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Facilitating is the process where the group leader engages with students as individuals and, more importantly, with the group as a whole.

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1. What do typical or expected behaviors look or sound like In this stage? Beginning stages  of the group session, It is expected that clients will be a little timid, reluctant, and scared to share their stories.

2. What are the group overall The group overall characteristics in this stage? The group characteristics
In the beginning stages of the group each client characteristics may look different. Some will be getting acquainted with one another while some may be closed off and unwilling to open themselves up due to fear and not knowing the group members.

3. What are somethings you would avoid as a group counselor? As a counselor, I would avoid being pushy and let each client express themselves at their own will. I would also allow them to open up as they see fit. I would also avoid sensitive topics that would trigger a sadness, anger, and emotional moment in the beginning. Also, unrelated topics that are not professional nor appropriate to discuss in the group session would also be avoided.

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4. What is the depth of the group process stage? The depth of the group at this point would be ice breakers getting to know each client and allowing them to get comfortable with me and each other.  Along, with allowing them to express themselves freely and to share what they feel comfortable sharing at the moment seeing that this is the beginning stage of the group session.
5.What are some ways to create trust? Encouraging each client to share their stories hoping it would help others in need. Creating an environment where clients feel safe and know that what they share in the group will not leave the group.
6. How does diversity impact the development stage of group counseling?  The developmental process can be affected in multiple ways, ranging from cultural differences, languages, and  the environment.  All contribute to the way a client or learns and interpret information that relates to the developmental process.

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7. Include an example activity ?An activity I feel that is fitting for high school students and any client is to create a  pass on the positivity board which they will create and will be fill with positive affirmations that will uplift them and carry them not only through the school year but beyond school.

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8. Confidentiality - Confidentiality within the group is pivotal for many reasons. Counselors are to keep every student's academic, personal, and mental health history, notes, and files privately in a place where the counselor are the only ones with access.  Confidentiality ensure that what a client share with you will not leave that session and it also builds a relationship and is the foundation for building trust as well. No one should have access this besides the counselor. According to the ACA Code of ethics, there should be a respect of privacy for each student, respecting client rights,  and protecting the client.

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This video displays how to properly facilitate a group session. This video also give pointers on how to engage with clients and clients engaging with one another.

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Gateway Generous Life Financial Stewardship

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Group safety is very important. When group members do not feel safe they will not open up nor will they feel comfortable doing so. The overall goal is to make everyone feel welcomed and safe and free to be who they are in these group sessions while being respectful  to one another and following the group rules.

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This video focuses on confidentiality within the counseling filed. How to protect your clients and their personal documents ranging from treatments, medical history, and academics.

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This video breaks down the basic skill a counselor should possess in order to be a successful counselor and advocate for students.

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This video not only speaks on the importance of confidentiality, it also includes the importance of building the foundation of trust with your clients and keeping the trust with your clients.

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Trust entails a sense of safety but it does not necessarily mean being comfortable.

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A lack of trust will entail an undercurrent of suspicion and anger will lead to mistrust and the group members being unwilling to share his or her feelings.

Building trust depends on many things you must earn trust before it's given. We also have to work from the ground up to build that trust. Another big key to trust is preparation we must professionally plan out our group sessions upon meeting with students.

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1.  What do or typical behavior look like at this stage. Typically in the beginning stages clients are warming up, becoming familiar with each other and myself.  Some clients will not be so willing to open up ans share their story. Some may even be defensive and apprehensive.  Clients will not fully begin intensive work until they feel they are in a safe and welcomed climate. As leaders we are to make them feel comfortable and safe and understand their position and not chastise them.
2. What does the group characteristics look like at this stage? Clients are reluctant to share what they are going through at this time. This  stage is known as the transition stage which consists of anxiety, defensiveness, guardness, ambivalence, and various other control issues.  This can be due to the fact of not wanting to share their business with everyone or culture related.
3. What does conflict look like at this stage? When conflict airse it can be a sign that something is wrong and needs to be addressed. Addressing conflict helps us to focus most of our time on the important work.  My goals is to acknowledge conflict and manage it effectively so that my clients can feel their voice is being heard while building that trust relationship. After we've address conflict I would  redirect the group back to the group  session and purpose of the group and to get them back on track. While also allowing them to safely express themselves  acknowledge their feelings,  while also  shifting  the atmosphere.
4.  Share the Six problems you share within the behavior stage? How can leaders work with these behaviors?
1. Fear
2. hesitation
3. defensive
4. uninterested in sharing
5. Unwilling to participate in group discussion.
6.  Anxiety/ lack of trust.
This can be changed by shifting your attitude as  a leader and acknowledge your clients feelings which will eventually result in a more positive outcome.
5.  How does working through conflict lead to trust? I would think that resolving
conflicts between clients  would
show them you care by talking with them getting them through what may be causing the conflict. Encouraging clients and respectfully letting them express what they may be bothering them while being understanding and helping them find ways to channel that into positive energy that will help them improve and grow through out the session.

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6. What would you avoid in this stage as a counselor? At this stage I would avoid anything that would set the client back and that would jepordize the clients progress to the next stage which would be the working stage.
7. How does diveristy affect the group counseling stage? Diversity affects the developmental  process because many clients who come from different backgrounds may interpret things differently due to their cultural differences and beliefs in which they learn.

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What are the overall group characteristics in this stage?

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What are the overall group characteristics in this stage?

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In the working stage of group therapy, group members start to feel comfortable enough to really get in to the deeper issues that the group was designed for. This is why this stage is known as the Working Stage. Each member is now able to explore their thoughts and emotions. These thoughts and emotions can be triggered by others' words so it can be tricky.

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Stages of Group Therapy: Initial, Transition, Working, and Final Stage

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Learn the 4 stages of group therapy, including the transition stage and working stage, plus what counselors and group members should expect in each phase.

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What do typical or expected group member behaviors look or sound like in this stage?

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What do typical or expected group member behaviors look or sound like in this stage?

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In the Working Stage, group members start to feel comfortable enough to begin the real work and delve into the deeper issues of why they are here.  Each member is able to explore their thoughts and emotions which may be triggered by someone else’s words. The counselor in this stage will guide the group through this process using techniques and challenges that bring out emotions.

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Stages of Group Therapy: Initial, Transition, Working, and Final Stage

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Learn the 4 stages of group therapy, including the transition stage and working stage, plus what counselors and group members should expect in each phase.

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Irvin Yalom identified 11 therapeutic factors that influence change and healing in group therapy.  These factors are:
1) Instillation of hope
2) Universality
3) Imparting Information
4) Altruism
5) Corrective recapitulation
6) Socializing techniques
7) Imitative behavior
8) Interpersonal learning
9) Group cohesiveness
10) Catharsis
11) Existential factors

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Irvin D. Yalom is a contemporary psychiatrist and educator who has written extensively about existential psychotherapy.

Professional Life

Irvin D. Yalom was born on June 13, 1931, in Washington, DC. His parents moved from Russia several years before his birth and opened a grocery store when they arrived in DC. Yalom and his family lived above the grocery store and most of his childhood was spent immersed in books.

Yalom received his BA from George Washington University in 1952 and his MD from Boston University School of Medicine in 1956. Over the next several years, he completed his internship at Mount Sinai Hospital, his residency at Johns Hopkins Hospital, and he served in the army. In 1962, Yalom began working as an instructor at Stanford University's School of Medicine, where he eventually advanced to professor of psychiatry in 1973. Yalom achieved professor emeritus status when he retired from Stanford in 1994.

Yalom began his literary career in 1970 with the publication of Theory and Practice of Group Psychotherapy. Since its release, it has been used as a textbook throughout the world. Yalom has published many more books since, including textbooks, nonfiction, and fiction. Yalom's 1989 bestseller, Love's Executioner and Other Tales of Psychotherapy, provided a less clinical and more human perspective on ten case histories. In 1992, Yalom published his first novel, When Nietzsche Wept: A Novel of Obsession that won the Commonwealth Gold Medal. Many of Yalom's fiction books incorporate themes from philosophy and existential psychology.

Yalom was awarded with the Foundations Fund Award in 1976 and the Oskar Pfister Award in 2001 from the American Psychiatric Association. His wife, Marilyn Yalom, is a university professor with a PhD in comparative literature.

Contribution to Psychology

Yalom was a pioneer in the area of existential psychotherapy. Existential psychotherapy emphasizes that mental health problems are frequently caused by struggles with existence. Common themes include fear of death, the drive toward freedom, and the desire to avoid isolation. Existential psychotherapy recognizes four basic human issues that all people struggle with: isolation, meaninglessness, mortality, and freedom. Through his writing, Yalom helped to explain existentialism and demonstrate its importance in therapy.

In addition, Yalom's study of and practice in group therapy led him to identify eleven specific factors that lead to significant changes and shifts for group members. Though he was first a skeptic, Yalom became a long-time advocate for group therapy; he believed that group therapy produced specific dynamics that increase healing while challenging the therapist. Group therapists are responsible for fostering a culture of cohesiveness, support, and integration. The interaction between group members provides the engine for change, and the therapist's role is to facilitate that experience.

Yalom's eleven therapeutic factors that influence change and healing in group therapy:

1. The instillation of hope creates a feeling of optimism.

2. Universality helps group members realize that they are not alone in their impulses, problems, and other issues.

3. Imparting information helps to educate and empower people with knowledge pertaining to their specific psychological situation.

4. Altruism allows clients to gain a sense of value and significance by helping other group members.

5. Corrective recapitulation provides for the resolution of family and childhood events within the safety of the group family.

6. Socializing techniques promote social development, tolerance, empathy, and other interpersonal skills.

7. Through imitative behavior group members learn to adopt the coping strategies and perspectives of other group members.

8. Interpersonal learning teaches clients how to develop supportive interpersonal relationships.

9. Group cohesiveness gives members a sense of acceptance, belonging, value, and security.

10. Catharsis releases suppressed emotions and promotes healing by disclosing information to group members.

11. Existential factors incorporate learning how to just exist as part of something larger than oneself. This factor brings a client into the awareness that life will continue on, with pain, death, sadness, regret, and joy. By living existentially, clients learn how to accept these conditions without escaping from them. Instead, they learn how to live with them and through them.

Selected Works by Irvin Yalom:

Love's Executioner and Other Tales of Psychotherapy (1989)

When Nietzsche Wept (fiction, 1992)

The Yalom Reader (1998)

Momma and the Meaning of Life (1999)

The Gift of Therapy:An Open Letter to a New Generation of Therapists and Their Patients (2002)

The Schopenhauer Cure (fiction, 2005)

Staring at the Sun: Overcoming the Terror of Death (2008)

The Spinoza Problem (fiction, 2012)

References:

1. Irvin D. Yalom. 2013. Contemporary Authors Online. Retrieved from http://www.gale.cengage.com/InContext/bio.htm

2. Levy, N. B. (2001). The Yalom Reader: Selections From the Work of a Master Therapist and Storyteller. The American Journal of Psychiatry, 158(4), 665-7. Retrieved from http://search.proquest.com/docview/220472173?accountid=1229

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Irvin D. Yalom is a contemporary psychiatrist and educator who has written extensively about existential psychotherapy. Irvin D. Yalom was born on June 13, 1931, in Washington, DC. His parents moved from Russia several years before his birth and opened a grocery store when they arrived in DC.

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Share something specific about one of Yalom’s nine therapeutic factors.

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Share something specific about one of Yalom’s nine therapeutic factors.

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One important factor among the 11 is in the beginning, Installation of Hope.  This is important to keep members.  The counselor begins this stage when he/she reinforces the positive expectations of the group and corrects negative preconceptions.

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GROUP PSYCHOTHERAPY  - YALOM's 11 Therapeutic Factors

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What is your personal leadership style? How does your style change in small group counseling? How do you see your style impacting a group?

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What is your personal leadership style? How does your style change in small group counseling? How do you see your style impacting a group?

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The chapter that I have provided goes over desirable leadership techniques.  My personal leadership style right now is centering around being a good listener.  In this article, it states that being an active listener is required to run a group.  This also means being able to watch for verbal and nonverbal cues from the group members.  I think that my laid back listening style is great for a group counseling session. I just want to sit back and watch others as be a good listener.

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Interventions

Interventions may be directed to an individual or the group as a whole. They can be used to clarify what is going on or to make it more explicit, redirect energy, stop a process that is not helpful, or help the group make a choice about what should be done. A well‐timed, appropriate intervention has the power to

Help a client recognize blocks to connection with other people

Discover connections between the use of substances and inner thoughts and feelings

Understand attempts to regulate feeling states and relationships

Perceive the effect of substance abuse on one's life

Notice meaningful inconsistencies among thoughts, feelings, and behavior

Perceive discrepancies between stated goals and what is actually being done

Any verbal intervention may carry important nonverbal elements. For example, different people would ascribe a variety of meanings to the words, "I am afraid that you have used again," and the interpretation will vary further with the speaker's tone of voice and body language. Leaders should therefore be careful to avoid conveying an observation in a tone of voice that could create a barrier to understanding or response in the mind of the listener.

Avoiding a leader‐centered group

Generally a counselor leads several kinds of groups. Leadership duties may include a psychoeducational group, in which a leader usually takes charge and teaches content, and then a process group, in which the leader's role and responsibilities should shift dramatically. A process group that remains leader‐focused limits the potential for learning and growth, yet all too often, interventions place the leader at the center of the group. For example, a common sight in a leader‐centered group is a series of one‐on‐one interactions between the leader and individual group members. These sequential interventions do not use the full power of the group to support experiential change, and especially to build authentic, supportive interpersonal relationships. Some ways for a leader to move away from center stage:

In addition to using one's own skills, build skills in participants. Avoid doing for the group what it can do for itself.

Encourage the group to learn the skills necessary to support and encourage one another because too much or too frequent support from the clinician can lead to approval seeking, which blocks growth and independence. Supporting each other, of course, is a skill that should develop through group phases. Thus, in earlier phases of treatment, the leader may need to model ways of communicating support. Later, if a client is experiencing loss and grief, for example, the leader does not rush in to assure the client that all will soon be well. Instead, the leader would invite group members to empathize with each other's struggles, saying something like, "Joanne, my guess is at least six other people here are experts on this type of feeling. What does this bring up for others here?"

Refrain from taking on the responsibility to repair anything in the life of the clients. To a certain extent, they should be allowed to struggle with what is facing them. It would be appropriate, however, for the leader to access resources that will help clients resolve problems.

Confrontation

Confrontation is one form of intervention. In the past, therapists have used confrontation aggressively to challenge clients' defenses of their substance abuse and related untoward behaviors. In recent years, however, clinicians have come to recognize that when "confrontation" is equivalent to "attack," it can have an adverse effect on the therapeutic alliance and process, ultimately leading to failure. Trying to force the client to share the clinician's view of a situation accomplishes no therapeutic purpose and can get in the way of the work.

