Ivey, A.E., Ivey, M.B. & Zalaquett, C.P. (2014). Intentional Interviewing and Counselling (8th ed.) (Part I: pp. 212-215; Part II: 224-227; Part III: 317-319). Brooks/Cole.
Nelida Zamora, a former graduate student at the University of South Florida, has given us permission to use her name and her community genogram in this chapter. She has a real concern, that of being made uncomfortable in an introductory counseling class. This is not an unusual situation; many students who come from non-European backgrounds do not always believe that they “fit in.” Beyond that, as you know, many “majority” also may not feel totally welcomed.
Nelida: Here I am, a grad student in counseling. I did well in college in Miami, and thought it was no big deal because I was only four and a half hours away. But my first day of class I raised my hand, made a comment that very first class, and a classmate asked me if I was from America (nervous laugh) or a native (nervous laugh). Yeah, and I said well I’m…, I was just four and a half hours away, and he just found it very hard to believe. So, after that comment was made, it kind of made me a little more hesitant to participate in discussions. It made me more self-conscious. (Here we see that a single comment affects the amygdala and prefrontal cortex so that cognitive and emotional memories are stored immediately and permanently in the hippocampus.)
Allen: It made you self-conscious. Could we explore that a little bit more? Ah, first of all, in English, what were the feelings that went with that? (As you will see later in the example transcript, those feelings are soon explored in Spanish.)
Nelida: Well, I was surprised being from Miami a lot of my family members have recently come from Cuba, so there they look at me as the American girl and they make fun.
Allen: … and that embarrasses you.
Nelida: Exactly, so when I’m in Miami, my family and friends tease saying that I’m the American who can’t speak Spanish a hundred percent correctly ‘cause I’ve forgotten a lot of it because of the English. Then, now, I move here to Tampa, I’m the Cuban girl who can’t speak English, so it seems like I’m torn. You know, I don’t know where I belong sometimes.
What are the issues that Nelida faces? What internal and external factors affect how she thinks, feels, and acts (behaves)? List as many items as you can before moving on.
Introduction to Focusing
We should first note that Nelida faces the stress of not belonging and feeling different, plus being caught between the culture of Cuban Miami and a university in Tampa. These stressors affect her emotionally and send damaging cortisol to her brain, imprinting her long-term memory with a negative picture of herself. She is in a high state of incongruence. Focusing will help clearly identify the major areas of conflicts and discrepancy, and help determine which ones will be approached first. Listening and using supportive challenges will help her clarify her situation and move more readily to problem solution.
Over this and the next chapter on empathic confrontation we will present an example of how counseling changes memory. This first session introduces the community genogram, a systematic way to review old positive memories and help clients see themselves in social context. The community genogram provides a visual picture that helps us understand the client’s personal and cultural background.
A central current issue for Nelida is cultural oppression, which she has internalized; she has come to “blame” herself for being different. Rather than focusing just on Nelida, as an individual, if you help her see other perspectives, such as being able to name the oppression of the classroom, she is better prepared to reframe and change the negative memory. In addition, focusing on family and cultural background will facilitate her pride in her Cuban family and culture and provide positive assets, strengths, and resources to deal more effectively with the cutting comments she has experienced. If you use focusing skills as defined below, you can anticipate how clients may respond.
| Focusing | Anticipated Result |
|---|---|
| Use selective attention to focus the counseling session on the client, theme/concern issue, significant others (partner/spouse, family, friends), a mutual “we” focus, the counselor, or the cultural/environmental context. You may also focus on what is going on in the here and now of the session. | Clients tend to focus their conversation or story on the areas that the counselor responds to. As the counselor brings in new focuses, the story is elaborated from multiple perspectives. If you selectively attend only to the individual the broader dimensions of the social context are likely to be missed. |
Selective attention (Chapter 3) is basic to focusing but works in different ways. We all tend to focus on or listen to different topics. Clients tend to talk about that which you give your primary attention. Through your attending skills (visuals, vocal tone, verbal following, and body language), you indicate to your client that you are listening and what you are paying attention to. Be aware of both your conscious and unconscious patterns of selective attention; clients may follow your lead rather than talk about what they really want to say.
