbal behaviors, there are also paraverbal behaviors that accompany interventions. In other words, the manner in which helpers speak makes a difference. We consider here tone of voice and grammatical style. Tone of Voice Consider how you feel when someone speaks with a soft, gentle, inviting tone of voice as opposed to when a person speaks in a loud, brash, demanding voice. You might have strong reactions to the two helpers based on their different speech mannerisms. Similarly, clients are more likely to explore when helpers speak gently rather than loudly and demandingly. In addition, it can be helpful for helpers to somewhat match the clientʼs pace of speech. In fact, Imel et al. (2014) found that synchrony in terms of vocal tone was related to perceptions of therapist empathy. Helpers might thus use a slower pace of speech with clients who speak slowly and a somewhat faster pace with clients who talk rapidly. If a client is speaking too rapidly, however, the helper might use a slower pace to encourage the client to slow down. Grammatical Style Another way helpers communicate attending is by matching the clientʼs language and grammatical style. Language must be appropriate to the cultural experience and educational level of the client, so the helper can form a bond with the client. If a client says, “I ainʼt never gonna make it with chicks,” it would probably be better for the helper to say something like, “Youʼre concerned about finding a girlfriend,” rather than “Your inferiority complex prevents you from establishing relationships with appropriate love objects.” The latter statement sounds too discrepant from the clientʼs language. Helpers should not compromise their integrity by using a language style that feels uncomfortable to them, but they can modify their style to be more similar to that of their client. Each of us has a comfort range of behaviors, and helpers need to find the place within that range to meet each client. MINIMAL VERBAL BEHAVIORS THAT FACILITATE CLIENT EXPLORATION There are five minimal verbal behaviors that helpers can use to facilitate client exploration: minimal encouragement, approval–reassurance, disclosures of similarities, avoiding interruptions, and silences. Minimal Encouragers Helpers encourage clients to keep talking through nonlanguage sounds, nonwords, and simple words such as “um-hmm,” “yeah,” and “wow.” Helpers use minimal encouragers to acknowledge what the client has said, communicate attentiveness, provide noninvasive support, monitor the flow of conversation, and encourage clients to keep talking. Minimal encouragers are often used in conjunction with and serve the same purpose as head nods. Too few minimal encouragers can feel distancing, whereas too many can be distracting and annoying to the client. I suggest helpers use minimal encouragers and acknowledgments, mostly at the end of client sentences or speaking turns (i.e., everything a client says between two helper interventions), to encourage clients to keep talking (assuming they are actively involved in exploration). A minimal encourager here suggests that you are giving up your speaking turn and would like the client to continue speaking. Interrupting a client to provide minimal encouragers, however, can be distracting, so helpers should pay attention to timing. Approval–Reassurance Approval–reassurance is a helpful skill that can be used occasionally (and I stress occasionally) to provide emotional support and reassurance, indicate that helpers empathize with or understand clients, or suggest that clientsʼ feelings are normal and to be expected. The key is to use approval–reassurance to foster exploration and to make clients feel safe enough to keep talking at a deep level about their concerns. For many clients, approval–reassurance that their problems are normal and that they are not alone in their feelings can be empowering and help clients in deeply exploring their concerns. The following are some examples of approval–reassurance that could be helpful depending on the situation:  “Thatʼs really hard to handle.” “Thatʼs a devastating situation.” “How awful!” “Wow! Thatʼs an awesome opportunity!” “Good try!” “It was really terrific that you were able to express your feelings to him!” “Yeah, I know what youʼre going through.” “Iʼve been there too.” Approval–reassurance can also be used to provide reinforcement, indicating that the helper values something the client has said or done and wants to encourage the client to continue the effort to change. Some clients need support or acknowledgment that they have done something well. In addition, approval, reassurance, and reinforcement can help some clients persist in exploring because they know someone is listening and sympathetic; this is especially important if clients are exploring difficult or painful topics. When using approval–reassurance, it is important that the helper stay close to where the client is and know the client well enough to know what behavior is being approved. For example, Beth had been working on being assertive; she came into her session and said that she finally told her boss that she wanted more control over her schedule. The helper immediately said, “Wow, that is great that you were able to stand up for yourself.” Beth burst into tears and said that she was fired from her job. It perhaps would have been more helpful for the