A more useful way to think about confrontation is "pointing out inconsistencies," such as disconnects between behaviors and stated goals. William R. Miller explains:

The linguistic roots of the verb "to confront" mean to come face to face. When you think about it that way, confrontation is precisely what we are trying to accomplish: to allow our clients to come face to face with a difficult and often threatening reality, to "let it in" rather than "block it out," and to allow this reality to change them. That makes confrontation a goal of counseling rather than a particular style or technique. . . [T]hen the question becomes, What is the best way to achieve that goal? Evidence is strong that direct, forceful, aggressive approaches are perhaps the least effective way to help people consider new information and change their perceptions ( CSAT 1999b, p. 10).

Confrontation in this light is a part of the change process, and therefore part of the helping process. Its purpose is to help clients see and accept reality so they can change accordingly ( Miller and Rollnick 1991). With this broader understanding of what interventions that "confront" the client really mean, it is not useful to divide therapy into "supportive" and "confrontative" categories.

Transference and Countertransference

Transference means that people project parts of important relationships from the past into relationships in the present. For example, Heather may find that Juan reminds her of her judgmental father. When Juan voices his suspicion that she has been drinking, Heather feels the same feelings she felt when her father criticized all her supposed failings. Within the microcosm of the group, this type of incident not only relates the here‐and‐now to the past, but also offers Heather an opportunity to learn a different, more self‐respecting way of responding to a remark that she perceives as criticism.

The emotion inherent in groups is not limited to clients. The groups inevitably stir up strong feelings in leaders. The therapist's emotional response to a group member's transference is referred to as countertransference. Vannicelli (2001) describes three forms of countertransference:

Feelings of having been there. Leaders with family or personal histories with substance abuse have a treasure in their extraordinary ability to empathize with clients who abuse substances. If that empathy is not adequately understood and controlled, however, it can become a problem, particularly if the therapist tries to act as a role model or sponsor, or discloses too much personal information.

Feelings of helplessness when the therapist is more invested in the treatment than the client is. Treating highly resistant populations, such as clients referred to treatment by the courts, can cause leaders to feel powerless, demoralized, or even angry. The best way to deal with this type of countertransference may be to use the energy of the resistance to fuel the session. (See "Resistance in Group," next section.)

Feelings of incompetence due to unfamiliarity with culture and jargon. It is helpful for leaders to be familiar with 12‐Step programs, cultures, and languages. If a group member uses unfamiliar terms, however, the leader should ask the client to explain what the term means to that person, using a question like, "'Letting go' means something a bit different to each person. Can you say a little more about how this relates to your situation?" ( Vannicelli 2001, p. 58).

When countertransference occurs, the clinician needs to bring all feelings associated with it to awareness and manage them appropriately. Good supervision can be really helpful. Countertransference is not bad. It is inevitable, and with the help of supervision, the group leader can use countertransference to support the group process ( Vannicelli 2001).

Resistance in Group

Resistance arises as an often unconscious defense to protect the client from the pain of self‐examination. These processes within the client or group impede the open expression of thoughts and feelings, or block the progress of an individual or group. The effective leader will neither ignore resistance nor attempt to override it. Instead, the leader helps the individual and group understand what is getting in the way, welcoming the resistance as an opportunity to understand something important going on for the client or the group. Further, resistance may be viewed as energy that can be harnessed and used in a variety of ways, once the therapist has helped the client and group understand what is happening and what the resistant person or persons actually want ( Vannicelli 2001).

In groups that are mandated to enter treatment, members often have little interest in being present, so strong resistance is to be expected. Even this resistance, however, can be incorporated into treatment. For example, the leader may invite the group members to talk about the difficulties experienced in coming to the session or to express their outrage at having been required to come. The leader can respond to this anger by saying, "I am impressed by how open people have been in sharing their feelings this evening and in being so forthcoming about really speaking up. My hope is that people will continue to be able to talk in this open way to make our time together as useful as possible" ( Vannicelli 2001, p. 55).

Leaders should recognize that clients are not always aware that their reasons for nonattendance or lateness may be resistance. The most helpful attitude on the clinician's part is curiosity and an interest in exploring what is happening and what can be learned from it. Leaders need not battle resistance. It is not the enemy. Indeed, it is usually the necessary precursor to change.

It would be a serious mistake, however, to imagine that resistance always melts away once someone calls attention to it. "Resistance is always there for a reason, and the group members should not be expected to give it up until the emotional forces held in check by it are sufficiently discharged or converted, so that they are no longer a danger to the safety of the group or its members" ( Flores 1997, p. 538).

When a group (rather than an individual) is resistant, the leader may have contributed to the creation of this phenomenon and efforts need to be made to understand the leader's role in the problem. Sometimes, "resistance can be induced by leaders who are passive, hostile, ineffective, guarded, weak, or in need of constant admiration and excessive friendliness" ( Flores 1997, p. 538).

Confidentiality

For the group leader, strict adherence to confidentiality regulations builds trust. If the bounds of confidentiality are broken, grave legal and personal consequences may result. All group leaders should be thoroughly familiar with Federal laws on confidentiality (42 C.F.R. Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records; see Figure 6-2 ) and relevant agency policies. Confidentiality is recognized as "a central tenet of the practice of psychotherapy" ( Parker et al. 1997, p. 157), yet a vast majority of States either have vague statutes dealing with confidentiality in group therapy or have no statutes at all. Even where a privilege of confidentiality does exist in law, enforcement of the law that protects it is often difficult ( Parker et al. 1997). Clinicians should be aware of this legal problem and should warn clients that what they say in group may not be kept strictly confidential. Some studies indicate that a significant number of therapists do not advise group members that confidentiality has limits ( Parker et al. 1997).

One set of confidentiality issues has to do with the use of personal information in a group session. Group leaders have many sources of information on a client, including the names of the client's employer and spouse, as well as any ties to the court system. A group leader should be clear about how information from these sources may and may not be used in group.

Clinicians consider the bounds of confidentiality as existing around the treatment enterprise, not around a particular treatment group. Clients should know that everyone on the treatment team has access to relevant information. In addition, clinicians should make it clear to clients that confidentiality cannot be used to conceal continued substance abuse, and the therapist will not be drawn into colluding with the client to hide substance use infractions. Clinicians also should advise clients of the exact circumstances under which therapists are legally required to break confidentiality (see Figure 6-2 ).

A second set of confidentiality issues has to do with the group leader's relationships with clients and clients with one another. When counseling a client in both individual therapy and a group context, for example, the leader should know exactly how information learned in individual therapy may be used in the group context. In almost every case, it is more beneficial for the client to divulge such information than for the clinician to reveal it. In an individual session, the therapist and the client can plan how the issue will be brought up in group. This preparation gives clients ample time to decide what to say and what they want from the group. The therapist can prompt clients to share information in the group with a comment like, "I wonder if the group understands what a hard time you've been having over the last 2 weeks?" On the other hand, therapists should reserve the right to determine what information will be discussed in group. A leader may say firmly, "Understand that whatever you tell me may or may not be introduced in group. I will not keep important information from the group, if I feel that withholding the information will impede your progress or interfere with your recovery."

Still other confidentiality issues arise when clients discuss information from the group beyond its bounds. Violations of confidentiality among members should be managed in the same way as other boundary violations; that is, empathic joining with those involved followed by a factual reiteration of the agreement that has been broken and an invitation to group members to discuss their perceptions and feelings. In some cases, when this boundary is violated, the group may feel a need for additional clarification or addenda to the group agreement. The leader may ask, both at the beginning of the group or when issues arise, whether the group feels it needs additional agreements in order to work safely. Such amendments, however, should not seek to renegotiate the terms of the original group agreement. See Figure 6-2 for helpful information on confidentiality and the law.

Figure 6-2. Confidentiality and 42 C.F.R., Part 2

Confidentiality is both an ethical and a legal issue. Federal law (Title 42, Part 2 or 42 C.F.R., Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records) guarantees strict confidentiality of information about all people receiving substance abuse prevention and/or treatment services. Clients should be fully informed regarding issues of confidentiality, and group leaders should do all they can to build respect for confidentiality and anonymity within groups.

There are six conditions under which limited disclosure is permitted under the regulations. These exceptions are

The group member has signed a Release of Information document that allows the group facilitator to communicate with another professional and/or agency.

A group member threatens imminent harm to him‐ or herself, and the group facilitator believes that the client may act on this threat.

A client threatens imminent harm to another named person, and the group facilitator believes that there is a reasonable likelihood that the client will act on the threat.

A medical emergency requires that a client's drug and alcohol status be revealed in order to ensure that the client gets appropriate medical attention.

A client is suspected of child neglect and/or abuse, as defined by the laws of the State in which the substance abuse treatment services are being provided.

A direct court order mandates the release of specific information related to a client's history and/or treatment. However, an authorizing court order alone does not compel disclosure-for example, if the person authorized to disclose confidential information does not elect to make the disclosure, he or she cannot be forced to do so unless there is a valid subpoena (i.e., the subpoena has not expired) or other compulsory process introduced that would then compel disclosure. An appropriate judge issues a court order. It specifies the exact information to be provided about a particular client and is properly signed and dated.

More detailed discussions of confidentiality can be found in TIP 25, Substance Abuse Treatment and Domestic Violence ( CSAT 1997b); TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse ( CSAT 1994a); TAP 13, Confidentiality of Patient Records for Alcohol and Other Drug Treatment ( Lopez 1994); and TAP 18, Checklist for Monitoring Alcohol and Other Drug Confidentiality Compliance ( CSAT 1996).

Source: Consensus Panel.

Because a group facilitator generally is part of the larger substance abuse treatment program, it is recommended that the group facilitator take a practical approach to exceptions. This practical approach is to have the group facilitator discuss the potential application of the exceptions with the program director or member of the program staff who is the lead on the confidentiality regulation.

Biopsychosocial and Spiritual Framework-Treating the Whole Person

Substance use disorders include a wide range of symptoms with different levels of associated disability. Clients always bring into treatment vulnerabilities other than their alcohol or illicit drug dependencies. Group interventions may be needed to resolve psychological problems, physical ailments, social stresses, and perhaps, spiritual emptiness or bankruptcy. In short, successful treatment for substance use disorders should address the whole person, including that person's spiritual growth.

While the group experience is a powerful tool in the treatment of substance use disorders, it is not the only tool. Other interventions, such as individual therapy, psychological interventions, pharmacological supports, and intensive case management, may all be necessary to achieve long‐term remission from the symptoms of addictive disorders.

For example, people who are homeless with a co‐occurring mental disorder have three complicated sets of problems that require a continuous and comprehensive care system-one that integrates or coordinates interventions in (1) the mental health system, (2) the addiction system, and (3) the social service system for homeless persons. In group therapy, each condition should be regarded as a primary interactive problem; that is, one in which each problem develops independently but contributes to both of the others ( Minkoff and Drake 1992).

One model offered for treating homeless persons with substance use disorder is a modified training group designed to accommodate a large number of members whenever a traditional small group is not possible. In this model, participants meet in a large group with the clinician and then break into smaller groups to discuss, practice, or role‐play the particular topic.

Each group has a client leader, and the clinician circulates among the groups to ensure that the topic is understood and that discussion is proceeding. The clinician does not participate in the groups. Researchers describing this model note that because the clinicians step back from assuming leadership roles in the groups, the clients become empowered to take group sessions in the necessary direction and demonstrate feelings and insights that might not occur in a group formally led by a clinician ( Goldberg and Simpson 1995).

It is well known that 12‐Step programs are an important part of many therapeutic programs ( Page and Berkow 1998). While 12‐Step programs have a proven record of success in helping people overcome substance use disorders, there is a basic conflict inherent in them that group therapists need to reconcile. In the 12‐Step program, people are urged to cede control to a higher power. Yet, in group, the clinician is prompting clients to take control of their emotions, behavior, and lives.

As a result, some researchers have stated that it is "impossible to integrate psychotherapy and AA approaches dealing with addictions without compromising one approach or the other" ( Page and Berkow 1998, pp. 1-2). Another researcher has argued that "the AA approach is consistent with existential philosophy" because both stress that people should accept their "human limitations and security‐seeking behaviors" ( Page and Berkow 1998, p. 2). Although the literature currently has few straightforward discussions of spirituality and its role in the dynamics of group therapy, most clinicians would agree that the spiritual well‐being of the client is essential to breaking free of substance abuse.

When clients join self‐help groups, they sometimes hear from individuals who strongly oppose the use of any medication. Some people in 12‐Step programs erroneously believe, for example, that the use of pharmacological adjuncts to therapy is a violation of the program's principles. They consequently oppose methadone maintenance, the use of Antabuse, or the use of medications needed to control co‐occurring disorders.

Clinicians should be prepared to handle these misapprehensions. One way to help would be to refer apprehensive clients to the pamphlet, The AA Member-Medications and Other Drugs: A Report from a Group of Physicians in AA ( Alcoholics Anonymous World Services 1984). It stresses the value of appropriate medication prescribed by a physician who understands addictive disorders and reassures clients that such use of medication is wholly consistent with AA and Narcotics Anonymous' 12‐Step programs (more information can be found at AA's Web site: www.aa.org).

Many clients enrolled in a process group for persons with substance use disorders are likely participating in a 12‐Step program or other self‐help groups as well. On occasion, apparently conflicting messages can be an issue. For instance, many people with addiction histories try to use AA and its jargon as material for resistance. Such problems can readily be managed, provided the therapist is thoroughly familiar with the self‐help group. Matano and Yalom (1991) strongly recommend that group leaders become thoroughly familiar with AA's language, steps, and traditions because misconceptions about the program, whether by the client or therapist, can raise barriers to recovery.

Recent research has clearly demonstrated the ability of self‐help groups to improve outcomes ( Tonigan et al. 1996). Research also has shown that clients receiving mental health services as well as participating in 12‐Step meetings have an even better prognosis ( Ouimette et al. 1998). Marilyn Freimuth's research on integrating group psychotherapy and 12‐Step work has shown that "if mere co‐participation in psychotherapy and 12‐Step groups supports a client's recovery, it is reasonable to expect that a more integrated approach will provide further benefits" ( Freimuth 2000, p. 298). Both activities "support abstinence and emotional growth" ( Freimuth 2000, p. 301). Together, the two modalities supply multiple relationship models, potentially of immense value to the client.

Some suggestions for maximizing the therapeutic potential of participation in both process and 12‐Step groups follow:

Orientation should prepare new group members who are also members of 12‐Step groups for differences in the two groups. A key difference will be the fact that members interact with each other. Such "cross talk" is discouraged at 12‐Step meetings. "The new psychotherapy group member may need to be told that the topic of conversation is much wider than the 12‐Step meeting's focus on addiction and recovery, and that it includes feelings and reactions toward other group members" ( Freimuth 2000, p. 300; see also Vannicelli 1992).