Counseling is, first and foremost, for the individual. When you focus on individual issues, clients will talk about themselves from their personal frame of reference. Thus, the first focus dimension is on the individual client before you. Using the client’s name and the word “you” helps personalize the counseling. While it is essential that you draw out the client’s story, don’t become so fascinated with the details of that story that you forget about the person talking to you. Some therapists have been known to become voyeurs, prying more deeply into personal affairs than necessary.
A second area of focusing is attending to the theme, or central topic(s), of the session. Drawing out strengths from the client’s memory through listening to and focusing on the theme, story, or concern is a valuable part of the process.
Here we draw out client stories, issues, or concerns, but also always search for client strengths and positive assets. Traditionally, this was termed drawing out the “problem.” We have noted that the word problem is itself a problem, tending to put the client in a one-down position. A wellness approach handles these issues quite differently. If a client has gone through a breakup of a significant relationship, has study difficulties, has cancer or another serious illness, we need to hear the details, and often we need to hear a lengthy story. Just telling the story is relieving. We feel better when someone seriously tries to listen and understand. Too many beginners and even professionals become transient voyeurs, so interested in the problematic story that they fail to focus on the unique client before them and their personal strengths to facilitate resolving issues.
Nelida lives in a broad context of multiple systems. The concept of self-in-relation may be helpful. The idea of person-in-community was developed from an Afrocentric frame by Ogbonnaya (1994), who pointed out that our family and community history and experience live within each of us. Since that time, the idea that we are persons-in-community has taken hold, and we often hear “It takes a village to raise a child.” The client brings to you many community voices that influence the client’s view of self and the world. The debriefing of Nelida’s community genogram in this chapter shows how this strategy is a useful way to understand your client’s history and a good place to identify strengths and resources.
Individual counseling usually focuses on issues of conflict, incongruity, and discrepancies between the individual and family and friends. But, in addition, many client problems are caused by and related to issues and events in the broader context (e.g., poor schools, floods, economic conditions), which can be missed if you focus only on the individual and the first stories that you hear. If you help clients see themselves and their issues as person-in-community, they can learn new ways of thinking about themselves and use existing support systems more effectively. The following list offers potential comments and questions that allow the counselor to focus the session in a specific area.
| Therapist's Focus | Examples |
|---|---|
| Significant others (partner, spouse, friends, family) |
|
| Mutual focus (“we” statements about client, therapist, or group) |
|
| Counselor focus (sharing one’s own experiences and reactions) |
|
| Cultural/environmental/contextual focus (including broader issues such as the impact of the economy) |
|
| Immediacy focus (talking about what is going on in that moment in the session) |
|
As a counselor, be aware of how you focus a counseling session and how you can broaden the session so that clients are aware of themselves more fully in relation to others and social systems: persons-in-relation, persons-in-community. In a sense, you are like an orchestra conductor, selecting which instruments (ideas) to focus on, enabling a better understanding of the whole. Some of us focus exclusively on the client and the issues that the client faces, neglecting to recognize the total context of client concerns.
Memories take in many things. If we just focus on one aspect, we miss the total picture. One route to ensure that the client and we have an understanding of the total picture is the community genogram.
Some school systems and agencies have written policies forbidding any discussion of abortion. Further, if you are working within certain agencies (e.g., a faith-based agency or a pro- or anti-abortion counseling clinic), the agency may have specific policies regarding counseling around abortion. Ethically, clients should be made aware of specific agency beliefs before counseling begins. Again, write your answers to the questions below, but there are no necessarily “right” answers to these difficult issues.
Imagine that a client comes to you who just terminated a pregnancy. How would you help this client, who clearly needs to tell her story? Below are several issues; we ask you to think through how you would respond using different focus dimensions.
Focus on the Individual and on Significant Others
Teresa: I just had an abortion and I feel pretty awful. The medical staff was great and the operation went smoothly. But Cordell won’t have anything to do with me, and I can’t talk with my parents.
What would you say to focus on Teresa as an individual?
