Thumbnails Document Outline

CHAPTER

Theories of Counseling:

Application to Speech-Language

Pathology and Audiology

CHAPTER OUTLINE

Introduction

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Humanistic Approaches to Counseling

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Interpersonal Approaches to Counseling

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Behavioral Approaches to Counseling

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Cognitive Approaches to Counseling

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Family Systems Approaches to Counseling

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Existential Approaches to Counseling

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Multicultural Approaches to Counseling

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Theoretical Integration

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Concluding Comments

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Discussion Questions

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Role Plays

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INTRODUCTION

Many exceptional practitioners have learned to integrate a number of theories of psy-

chotherapy with their personal therapy experiences and over time have developed an in-

dividual style of therapy (Corsini & Wedding, 2008; Gladding, 2009; Truscott, 2010).

Meanwhile, most beginning therapists are working to master a particular theory and its

applications. However, no one theory or therapy approach fits all situations, and a clini-

cian may actually apply multiple therapy approaches with any one client, patient, or fam-

ily. The theoretical and therapy approaches that an individual clinician selects and uses

often depends on the clinician’s personal orientation (e.g., humanistic, behavioral, or mul-

ticultural), what the clinician has learned in her training, and what has worked for the cli-

nician in the past. There is no one “right” theoretical or therapeutic framework, although

empirical research during the last couple of decades has provided more validation for some

therapeutic approaches than for others (e.g., American Psychological Association, 2005;

Hibbs & Jensen, 2005; Messer, 2004). As it is impossible to learn and use the over 400

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counseling and psychotherapy approaches that are currently in the literature (Prochaska &

Norcross, 2009), speech-language pathologists and audiologists can be most effective by

learning about a few of the major theories that offer relevant concepts that can be applied

to our professions. The theories presented in this chapter are among those that are consid-

ered to form the conceptual and clinical bedrock of the fields of clinical psychology and

counseling (Corsini & Wedding, 2008; Wachtel & Messer, 1997).

There is much value in a clinician having multiple theoretical and therapeutic frame-

works from which to draw. If a clinician only has one or two to select from, she is limited

in ability to understand and help clients, patients, and families. (“If a person only has a

hammer, then everything looks like a nail.”) Theoretical purity (i.e., following a singular

approach) is seldom helpful with the vast variety of people and problems we work with.

Lazarus and Beutler (1993) found that 60 to 70 percent of professional counselors identify

themselves as

eclectic

in the use of theory and techniques. However, beyond a piecemeal

eclectic approach we can use an

integrative

approach in which we tie together concepts and

approaches that have commonalties or are complementary to each other. For further read-

ing in the area of psychotherapy and counseling theories, the student or clinician may wish

to refer to one of many excellent textbooks in the area, for example, Capuzzi and Gross

(2003); Corey (2008); Corsini and Wedding (2008); George and Cristiani (1995); Gurman

and Messer (2003); Prochaska and Norcross (2009). A personal favorite of the author (L.V.

F.) is the Prochaska and Norcross text, which inspired the format for this chapter and the

presentation of a case example seen through the lenses of various theoretical perspectives.

This chapter begins with two therapy approaches that emphasize the clinician–client

relationship: understanding how to use the relationship to promote therapeutic change. It

then moves into therapies that emphasize helping people change their ways of thinking

about particular issues and their problematic behaviors as they relate to our professions.

Additional therapy approaches are discussed that help expand our way of seeing the client

or patient’s world as well as our own.

HUMANISTIC APPROACHES TO COUNSELING

Carl Rogers (1951, 1957, 1961, 1980) developed in the 1940s and 1950s what is known

today as humanistic therapy and client-centered (person-centered) therapy. Rogers empha-

sizes that people are rational and inclined toward positive growth or

self-actualization

(re-

izing one’s potential). This viewpoint is considered the central assumption of humanistic

therapy. Healthy personality development occurs if the person receives sufficient

uncondi-

nal positive regard

, that is, love and acceptance from parents or significant others for

r unique, individual self. Often times the best example of unconditional positive regard

is the love and acceptance a parent has for her child. For example, the parents of a child

with hearing impairments who show consistent love and acceptance help the child to grow

and develop feelings of self-worth. The child learns

congruence

, that is, to be in touch

th her own thoughts and feelings, and to communicate with facial expressions and body

language that mirrors (i.e., is consistent with) verbal or sign language.