During early recovery, it is particularly important to avoid making the 12‐Step program's encouragement of "unquestioning acceptance" a focus of analysis in group therapy. Too critical an interpretation offered too early may disrupt the 12‐Step program's status as an "ideal object," belief in which "is critical to maintaining early abstinence" ( Dodes 1988; Freimuth 2000, p. 305).

Sometimes clients experience "splitting"-seeing "the [12‐Step] program as the all‐good parent and all others, including the therapist/group as the all‐bad/ambivalent object." Later, the split may be just the opposite ( Freimuth 2000). The group leader should be attuned to this potential and should be prepared to work through these perceptions and the feelings underlying them. Further, when the process group is perceived as the "less than" modality and the client enthusiastically quotes insights from a 12‐Step group, the therapist should watch for possible countertransference and bear in mind the benefits the client is receiving from both programs.

Sponsors of 12‐Step members may distrust therapy and discourage group member from continuing in treatment. The leader should be prepared to respond to a variety of potential issues in ways that avoid appearing to compete with the self‐help group. For example, if a client says, "In my AA group, they say I don't need to be here. As long as I'm not drinking, my life is fine." The therapist might acknowledge the importance of continued sobriety, but remind the client of depression experienced before the onset of heavy drinking.

Group leaders should beware of their possible biases against 12‐Step groups that may be based on inaccurate information. For example, it is not true that the 12‐Step philosophy opposes therapy and medication, as AA World Service pamphlets clarify. It also is a misconception that 12‐Step programs encourage people to abdicate responsibility for substance use. AA, however, does urge people with addiction problems to attend meetings in the early stages of recovery, even though they may still be using alcohol or illicit drugs. Finally, some clinicians believe that 12‐Step programs discourage strong negative emotions. On the contrary, "there is no unilateral discouragement of negative affects within [12‐Step] program philosophy; only when anger threatens sobriety is it considered necessary to circumvent negative feelings" ( Freimuth 2000, p. 308).

The following vignette illustrates a typical intervention intended to clarify and harmonize appropriate participation in 12‐Step and process groups:

The group leader knew that Henry, who was well along in recovery but new to group, had not expressed his anger at Jenna for having cut him off for the third time. When asked how he experienced Jenna, he simply replied that according to the program you are not to take another person's inventory. The leader took the opportunity to say that in group therapy it is important to consider one's feelings about what others say and do even if [the feelings] are negative. Expressing one's own feelings is different from focusing on another's character (taking his inventory) ( Freimuth 2000, p. 308).

No matter what the modality, however, group therapy is sure to remain an integral part of substance abuse treatment.

Addressing life issues

Substance abuse affects every aspect of life: home, family, friends, job, health, emotional well‐being, and beliefs. As clients move into recovery, the wide range of issues they should face may overwhelm them. Leaders need to help clients rank the importance of the challenges, taking care to make the best possible use of the resources the client and the leader can bring to bear.

Naturally, clients will vary in their ability to address many concerns simultaneously; capacity for change also is variable. For example, some individuals with cognitive impairments will have a much harder time than others engaging in a change process. In the early stage of treatment, such clients need simple ideas, structures, and principles.

As the client moves forward, the clinician can keep in mind the issues that a client is not ready or able to manage. As this process goes on, the leader should remember that the client's priorities matter more than what the leader thinks ought to come next. Unless both client and leader operate in the same motivational framework the leader will not be able to help the client make progress.

No matter what is missing-even if it is a roof over the client's head-it is possible to engage the client in treatment. A client never should be told to come back after problems other than substance abuse have been resolved. On some front, constructive work can always be done. Of course, this assertion does not mean that critical needs can be ignored until treatment for substance abuse is well underway. The therapist should recognize that a client preoccupied with the need to find a place to sleep will not be able to engage fully in treatment until urgent, practical needs are met.

Life issues facing the client provide two powerful points of therapeutic leverage that leaders can use to motivate the client to pursue recovery. First, group leaders should be aware that people with alcoholism and other addictions will not give up their substance use until the pain it brings outweighs the pleasure it produces. Consequently, they should be helped to see the way alcohol and drugs affect important areas of their lives. Second, early in treatment, group leaders should learn what is important to each client that continued substance abuse might jeopardize. For some individuals, it is their job. For others, it is their spouse, health, family, or self‐respect. In some cases, it might be the threat of incarceration. Such knowledge can be used to encourage, and even coerce, individuals to utilize the tools of treatment, group, or AA ( Flores 1997).

Incorporating faith

While spirituality and faith may offer to some the hope, nurturing, sense of purpose and meaning, and support needed to move toward recovery, people obviously interpret spiritual matters in diverse ways. It is important not to confuse spirituality with religion. Even if clients are not religious, their spiritual life is important. Some clinicians mistakenly conclude that their own understanding of spirituality will help the client. Other clinicians err in the opposite direction and are overly reluctant to address spiritual beliefs. Actually, a middle ground is preferable. The leader should explore the importance of spiritual life with the group, and if the search for spiritual meaning is important, the clinician can incorporate it into group discussions.

For clients who lack meaningful connection to anything beyond themselves, the group may be the first step toward a search for meaning or a feeling of belonging to something greater than the self. The clinician's role in group therapy simply is to create an environment within which such ego‐transcending connections can be experienced.

Management of the Group

Handling conflict in group

Conflict in group therapy is normal, healthy, and unavoidable. When it occurs, the therapist's task is to make the most of it as a learning opportunity. Conflict can present opportunities for group members to find meaningful connections with each other and within their own lives.

Handling anger, developing empathy for a different viewpoint, managing emotions, and working through disagreements respectfully are all major and worthwhile tasks for recovering clients. The leader's judgment and management are crucial as these tasks are handled. It is just as unhelpful to clients to let the conflict go too far as it is to shut down a conflict before it gets worked through. The therapist must gauge the verbal and nonverbal reactions of every group member to ensure that everyone can manage the emotional level of the conflict.

The clinician also facilitates interactions between members in conflict and calls attention to subtle, sometimes unhealthy patterns. For example, a group may have a member, Mary, who frequently disagrees with others. Group peers regard Mary as a source of conflict, and some of them have even asked Mary (the scapegoat) to leave so that they can get on with group work. In such a situation, the therapist might ask, "Do you think this group would learn more about handling this type of situation if Mary left the group or stayed in the group?" An alternative tack would be, "I think the group members are avoiding a unique opportunity to learn something about yourselves. Giving in to the fantasy of getting rid of Mary would rob each of you of the chance to understand yourself better. It would also prevent you from learning how to deal with people who upset you."

Conflicts within groups may be overt or covert. The therapist helps the group to label covert conflicts and bring them into the open. The observation that a conflict exists and that the group needs to pay attention to it actually makes group members feel safer. The therapist is not responsible, however, for resolving conflicts. Once the conflict is observed, the decision to explore it further is made based on whether such inquiry would be productive for the group as a whole. In reaching this decision, the therapist should consider the function the conflict is serving for the group. It actually may be the most useful current opportunity for growth in the group.

On the other hand, as Vannicelli (1992) points out, conflicts can be repetitive and predictable. When two members are embroiled in an endless loop of conflict, Vannicelli suggests that the leader may handle the situation by asking, "John, did you know what Sally was likely to say when you said X?" and "Sally, did you know what John was likely to say when you said Y?" "Since both participants are likely to answer, 'Yes, of course,' the therapist would then inquire what use it might serve for them to engage in this dialogue when the expected outcome is so apparent to both of them (as well as to other members of the group). This kind of distraction activity or defensive maneuver should come to signal to group members that something important is being avoided. It is the leader's task to help the group figure out what that might be and then to move on" ( Vannicelli 1992, p. 121).

Group leaders also should be aware that many conflicts that appear to scapegoat a group member are actually displaced anger that a member feels toward the therapist. When the therapist suspects this kind of situation, the possibility should be forthrightly presented to the group with a comment such as, "I notice, Joe, that you have been upset with Jean quite a bit lately. I also know that you have been a little annoyed with me a since couple weeks ago about the way I handled that phone call from your boss. Do you think some of your anger belongs with me?"

Individual responses to particular conflicts can be complex, and may resonate powerfully according to a client's personal values and beliefs, family, and culture. Therefore, after a conflict, it is important for the group leader to speak privately with group members and see how each is feeling. Leaders also often use the last 5 minutes of a session in which a conflict has occurred to give group members an opportunity to express their concerns.

Subgroup management

In any group, subgroups inevitably will form. Individuals always will feel more affinity and more potential for alliance with some members than with others. One key role for the therapist in such cases is to make covert alliances overt. The therapist can involve the group in identifying subgroups by saying, "I notice Jill and Mike are finding they have a good deal in common. Who else is in Jill and Mike's subgroup?"

Subgroups can sometimes provoke anxiety, especially when a therapy group is made up of individuals acquainted before becoming group members. Group members may have used drugs together, slept together, worked together, or experienced residential substance abuse treatment together. Obviously, such connections are potentially disruptive, so when groups are formed, group leaders should consider whether subgroups would exist.

When subgroups somehow stymie full participation in the group, the therapist may be able to reframe what the subgroup is doing. At other times, a change in the room arrangement may be able to reconfigure undesirable combinations. On occasion, however, subtle approaches fail. For instance, adolescents talking among themselves or making obscene gestures during the session should be told factually and firmly that what they are doing is not permissible. The group leader might say, "We can't do our work with distractions going on. Your behavior is disrespectful and it attempts to shame others in the group. I won't tolerate any abuse of members in this group."

Subgroups are not always negative. The leader for example may intentionally foster a subgroup that helps marginally connected clients move into the life of the group. This gambit might involve a question like, "Juanita, do you think it might help Joe if you talked some about your experience with this issue?" Further, to build helpful connections between group members, a group member might be asked, "Bob, who else in this group do you think might know something about what you've just said?"

Responding to disruptive behavior

Clients who cannot stop talking

When a client talks on and on, he or she may not know what is expected in a therapy group. The group leader might ask the verbose client, "Bob, what are you hoping the group will learn from what you have been sharing?" If Bob's answer is, "Huh, well nothing really," it might be time to ask more experienced group members to give Bob a sense of how the group works. At other times, clients tend to talk more than their share because they are not sure what else to do. It may come as a relief to have their monolog interrupted ( Vannicelli 1992, p. 167).

If group members exhibit no interest in stopping a perpetually filibustering client, it may be appropriate to examine this silent cooperation. The group may be all too willing to allow the talker to ramble on, to avoid examining their own past failed patterns of substance abuse and forge a more productive future. When this motive is suspected, the leader should explore what group members have and have not done to signal the speaker that it is time to yield the floor. It also may be advisable to help the talker find a more effective strategy for being heard and understood ( Vannicelli 1992).

Clients who interrupt

Interruptions disrupt the flow of discussion in the group, with frustrating results. The client who interrupts is often someone new to the group and not yet accustomed to its norms and rhythms. The leader may invite the group to comment by saying, "What just happened?" If the group observes, "Jim seemed real anxious to get in right now," the leader might intervene with, "You know, Jim, my hunch is that you don't know us well enough yet to be certain that the group will pay adequate attention to your issues; thus, at this point, you feel quite a lot of pressure to be heard and understood. My guess is that when other people are speaking you are often so distracted that it may even be hard to completely follow what is going on completely" ( Vannicelli 1992).

Clients who flee a session

Clients who run out of a session often are acting on an impulse that others share. It would be productive in such instances to discuss these feelings with the group and to determine what members can do to talk about these feelings when they arise. The leader should stress the point that no matter what is going on in the group, the therapeutic work requires members to remain in the room and talk about problems instead of attempting to escape them ( Vannicelli 1992). If a member is unable to meet this requirement, reevaluation of that person's placement in the group is indicated.

Contraindications for continued participation in group

Sometimes, clients are unable to participate in ways consistent with group agreements. They may attend irregularly, come to the group intoxicated, show little or no impulse control, or fail to take medication to control a co‐occurring disorder. Though removing someone from the group is very serious and should never be done without careful thought and consultation, it is sometimes necessary. It may be required because of a policy of the institution, because the therapist lacks the skills needed to deal with a particular problem or condition, or because an individual's behavior threatens the group in some significant and insupportable way.

Though groups do debate many issues, the decision to remove an individual is not one the group makes. On the contrary, the leader makes the decision and explains to the group in a clear and forthright manner why the action was taken. Members then are allotted time to work through their responses to what is bound to be a highly charged event. Anger at the group leader for acting without group input or acting too slowly is common in expulsion situations, and should be explored.

Managing Other Common Problems

Coming late or missing sessions

Sometimes, addiction counselors view the client who comes to group late as a person who, in some sense, is behaving badly. It is more productive to see this kind of boundary violation as a message to be deciphered. Sometimes this attempt will fail, and the clinician may decide the behavior interferes with the group work too much to be tolerated.

Silence

A group member who is silent is conveying a message as clearly as one who speaks. Silent messages should be heard and understood, since nonresponsiveness may provide clues to clients' difficulties in connecting with their own inner lives or with others ( Vannicelli 1992).

Special consideration is sometimes necessary for clients who speak English as a second language (ESL). Such clients may be silent, or respond only after a delay, because they need time to translate what has just been said into their first language. Experiences involving strong feelings can be especially hard to translate, so the delay can be longer. Further, when feelings are running high, even fluent ESL speakers may not be able to find the right words to say what they mean or may be unable to understand what another group member is saying about an intense experience.

Tuning out

When the group is in progress and clients seem present in body but not in mind, it helps to tune into them just as they are tuning out. The leader should explore what was happening as an individual became inattentive. Perhaps the person was escaping from specific difficult material or was having more general difficulties connecting with other people. It may be helpful to involve the group in giving feedback to clients whose attention falters. It also is possible, however, that the group as a whole is sidestepping matters that have to do with connectedness. The member who tunes out might be carrying this message for the group ( Vannicelli 1992).

Participating only around the issues of others

Even when group members are disclosing little about themselves, they may be gaining a great deal from the group experience, remaining engaged around issues that others bring up. To encourage a member to share more, however, a leader might introduce the topic of how well members know each other and how well they want to be known. This topic could be explored in terms of percentages. For instance, a man might estimate that group members know about 35 percent about him, and he would eventually like them to know 75 percent. Such a discussion would yield important information about how much individuals wish to be known by others ( Vannicelli 1992).

Fear of losing control

As Vannicelli (1992) notes, sometimes clients avoid opening up because they are afraid they might break down in front of others-a fear particularly common in the initial phases of groups. When this restraint becomes a barrier to clients feeling acute pain, the therapist should help them remember ways that they have handled strong feelings in the past.

For example, if a female client says she might "cry forever" once she begins, the leader might gently inquire, "Did that ever happen?" Clients are often surprised to realize that tears generally do not last very long. The therapist can further assist this client by asking, "How were you able to stop?" ( Vannicelli 1992, p. 152).

