The Secrets of Exceptional Counselors

Jeffrey A. Kottler

• Publisher: American Counseling Association
• Year: 2017
• ISBN:
  9781119457374
• Edition: 1
• Topic: Education
• Subtopic: Professional Development

Every profession has trade secrets that are passed on from one generation to the next and counseling is no exception. These cherished lessons based on wide-ranging experiences and passion for the craft are shared by masters with students and colleagues and include fresh ideas, noteworthy interventions, and even little tricks learned over time that increase both professional effectiveness and personal satisfaction.

These unique practices are captured in this entertaining book that collects the wisdom of some of the most accomplished practitioners in the field, those who have been most influential in developing theoretical approaches, clinical innovations, and standards of practice. These master clinicians disclose ingenious methods and practical tips to better serve clients. Discussing techniques that have been mostly kept private until now, they talk about their creative breakthroughs, spiritual transcendences, monumental successes, and their own developmental adjustments over time. They also reveal some of their most unusual cases, disappointing failures, and disturbing deceptions, and share stories about the clients who have changed them.

New practitioners and veterans alike will find innovative ways to remain fresh and engaged with clients. Because of its focus on practical knowledge and useful strategies, this book can be used as a supplemental text in a variety of introductory and advanced courses, or as an inspirational guide for experienced counselors.

*Requests for digital versions from ACA can be found on www.wiley.com

*To request print copies, please visit the ACA website https://imis.counseling.org/store/

*Reproduction requests for material from books published by ACA should be directed to [email protected]

Chapter 1
A Tough Lesson that Forever Changed the Way I Work

I was waiting anxiously in my office, listening for the sound of the door opening in the waiting room to signal the arrival of my new client. I had just launched my private practice a few months earlier, and I was struggling to meet even basic expenses. It was a misguided and naïve belief that I could just hang out my shingle, so to speak, and expect that people would come flocking to my door or that referral sources would deliver as promised. In fact, I had a grand total of four clients in my caseload. Oh yeah, plus this new referral, which would boost my practice by 20%!

I briefly mentioned this story in a previous book with Rick Balkin about the importance of relationships in counseling, but it bears describing in further depth to emphasize one of the secrets of exceptional counselors: their ability to connect immediately with a new client during an initial consultation. After all, the overriding goal of any initial interview is not just to collect information, as well as to form a diagnosis and treatment plan, but rather to get the client to return for a second appointment! If we can't secure that commitment, nothing else really matters, no matter how comprehensive the data we collected.

I had scheduled my precious few clients throughout the week, which means that I would go into the office to fool around, make calls, try to pretend like I had a full-time job, and then wait for my single appointment. This was a Friday, the one day of the week that I had promised never to book, but it was the only time my new client said was convenient. I was so desperate for business that I decided not to negotiate.

I arrived at my office a few hours earlier than the single scheduled appointment, supposedly to do paperwork but really just to create the illusion I had something to do. I would stare out the window across the street at a retail strip of establishments selling obscure products. One in particular that caught my eye was a place called Flute World. I wondered how one could possibly earn a living selling a single kind of musical instrument, especially one that wasn't exactly very popular. With time to spare, I actually decided to walk across the street and check the place out, then impulsively bought a flute to play with as a means of occupying myself during frequent idle times waiting for the world to discover me.

Once I assembled the instrument, with no real clue how to produce actual music, I realized that it might be a good idea to schedule some lessons, perhaps even begin after my new client left this afternoon. After all, I had little else to do. I actually started calculating in my head how much flute instruction I might be able to afford after I collected my fee.

“Self-discipline and prudence!” I reminded myself. After all, I had expenses to cover and a family to support.

I reviewed my notes regarding the person who would soon be arriving. She had been referred by her physician, whose office was in the building. I could feel my excitement building: If things worked out well and I did a good job, maybe the good doctor would send a stream of future patients and I'd be well on my way. But for now, all I knew was that she was presenting symptoms of extreme anxiety and there didn't appear to be any organic cause. “Let me know what you think,” the internist instructed me. “I'm just at a loss other than to up her prescription of Xanax.”