What could you say to focus on Cordell, the significant other?
How might you focus on the attitudes and possible supports from her friends?
Choosing an appropriate focus can be most challenging. Too many beginners focus only on the problem. The prompt “Tell me more about the abortion” may result in drawing out details of the abortion but may reveal little about the client’s distinctive personal experience. “I’d like to hear your story” or “What do you want to tell me?” There are no final rules on where to focus, but generally, we want to hear the client’s unique experience. Focusing on the individual is usually where to start – note the emphasis on the words you and your.
Other key figures (Cordell, family, friends) are part of the larger picture. What are their stories? How do they relate to Teresa as a person-in-relation? You can more fully understand her situation when you draw out other stories and viewpoints. Keep all significant others in mind in the process of the problem examination and resolution. For a full understanding of the client’s experience, all pertinent relationships eventually need to be explored.
Focus on Family
Teresa: My family is quite religious and they have always talked strongly against abortion; it makes me feel all the more guilty. I could never tell them.
How might you focus on the family in response to her statement?
How would you search for others in the family who might be helpful or supportive?
The family is where personal values and ethics are first learned. How does Teresa define “family?” There are many styles of family beyond the nuclear. African American and Hispanic clients may think of the extended family; a lesbian may see her supportive family as the gay community. Issues of single parenthood and alternative family styles continue to make the picture of the family more complex. Developing a community or family genogram may help Teresa locate resources and models that might help her. If her parents are not emotionally available, perhaps an aunt or grandmother might help.
Mutuality Focus
Teresa: I feel everyone is just judging me. They all seem to be condemning me. I even feel a little frightened of you.
How would you appropriately focus on the relationship between yourself and the client?
What might you say to Teresa that focuses on here-and-now feelings?
A mutual immediate focus often emphasizes the we in here-and-now relationships. Working together in an egalitarian relationship can empower the client. Also, helping clients recognize the depth of their feelings in the here and now can be immensely valuable and powerful. “Right now at this moment, we have an issue.” “Can we work together to help you?” “What are some of your thoughts and feelings about how we are doing?” The emphasis is on the relationship between the counselor and client. Two people are working on an issue, and the counselor accepts partial ownership of the problem.
In feminist counseling, the “we” focus may be especially appropriate: “We are going to solve the problem.” The “we” focus provides a sharing of responsibility, which is often reassuring to the client regardless of his or her background. Many feminist counselors emphasize “we.” In some counseling theories and Western cultures, emphasizing the distinction between “you” (client focus) and “me” (counselor focus) is more common and “we” would be considered inappropriate.
The mutual focus often includes a here-and-now dimension and brings immediacy to the session. To focus on the here and now, you can choose several different types of response. “Teresa, right now you are really hurting and sad about the abortion.” “I sense a lot of unsaid anger right now.” There is also the classic “What are you feeling right now, at this moment?”
Counselor Focus
Teresa: What do you think about what I did? What should I do?
What would you say? A counselor focus could involve self-disclosure of feelings and thoughts or personal advice about the client or situation: “I feel concerned and sad over what happened”; “Right now, I really hurt for you, but I know that you have what it takes to get through this”; “I want to help”; or “I, too, had an abortion…my experience was…” Opinions vary on the appropriateness of counselor or psychotherapist involvement, but the value and power of such statements are increasingly being recognized. They must not be overused; keep self-disclosure brief.
How might you share your own thoughts and feelings appropriately?
Would you give advice from your frame of reference? What would it be?
Cultural/Environmental/Contextual Focus
Given Teresa’s discussion so far, what would you say to bring in broader cultural/ environmental/contextual issues?
Perhaps the most complex focus dimension is the cultural/environmental context. Some topics within these broad areas are listed here, along with possible response to the client. A key cultural/contextual issue in discussing abortion will often be religion and spiritual orientation. Whether the client is a conservative or liberal Christian, a Jew, Hindu, Muslim, or nonbeliever, discussing the values issue from a spiritual perspective may be central to her thinking and being.
- Moral/religious issues: “What can you draw from your spiritual background to help you?”