When a client's fears of breaking down or becoming unable to function may be founded in reality (for example, when a client has recently been hospitalized), the therapist should validate the feelings of fear, and should concentrate on the strength of the person's adaptive abilities ( Vannicelli 1992).

Fragile clients with psychological emergencies

Since clients know that the group leader is contractually bound to end the group's work on time, they often wait intentionally until the last few minutes of group to share emotionally charged information. They may reveal something particularly sad or difficult for them to deal with. It is important for the leader to recognize they have deliberately chosen this time to share this information. The timing is the client's way of limiting the group's responses and avoiding an onslaught of interest. All the same, the group members or leader should point out this self‐defeating behavior and encourage the client to change it.

Near the end of a session, for example, a group leader has an exchange with a group member named Lan, who has been silent throughout the session:

Leader: Lan, you've been pretty quiet today. I hope we will hear more about what is happening with you next week.

Lan: I don't think you'll see me next week.

Further exploration reveals that Lan intends to kill herself that night. In view of the approaching time boundary, what should the leader do?

In such a situation, the group leader has dual responsibilities. First, the leader should respond to Lan's crisis. Second, the incident should be handled in a way that reassures other group members and preserves the integrity of the group. Group members will have a high level of anxiety about such a situation. Because of their concern, some group leaders are willing to extend the time boundary for that session only, provided that all members are willing and able to stay. Others feel strongly that the time boundary should be maintained and that the leader should pledge to work with Lan individually right after the session. Whatever the decision and subsequent action, the leader should not simply drift casually and quietly over the time boundary. The important message is that boundaries should be honored and that Lan will get the help she needs. The group leader can say explicitly that Lan's needs will be addressed after group.

Figure 6-3 shows that group leaders should be prepared to deal not only with substance abuse issues, but with co‐occurring psychiatric concerns as well.

Anxiety and resistance after self‐disclosure

Clients may feel great anxiety after disclosing something important, such as the fact that they are gay or incest victims. Often, they wonder about two possibilities: "Does this mean that I have to keep talking about it? Does this mean that if new people come into the group, I have to tell them too?" ( Vannicelli 1992, p. 160).

To the first question, the therapist can respond with the assurance, "People disclose in here when they are ready." To the second, the member who has made the disclosure can be assured of not having to reiterate the disclosure when new clients enter. Further, the disclosing member is now at a different stage of development, so the group leader could say, "Perhaps the fact that you have opened up the secret a little bit suggests that you are not feeling that it is so important to hide it any more. My guess is that this, itself, will have some bearing on how you conduct yourself with new members who come into the group" ( Vannicelli 1992, p. 160 & p. 161).

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6 Group Leadership, Concepts, and Techniques

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This chapter describes desirable leader traits and behaviors, along with the concepts and techniques vital to process groups-though many of the ideas can apply in other types of groups. Most of the ideas seem perfectly logical, too, once they are brought to mind.

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What things would you avoid as a group counselor in this stage?

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What things would you avoid as a group counselor in this stage?

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One big mistake that counselors make in the working stage is not understanding a client's cultural background.  Counselors need to be sensitive to each client's cultural background.  Trust is diminished when therapists are unable to relate to or empathize with a client’s acculturation challenges.

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Counseling has been used to guide individuals toward new insights and coping mechanisms since the beginning of the 20th century.

With its widespread use, it is imperative that counseling is performed based on research-supported methods that promote positive client adjustment.

Researchers have identified some key behaviors that should be avoided for counselors to be effective in their therapeutic roles, and this article consolidates the biggest mistakes and how to prevent them.

By avoiding these common counseling pitfalls, therapists will be in a better position to empower, guide, and support their clients toward greater emotional fulfillment and well-being.

Before you read on, we thought you might like to download our 3 Positive Psychology Exercises for free. These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

General Counseling: 11 Mistakes

The following mistakes, which are of general importance across counseling types, are divided by the following categories listed below.

1. Confidentiality

As maintaining confidentiality is paramount to the ethical implementation of mental health treatments, violating confidentiality represents a significant clinical mistake. Unless the client has provided permission OR there is a sufficient reason to break confidentiality (e.g., the client poses a danger to him/herself or others), counselors are bound by specific confidentiality regulations (Hodgson, Mendenhall, & Lamson, 2013).

Not only is protecting privacy and confidentiality the client's right, but it also provides legal protection for the therapist. There are several ways in which mental health professionals are required to protect a client's privacy. For example, it is the counselor's responsibility to maintain secure paper and electronic files and to only discuss a patient's information with those for whom legal access is permitted.

Along with understanding confidentiality requirements, counselors must also ensure the physical nature of the counseling office affords adequate client privacy (Hodgson et al., 2013). Therefore, the waiting room should have proper seating and space, and counseling offices need to be private and soundproof.

Similarly, all counseling staff must understand the importance of confidentiality and thus avoid exposing client information to others in the waiting room. Not only is maintaining confidentiality the law, but it is the professional counselor's ethical imperative. Moreover, it is essential for achieving counselor-client trust and thereby enhancing the likelihood that a client will be open and responsive to treatment.

2. Rapport-Building

Undergoing counseling is a difficult experience for most people, as it often involves sharing deeply personal and distressing information. It takes time for a client to feel safe enough to open up, particularly when he/she has trust issues, to begin with.

Quality counseling means that the therapist does not make the mistake of jumping in too quickly, but instead, builds rapport early on, taking adequate time to establish trust.

While the exact process of building rapport is dependent on the individuals involved, skilled counselors can gauge each client's degree of responsiveness at the beginning of treatment. Building rapport in ways that serve the unique needs of clients is essential, as it enhances the client's motivation to work with the therapist toward achieving his/her treatment goals (Tahan & Sminkey, 2012).

3. Fit between Client and Counselor

Just as there is a wide range of physician specialties, mental health professionals are also diverse in terms of academic training and treatment focus. Therefore, mental health counselors also need to be matched with their clients' needs, presenting problems, and expectations.

Individuals seeking counseling will benefit from doing their homework regarding differing counseling styles. The therapist's transparency aids this in terms of his/her background, training, and professional manner.

Along with providing clients with easy access to such information, a discussion regarding the counselor's background and treatment approach should occur before initiating therapy. By taking these steps, the counselor is in a better position to avoid the mistake of poor client-counselor fit.

A typical example of a mismatch between counseling approaches and client needs occurs when clients expect more direction than is offered. For example, a counselor trained in client-centered therapy might be less inclined to provide specific guidance to clients; but rather, may guide them toward discovering their own solutions (Rogers, 1945).

On the other hand, a therapist trained in a directive approach would be more inclined to actively advise, teach and support clients in ways to deal with their issues (e.g., Rational Emotive Behavior Therapy; Ellis, 1996).

Stated more simply, a client who sits through silent sessions wishing for the counselor to say something, is not likely to benefit from or continue with such treatment.

Of course, most people are not educated concerning counselor training philosophies, but they do have an idea of what they generally expect from a therapist. If the counseling approach does not seem to fit with the client's needs, it is essential for the counselor to check-in with the client to ensure that his/her expectations are being met.

Therapy may also be undermined due to a poor client-counselor fit in terms of demographic qualities such as age or gender. For example, a female with a violent history with males may be best supported by a female counselor. In sum, research supports the importance of a compatible therapist-client match as a predictor of therapeutic success (Bernier & Dozier, 2002).

4. Empathy

In the words of noted psychologist Alfred Adler (goodreads.com):

We learn in friendship to look with the eyes of another person, to listen with her ears, and to feel with her heart.

Adler is referring to a quality that is fundamental to good therapy: Empathy. Making the mistake of conveying a non-empathetic attitude may result in a resentful, unmotivated client; while also obscuring the therapist's ability to understand the client's situation truly.

Of course, counselors are human and thus may be emotionally affected by a client's problems and behaviors. Nonetheless, professional counselors need to " develop an understanding of how their clients feel and must be able to respect those feelings even when they appear to be making the counselor's job difficult" (Vacc & Loesch, 2000, p. 22).

The construct of empathy plays such a key role in the therapeutic relationship that empathetic listening skills have been suggested as an essential component of evidence-based counselor training (Moyers & Miller, 2013).

5. Professionalism

Non-professional therapist behavior represents a grave mistake with the potential to undermine the goals of therapy.

In many ways, professionalism in the therapeutic setting is much the same as that in other types of jobs.

For example, counselors are expected to be on time, well-groomed, and appropriately dressed. Showing up late is a significant error for therapists, as it sends a message that the client's time is not important. Such a message is, of course, contradictory to the counseling objective of promoting a client's self-esteem and positive well-being.

Additionally, counseling sessions are typically brief and expensive, so tardiness has other costs for clients.

Clients also are put off by counselors who fail to respond to their phone calls, act distracted during sessions (e.g., glancing at the clock), or talk either too much or about themselves. The client is there to receive attention focused on his/her problems and is likely irritated by a counselor who doesn't listen or comes across as self-interested.

The office setting also needs to project a professional climate, as a disorganized office does not inspire confidence. Additionally, disorganized files may elicit privacy-related concerns for the client. Professional therapists also engage in adequate preparation for each counseling session.

For example, when counselors fail to remember important client information from week to week, clients are unlikely to feel that they are being heard. While many examples of professional counseling behaviors are commonsensical, more detailed and specific guidelines regarding ethical and professional counseling practices are also available to readers (e.g., ' Professionalism, Ethics, and Value-Based Conflicts in Counseling,' Francis & Dugger, 2014).

6. Skill, Knowledge, and Confidence

Counselors are expected to be skilled communicators who are " knowledgeable of those aspects of mental health that relate to the development, relief, and solution of an individual's emotional and other concerns which are associated with quality of life" (Vacc & Loesch, 2000, p. 18).

Making the mistake of administering treatment without adequate skill, knowledge, or confidence diminishes the client's trust in the guidance being provided. Similarly, if a counselor comes across as nervous and lacking self-confidence, he/she has personal work to do before seeing clients.

A good counselor also has acquired adequate substantive knowledge and is confident about his/her theoretical approach. Losing sight of one's theory is problematic as it may result in advice that is not scientifically based.

Skilled counselors also understand timing and can avoid the negative consequences of prescribing a particular intervention before the client is ready (Methven, Odell, & Weeks, 2005).

Performing as a competent therapist is an ongoing process. It means that counselors are informed about evidence-based practices and that they stay abreast of new developments. As such, it is through continued growth and education that counselors can provide the best available treatment for their clients.

7. Boundaries

The client-counselor relationship is not like those that occur in other aspects of life.

It is bound by specific constraints for a good reason, as it is a professional relationship and not a friendship.

Making the mistake of blurring client-therapist boundaries leads to several issues related to trust, as well as a misunderstanding regarding the roles and responsibilities of both parties.

For example, pursuing a client relationship outside of therapy is a major boundary violation that diminishes the therapist's professional role. Being emotionally reactive to or overprotective of clients also represent additional ways in which a counselor may blur therapeutic boundaries and increase the likelihood of making poor treatment choices (Methven et al., 2005).

Therapists also violate boundaries by allowing sessions to go over-time and by oversharing personal information. Failing to attend to their nonverbal cues is another area related to boundaries, as clients have reported a therapist's body language as important for early therapeutic alliance-building (Bedi, 2006).

Generally speaking, some boundary violations are pretty obvious; whereas, others depend upon the individuals involved. The important point is that both the therapist and the client are comfortable and in agreement with the parameters established during the counseling process.

8. Assumptions

It is often the case that clients continue to attend treatment despite a lack of satisfaction with the process. However, as clients will not always raise these issues, it is a mistake for therapists to make assumptions regarding the client's satisfaction with the nature and progression of treatment.

For example, if a client would prefer that the counselor offer more directive guidance, he/she may not have the confidence to make such a request. Moreover, the client may not even realize that the counselor has the flexibility to alter his/her approach.

By checking in regularly with the client, the counselor is better able to avoid making assumptions and thus to develop a counseling strategy that is consistent with the client's needs and expectations.

It is for this reason that consistent monitoring of a client's responses to counseling is encouraged by the Task Force on Empirically Supported Relationships (Ackerman, Benjamin, & Beutler et al., 2001).

9. Optimism

A client seeking mental health treatment needs to feel that the practitioner has hope in his/her ability to get better. After all, if the counselor isn't optimistic about the client's future, then why should the client have confidence in the treatment?

This notion is supported by research indicating that an optimistic and confident attitude among counselors is vital for positive patient outcomes during short-term therapy (Heinonen, Lindfors, & Laaksonen et al., 2012).

Along these lines, competent counselors express genuineness, courage, and positive skepticism toward their clients (Vacc & Loesch, 2000).

Failing to convey a generally optimistic attitude represents a significant counseling mistake, as it is the role of the counselor to instill a sense of encouragement, as well as to inspire and motivate. Moreover, by identifying and encouraging specific goals along the way, the counselor sets-up a hopeful trajectory that inspires the client's confidence in the therapeutic process.

10. Multicultural Competence

Counselors need always to be sensitive to each client's cultural background-a concept that is becoming increasingly relevant in countries where the prevalence of minority groups is on the rise.

The mistake of failing to understand and convey multicultural competence with diverse clients represents such a vital counseling mistake that multicultural competence in counseling is among the ethical guidelines established by both the American Psychological Association and the National Association of School Psychologists (Prout & Brown, 2007).

Trust is diminished when therapists are unable to relate to or empathize with a client's acculturation challenges. While it may be optimal for clients to be matched with counselors in terms of ethnic background, this is rarely feasible. However, counselors convey respect by educating themselves in terms of the history and culture of minority clients, as well as methods that enhance multicultural sensitivity.

The importance of multicultural competence is indeed supported by academic literature. For example, cultural competency training has been associated with increased client satisfaction with the counseling process (Way, Stone, & Schwager et al., 2002). Additionally, cross-cultural sensitivity has been reported as an essential counseling component across various racial and ethnic groups.

For example, in her work with Muslim refugees, Eltaiba (2014) found rapport-building to be an essential aspect of culturally sensitive therapy. Similarly, in a study examining cross-cultural counseling with Asian clients, miscommunications and unintended insensitivities were diminished when therapists understood important language and cultural differences between themselves and their clients. (Eum Kim, 2004).

Generally speaking, a counselor's beliefs, background, sexual orientation, prejudices, and racial or cultural identity may come into play during therapy-mainly when working with clients from diverse backgrounds (Prout & Brown, 2007).

The counselor's ability to be introspective and to understand the potential impact of his/her personal beliefs and attributes on the therapeutic process is essential for achieving sensitive, unbiased therapy. Included in this understanding is the counselor's examination of his/her degree of privilege (Arredondo, Tovar-Blank, & Parham, 2008) and the potential for abuse of power.

Additionally, a multiculturally competent therapist is better able to select culturally appropriate therapy intervention approaches for clients (Prout & Brown, 2007).