helper, instead of assuming that the experience was positive and thus giving approval–reassurance, to say something like, “And how did that go for you?” Approval–reassurance is especially inappropriate if used to minimize or deny feelings (e.g., “Donʼt worry about it,” “Everyone feels that way”). When used in this manner, approval–reassurance stops rather than facilitates clientsʼ exploring and accepting feelings. Such statements can make clients feel they have no right to their feelings. Helpers sometimes use these interventions as misguided attempts to reassure clients that everything is okay. Unfortunately, problems typically do not go away because they are minimized or denied. Most of us have heard the old sayings “Give it time” or “Time cures all.” It is not “time” that makes feelings go away; in fact, feelings often fester when they are bottled up or denied. Rather, it is awareness, acceptance, and expression of feelings that aid in resolution of painful affect. To reiterate, our goal as helpers is generally to help clients identify, intensify, and express feelings rather than minimize or deny them. Furthermore, approval–reassurance can sound false if used excessively, prematurely, or insincerely. If such interventions are used to promote helper biases (e.g., “I think youʼre right to feel guilty about getting an abortion”), they can also be problematic because they stop client exploration or make clients feel compelled to agree or comply. Helpers sometimes use approval–reassurance to feel liked by the client, which of course can be counterproductive and reflect the helperʼs insecurity. Or the helper may feel bad about making the client experience negative emotions or feel unable to handle negative emotions and use reassurance as a way of moving the client away from such emotions. Helpers need to stay aware of why they want to reassure or compliment their clients. In general, then, if done judiciously and sparingly, approval–reassurance can encourage clients and facilitate exploration of thoughts, feelings, and experiences. Approval–reassurance should not be used, however, to diminish feelings, deny experiences, stop exploration, or provide a moral judgment. When helpers find themselves using approval–reassurance in a counterproductive way, they may want to think about what is going on in their own lives. Here is an example of a positive use of approval–reassurance (in italics): CLIENT: I just learned that my sister needs to have a kidney transplant. Sheʼs been sick a lot lately and hasnʼt been getting better. HELPER: Oh wow! How does that feel? CLIENT: I feel terrible for her. Sheʼs only 21 and has always been active, so this is a real shock for her. I feel guilty that she got this horrible disease while Iʼm healthy and able to function. HELPER: Yeah, it sounds like youʼve been hit really hard by this. CLIENT: Yeah, Iʼve been thinking about it a lot. I mean, why am I still healthy? It just doesnʼt seem fair. HELPER: Itʼs pretty natural to feel some guilt. CLIENT: Really? Iʼm glad to hear that. I have been trying to do more for her. Iʼm thinking of organizing a campaign to find a donor and raise money for her treatment. Because she has an unusual blood type, it will be difficult to find the right person, and itʼs going to cost a lot of money. HELPER: How is that working for you? CLIENT: I feel like itʼs the least I can do. It does interestingly bring up a lot of issues for me about obligation versus doing things because I want to. (Client continues exploring) Disclosures of Similarities In disclosures of similarities, helpers reveal personal information about ways in which they and the client are alike. Given that the intent is generally for the client to feel less alone or different, they can serve to provide a sense of universality as does approval–reassurance. Universality is an important mechanism of change because it enables clients to feel that they are not the only ones who have been in similar situations (Yalom & Leszcz, 2005). In later chapters of this volume, I cover other types of disclosures (of feelings, insight, and strategies) that are appropriate for intentions other than providing support. Humanistic theorists (e.g., Bugental, 1965; Jourard, 1971; Robitschek & McCarthy, 1991; Rogers, 1957; Truax & Carkhuff, 1967) have long valued therapist disclosure. Because they value transparency, realness, and genuineness in the therapeutic relationship, they think that helper disclosure can have a positive effect on treatment. Humanists believe that a personal and transparent style of intervention benefits both the process and the outcome of helping because it allows clients to see helpers as real people who also have problems and as fellow travelers in the journey of life. In addition, humanists believe that when helpers disclose, there is more of a balance of control in the relationship, in that clients are not the only ones who are vulnerable. Humanists also contend that disclosure enhances rapport because clients feel friendlier toward and trusting of helpers who disclose. Interestingly, humanists think that disclosure can help to correct misconceptions as they occur because helpers are direct and honest with disclosures and, hence, challenge distortions as they arise. Additional benefits claimed by humanists for disclosures are that helpers are able to be more spontaneous and authentic and can thus