- Legal issues: “The topic of abortion brings up some legal issues in this state. How have you dealt with them?”
- Women’s issues: “A support group for women is just starting. Would you like to attend?”
- Economic issues: “You were saying that you didn’t know how to pay for the operation.”
- Health issues: “How have you been eating and sleeping lately? Do you feel after-effects?”
- Educational/career issues: “How long were you out of school/work?”
- Ethnic/cultural issues: “What is the meaning of abortion among people in your family/church/neighborhood?”
Any one of these issues, as well as many others, could be important to a client. With some clients, all of these areas might need to be explored for satisfactory problem resolution. The counselor or psychotherapist who is able to conceptualize client issues broadly can introduce many valuable aspects of the problem or situation. Note that much of cultural/environmental/contextual focusing requires sensitive leading and influencing from the counselor.
Consider every action in terms of its consequences for seven generations to come.Yakima nation proverb
Decisions and actions have logical consequences that reverberate throughout a client’s here-and-now life. In addition, critical decisions change one’s future life. If important decisions are made poorly, with little attention to the logical consequences of the decisions, lifetime difficulties can result for both clients and those around them. Logical consequences is a strategy appropriate for most theories of counseling and psychotherapy, particularly decisional counseling, cognitive behavioral therapy, motivational interviewing and brief counselling. Generating clear, logical decisions is critical in crisis counseling.
The strategy of logical consequences is typically a gentle strategy with the goal of clarifying what happens when behaviors don’t change, decisions are made without adequate thought, or the client is unaware of dangers that lie ahead. On the other hand, some clients will welcome and respond to a more dynamic and active approach. There are also positive consequences that can result from counseling that increases thoughtful, emotionally aware decisions and behaviors.
The task is to help clients foresee the results and consequences of each possibility for action: “If you do _____, then _____ will/may result.” When you use this strategy, you can anticipate how clients are likely to respond and how they can anticipate the potential consequences of alternative decisions.
As an example of how the strategy of logical consequences relates to decision counseling, suppose that a client comes to the session excited about a new job opportunity that offers advancement and higher pay, but fearful of the effects of moving the family to a new city. Through further questioning and discussion, the counselor can help the client clarify the factors and the consequences of the decision.
For many decisions, the various alternatives are apt to have both negative and positive consequences. Potential negative consequences of changing jobs could include leaving a smoothly functioning and friendly work-group, disrupting long-term friendships, and moving teenage children to a new school. Positive consequences might be the pay raise, a better school system, and money for a new home, plus the opportunity for further advancement.
The counselor can help clients become aware of the potential negative consequences of actions, including negative results and even punishment. Consideration of possible negative consequences is necessary for a client who is thinking of dropping out of school, a pregnant client who continues smoking, or a client who wants to “tell off” a boss, co-worker, or friend.
We also need to enable clients to anticipate the positive consequences, results, and rewards of decisions and behaviors. Finishing school will lead to a better job, the non-smoking pregnant woman’s baby is likely to be healthier, and a better alternative for handling difficult people may be simply to keep one’s mouth shut for the moment. It is best when your clients can generate the likely consequences of any given action through your listening skills, questioning, and confrontation.
Choices and decisions have a central emotional and feeling component. The decision may be rational and seemingly correct, but the client needs to feel satisfaction or a sense of peace before moving forward. There are many examples of tough but wise choices, such as accepting a new job in a new city that is a good move professionally but means leaving behind friends and family. Clients need to balance the advantages and disadvantages. Other difficult decisions center around leaving an abusive partner and facing financial hardship, or saying no to drugs or to cheating at school and then being teased by friends who do. Many ultimately wise and positive choices have some short-term emotional consequences, and we need to prepare our clients to face those issues as well.