11. Self-compassion

Mental health professionals are often compassionate people by nature. However, being a therapist is not easy, as listening to others' problems on a day-to-day basis can take an emotional toll. As such, failing to practice self-compassion is a mistake that increases the risk of burn-out among therapists (Patsiopoulos & Buchanan, 2011).

There are a variety of effective ways for a counselor to exercise self-care (e.g., regular breaks, relaxation exercises, eating well, exercising, etc.); the choice of approaches depends upon his/her unique interests and needs.

For example, engaging in meditation is a self-care method that has been associated with reduced burnout among professional counselors (Ringenbach, 2009). Overall, by identifying and practicing self-compassion, therapists will be in a far better position to enjoy a fulfilling career in which they support the emotional needs of their clients.

Couples' Counseling: 5 Mistakes

While the above counseling mistakes apply across counseling types, several issues are especially applicable within particular counseling contexts.

Couples' counseling represents one such situation.

For example, couples counselors must work consistently to avoid showing a bias toward one individual. This is tricky territory, as the counselor may feel that one member of a couple is relatively more at fault.

However, showing favoritism toward one person is likely to perpetuate the couple's mutual antagonism. Moreover, it may create resentment toward the therapist or alienate a spouse who was not overly motivated about participating in counseling in the first place.

When working with two clients, the counselor also must be mindful that he/she is dealing with two-often highly opposing-sides of a story. Therefore, to avoid making incorrect assumptions, the counselor needs to collect sufficient information to get a good sense of the couple's presenting issues and individual perspectives (Methven et al., 2005).

In a similar vein, counselors need to recognize how their own experiences may impact the assumptions they make about clients. For example, Kottler and Carlson (2011) describe a teachable moment in which, based on his sexual orientation, a therapist made the problematic assumption that his clients also belonged to the dominant heterosexual population.

Other mistakes made among couples counselors include not identifying the actual client (e.g., the couple versus one individual), not establishing ground rules at the outset, and believing that there is an objective truth to be discovered (Methven et al., 2005).

In summary, when dealing with couples, counselors should avoid making the following mistakes:

Showing bias or favoritism

Failing to collect enough information about both people to avoid making assumptions

Failing to establish ground rules at the beginning

Failing to identify the actual client

Engaging in a "search for truth"

Group Counseling: 8 Mistakes

As with couples counseling, group therapy requires a seemingly unbiased therapist who allows equal attention and time for each member of a group.

Because the counselor is dealing with multiple people, personalities, and issues at once, he/she needs to be prepared for several problems that may arise. In their informative book: ' Group Counseling: Strategies and Skills,' Jacobs, Masson, Harvill, and Schimmel (2012) outline several problematic situations that are common in group counseling.

One such issue occurs when the leader's approach lacks in purpose or structure. Group counseling is challenging, as it requires a confident leader who establishes the objectives, rules, and general structure of the group at the beginning.

If a counselor lacks the leadership skills and confidence needed to do so, performing group therapy may not be the best idea-at least not until undergoing relevant training. Otherwise, group dynamics may take over, resulting in disorganized and nonproductive sessions.

Other salient issues that occur during group counseling include the following: Chronic talkers who monopolize conversations; group members who refuse to speak at all; dominating personalities who attempt to take over the group; pessimistic group members; individuals who try to distract others; persistent criers; and those who behave with hostility (Jacobs et al., 2012).

Additionally, group leaders are more likely to create successful sessions when they give participants sufficient time to speak, model appropriate ways to respond, are sensitive to minority group participants, react appropriately to tearful individuals, and help quiet group members to be heard (Chen & Rybak, 2018).

Overall, failing to be a confident leader and mentor who can successfully manage these types of situations during group counseling is a proven way to derail the therapeutic benefit for everyone involved.

In summary, when dealing with groups, counselors should avoid making the following mistakes:

Lacking a clear purpose

Failing to establish objectives, rules, and structure at the outset

Lacking in leadership skills or confidence

Failing to deal with challenging client personalities and behaviors

Failing to show sensitivity to emotional clients

Failing to model adaptive responses when needed

Failing to divide time among group members fairly

Failing to show sensitivity to diversity within the group

Child and Adolescent Counseling: 9 Mistakes

Working with children and adolescents is a unique skill that requires many important considerations.

First, counselors working with minors must be highly aware of state laws surrounding issues of privacy (e.g., with respect to sexual behavior or drug use).

Moreover, failure to discuss such laws with both the child and participating adults may result in a variety of problems.

For example, if a parent is not aware that his/her child has the right to discuss topics privately with the therapist, he/she may become upset and insistent on breaching the minor's rights to confidentiality. The therapist's transparency easily avoids this situation before commencing therapy.

Second, child/adolescent therapists must understand that children are different from adults in multiple ways, including linguistic and cognitive development. As such, expressing emotions may be more challenging for children because of their relative lack of verbal ability and abstract thinking (Prout & Brown, 2007).

Therefore, the counselor may need to create alternative ways for the child to express his/her feelings. Similarly, counselors may fail to recognize the unique motivation of children/adolescents versus adult family members with respect to attending therapy.

For example, a child or teen may not have volunteered for therapy nor understand why it is needed-situations that may quickly diminish his/her level of treatment motivation.

Third, child therapists must be able to deal with a troubled and dysfunctional family system. This may result in a child who lacks trust in adults in general, particularly authority figures. Failure to recognize the youth's perspective concerning treatment and the counselor's role may result in an unwilling participant.

To avoid this situation, counselors working with children and adolescents need to take extra time and care in developing rapport early on (Vernon, 2002). Additionally, therapists will achieve better results if they avoid perpetuating child labels within the family dynamic, ensure that their young clients are told the truth, and involve kids and teens in counseling-related decisions and objectives (Myers, Shoffner, & Briggs, 2002).

Approaching youth counseling in this way provides young people with the confidence and empowerment that comes from knowing that their opinions matter.

Fourth, successful youth counseling requires the therapist to understand the client's developmental period (Myers et al., 2002). Clearly, how a child or adolescent perceives the world will be reflected in his/her behavior. Failure to recognize developmental processes will lead to potential misunderstandings and assumptions regarding client needs.

For example, it is not uncommon for adolescents to display symptoms of depression that are somewhat different than those presented by children and adults. Along with different emotional and intellectual capacities, adolescents are in the unique position of trying to navigate their autonomy while transitioning into adulthood. Failure to recognize this may result in teen clients who feel misunderstood by the counselor.

Group therapy counselors who work with children and adolescents also need to adequately account for differing ages, developmental stages, and behavioral issues. For example, in terms of group size, young children-versus adolescents-are more likely to benefit from small positive psychology groups. Additionally, children with behavioral problems may require even smaller groups (Prout & Brown, 2007).

In summary, when dealing with youths, counselors should avoid making the following mistakes:

Failing to understand and communicate privacy issues

Failing to recognize the differing needs of children versus adults

Failing to communicate the reason for treatment and to motivate children and teens

Failing to recognize the youth's role and perspective within a family system

Failing to establish rapport among youths adequately

Failing to involve youths in counseling-related decisions and objectives

Failing to recognize different developmental periods

Failing to understand the unique needs of adolescents in a therapeutic setting

Failing to develop a group counseling structure based on the specific needs of youth participants

A Take-Home Message

Countless individuals worldwide undergo mental health counseling each year. Therapists are tasked with the difficult job of providing best practices for clients who have a multitude of diverse backgrounds, problems, and expectations. Therapists also have their own biases and other qualities that may affect the counseling process.

The primary take-away from this article is that there is a wealth of research-guided information available to therapists that will help to steer them away from making potentially damaging counseling errors. Such mistakes are wide-ranging and fall into categories such as rapport-building, confidentiality, client-counselor fit, and multicultural competence.

Additionally, counseling mistakes are easily identified across a range of counseling situations such as couples counseling, group counseling, and youth counseling.

Generally speaking, therapists who approach counseling in a professional, ethical, empathetic, and optimistic way will be on a more positive track toward achieving desired treatment results.

Moreover, optimal outcomes are more attainable when counselors build trust with clients; are sensitive to the influence of boundaries; avoid making assumptions; practice self-compassion, and approach therapy with adequate knowledge, skills, confidence, and flexibility.

By recognizing the importance of these concepts, therapists will avoid countless mistakes and thus be better equipped to support their clients in achieving meaningful therapeutic outcomes.

We hope you enjoyed reading this article. Don't forget to download our 3 Positive Psychology Exercises for free.

If you wish for more, our Positive Psychology Toolkit© contains over 300 science-based positive psychology exercises, interventions, questionnaires, and assessments for practitioners to use in their therapy, coaching, or workplace.

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33 Counseling Mistakes Therapist Should Avoid and How to Prevent Them

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Counseling has been used to guide individuals toward new insights and coping mechanisms since the beginning of the 20th century. With its widespread use, it is imperative that counseling is performed based on research-supported methods that promote positive client adjustment.

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How are member interactions in a small group counseling session a microcosm of the world? 

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How are member interactions in a small group counseling session a microcosm of the world? 

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An interpersonal therapy group becomes a reflection of group members' general tendencies.  This can be used as information about members' interpersonal functioning as well as an opportunity for learning and behavior change within the group

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Group as Social Microcosm: Within-Group Interpersonal Style IsCongruent With Outside Group Relational Tendencies

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How does diversity impact the development of this stage of group counseling?

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How does diversity impact the development of this stage of group counseling?

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Using the lens of diversity in group counseling includes the following: race, gender, socioeconomic status, age, ethnicity, sexual orientation, disability, and religion.  It is important that the facilitator understand that clients come from many different backgrounds.

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chapter 8: diversity issues in group work

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Chapter 8: Diversity Issues in Group Work - ppt video online download

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Social Identity Groups Social identity groups: a collection of people who share physical, cultural, or social characteristics within one of the categories of social identity Categories Race  Ethnicity Gender  Sexual orientation Socioeconomic status  Disability Age  Religion

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What do typical or expected group member behaviors look or sound like in this stage?

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What do typical or expected group member behaviors look or sound like in this stage?

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The final, closing, or ending stage of group is devoted to bring definitive closure to the group. During this stage, members are encouraged to share what they have learned, note how they have changed, and consider how they plan to use what they have learned. Additionally, members prepare to say good-bye and deal with the group’s end. Some of the tasks that are associated with the termination stage are:
1) Learning from members
2) Maintaining and generalizing change efforts
3) Reducing group attraction and promoting independent functioning

of individual members
4) Helping members deal with their feelings about ending Planning for the future
5) Making referrals
6) Evaluating the work of the group

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What are the overall group characteristics in this stage?

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What are the overall group characteristics in this stage?

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The final stage is when the group understands that they are no longer going to be together. This stage allows the group members to reflect on their experience and decide how they will use the knowledge that they acquired in their future occurrences. This stage often comes with feelings of sadness and separation. During this stage, feedback is very important. It is the role of the counselor to educate on what each member should expect from the experience which includes reminders of confidentiality and change that may not be noticeable immediately. Group members will be encouraged to give feedback to other group members as well and in the end it is up to each member to decide what to do with the experience that they received.

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Stages of Group Therapy: Initial, Transition, Working, and Final Stage

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Learn the 4 stages of group therapy, including the transition stage and working stage, plus what counselors and group members should expect in each phase.

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The counselor or group leader's role is to encourage members to reflect on the progress they have made and identify post-termination goals

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How does member group work transfer to the world outside of the group?

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How does member group work transfer to the world outside of the group?

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It is important that during the termination phase members are urged to consider ways in which they will incorporate their gains in their daily lives.  It is important to be specific, clear, and realistic when helping clients with this process.

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What things would you avoid as a group counselor at this stage?

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What things would you avoid as a group counselor at this stage?

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In the termination phase, it is important to avoid feelings of abandonment.  It is important to discuss ongoing treatment needs of the client before ending the group.  Some members may need more support before the termination phase.

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By Elizabeth M. Felton, JD, LICSW, Associate Counsel and Carolyn I. Polowy, JD, General Counsel
© March 2015. National Association of Social Workers. All rights reserved. Termination
Social workers' therapeutic relationships with their clients eventually come to an end. However, the way they end and how the social worker handles terminations can have ethical and legal implications.

This article will address some of the more common issues that may arise during termination and ways to enhance client care while avoiding allegations of abandonment.

Social workers should assess a client's ongoing treatment needs prior to initiating termination. The NASW Social Work Dictionary defines termination as: "The conclusion of the social worker -client intervention process; a systematic procedure for disengaging the working relationship. It occurs when goals are reached, when the specified time for working has ended, or when the client is no longer interested in continuing. Termination often includes evaluating the progress toward goal achievement, working through resistance, denial, and flight into illness. The termination phase also includes discussions about how to anticipate and resolve future problems and how to find additional resources to call on as future needs indicate."

There are many reasons why therapy ends. A client may terminate at any time for any reason. Ideally, termination occurs once the client and therapist agree that the treatment goals have been met or sufficient progress has been made and/or the client improves and no longer needs clinical services. However, there are many valid reasons that are discussed below as to why the therapist-client relationship may end the treatment before it is completed. Some of those reasons include:

Client has mental health needs that are beyond the social worker's area of expertise. For example, the client requires a different level of treatment (e.g., inpatient or crisis intervention) or more specialized treatment (e.g., trauma or substance abuse) than the social worker provides in the practice setting.

Therapist is unable or unwilling, for appropriate reasons, to continue to provide care (e.g., therapist is retiring/closing practice or client threatened therapist with violence).

Conflict of interest is identified after treatment begins.

Client fails to make adequate progress toward treatment goals or fails to comply with treatment recommendations.

Client fails to participate in therapy (e.g., non-compliance, no shows, or cancellations).

Lack of communication/contact from the client.

It is recommended that therapists have a final session with their clients to review the overall progress before ending therapy, but sometimes this cannot happen, e.g., when the client stops communicating with the therapist. It is suggested that therapists create a policy for their practice so that cases are routinely closed after a certain amount of time without any contact from a client, for example: "If I do not have contact or communication from you for a period of xxxx days, I will assume that you no longer intend to remain active in this therapeutic relationship and your case will be closed. You can return to therapy in the future if you decide to continue treatment."

One way to establish that timeframe is to think about how long you want to be the therapist of record without seeing a client.

Non-payment of agreed upon fees:

Before a social worker terminates for non-payment, the following criteria should be met:
Abandonment

The financial contractual arrangements have been made clear to the client, preferably in writing.

The client does not pose an imminent danger to self or others.

The clinical and other consequences of the non-payment (i.e., disruption of treatment/interruption of services) have been discussed with the client. NASW Code of Ethics, 1.16c

Certain circumstances may support a delay of the termination. For instance, it is not recommended that a therapist end treatment with a client who is in crisis at the time termination is being considered. A social worker has a responsibility to see that clinical services are made available when a client is in crisis. Postponing termination is preferred, if possible, until steps are in place to handle the crisis.

Abandonment is a specific form of malpractice that can occur in the context of a mental health professional's termination of services. Abandonment, also referred to as 'premature termination,' occurs when a social worker is unavailable or precipitously discontinues service to a client who is in need.