model appropriate disclosure. Moreover, helpersʼ disclosures can facilitate client disclosure and repair ruptures in the therapeutic relationship. In effect, humanists believe that helpersʼ disclosures encourage an atmosphere of honesty and understanding between helpers and clients that fosters stronger and more effective therapeutic relationships. A major caveat is for helpers to determine whether the disclosure is for their own needs or for the clientʼs needs. It is also critical to keep the disclosure short and turn the focus back to the client. The tone of the disclosure should be “Weʼre all human and imperfect” rather than “You think you have it bad, let me tell about my experience.” It is also important for helpers to disclose only problems that are relatively resolved rather than ones that they are currently experiencing (see also Hill & Knox, 2002). For example, if a client expresses feeling that she is the only one who is having a difficult time adjusting to college, the helper might say, “I had a difficult time too when I first came to the university,” and then turn the focus back to the client, saying something like, “Tell me more about your experience.” Avoid Most Interruptions One particularly distracting helper behavior is interruptions. When the client is exploring productively (i.e., talking about innermost thoughts and feelings), the helper does not need to interrupt. Often in the exploration stage, the helper simply has to attend and listen to the client—and stay out of the way—so that the client has the opportunity to keep talking. Matarazzo, Phillips, Wiens, and Saslow (1965) stressed that helpers should not interrupt and should delay talking for several seconds after the end of client statements. This pause (noninterruption) allows clients to continue thinking and talking without undue pressure from helpers. Matarazzo et al. found that inexperienced helpers interrupted far more often than did experienced helpers. Interruptions can, however, occasionally be helpful. For example, if the client is stuck, cannot think of what to say, or is rambling or talking nonstop but not exploring in much depth (e.g., telling stories in a bland tone), the helper may need to interrupt to help the client get back on track through the use of exploration skills (e.g., restatements or reflections of feelings, or open questions for thoughts or feelings). In such cases, the helper could perhaps raise a hand (as a stop sign), and say something like “Iʼm sorry to interrupt you, but I want to make sure I understand what youʼre saying,” “I want to make sure I answer your questions,” or “I want to make sure we process how youʼre feeling about the session.” Interrupting can be difficult to do without offending the client, particularly if the client is older, from a hierarchical culture, and used to not being interrupted. One experienced therapist who had difficulty interrupting watched the DVD of his session, stopped it at the point when interruption would have been helpful, and then role- played several ways of delivering an effective interruption until he felt comfortable that he could more spontaneously interrupt in the next session with the client. Silence A silence is a pause during which neither helper nor client is speaking. The silence can occur after a clientʼs statement, within a clientʼs statement, or after a simple acceptance of the helperʼs statement. For example, after the client says something like, “I just feel so confused and angry and donʼt know what to say,” the helper might pause to allow the client time to reflect on the feelings and see if the client has anything new to add. If the client pauses in the middle of saying something and is obviously still processing the feelings, the helper might be silent to let the client think without interruption. If the client responds minimally to something the helper said, the helper might be silent to see if the client can think of something more to say. It is important to note that saying nothing is not necessarily doing nothing. Helpers can be attentive and supportive, and they can listen without saying anything. In fact, sometimes the most useful thing a helper can do is to say nothing. Silence can be used to convey empathy, warmth, and respect and to give clients time and space to talk (Hill et al., 2018; Hill, Thompson, & Ladany, 2003; Ladany, Hill, Thompson, & OʼBrien, 2004). Silence can also allow clients time to reflect or think through what they want to say without interruption. Some clients pause for a long time because they process things slowly and thoroughly or because they are in the middle of thinking through something and need time to get in touch with their thoughts and feelings. At such times, silence is respectful because it provides space for clients to think without feeling pressured to say anything. Warm, empathic silences give clients time to express their feelings. By allowing clients the space, helpers can encourage clients to express feelings from which they might otherwise run away. Silence can indicate to clients that helpers are patient and unrushed and have plenty of time to listen to whatever comes out. During these empathic silences, helpers can sit attentively focused on being with the client while the client is deeply immersed in thoughts and feelings. Hence, I suggest that helpers avoid interruptions and give clients