How do strategies relate to skills? A skill is something that you can do, and typically a skill can be identified through counselor verbal and nonverbal behavior (e.g., attending behavior, paraphrasing, feedback). A strategy is a plan for action that may involve the use of several microskills, but may also require unobservable cognitive thought. Many influencing strategies require a combination of skills. For example, logical consequences and providing instruction or psychoeducation typically require us first to listen with empathic understanding, then to make sure that the client is interested and involved in what we are sharing via strategy, and only then should we move to more direct action. Skills are implemented in counseling via thought, which is then turned into action for the client’s benefit.
| Logical Consequences | Anticipated Result |
|---|---|
| Explore specific alternatives with the client and the concrete positive and negative consequences that would logically follow from each one. “If you do _____, then _____ may result.” | Clients will change thoughts, feelings, and behaviors through better anticipation of the consequences of their actions. When you explore the positives and negatives of each possibility, clients will be more involved in the process of decision making. |
The following brief vignette illustrates the logical consequences strategy in action. Note that the counselor (who has previously listened to the story) uses a combination of questioning and paraphrasing so that the client brings out the answer rather than being told what to do by the counselor.
Counselor: What is likely to happen if you continue smoking while pregnant?
Brightstar: I know that it isn’t good, but I can’t stop and I really don’t want to. Smoking relaxes me and I’ve done it for years with no harm. (The client partially answers the question and avoids the consequences for the child.)
Counselor: You really feel more relaxed when you smoke. I wonder what you think are the possible negative consequences of continuing to smoke? (Reflection of feeling, followed by a somewhat confrontive open question.)
Brightstar: (pause) I’ve been told that the baby could be harmed.
Counselor: Right, is that something you want? What is the benefit of stopping smoking for the baby? (The use of logical consequences can involve too much leading. Be careful or you will soon lose the client.)
Brightstar: No, I don’t want to do harm. I’d be so guilty. But how can I stop smoking?
Counselor: You would really miss smoking, but you feel a bit guilty about the possible harm. Let’s explore those feelings a bit more. Tell me more about what you are thinking… (Here the discussion becomes open to a more mutual exploration, short- and long-term consequences.)
For disciplinary issues or when the client has been required to come to the session, remember that considerable power rests with the counselor, often resulting in a lack of trust. Trust issues and limits of confidentiality need to be explored thoroughly. The school, agency, or court may ask the counselor for recommendations that they may follow. Warnings are a form of logical consequences that may center on anticipation of punishment. If used effectively and coupled with clients’ rapport and listening, warnings may reduce dangerous risk taking and produce desired behavior. But warnings are only truly effective if the client is motivated to change and willing to listen.
In disciplinary situations, clients need to think about the fact that they will have happier lives in the long run if they select more positive alternatives for their lives. A school disciplinary official, an attorney, or a correctional officer often needs to help the client see clearly what might be ahead. But people who hold power over others need to follow through with the consequences they warned about earlier, or their power to influence will be lost. The “if, then” language pattern is especially useful to summarize the situation: “If we don’t make the counseling sessions work, then you know what the judge will do.”
Finally, when counseling a child diagnosed with conduct disorder or a teen or adult termed antisocial, your first consideration is safety and preventing harm to self or others. While gentleness remains the basic style, authentic and real firmness and strength are often needed. Counselors and therapists are often seen as easy “cons” by these clients.
Here are some specifics for using the logical consequences skill. Note that you will be using listening skills as part of the process.
- Draw out story and strength. Through listening skills, make sure you have drawn out the client’s strengths and resources that may be useful in resolving issues.
- Generate alternatives. Use questions and brainstorming to help the client generate alternative possibilities for restorying and resolving issues. Where necessary, carefully provide your own additional ideas.
- Identify positive and negative consequences. Work with the client to outline both the positive and negative consequences of any potential decision or action. Ask the client to generate a possible future story of what might happen if a particular choice is made. For example, “Imagine yourself two years from now. What will your life be like if you choose the alternative we just discussed?” In anticipating the future, special attention needs to be paid to likely emotional results of decisions and continued or changed behavior. Emotions are often the ultimate “decider.”
- Provide a summary. As appropriate to the situation, provide clients with a summary of positive and negative consequences in a nonjudgmental manner, or ask them to make the summary. Pay special attention to emotional issues. With many people this step is not needed; they will already have made their own judgments and decisions.
- Encourage client decision and action.