In a malpractice case based on abandonment, the client alleges that the therapist was providing treatment and then unilaterally terminated treatment improperly. The client must show that he was directly harmed by the abandonment and that the harm resulted in a compensable injury. The client's dissatisfaction with the outcome is not sufficient to establish the therapist's negligence. The client must also show that the termination was not his fault, e.g., that he kept his appointments, complied with treatment recommendations, and paid his bills.
1.16 Termination of Services
It is critical to be able to establish both the reason for termination and the manner in which it is carried out. After beginning a therapeutic relationship with a client, a social worker must not terminate therapy abruptly without referring the client to another mental health practitioner. If the social worker does not properly terminate the client-therapist relationship, the social worker exposes himself to allegations of abandonment which could lead to a lawsuit, a complaint to the state licensing board, or a request for professional review by the NASW Ethics Committee. Proper termination that has been documented is a defense to abandonment allegations, and it supports good client care.

The NASW Code of Ethics addresses the issue of termination of services in 1.16:

(a) Social workers should terminate services to clients and professional relationships with them when such services and relationships are no longer required or no longer serve the clients' needs or interests.

(b) Social workers should take reasonable steps to avoid abandoning clients who are still in need of services. Social workers should withdraw services precipitously only under unusual circumstances, giving careful consideration to all factors in the situation and taking care to minimize possible adverse effects. Social workers should assist in making appropriate arrangements for continuation of services when necessary.

(c) Social workers in fee-for-service settings may terminate services to clients who are not paying an overdue balance if the financial contractual arrangements have been made clear to the client, if the client does not pose an imminent danger to self or others, and if the clinical and other consequences of the current nonpayment have been addressed and discussed with the client.

(d) Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.

(e) Social workers who anticipate the termination or interruption of services to clients should notify clients promptly and seek the transfer, referral, or continuation of services in relation to the clients' needs and preferences.
Tips for Termination
(f) Social workers who are leaving an employment setting should inform clients of appropriate options for the continuation of services and of the benefits and risks of the options.
What to include in a termination letter?
For more information, see NASW Code of Ethics.

Prepare for termination from the beginning. Termination should be discussed early so both parties can have a number of sessions to discuss ending therapy.

If continued treatment is needed, provide referrals to several mental health professionals, with addresses and phone numbers. Three referrals is the "rule of thumb" minimum. If possible and with the client's consent, assist in the transition to other health care providers.

Conduct the final session face -to-face, if possible. Avoid ending with a text, in an email or with a voicemail message.

Make sure the client understands when, why and how therapy will be terminated.

Document discussions about termination.

Formalize the termination with a personalized termination letter (not a form letter).

Conclusion
It is good practice for a social worker to draft a termination of treatment letter to every client once treatment has ended, regardless of the reason, to formally end the therapeutic relationship. This provides clarity to the client, and it helps avoid any implication that the social worker has an ongoing therapeutic responsibility. The termination letter would be in the form of a business letter and include:

Resources and References

Client's name

Date treatment began

Effective date of termination

State the reason(s) for the termination. (e.g., treatment goals have been met, client's needs are beyond the scope of social's workers practice or area of expertise, non-compliance with treatment recommendations, therapist is retiring/closing practice)

Summary of treatment, including whether you feel further treatment is recommended

If continued treatment is needed, provide three referrals to mental health professionals, with contact information

Present the letter in person during a session or send it with delivery tracking and confirmation of service and/or certified return receipt

Retain a copy of the letter and delivery documentation in the client's file

Mark the letter "confidential"

Don't mention confidential therapeutic treatment information

Addressing the termination of treatment is an important phase of the therapeutic process. For termination to be handled properly, discussions between the social worker and client should occur in advance and be addressed in a thoughtful and sensitive manner. It is best that clients not feel that they have been abandoned, for the sake of the client as well as the social worker. If continued treatment is needed, the social worker must make an effort to assist the client in obtaining ongoing services to ensure that these needs are adequately addressed. Proper documentation of the termination of the therapeutic relationship with the client will provide support for the social workers' effort to meet the clients' needs as treatment ends.

Barbara A. Weiner, J.D. & Robert M. Wettstein, M.D., Legal Issues in Mental Health Care 164-165 (1993). "Codes of Ethics on Termination in Psychotherapy and Counseling," Zuri Institute, Inc.

NASW Code of Ethics (2008)

Richard S. Leslie, J.D., Termination and Referral - When Does the Duty to the Patient End?, October 2008.

Robert L. Barker, NASW Social Work Dictionary 336, 433, (5 th ed. 2003).

Robert L. Barker, NASW Social Work Dictionary 433, (5 th ed. 2003).

Barbara A.Weiner, J.D. & Robert M. Wettstein, M.D., Legal Issues in Mental Health Care 164-165 (1993).

Richard S. Leslie, J.D., Termination and Referral - When Does the Duty to the Patient End?, October 2008.

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By Elizabeth M. Felton, JD, LICSW, Associate Counsel and Carolyn I. Polowy, JD, General Counsel © March 2015. National Association of Social Workers. All rights reserved. Social workers' therapeutic relationships with their clients eventually come to an end. However, the way they end and how the social worker handles terminations ..Read More...

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How does diversity impact the development of this stage of group counseling?

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How does diversity impact the development of this stage of group counseling?

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Diversity in counseling impacts the termination phase in how the client views his/her support system once the group ends.  Some clients may be ready to use the skills they learned during the group.  Others may not have any support outside of the group setting.

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Abstract

Achieving effectiveness of therapeutic interventions across a diversity of patients continues to be a foremost concern of clinicians and clinical researchers alike. Further, across theoretical orientations and in all treatment modalities, therapy alliance remains a critical component to determine such favorable outcome from therapy. Yet, there remains a scarcity of empirical data testing specific features that most readily facilitate effective collaboration in a multi-cultural therapy relationship. This article reviews the literature on terminology, empirical findings, and features to enhance collaboration in multi-cultural therapy, suggesting guidelines for achieving this goal in therapy with patients (and therapists) of various cultural/racial backgrounds. This is followed by a multi-cultural case study presenting with several co-morbid Axis I disorders, to exemplify the application of these guidelines over the course of therapy.

The role of culture in psychotherapy has been gaining significant attention in the past few decades ( Wohl, 1989; Seiden, 1999; Draguns, 1997), particularly as the populations seeking psychological services grow increasingly diverse. Indeed, an often prominently stated aim of training programs for mental health practitioners includes the need to ensure the cultural competency of those delivering psychological treatments ( Heppner, Leong, & Gerstein, 2008). Unfortunately, often this recognized need is insufficiently met because (1) of a lack of a definitive structure and specific goals to achieve this cultural competency in therapists, and (2) scant empirical data to support one training model over another ( Laungani, 2005; Whaley & Davis, 1997). This distinct gap between stated intent of incorporating cultural differences into current evidence-based treatments, and actual clear guidelines for accomplishing this goal must be more directly addressed.

Further, the importance of establishing a strong rapport with patients and developing a firm therapist-patient alliance to target emotional symptoms remains an overarching goal of the field of mental health ( Taber, Leibert, & Agaskar, 2011). This article therefore aims to review the empirical literature on effective enhancement of collaboration in the multicultural therapy setting, to reveal the common and specific features across a range of treatment modalities. This is followed by a case study of an actual patient to exemplify how these features may be incorporated into treatment with a multicultural client, both in terms of establishment/maintenance of a strong working alliance during treatment, and then in healthy termination of the therapy relationship after a course of treatment.

Key Terms

Researchers have provided several relevant working definitions within cultural therapy that are noted here. The first is culture itself, which in the currently discussed context broadly refers to a system of beliefs, perspectives, and values a group of a particular race/ethnicity or geographic region collectively share. Of course, cultural influence does not work in a vacuum, and Hays (2008) coined an acronym that serves as a reminder to clinicians about the multi-faceted nature of multi-cultural therapy (MCT) in terms of what they need to be ADDRESSING: Age and generational influences, Developmental disabilities and Disabilities obtained in later life), Religion and spiritual orientation, Ethnic and racial identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender. Such a term captures the complexity of cultural identity and the number of factors to consider when we discuss the impact of cross-cultural differences in therapy.

In addition, cultural identity of an individual is tied into other key processes not noted in even this rather comprehensive acronym, such as discrimination and acculturative stress. Briefly, cultural/racial discrimination can be described as a differential treatment of an individual specifically due to certain negative beliefs about that person's cultural/racial group membership ( Karlsen & Nazroo, 2002), and has been found to be linked to negative psychological outcomes ( Chou, Asnaani, & Hofmann, in press). Acculturative stress is more specific to recently immigrated individuals who are undergoing the often difficult process of acquiring and assimilating the cultural characteristics of the host country ( Hwang & Ting, 2008), such that one's own cultural identity is constantly being challenged and changed to varying degrees. Finally, a major construct that certainly influences each individual's cultural beliefs is the idea of individualism versus collectivism, or independence versus interdependence ( Markus & Kitayama, 1991). This broader concept delineates key differences between taking a collectivist/interdependent world view (i.e. that the greatest priority lies in maintaining harmony within the cultural group, and thus individual gain is deemphasized), from an individualist/independent value system (i.e. focus on individual achievement and success is deserving of the greatest social admiration/reward). Indeed, several empirical studies have found differences based on this construct in acceptability towards, and extent of, certain psychological symptoms, including social anxiety ( Heinrichs et al., 2006), and depression, personality disorder features, and OCD ( Caldwell-Harris & Aycicegi, 2006). Again, these are important considerations that inform our understanding of the cultural lens of patients engaging in something as personally revealing as psychological therapy.

One other concept that is of particular importance in the current discussion is that of cross-cultural competency, which provides an index of how skilled (1) a clinician feels about their abilities to manage cultural issues raised in therapy, and (2) a patient perceives the clinician to be in their ability to handle such topics in the therapeutic context ( Lee, 2011). A survey of 689 APA-licensed psychologists found that while practitioners reported having discussions about cross-cultural issues, they only did this with less than half of their cross-ethnic/racial clients, although this was for a variety of verbalized reasons ( Maxie & Arnold, 2006). Further, the therapists most likely to discuss cultural differences with patients were those who were older, female, of non-minority racial status, those who felt they were less experienced with treating diverse clients, and those who felt training is an important feature of effective therapy delivery. Indeed, a considerable amount of discussion has revolved around the need to develop a cultural competency in the field of cross-cultural psychotherapy ( Sue, 1998; Kaweski, 2010; Taylor, Gambourg, Rivera, & Laureano, 2006). Yet, an empirical study examining the impact of the competency ratings by 143 patients of their therapists (N= 31) found no significant association between patients' perceptions of therapist cross-cultural competency and actual therapy outcome ( Owen, Leach, Wampold, & Rodolfa, 2010). Such a finding indicates that the process is likely to be more complex than simply providing superficial mention of cultural issues during therapy, or clinicians' degree of experience with diverse patients. Other experts in cross-cultural treatment have noted that simply instructing clinicians to simply be sensitive to cultural differences or to familiarize themselves with the culture-specific norms of clients is insufficient and not particularly beneficial ( Sue & Zane, 2009). Given this inconsistency in the literature on the impact of cultural competency on outcome, there needs to be a more systematic empirical study of this concept across a diversity of populations.

Empirical Data Identifying Specific Features

While differential rates in report and diagnosis of certain disorders across race-ethnic groups in the United States have been noted in several large-scale epidemiological studies ( Grant et al., 2005a, b; Pole et al., 2008; Asnaani, Richey, Dimaite, Hinton, & Hofmann, 2010), the empirical data in the efficacy and structure of culturally responsive therapy is still limited. One meta-analysis examining a mix of 65 experimental and quasi-experimental studies (which included 8, 620 participants) revealed a modest effect size (d = 0.46) in favor of culturally-adapted treatments for clients of color as compared to traditional treatment procedures ( Smith, Rodriguez, & Bernal, 2011). Further, results indicated that when mental health treatments were designed targeting one particular cultural group in mind, these treatments outperformed other treatments serving patients from a variety of cultural backgrounds. Such findings highlight two needs: (1) more rigorous, stricter treatment designs to fully examine the relative benefit of culturally-specific treatments, and (2) more systematic research into the specific components of culturally-sensitive therapy that predict maximal benefit to clients. While both of these needs are recognized by proponents of culturally-responsive psychotherapy, there have been a reasonable number of smaller qualitative studies on specific aspects of multicultural therapy. Such studies provide rich insight into the factors that clinicians are advised to consider when engaging in therapy with clients of varying cultural backgrounds, and preliminary directions for most robust, experimental study designs.

One study by Tsang, Bogo, & Lee (2011) analyzed the session transcript data of nine cases from pre- to post-treatment. Complex coding procedures from a narrative research perspective were supplemented by the information provided on various process and symptom measures (which were both subjective and objective in nature). The analysis revealed that therapists who actively and positively engaged in cross-cultural conversations during therapy more effectively expressed an understanding of what the patient's goals and needs in therapy were, appeared more emotionally in-tune with clients, and demonstrated appropriate management of cultural experiences raised by the client.

Another qualitative study investigated the impact of how practitioners from a dynamic or relational treatment perspective addressed cultural issues with clients on the strength of the treatment alliance ( Lee, 2009). The therapists in this study consisted of 4 white clinicians, and the content of their therapy sessions with 6 minority patients were analyzed using Conversation Analysis and Structural Analysis of Social Behavior. The study results revealed that therapists' specific interactions during cross-cultural discussions were associated with the Bond subscale of the Working Alliance Inventory-Short Revised (WAI-SR; Hatcher & Gillaspy, 2006), which measures the interpersonal connection shared between clinician and patient. There was no significant association between these moment-by-moment interactions and the other two main subscales, i.e. extent of agreement on the target of treatment (Goals subscale) or degree of agreement on what needs to be done specifically to achieve these goals (Tasks subscale). Again, it appears that cultural congruence between client and therapist plays a role in enhancing the moment-to-moment collaboration and alliance of the therapeutic relationship. Such a finding further points to the need to incorporate cross-cultural features explicitly into treatment to facilitate the therapy relationship, regardless of treatment modality.

Features of Effective Collaboration in Multicultural Therapy

Taken together, the empirical and observational findings discussed thus far reveal several data-driven guidelines and hypotheses about how therapists' cross-cultural competency may be improved, and how the therapeutic bond may be most strengthened in a cross-cultural therapy setting. In addition, there are several other cross-cultural models examining the establishment of a strong working alliance, which are themselves grounded in existing evidence-based research findings (e.g., Hays, 2009; Fontes, 2008; Sue & Zane, 2009). The common features and themes as gleaned from these various sources are integrated to produce the following guidelines for practitioners.

