Therapeutic Communication

Developing Professional Skills

Herschel Knapp

• Publisher: SAGE Publications, Inc
• Year: 2014
• ISBN:
  9781483344607
• Edition: 2
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

The Second Edition of Herschel Knapp's Therapeutic Communication: Developing Professional Skills provides beginners and seasoned professionals with the skills to navigate the facts and feelings endemic to professional therapeutic communication. With a comprehensive perspective, Dr. Knapp clearly and effectively explains differences between casual and therapeutic relationships, focusing on key elements such as the therapeutic process, social and emotional factors, and professionalism. Organized into discrete sections to highlight individual skills, each chapter follows a unified format, encouraging readers to apply their knowledge frequently.

1 Defining the Therapeutic Relationship

This chapter contrasts the role of the casual helper—who informally provides help or guidance to friends and family—with the role of the professional helper.

Therapeutic Figures

Our conception of a proper therapeutic relationship may come from a variety of sources: We may have been involved in therapy as a client and seek to emulate various aspects of the therapist who we utilized. Readings of various therapeutic orientations can also influence our ideas about the kind of therapist we aspire to be. Undeniably, another influential source of our conception of therapy is the media. There is no shortage of fictional therapists and television/radio “shrinks” providing some sense of entertainment. In some cases, such intervention efforts may be facilitative; however, for the sake of theatrical performance or literary license, much of what is depicted as therapy in movies or other popular media cannot be thought of as appropriate models for more traditional therapeutic practice.

Each of us has, on occasion, provided guidance, advice, and help to family, friends, and acquaintances in an informal manner. Typically, good intentions, common sense, personal experience, and the wish to be helpful provide a good compass for these facilitative efforts. The purpose of this chapter is to delineate the therapeutic role by contrasting social relationships with the client-therapist relationship in four domains: (1) the therapeutic process, (2) social and emotional aspects, (3) professionalism, and (4) self-disclosure.

The Therapeutic Process

Ethics

Ethics fundamentally consist of a code of conduct that delineates right from wrong (Koocher & Keith-Spiegel, 2008). Personal ethics may be derived from one or several sources (e.g., values and practices inherited from one’s family, community norms, religious/spiritual beliefs, personal beliefs, etc.); each individual is free to assemble and lead their life based on the ethical principle(s) of his or her own choosing. In casual relations with loved ones, friends, and acquaintances, you are free to conduct yourself any way you see fit. In the professional realm, various professions have developed and published a professional code of ethics to provide fundamental practice guidelines designed to facilitate quality service and professional integrity/reputation. While there is considerable variability among professional domains (e.g., clergy, education, legal, medical, psychological, etc.), most codes of ethics concur regarding valuing honesty, client autonomy/self-determination, competence, respect for others (clients and colleagues), working within scope of practice, confidentiality, providing quality goods/services, managing conflicts of interest, and professional development. This text references a relatively representative professional code of ethics: The Ethical Standards for Human Service Professionals. Codes of ethics tend to be updated over time to reflect evolution of such things as standards of practice, technology, and societal values. It is recommended that you identify the online resources pertaining to your unique field of practice and keep apprised of the most recent code of ethics published for your profession.

Selection

Typically, we think of ourselves as free to select our friends at will based on personal preferences. A variety of things can attract us to an individual: similar interests, physicality (overall appearance, fashion, grooming, stature, etc.), talents, common backgrounds, ethnicity, attitudes, demeanor, and common friends. In a professional setting, there is usually no such privilege. Your role as a therapist involves the commitment to provide quality care to clients without bias with respect to age, ethnicity, culture, race, disability, gender, religion, sexual orientation, or socioeconomic status (Council for Standards, 1996, Statement 17).

It is common that managers will assign clients based on the expectation that you possess the skills necessary to competently provide services to the client. Skilled supervisors may choose to take into account such attributes as gender, age, ethnicity, specialized training, or expertise when considering making such assignments, such as by assigning an adolescent boy who is exhibiting conduct problems to a male therapist, whereas a female rape survivor would likely be paired with a female therapist. Generally, as a professional therapist, you do not get to select who your clients will be; in fact, it is likely that the individuals who present themselves as potential clients are not going to be the specific types of individuals that you would voluntarily select for friendship.

Unlike social relationships, the selection process involves some deliberate information exchanges: A potential client is usually required to schedule an appointment, complete forms, and be screened for eligibility for services and identification of the primary problems (Neukrug, 2002).

Additionally, an agency or organization may be set up to provide only a selected set of services to those who meet a particular set of needs criteria such as homeless, substance addicted, low income, young mothers, HIV positive, or over 65. Unlike in social settings, there may be any number of eligibility criteria that may contribute to client selection.