several seconds after speaking to see whether they have anything else to say. Likewise, some empirical evidence suggests that clients talk more when therapists delay speaking (Matarazzo et al., 1965). Silence also is often inadvertently used for negative or inappropriate reasons (Hill, Thompson, & Ladany, 2003; Ladany et al., 2004). Some helpers are silent because they are anxious, angry, bored, or distracted. Many beginning helpers are uncomfortable with silence. They do not know what to do and are often concerned about how clients might perceive them. To relax, helpers can breathe deeply, relax, and think about what might be going on inside the client. In other words, helpers should try to establish an empathic connection with clients during silence rather than focusing on themselves. If silences go on for a long time (i.e., more than 30 seconds) or if clients are obviously uncomfortable, the helper should consider breaking the silence and asking clients how they are feeling. As with other skills, the acceptability of silence varies by culture. D. W. Sue and Sue (1999) noted that in Japanese and Chinese cultures, silence can indicate a desire by the person to continue talking after making a point. In contrast, European Americans are less comfortable with silence and often rush to fill the space. I often recommend that beginning helpers try to use some brief silences because it gives them a chance to listen to clients without having to formulate an immediate response. Thus, when clients pause, the helper ponders how to reflect all that has been said while of course still attending to the client. Beginning helpers are often surprised to discover that clients keep talking, indicating that they just need permission to talk and have someone listen. Many beginning helpers, however, get anxious during silence because they are not used to being silent. Again, this skill often requires practice. Here is an example of how silence might be used therapeutically when the client is actively exploring and engaged in the process: CLIENT: My dog Sam just died. Iʼm really upset because Iʼve had that dog since I was very little. I grew up with the dog. HELPER: (Silence of about 10 seconds) How are you feeling right now? CLIENT: I was just thinking about when I got Sam. I had begged my parents to get me a dog. I said I would take care of it. Of course, I didnʼt much at first, but I did later. Sam was kind of like Red Rover in the comics—he waited for me at the  bus stop, and we had great adventures together. I could tell Sam everything. (Client seems absorbed in thought) HELPER: (Silence of 30 seconds) CLIENT: Sam helped me get through my parentsʼ divorce. I felt like I could rely on him then like no one else. Itʼs like losing my best friend—we went through so much stuff together. I felt so terrible when I left for college and couldnʼt take him with me. He looked so sad, and I didnʼt even say goodbye to him. EXAMPLES OF ATTENDING AND LISTENING It helps to have examples of how these attending and listening behaviors might look in a session with a beginning helper. The first example is of a really inappropriate use of these behaviors, whereas the second example is less egregious but still poor, and the final example is of an appropriate use (although remember that these will vary based on the client and helper). Example of Egregiously Inappropriate Attending and Listening In the following example, the beginning helper is distracted by other events and has a hard time paying attention to the client: HELPER: (leaning back, arms folded, and looking at the ceiling) So, how come you came today anyway? CLIENT: (very softly) Well, Iʼm not sure. I just havenʼt been feeling very good about myself lately. But I donʼt know if you can help me. HELPER: (shifts forward in seat and looks intently at client) Well, so what is happening? CLIENT: (long pause) I just donʼt know how to... HELPER: (interrupts impatiently) Just tell me what the problem is. CLIENT: (long pause) I guess I really donʼt have anything to say. Sorry I wasted your time. Example of Poor Attending and Listening In this example, the beginning helper intends to be empathic and compassionate but is not picking up on the verbal and nonverbal cues from the client: HELPER: (leaning back, arms folded) Hello. What would you like to talk about? CLIENT: (very softly) Iʼm not sure. I just havenʼt been feeling good about myself lately, but I donʼt know if you can help me. HELPER: Oh yeah, I understand. It was hard for me when I went to a helper for the first time. Youʼre probably anxious about talking to a man. CLIENT: (pause) Well, actually, no. Iʼm just not sure if I should come out or not... HELPER: (interrupts) Iʼm glad you did come in for a session. It takes time, but soon youʼll feel comfortable. CLIENT: Yeah, I guess. (silence) Example of Appropriate Attending and Listening In this example, the beginning helper is fully present with the client and able to attend and listen to the client, as well as observe what is going on with the client: HELPER: Hi. My name is Debbie. We have a few minutes to talk today. What would you like to talk about? CLIENT: (very softly) Well, Iʼm not sure. I just havenʼt been feeling very good lately about myself. But I donʼt know if you can help me. HELPER: (matches the clientʼs soft voice) Yeah, you sound kind of scared. Tell me a little bit more about wh