Guideline #1: Conduct a thorough culturally-informed but person-specific functional assessment of presenting problem

Before modifying an existing treatment to be more culturally sensitive, therapists should fully assess how much of the individual patient's presenting problems may be interlinked to his or her cultural identity/related constructs. That is, clinicians must be wary of premature adoption of a modified treatment simply because an individual is from a particular cultural group ( Sue & Zane, 2009). All patients must still be regarded as unique individuals who lie on a more dynamic spectrum of cultural identification, and cultural groups must be seen as heterogeneous populations with some more or less likely dominant themes. Related to this, before engaging in any adaptation of existing treatment techniques, there must be adequate information gathered about how cultural beliefs are specifically shaping or maintaining problematic emotional symptoms. A clinician should not make blanket assumptions about how a specific cultural belief introduced by patients informs their experience of distress. After a comprehensive functional assessment of the patient's problems, the clinician can consider the remaining guidelines.

Guideline #2: Engage in self-education about specific cultural norms and consult the literature for culture-specific treatment techniques

As the meta-analytic findings by Smith and colleagues (2011) would indicate, patients might most benefit from treatments that have been specifically modified for a certain population rather than more generally culture-sensitive treatment techniques. As mentioned earlier, it is imperative that as we embark on cross-cultural therapy that we stay as close to the empirical data to guide us about effective treatments with different populations. Therapists should therefore first refer to the literature about whether specific cultural adaptations of existing treatments have already been tested and validated (e.g. Latinos: Borrego, 2010; Native Americans: BigFoot & Schmidt, 2009; East Asians: Hwang, Wood, Lin & Cheung, 2006; Southeast Asians: Otto & Hinton, 2006; African Americans: Kelly, 2006). Further, such a review of the literature will enlighten the therapist on what beliefs are the norm of that culture to reduce miscommunication in therapy, and will garner patient confidence in the therapist's abilities and knowledge.

Guideline #3: Ensure adequate and effective training of therapists in cross-cultural competency

While the literature is mixed (e.g. Owen et al., 2010), there is some evidence that patients' perceptions of how culturally competent the provider is can affect the working alliance ( Maxie & Arnold, 2006). Also, it is clear that cross-cultural therapy is a complex and multi-layered process, and therefore ensuring cultural competency in mental health work is not simple for trainees to undergo. It is therefore obviously not enough to assume that garnering cross-cultural competency is just a matter of educating oneself about cultural differences between therapist and client ( Sue & Zane, 2009). Rather, others have suggested that therapists need to have a keen awareness of their own cultural and racial identity, and how this may impact their relationship with clients ( Plummer, 1997). For instance, multicultural researchers have noted the importance of having practitioners discuss their feelings about treating cross-cultural patients with their professional peers or supervisors ( Barbarin, 1984), and exploring attitudes toward psychological help-seeking in their own communities ( Chung & Lu, 1996). Such a reflection is indicative of an appreciation for the bidirectional influence of culture in a therapy interaction, to facilitate a healthy dialogue about sensitive cross-cultural topics that might arise during treatment.

Guideline #4: Explore the patient's perspective on both seeking psychological treatment, and the nature of the therapeutic relationship

There have been observed differences in perceptions of obtaining mental health treatment among minority groups, and empirical evidence for the distinctly higher stigma associated with obtaining psychological help in a number of minority cultures ( Shea & Yeh, 2008; Alvidrez & Azocar, 1999). Therefore, it may become necessary to first address the stigma around receiving such treatment, particularly assessing for the impacts of this on the individual's sociocultural network. For instance, an individual identifying with predominantly collectivist or interdependent cultural values may regard the need for therapy as a sign of weakness and embarrassment to one's family or community ( Furukawa & Hunt, 2011), and this topic must be made explicit, particularly if treatment progress or adherence becomes stalled. In addition, giving validation and respect for the client's perspective on mental health treatment will further enhance clinician-patient trust and bolster the therapeutic bond.

A related matter is being aware of the preference for a preconceived ideal of an appropriate relationship between the client and clinician. Specifically, most treatment perspectives in the West emphasize a collaborative therapeutic relationship ( Taber et al., 2011), but this might be isolating or confusing to individuals from certain cultural backgrounds. In fact, individuals identifying with cultures which are hierarchy-based (e.g., Eastern cultures) might expect a more directive, authoritarian approach in the therapy relationship ( Tsui, 1985), and an over-emphasis on an equal therapist-patient relationship and socratic, open-ended questioning might raise doubt in the patient about the therapist's capabilities to treat the problem at hand. On the other hand, certain treatment perspectives (e.g. CBT) involve a considerable amount of direct questioning, which might be construed as disrespectful in other cultures (such as Native Americans, and older European Americans; Hays, 2009). Such considerations serve as a reminder of the importance of thorough initial assessment of an individual's cultural beliefs and influences, to prevent an early rupture in the therapeutic alliance.

Guideline #5: Be aware of the importance of respect in the cross-cultural therapy setting

Clinicians engaging in multi-cultural therapy must set an overarching tone of respect in order to meet the goals of therapy collaboratively with the client. This means allowing individuals to fully express their individual stories and to explain how their cultural beliefs have been uniquely part of this story ( Coronado & Peake, 1992). Furthermore, establishing trust in the therapy relationship is intricately interconnected to the level of respect shared between the client and therapist. To that end, it is important that therapists validate the client's experiences, including encounters with cultural or racial discrimination, and possible oppression in the majority culture. Patients want to feel believed and therefore clinicians are advised to assume the reported incident occurred just as it was described by the patient, to provide support around such an experience, and then to later examine how much that experience has influenced the current symptoms of interest ( Kelly, 2006). Aligning oneself with patients by demonstrating full support for the difficult race- or culture-related stressors they may be facing will mitigate hesitation in discussing such sensitive issues with the therapist ( Vasquez, 2007).

Guideline #6: Identify and incorporate client's culturally-related strengths and resources into treatment

One general guideline across contemporary models of psychotherapy refers to an exploration of individual strengths in order to enhance treatment success and adherence, and this can be taken one step further in MCT. For instance, the identified culture itself can be a major resource and provide an extensive support network for the client ( Cross, 2003). Also, culture itself influences a range of culture-specific skills (e.g. naturalistic medicinal knowledge, cooking, fishing, farming, etc.), coping mechanisms (e.g. culture-specific metaphors for understanding emotional symptoms; Hinton, Lewis-Fernandez, & Pollack, 2009), interpersonal organizations and community resources (culturally-oriented political or social causes, places for worship, or financial resources), and artistic outlets for emotion (through dance, art, and music; Hays, 2007).

Thus, it is important to bring these culture-influenced strengths of the individual to the therapy discussion, particularly if these positive attributes may be incorporated into treatment techniques and practice. Hays (2009) astutely notes, however, that certain cultures (e.g. Asians & Native Americans) are culturally socialized to be modest about individual strengths, and therefore these might not be easily verbalized if such individuals are directly questioned about their own strengths. It is therefore suggested that individuals from this more interdependent cultural set-up be asked to think what other significant individuals in their lives might say the strengths of the patient are, in order to access this information and incorporate it into the therapeutic relationship more readily.

Guideline #7: Identify and utilize technique-specific cultural modifications

Finally, as clinicians and clinical researchers, our foremost concern in mental health treatment is ensuring adequate delivery of treatment techniques that will result in noticeable improvement in our clients' symptoms. Therefore, while it is reasonable to utilize treatment techniques that have been seen to be efficacious, we must be ready to modify these techniques in a culturally-sensitive fashion. Again, it is ideal to make cultural modifications that have been validated in the population of interest, but in the absence of definitive empirical evidence for all possible modifications, we must use our cross-cultural knowledge to make reasonable changes to effective techniques. For instance, in the CBT framework, we often ask clients to question the validity or reasonableness of a particular negative automatic thought, but this might be regarded as uncaring on the part of the therapist, and places negative judgment on the client's belief system ( Wood & Mallinckrodt, 1990). The therapist might choose instead to take a more culturally responsive approach ( Beck, 2005) and ask clients to question the utility or helpfulness of the thought, encouraging them to weigh out the pros and cons of holding on to this belief. Similarly, CBT often leads to an eventual challenging of core (negative) beliefs that a patient holds about themselves or the world. Therapists must be cautious of directing patients to challenge their core cultural beliefs, even if a particular belief of the client seems incongruent or problematic within the therapist's own cultural value system.

With these guidelines in mind, the next section describes a case treated by one of the authors (AA) and highlights the practical use of these techniques throughout the treatment episode. The influence of these culturally-responsive directives are demonstrated in the progressive development of a strong working alliance in the following clinical case study.

Application of Alliance-Building Techniques: The Case of Karen

Karen was a 37-year-old Jamaican-American female and a single mother of 3 teenage-age children, who had recently lost her job due to a change in ownership at her medical insurance firm. Karen presented to our cognitive-behavioral treatment (CBT) clinic with a primary diagnosis of panic disorder with significant agoraphobia, and additional diagnoses of obsessive-compulsive disorder and generalized anxiety disorder. She had also had a past history of major depression and post-traumatic stress disorder from chronic and multiple traumatic experiences. Karen had pursued significant prior treatment, but with little relief in her ongoing anxiety symptoms.

She had decided to pursue treatment at our clinic because she had read about the efficacy of CBT for treatment of various anxiety symptoms. She also hoped that the more structured and short-term nature of this type of treatment might help her develop a more healthy attachment to her provider, which had been difficult in the past. It therefore became apparent from early on in treatment that one therapy goal would have to be to effectively develop a strong working alliance while balancing reasonable boundaries to keep the purpose of the therapeutic relationship clear. This goal was explicitly stated from the outset, and framed as being in the best interest of both the patient's progress and to maintain treatment fidelity and effectiveness. However, it was recognized that much of Karen's current support system lay in the familiarity of relationships in her religious and ethnic community, therefore it might take some time for her to feel comfortable with a more formalized and boundary-imposed relationship with her therapist.

Guideline #1: Conduct a thorough culturally-informed but person-specific functional assessment of presenting problem

The primary aim in the first several sessions was to fully explore the role of cultural beliefs in the development and maintenance of Karen's symptoms. Within the first session itself, Karen expressed her strong religious belief and heavy involvement in church. Related to this, it was clear that Karen received many negative messages from her children, mother, and church friends about both her experience of panic-symptoms, and her decision to receive "outside" (i.e. outside of the Caribbean American community) psychological help. This did not deter Karen from seeking treatment, but through therapist exploration, Karen admitted that this certainly fueled her own negative beliefs about being different from everyone around her and made her feel discouraged about ever becoming better. She also felt depressed about not being able to "kick these symptoms" on her own simply through prayer and faith as others suggested, and felt like a failure about this perceived deficiency.

With these larger cultural themes in mind, the therapy content started focusing on specific anxiety symptoms, and explored how culture infused her psychological symptoms in more detail. For instance, Karen reported that her obsessive thoughts about being poisoned by others (which would result in avoidance of eating or drinking items given to her by others at their homes, or in other settings outside her own home) stemmed from a strong belief in black magic, and that others were trying to harm her out of jealousy and control by the devil.

Guideline #2: Engage in self-education about specific cultural norms and consult the literature for culture-specific treatment techniques

The strong belief in black magic and having "an evil eye" cast upon someone was recognized as a widely-accepted, culturally-congruent belief in individuals from the Caribbean, and the therapist therefore did not question the validity of this belief. Pathologizing such a common belief from that cultural system as disordered or undesirable was regarded as culturally insensitive and potentially isolating for the patient. Instead, the therapist focused more on increasing her motivation to target the avoidance and interference associated with this thought.

Similarly, given the expressed importance of religion in Karen's life view, the therapist explicitly incorporated Karen's spiritual strengths into the treatment very early on, particularly to target the stigma she experienced from others surrounding her decision to pursue psychological treatment. Specifically, the therapist proposed the idea that Karen's decision to seek formal help to address her anxiety symptoms was an example of her following her own internal spiritual compass in order to maximize her strengths and abilities to contribute to her community and family. Karen really started identifying with this perspective shift, and became much more receptive to the more traditional treatment techniques presented when they were framed with this religious lens.

Guideline #3: Ensure adequate and effective training of therapists in cross-cultural competency

An interesting feature regarding these two interrelated themes (philosophical perspective and stigma) was that Karen actually challenged the therapist to reflect at a very early stage in treatment about her own beliefs regarding these issues, and how that might affect the therapeutic relationship. Typically, therapists' opinions on such topics are avoided; that is, as clinicians we are instructed to re-direct patients' questions about our own personal beliefs. However, this was recognized as quite likely to be detrimental to the therapeutic alliance, and would run the risk of having Karen disengage from treatment because of a feeling of disconnection from the therapist. An excerpt from the session where the patient directly questioned the therapist about her own beliefs is given below:

Karen:"There's one more thing I need to ask you before we end today. Do you think people who need therapy are weaker?"

Therapist:"I want to make sure I understand what you're asking me, since this seems pretty important to you. Do I think such individuals are weaker than who - those who do not seek a therapist, or those who do not experience emotional distress? And why is it important for you to know how I feel about it?"

Karen:"Those who do not go to a therapist - I don't think anyone is completely free from emotional distress. Do you think that I really should be able to deal with this on my own, and that generally your work is to help people who are weak?"

Therapist:"First, I completely agree with you - I think each and every one of us struggle with emotional distress, and therapy can be a great way for all of us to get some support and skills to deal with our tough times better. That also means that I actually think you're not weak, but very strong to take the steps to come to therapy, particularly because I know you don't get a lot of support for that from those who are close and important to you. Is that partly why you were asking, to see if I feel the way they [her mother, children, and church community] do?"

Karen:"Kinda, yeah. It's hard not to feel weak, because no one else in my life is in therapy."

Therapist:"I can completely understand that feeling. You know, Karen, when I told my family that I wanted to study Clinical Psychology, they were extremely resistant to it. They didn't feel "mental health" was a real thing, and weren't even quite willing to accept that anything except willpower or prayer to a higher power could affect our emotional distress. Yet, I had to make a tough decision to stay true to my course of study despite their protest, because I felt that while willpower and spiritual pursuits can be extremely powerful, they are not always effective on their own, in the absence of other resources. I think you and I are a lot alike in that way - both determined to do our best and get the most out of our lives, even when our families or communities might not agree. It's hard to stay patient until they come around and see the benefits like we do though, isn't it?"

Karen:"I know! Sometimes I just want them to open their eyes and minds to see that I was right about this being important and useful for me, and I even think some of them need similar help, but they're too stubborn to get it. You're right, I am determined, and I do feel good about sticking to my beliefs about making my mental health a priority. I can feel God's guidance in doing that. So even if they disagree, I'm not going to give up on this. I need this jumpstart in my life."

As exemplified in this excerpt, the therapist adequately revealed some personal beliefs and experience with stigma observed around seeking psychological help in her own life. This was presented after consultation with other clinicians, the literature, and reflection on her personal beliefs towards psychological dysfunction. Even with only this partial disclosure on the part of the therapist, Karen expressed feeling respected and more willing to continue with treatment with this provider.