Initial Contact

Social relationships can begin in a variety of ways, such as introductions through friends; incidental conversations at parties, with coworkers, with fellow students; or Internet contact. Additionally, there are no fixed ground rules that need to be articulated or followed to start a friendship or relationship; social and personal norms guide this process. In the professional realm, clients may be self-referred or they may seek out a facility based on a referral from another such as a family member, significant other, friend, physician, or a member of the clergy. The initial contact may also include a professional disclosure statement detailing the therapist’s characteristics, which may contain information regarding qualifications, education, license status, treatment modalities, or specialties. The potential client is also given information regarding the agency’s policies involving such things as appointment cancellations, fee structure, and services provided and not provided. The client signs an appropriate “consent for treatment” form, which typically spells out the information and legal parameters regarding confidentiality (Corey, Corey, & Callanan, 2006).

Termination

Social relationships may end in a variety of ways for a variety of reasons, ranging from irreconcilable differences to geographical relocation. Such deliberate endings may be gradual or abrupt. Alternatively, people may drift apart or become more occupied with other people, projects, or interests. Unlike social relationships, which may last a lifetime, the professional therapeutic relationship is ultimately meant to be finite. The termination phase of the therapeutic process is handled in a purposive and deliberate manner; termination often involves a systematic review of the progress that the client has achieved in therapy and issues that will require continued work, along with strategies and resources for the client to continue this work after therapy ends. As the final session approaches, feelings regarding termination are discussed and processed by both the client and therapist. Occasionally, termination may happen abruptly. A client may quit therapy with little or no notice. Termination is discussed in more detail in “Overview of Appendixes A, B, and C.”

Time

When it comes to friends and family, we usually do not think about the duration of the relationship. Such relationships are typically considered as enduring over time. Although we may set a time to meet with such acquaintances, less often is there a predetermined end time. Spontaneous or unannounced visits may also be characteristic of our social contacts. In a therapeutic setting, time is considered to be a more crucial factor. Your professional contact with a client may be limited by a fixed number of sessions, or termination may be indicated on the accomplishment of the designated goal or goals. Unlike casual contacts, therapeutic appointments are scheduled with a specified beginning and ending time. Usually clients establish a standing weekly appointment, traditionally 50 minutes in duration and typically not extended with the exception of genuine crisis situations.

Despite wishes to methodically fit clients into consistent appointment time slots, it is important to be flexible when working with some Latino clients, who by tradition may place a higher priority on the task completion—such as tending to a friend—than adherence to a rigid appointment time (Martinez, 1986; Sue & Sue, 2003). Similarly, traditional American Indians may perceive time as a naturally occurring event, as opposed to a phenomenon that controls their lives (Barcus, 2003; Ho, 1992; Sue & Sue, 2003).

Goal

Social contacts need not be goal-directed. Sometimes, we just choose to visit and casually “shoot the breeze” with friends. It is socially appropriate and common to desire friendly companionship with or without a particular task or project in mind. Conversely, effective psychotherapy largely depends on the identification of specific goals and consistent efforts directed toward advancing the accomplishment of such goals (Council for Standards, 1996, Statement 1).

In social circumstances, there are no enforceable guidelines with respect to setting goals. Either individual may submit a goal. In professional settings, you will collaborate with the client to articulate appropriate goals that are acceptable to him or her (Council for Standards, 1996, Statement 1). In your role as the therapist, you may provide recommendations with respect to setting goals, but despite your good intentions, it is essential to resist the temptation to unilaterally set goals for the client. The client’s self-determination must remain at the forefront at each step of the therapeutic process (Council for Standards, 1996, Statement 8). Provisional goals can be established by engaging the client to thoughtfully discuss the problem. Consider asking the client what, if anything, he or she has tried in the past to address the problem, the outcome of these efforts, and what the client’s life might be like once the problem is reduced or resolved (Sperry, Carlson, & Kjos, 2003).

There are no practical limitations on setting socially defined goals. As such, one may encourage or coordinate with a friend to carry out a vengeful or illegal goal, such as formulating a retaliatory plan against a disliked person or organization, whereas in your professional role as a therapist, you are constrained by legal and ethical considerations and cannot suggest, condone, or facilitate the setting, planning, or execution of any such illegal, unethical, or (self-)destructive goals. In such cases, your familiarity with and commitment to the professional code of ethics pertaining to your particular field of practice should provide a useful framework for making responsible clinical judgments (Brammer, 1993). Case in point: Suppose a client presents that the ex-spouse persistently fails to provide child support as specified in their divorce agreement. In your role as a therapist, you are ethically and legally obliged to discourage illegal actions. As an alternative to participating in or encouraging any possibly illegal actions that the client may be considering or fantasizing about, you may provide an environment for venting and processing such feelings along with appropriate referrals for legal or arbitration services that could be used to address this problem within legal and ethical boundaries.