Unhealthy personality development occurs when an individual experiences conditions

of worth, repeatedly receiving messages from parents that she will be loved and accepted

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only if certain conditions are met; for example, the child must never cry or show anger

and, instead, must be compliant, studious, and easy to get along with. As a result of these

experiences, the child learns to conceal her real self and present a façade that is incongru-

ent (discrepant with what the child thinks, feels, and expresses verbally or nonverbally)

with her genuine feelings. In presenting a façade, the child sacrifices natural tendencies

toward positive growth in order to receive conditional love and approval. For example, a

child with a hearing loss may not feel accepted by parents when she observes that they give

more attention and love (“regard”) to siblings. The child with a hearing impairment may

try to conceal from parents that she could not hear or understand them in order to appear

more like her siblings.

SLPs or Auds using humanistic or person-centered techniques attempt to promote the

client’s natural positive striving and growth. The clinician’s role is

nondirective

(not try-

g to influence; being primarily reflective) and supportive. The clinician avoids engaging

in confrontation or direct attempts to change the person’s behavior.

Conditions Necessary and Sufficient for Therapeutic Change

Rogers (1957) discussed therapeutic conditions that he regards as necessary and suf-

ficient for therapeutic change, which are outlined in the following sections.

GENUINENESS

The genuine clinician presents herself in an open manner and is not showing a façade.

e clinician behaves in a way that is congruent (consistent and genuine) with her real

feelings. For example, if a client comments to the clinician, “You look tired today,” the

clinician may say, “Yes, you’re right, I am a little tired today.” In this response, the clinician

validates the client’s (correct) perceptions.

Presenting a congruent response is challenging when how we feel toward a client is not

congruent with how we think we

should

feel toward the client. For example, we may feel

irritated with a client who has not followed through with exercises or comes late to ses-

sions. Yet we are striving to respond respectfully and therapeutically. If we are not careful,

what the client may experience is a mixed message based upon our real feelings “leaking

out.” Our behavior may be polite on the surface but contain undertones of anger or resent-

ment. Another example of incongruence may occur when the clinician is not aware of how

angry or annoyed he actually is with the client.

In either case above, the clinician focuses on presenting a positive and warm response

to the client. However, the client may perceive both levels of the clinician’s response: the

polite surface behaviors and the angry, irritated undertones. The incongruence between

the two levels of communication will likely cause discomfort in the client, and the client

may respond negatively. The clinician, unaware of the client’s perceptions, may view the

client as uncooperative, unappreciative, or difficult. In order to work with this challenging

situation, the clinician first needs to become aware of any tendency toward an incongruent

response, and work through the negative feelings toward the client rather than just trying

to conceal them. The clinician also may choose to express feelings to the client in a non-

threatening manner using “I-messages” (e.g., “When you do . . . , I feel . . .” ) As we have

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seen in the above example, trying to conceal negative feelings often does not work and can

impair the clinician’s working relationship with a client.

Working through negative feelings towards a client involves trying to better under-

stand the client’s viewpoint (empathy). The clinician may want to ask herself some ques-

tions, such as, “What stops the client from coming on time?” or “What is the client afraid

of?” Usually if the clinician can better understand the client’s fears, behaviors, and life

circumstances, she will feel more empathic and less annoyed with the client. The point is

that the clinician needs to reflect on her own behavior toward the client and not simply

blame the client. By taking these steps the clinician will be better able to develop or return

to a stance of unconditional positive regard toward the client. It is important to note that

Rogers’ (1957) concept of clinicians’ genuineness has sometimes been misunderstood as a

license for clinicians to talk about themselves or engage in excessive self-disclosure. This

was not Rogers’ intention; he was primarily concerned with the idea that clinicians should

not feign interest or caring, as this façade is likely to be detected by clients and damage the

therapeutic relationship.