Already I had reviewed my books and resources about all the nuances, symptoms, causes, and precipitating factors associated with anxiety. Next I had consulted the Physicians' Desk Reference to study the dosages, side effects, and contraindications related to her medication. In other words, I had invested a tremendous amount of time and energy into preparing myself to function at my absolute best.

I put the flute away. Then I sat at my desk, drumming my fingers, willing time to speed up. If the clock sometimes seems to move glacially slow when you are sitting in a session that seems to be going nowhere, it is positively maddening when you are waiting for a new client. I always feel nervous in such circumstances, wondering whether I will know what to do or even whether I've lost my healing magic. During those first few minutes after meeting a new client I often feel a surge of panic once the person begins to speak. I usually feel lost and confused, stumbling around trying to get a handle on what might be going on and what I should do about it. I am often filled with doubts regarding whether I even have anything meaningful to offer. I start to question the legitimacy of what I'm doing: Is it really enough just to talk about problems? Will these sessions actually put in a dent in the chronic suffering that has so far been impervious to any other action or intervention?

I studied for the sixth or seventh time the brief notes that I had scribbled down after my initial phone call with the expected client: Unmarried. Early 30s. Possible anxiety disorder. Doctor says she's skittish and uncommunicative. But troubled. Prescribed Xanax. Wants Friday appointment. UGH!

As often as I read those words, they didn't really tell me much. I was eager to collect a lot more information about the case, as much to address my own uncertainties as to get to know her. I had developed some intake forms (actually I borrowed and adapted them from an agency where I had been working previously) that followed standard protocol, asking questions about presenting symptoms, prior family and medical history, lifestyle activities, current functioning, as well as provided informed consent documents. This is standard operating procedure and the way I had been trained and supervised in order to assist in differential diagnosis and treatment planning. After all, every doctor's office and mental health facility asks patients to fill out forms once they check in for an initial appointment.

I was quite curious how my new client would fill in the blanks, so I carefully attached the forms to a clipboard, stuck a pen underneath the metal clip, and began to rock back and forth in my chair, continuing to stare at the clock. Precisely 6 minutes before the appointed time I heard the door to the waiting room open and close. Actually I felt the door slam shut with a finality that seemed to shake the walls, which reminded me to get the damn thing adjusted. There were just so many little details to take care of in starting a practice from scratch that I'd never considered before. As a salaried employee of public institutions thus far in my life, I'd never needed to actually depend on outside income in order to earn a living. I was clearly way over my head.

I wondered whether I should wait until the exact time of our scheduled session or whether it would seem like I was too anxious if I greeted her earlier. Should I give her the forms now, a few minutes ahead of time, so we could start the session on time? Or maybe the time she spent filling out the forms counted on the clock? I found this all so confusing.

I decided it was better to greet her right away even if it seemed like I was overanxious. After all, she was anxious too, wasn't she? That's what her doctor had told me and why she was actually consulting me in the first place. And it felt like there was so much at stake for me. I was desperate to increase my caseload. I was beginning to wonder whether this was ever going to pan out.

I opened the door to the waiting room to find a woman who looked older than her chronological age, to use the parlance of the intake and mental status review that I was soon to begin. She looked up at me for a moment but then quickly looked away. Skittish indeed, I thought.

“Hi. I'm Dr. Kottler,” I said in my most soothing, reassuring voice. “I'll be with you in a few minutes, but before then could you please fill out these forms?” I hesitated for a moment because she still wasn't making much eye contact. “It will only take a few minutes and then we'll get started.” Another reassuring smile.

I retreated back to my office to pretend that I had something else to do besides wait for her to complete the questionnaires. I wished I could play with the new flute to occupy myself but figured that the whispery, discordant sounds I could produce thus far might sound pretty strange coming through the door. During my compulsive preparations, I'd practiced filling out the forms myself just to estimate how long it would take to complete them. Under 10 minutes was my best guess. So I waited. And waited. Then I felt a slight shudder in the walls, as if a door had been carefully opened and closed. Or maybe it was just a premonition.