For some cultures and individuals, it is customary to engage in some initial “small talk” as a warm-up prior to embarking on clinically goal-related discussion; in the interest of facilitating rapport, you may find it useful to engage the client in such dialogue and then appropriately guide the discussion to address the therapeutic issues at hand. To enhance your effectiveness as an evolving therapist, it can be useful to orient yourself to the multicultural characteristics of your community and the social norms of such groups (Pendersen, Draguns, Lonner, & Trimble, 1996; Sue, 1992). Specifically, Latino clients may prefer to engage in some brief nontherapeutic chatting (la plática) as a customary warm-up prior to embarking on therapeutic issues (Martinez, 1986). Conversely, this practice would be inappropriate for Asian clients who, per cultural practice, may perceive such social conversation as an unnecessary delay to discussing tangible immediate goals (Root, Ho, & Sue, 1986; Sue & Sue, 2003).

Occasionally, the client may enter the session with a crisis issue that may be unique from the predominate goal for therapy. In such cases, a temporary departure from the primary goal may be appropriate in order to help the client manage such acute circumstances.

Goals must also be consistent with the client’s belief system. For example, suppose a client expresses that he or she has a problem with alcohol addiction and that it is mutually agreed that the client will attend AA meetings daily for the next 90 days; however, the client’s spiritual beliefs require ceremonial attendance at some point during that period, which interrupts the 90-day commitment. Although you are welcome to address concerns regarding the impact that this may have on the client’s sobriety, you are not in a position to insist on the client’s strict compliance with the 90-day plan. Again, the client is recognized as the chief decision maker in his or her life. One way to conceptualize your role might be to think of yourself as the client’s “mental health consultant.” In this case, you would work with the client to arrive at alternative ways of coping with the recovery issue. This might involve the client calling to check in with his or her sponsor on missed meeting days, thus respecting the client’s spiritual beliefs.

Topic of Conversation

Social conversations have no particular limitations regarding subject matter; participants may raise any topic at will. Within professional domains, the focus of conversation can vary depending on the setting and purpose for the conversation (e.g., job interview, customer satisfaction survey, focus group, etc.). In a therapeutic setting, topics of conversation are not necessarily limited, but they are typically more focused. Topics of conversation are guided in order to address those issues specifically related to the therapeutic goals. Unlike casual conversations, wherein the participants typically discuss things that they mutually want to discuss, therapeutic discussions may involve emotionally challenging issues the client may be hesitant to discuss but that are essential to addressing and resolving the problems at hand (Kadushin, 1990). Whereas casual conversations are free to drift seamlessly or abruptly from one topic to the next, therapy is typically more focused. When a client drifts off topic, part of your role is to recognize this departure and assess the value of such conversation. Valuable ancillary information may be revealed in the content of such discussion. Conversely, you may feel that it is beneficial to discuss the nature of this shift by asking the client some questions about it: Did the client feel anxious and feel the need to switch to a more comfortable line of discussion? Did some critical piece of information suddenly come to mind? As the therapist, it is your responsibility to keep the discussion on track. This may involve deliberately directing the discussion back to the (most) relevant therapeutic issues. Specific techniques for redirecting and refocusing are discussed further in Chapter 4.

Social conversations are usually balanced between the members regarding who the subject of the conversation will be. For instance, sometimes Jane will tell Mike about what is going on in her life, and sometimes Mike will tell Jane about his life issues. This reciprocity is not characteristic of the therapeutic process. The client consistently remains the focal point of the discussions; typically you would not indulge in confiding in the client. Exceptions to this rule may include profession-related inquiries, such as the client seeking information regarding the therapist’s education, qualifications, clinical experience, special training, or certifications. Guidelines for the use of therapeutic self-disclosure are discussed later in this chapter.

Advice

Social conversation is often laced with casual advice, suggestions, recommendations, and sometimes even firm demands. Such guidance can be based on anything including empirical research, personal opinions, anecdotes, impulsive ideas, or belief systems. Though well intended, there are no formal guidelines with respect to the quality or appropriateness of recommendations given in the role of the casual helper. As a therapist, advice giving is typically not the first order of business. Prior to submitting recommendations, you would typically take the time to assemble a comprehensive profile of the client to better ensure that the advice will be suitable to the unique attributes and circumstances of the client. Factors that should be taken into account include the client’s perception of the problem and internal factors, which might include the client’s personality, prior coping, motivation, belief systems, personal ethics, spiritual base, physical health, and external factors such as social system, family, friends, community resources, and culture. Advice that is given prematurely is less likely to fit within the boundaries of the client’s life. Haphazardly given advice is likely to be a mismatch to the client’s characteristics and is seldom followed. The better the fit, the better the likelihood that the clien...