EMPATHY

athy

involves “being with” the person and his experiences on a moment-to-

ment basis. It involves a personal encounter, not simply an objective appraisal of the

person’s problems. In order for the clinician to experience and show empathy, she must

understand not only the communication disorder (e.g., stuttering), but how the commu-

nication disorder is affecting the person’s self-image and life. Although we can never truly

feel what the client is experiencing, we can try to get a sense of what the person must cope

with almost every time he tries to talk.

In striving to be empathic, clinicians should take care not to go overboard. Sometimes

excessive efforts to appear friendly, caring, and empathic, especially in the early stages of

the working relationship, can appear phony and disingenuous to the client. This is a dif-

ferent kind of incongruence than discussed above. In this case the clinician is trying to

appear warmer and more empathic than she is truly feeling. The clinician may have good

intentions, for instance, to help the client feel understood and valued, but a saccharine

(i.e., too sweet and overly caring) presentation may be viewed negatively by clients.

UNCONDITIO

NAL POSITIVE R

EGAR

When SLPs and Auds communicate genuine respect and caring in a consistent manner

clients they are demonstrating unconditional positive regard. This allows clients to ex-

perience a nonjudgmental environment in therapy, which may encourage them to be more

honest with the clinician, such as when they cannot (or will not) perform therapy tasks

with maximum involvement or effort.

In humanistic therapy there is an emphasis on providing a positive relationship rather

than on therapeutic techniques. As the person expresses himself, however, the clinician

is alert for statements pertaining to the self (for example, “I haven’t felt like doing my

exercises lately” or “I don’t understand how these exercises will help”). The clinician also

attends to the person’s nonverbal communications that are incongruent with verbal com-

munications (e.g., smiling while discussing a negative feeling or personal loss).

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In order to help both the client and clinician understand the client’s feelings, the clini-

cian may provide reflections that paraphrase the statements or, when needed, point out

discrepancies in the communications (these skills, rooted in Rogers’ theory, are expanded

in Chapter 4). To provide a simple reflection the clinician should let the person know she

has been heard and that the clinician is interested in hearing more. The clinician’s reflec-

tions should, however, not simply mimic or parrot the client’s last words. For example, a

patient may mention symptoms that suggest penetration of food or liquid into the larynx

(e.g., episodes of coughing or choking), and then deny that they are a problem. The clini-

cian may reflect on both of these statements and then ask about the person’s feelings. The

patient may be feeling embarrassment or have fear around meal times. For example, the

clinician might say, “You say you are doing some coughing and choking while eating, but

that it’s not really a problem for you. Are you sometimes a little embarrassed about cough-

ing and choking, or are you a little afraid that you won’t be able to continue eating regular

food?” While it is important not to force a particular interpretation on a client or to as-

sume what he is feeling, the clinician can ask questions such as these which express empa-

thy for the client’s probable experiences. Providing an environment where all of the client’s

feelings and experiences are respected and validated is central to humanistic therapy and

can maximize disclosure in therapy sessions.

COUNSELING SKILLS IN ACTION

Reflecting Empathy to a Child Who Stutters

A 13-year-old boy was brought to therapy by his parents because of the child’s stutter-

ing problem.

Clinician: “Tell me what it’s like to talk in different situations.”

Child: “I don’t talk much at school. It makes me nervous.”

Clinician: “You don’t talk much because it makes you nervous.”

Child: “Yeah, and I get

really

nervous about speaking out in front of the class.”

Clinician: “Speaking out in front of the class. Is that one of the hardest things for

you to do?”

Child: “Uh huh, especially if the teacher wants me to read from the science book.”