But I had this terrifying thought: What if she just left? What if she walked out once I left her alone?

I tiptoed up to the door to the waiting room, slowly and carefully prying it open for a peek outside, and found to my horror that my new client—my brand new referral—had fled! The clipboard and forms were sitting on her vacant chair. For some reason, all I could think of was that the pen was missing: She took my pen! But then I noticed that it had simply fallen underneath her chair. I felt this hysterical giggle building up in my throat as I thought to myself, Well, thank goodness I still have my pen!

I lifted up the clipboard and saw scrolled in big, heavy, bold letters across the first page of the intake forms a handwritten note: “SORRY, BUT I CAN't GO THROUGH WITH THIS.”

I could feel my chest constrict. For a moment, I wondered whether I was going to be the one with a panic attack. I wanted to just sit down on the floor and cry. I had been counting so much on this client being the turning point, the one that signaled that things were finally looking up. Instead, I just lost one fifth of my caseload. I felt so discouraged that I wanted to give up. How would I pay my bills? How would I support my family? How would I ever get this practice on a solid footing?

I decided, in that moment, leaning against one of those flimsy walls for support, that I would never, ever lose a client again by failing to first engage that person in a relationship before collecting the information that I thought was usually collected. I decided that I didn't really need—or even want—to know anything about the case or the client's background until I first got to spend time with that person and form my own impressions. I didn't want to read background information, or even know what others thought, until such time that we had established some kind of alliance, some basis for trust. In retrospect, it seems ridiculous to me that we would ask clients to supply all of this incredibly personal information about themselves before they really knew who we were and that we were actually worthy of these very private data. As I reviewed my forms I realized that I was asking perfect strangers to confess their medical history, family history, medications and illicit drugs they were consuming, sleep and eating habits, sexual preferences, legal problems, previous suicidal ideation or suicide attempts, and on and on—just the kinds of things that almost anyone would be reluctant to disclose to a stranger, even a health professional. I know this flies in the face of standard practice in any medical or mental health facility, in which patients are routinely required to supply all kinds of personal details before they are allowed to meet with a health care professional. But just because this was the most convenient and efficient system didn't mean that it was really in the client's best interests or even advantageous for a future helping relationship.

Secrets and Best Practices During First Contact

There are all kinds of research, in so many different contexts, on the critical importance of the first few seconds of a first impression during an initial meeting. Whether formed by the firmness of a handshake, a quick assessment of appearance, or unconscious readings of microexpressions, such first readings become indelible. Although most of the time counselors feel absolutely overwhelmed and flooded to gather as much information as possible, what is often lost in this process is attention to the most important secret of all, which is to solidify an alliance that makes everything else that follows possible.

We have our own agenda and lists. Identify the chief complaint (not to mention the dozen other related or corollary concerns and issues). Collect a personal history, including physical, emotional, cognitive, and interpersonal functioning. Review functioning in a variety of domains, including work, school, and leisure pursuits. Explore lifestyle choices and behavior. Check out family dynamics. Conduct a mental status exam. Determine any dependency on substances or alcohol. Assess for suicide risk. Check out favored coping strategies. Identify signature strengths and resources. Find out what's been working already and what has consistently failed. Explore existing support systems—or the lack thereof. Plan a treatment strategy. Take voluminous notes so you can actually recall these important details. Oh yeah, and also complete all these tasks in a single session.

I actually used to have a cheat sheet hidden on my lap so I could remember the 20 tasks that my supervisor required me to complete during any first session. I was required to begin by checking out the client's expectations for the sessions so I could then correct unrealistic goals. The list continued all the way through to the last item, for which I was required to negotiate a homework assignment for the next session. I was so anxious that I might forget something that I taped the list to my refrigerator so I could memorize every item before my clients caught me looking at my reminder notes.

Finally, I eventually boiled everything down to a h...