Guideline #4: Explore the patient's perspective on both seeking psychological treatment, and the nature of the therapeutic relationship

As mentioned previously, Karen reported having several past treatment episodes, with little sustained improvement in her anxiety symptoms. She noted, however, that she had deeply enjoyed several of these therapy experiences, specifically because of the strong therapeutic relationship she shared with the providers during those experiences. That being said, in the first session she verbalized a concern that her close relationship with her past therapists eventually became a disadvantage, primarily because she found it difficult to terminate these relationships or to continue with skills independently once therapy ended. This provided insight into Karen's own perceptions and concerns around an ideal therapist-client relationship.

Boundary setting in the therapy relationship therefore became a shared goal throughout the course of treatment. This had to be handled in a culturally-responsive way, because it was important not to make Karen feel isolated in her experiences so she would feel comfortable confiding in the therapist. Yet, Karen often pushed the boundaries of the professional therapy relationship by wanting to call "just to chat", asking the therapist details about her family and upbringing, and wanting the therapist to come to her home community to meet other members of her family and church. These were handled in a manner similar to how matters of religiosity, politics, and related beliefs are typically dealt with in therapy, but the cultural need to feel connected and incorporate the therapist into Karen's own community was acknowledged explicitly.

Guideline #5: Be aware of the importance of respect in the cross-cultural therapy setting

One recurrent problem area was Karen's ongoing worry surrounding a "love-hate" relationship with her mother. Specifically, she felt significant distress when interacting with her mother, and yet she worried constantly about her mother dying, and felt that she would be unable to function with her mother gone. Most of her inner conflict in this relationship stemmed from a strongly ingrained cultural pressure to maintain an active relationship with her mother, but this relationship posed significant barriers to her own ability to be productive and stress-free. The therapist would have been remiss in this case to suggest to Karen that she disengage from this relationship with her mother (which would be inconsistent with the interdependent family/community system). Instead, Karen was asked to reflect thoroughly on this relationship (with various in-session exercises on the pros and cons of her relationship with her mother), to help the patient become comfortable with finding her own balance of meeting her familial responsibility and yet, protecting her own mental health.

Similarly, while Karen expressed many traditional cognitions associated with her agoraphobic concerns (e.g., inability to reach medical help promptly, or to escape when experiencing panic symptoms), she also reported anxiety during exposure exercises around the Center because of a prior experience of racial discrimination when in distress in a similar predominantly White location. This experience was met with empathic validation and it was discussed at length how much her own perceptions of being negatively regarded by others due to her race tie into her fears around being helpless when experiencing panic outside from her own geographic community. Once the patient felt supported and listened to around this concern, the therapist worked on gradually exploring how Karen may more rationally weigh out the probability that every individual around her will refuse to help her based on her race/appearance, and she was receptive to this. In particular, the therapist encouraged her to think of the instances in her life that others from the majority culture had actually been caring and helpful towards her, in order to more rationally evaluate her fears about being completely unsafe or alone.

Guideline #6: Identify and incorporate client's culturally-related strengths and resources into treatment

Again, Karen's major positive characteristics were many, but several were directly linked to her community and spiritual values. A recurrent theme throughout treatment was the importance of belief in God and service to her church. Consequently, this particular community/belief system was often referred to and integrated into the homework exercises and therapy discussions. Aside from its previously-described use to increase her motivation to address the anxiety symptoms that were interfering with her meeting her full potential, the use of her community and church involvement were utilized. For instance, as she was nearing the end of treatment, she independently volunteered to work with the clinic administrators to disseminate information about available services, e.g. by going into local churches in her neighborhood to share her positive experiences with therapy and anxiety reduction. This exercise was extremely empowering for Karen, and met this need to contribute meaningfully to her community. There was also a focus on strengthening interpersonal relationships with her family members (e.g. going to get her nails done with her young adolescent daughter), because of her highly expressed cultural value of staying close-knit as an immigrant family. Thus, spending time with such individuals served both as an exposure exercise (to reduce agoraphobic avoidance) and to meet this valued interdependent cultural goal.

Guideline #7: Identify and utilize technique-specific cultural modifications

Treatment therefore progressed using empirically supported techniques with these cultural guidelines integrated into the session content. Karen actually came for a relatively longer treatment course than what is typical for CBT in this treatment setting (around 30 sessions), primarily due to a other stressors (legal and significant medical conditions involving two of her children) that suddenly happened about 15 sessions into the treatment. At this point in therapy, there had already been a considerable objective and subjective improvement in Karen's anxiety symptoms (particularly in her panic and agoraphobic symptoms). These sudden crises forced the treatment to take a different focus for about 5 sessions, in order to maintain the therapeutic alliance and to meet the immediate needs of the patient. Once these external circumstances had reduced in urgency, treatment focus returned to managing with her overall stress level and specific lingering anxiety symptoms.

There appeared to be a plateau reached in several of her symptoms (particularly her chronic worry symptoms), and therefore it was decided that first-line CBT skills needed to be supplemented with other related techniques. Of note, the technique of mindful meditation was presented to Karen. However, to make this technique more palatable to this client, mindfulness activities that emphasized resilience (with Karen's history of experienced racism and trauma as an explicit part of the extensive metaphor for mediatation) and spiritual values-driven mindfulness practices were presented. Karen really enjoyed these exercises, and reported a significant relief in the frequency and severity of her chronic worry through consistent use of this skill.

Termination of therapy

Termination of therapy was collaboratively decided upon, on the basis of significant reduction in anxiety symptoms, and at a point where the patient herself verbalized a need to detach from her dependence on the therapeutic relationship to try the skills independently. At the last session, Karen brought in a gift (a velvet rose) and a card with religious themes as a gesture of gratitude for the therapist. At this particular treatment setting, gifts are usually declined, but the therapist regarded Karen's gift choice as a noted effort to stay within the discussed boundaries and recognized the card as her desire to express herself from within her own belief system. Given this, the token was accepted by the therapist, and Karen also asked if she could occasionally call the therapist to update her on how things were, which was discussed in terms of reasonable frequency of such updates. Three months after the termination of treatment, Karen called the therapist to let her know she had found a job, and was planning a trip to New York with her friends after over 20 years of feeling too anxious to leave her hometown. The therapist responded to Karen with warm reinforcement for her achievements, and reminded her of how far she had progressed since she had first started treatment almost a year earlier, encouraging her to keep using the skills she had learned.

Concluding Thoughts

This case highlights some practical applications of empirically-driven guidelines for enhancing collaboration when working with cross-cultural patients. Over the treatment episode, one may observe how the therapist modified the entire process (from assessment, to treatment interventions, and through to termination) to make it more culturally relevant to Karen. There was an equal emphasis on delivering evidence-based treatment techniques and on cultivating a strong therapeutic relationship to meet this goal. Tailoring the treatment procedures to Karen's individual needs (which were largely influenced by group-level cultural, religious, and societal beliefs), and doing this explicitly, contributed to her significant progress, as she expressed in the termination session. She reported feeling respected, listened to, and entrusted in contributing to her own progress, which gave her confidence to continue the skills on her own even after therapy had ended.

Certainly, the presented case study is not an exhaustive application of the described guidelines. The discussion in this article assumes primarily a traditional therapy set-up, and therefore the focus is on how to make more traditional modes of therapy more culturally responsive. There are, however, several other features that have shown some indication of aiding in treatment engagement in certain cultural groups in other countries, and should be considered if feasible. For instance, clinicians should consider delivering therapy in more naturalistic, familiar settings (such as in the person's residence, place of worship, or general community area), in order to make the patient feel more comfortable and connected to the therapy interventions introduced by the provider ( Hickling, 1994). Also, this case highlights the important role spirituality/religiousity can play in a patient's willingness to seek or adhere to treatment, particularly if religion is intricately tied into the person's cultural identity. Further, it is important to focus on both individual events in the patient's life (socioeconomic status, family structure, and potential trauma history), and the broader cultural events that may intrinsically and more systematically impact a particular population's views toward help-seeking and the therapist as a person (e.g. Holocaust experiences in Jewish patients, slavery/racism in African Americans, and English language difficulties and resultant discrimination in Latinos). Part of the process with familiarizing oneself with the customs and practices of a particular culture is being aware of, and assessing the impact of, these significant historical/social themes ( Comas-Diaz & Greene, 1994; Sue, 2009).

Finally, even clinicians who are aware of the nuances of these various cultural considerations and who have engaged in extensive multi-cultural therapy must challenge themselves to treat each case as unique. This overall attitude of curiosity and respect towards clients, across treatment orientations, establishes a strong working alliance between the therapist and patient. Our primary aim should be to use such resources/guidelines to systematically provide the most comprehensive care, and to meet the needs of these individuals who, regardless of culture, gender, or sexual orientation, are coming to practitioners for help in their times of distress.

Footnotes
Author Note
Dr. Hofmann is a paid consultant of Merck Pharmaceutical (Schering-Plough) for work unrelated to this study. This study was partially supported by NIMH grants MH-078308 and MH-081116 awarded to Dr. Hofmann and MH-73937.

¹ Name and identifying information changed to protect patient's privacy.

Contributor Information

Anu Asnaani, Boston University, Boston, MA.

Stefan G. Hofmann, Boston University, Boston, MA.

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Collaboration in Culturally Responsive Therapy: Establishing A Strong Therapeutic Alliance Across Cultural Lines

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Achieving effectiveness of therapeutic interventions across a diversity of patients continues to be a foremost concern of clinicians and clinical researchers alike. Further, across theoretical orientations and in all treatment modalities, therapy alliance remains a critical component to determine such favorable outcome from therapy.

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Include an example of a closing activity.

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Include an example of a closing activity.

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There are many counseling termination exercises for group counseling members.  One example is the following questions:

What are some of the different feelings people are having about this group ending?

What kind of feelings are you having about the members leaving the group?

What are some of the reactions people have to have new group members next term?

I would also say that my survey in Survey Monkey could also be part of the termination exercise which would give me valuable feedback on how the members of the group viewed our sessions.

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Extra information: Work at the ending stage of the group: separation issues

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Extra information: Work at the ending stage of the group: separation issues

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There are some things to look out for during the end or termination stage.  These are: denial, regression, flight, and reviewing.  During the ending or termination stage, members may express denial and claim they forgot that the group would end.

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This survey preview allows you to see what respondents will see when they take the survey, however, no data will be collected or recorded. Your survey respondents won't be able to add comments to this survey or view any existing comments.

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[SURVEY PREVIEW MODE] Copy of Group counseling evaluation Survey

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This survey preview allows you to see what respondents will see when they take the survey, however, no data will be collected or recorded. Your survey respondents won't be able to add comments to this survey or view any existing comments.

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At this stage, group members have reached a consensus of group dynamics and norms that allows for both the commonalities and unique individual qualities of each group member

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Like all groups, therapeutic groups change and evolve over time. Knowledge of group development can help the group therapist distinguish if members reflect personal and individual or group developmental issues. Furthermore, knowledge of how members cope in the face of group developmental issues can aid the therapist in formulating specific interventions at those times (Bernard, Burlingame, Flores, Greene et al., 2008).

There are four major assumptions underpinning all models of group development. The first assumption is that groups develop in regular and observable patterns allowing for predictions of future group behaviour. Understanding the group's developmental status may inform the therapist about the maturity of the group member's interaction, while clarifying the path needing to be taken to encourage greater levels of growth and development as a group for members to benefit.

The second assumption asserts that the same developmental features of the group will be evident across all treatment groups that develop in a normative fashion. For example, most models assume that conflict emerges in the second stage of group development so this is to be expected in any group taken when emersed in the second stage of group development. However, while a general assumption, it is also understood that there is variation to this standard norm. For example, conflict may also emerge in the later stages of group development after sufficient safety and trust have been established due to differences of opinion or other as a consequence of any number of mitigating variables (Bernard, Burlingame, Flores, Greene et al., 2008).

The third assumption is that later stages of group development are dependent on the successful negotiation of earlier developmental stages. However, it is also important to note that development in certain groups may not always be graduated, whereby they may not follow a normal progression through proposed stages. The fourth assumption of most models is that over time groups will manifest increased interactional complexity, but may also on occasion revert back to earlier stages of development (Bernard, Burlingame, Flores, Greene et al., 2008).
Group Developmental Stages
The most popular model of group development is from Tuckman (1965). This model suggests that group development occurs in five stages. These stages are titled; forming, storming, norming, performing and adjourning. Each of these stages are explained in more detail below

Stage 1 - Forming

In the Forming stage, personal relations are characterised by dependence. Group members rely on safe, patterned behaviour and look to the group leader for guidance and direction. Dependency on the group leader or the therapist is high while the group member's focus will primarily be on issues of dependency and inclusion. The members may also be experiencing anxiety, ambivalence and uncertainty about the group. This is because group members have a desire for acceptance by the group and a need to know that the group is safe. Group members will set about gathering impressions and data about the similarities and differences among members of the group and start forming preferences for future sub grouping. The common behaviour at this stage of the group seems to be to keep things simple and to avoid controversy. Serious topics and feelings are generally avoided although members may engage in tentative self disclosure and sharing.

The major task at this stage is concerned with orientating members to the tasks and each other. So discussion will often centre around defining the scope of the task, how to approach it, and similar concerns. The role of the therapist at this stage is to be educative and clarify the group's purpose and the therapist's role and to offer guidance for the operation of the group and member participation. Strategically the leader allows for regulation of interpersonal distance but invites trust while assisting each member to identify personal goals and identify commonalities between each other (Bernard, Burlingame, Flores, Greene et al., 2008). To grow from this stage to the next, each member must relinquish the comfort of non-threatening topics and instead, risk the possibility of conflict (Bernard, Burlingame, Flores, Greene et al., 2008).

Stage 2 - Storming

The next stage storming is characterised by competition and conflict in the personal relations being developed between group members and the group therapist. As the group members attempt to organise for the task, conflict inevitably result. Individuals have to bend their feelings, ideas, attitudes, and beliefs to suit those of the group organisation. This requires a process of listening to and understanding differences between members. Because of "fear of exposure" or "fear of failure," there will usually be an increased desire for structural clarification and commitment. Questions will arise about who is going to be responsible for what, what the rules are, what the reward system is, and what is the criteria for evaluation. These reflect conflicts over leadership, structure, power, and authority. There may be wide swings in members' behaviour based on emerging issues of competition and hostilities. Because of the discomfort generated during this stage, some members may remain completely silent while others attempt to dominate.

Many theories of group development hold that these types of conflicts and tensions over authority and status are essential for the emergence of genuine cohesion and cooperation. In order to progress to the next stage, group members must move from a "testing and proving" mentality to a problem-solving mentality. The therapist's role at this stage is to reaffirm the group's purpose and members' common goals. Group rules and expectations are reinfused and the therapist encourages group cohesion and interpersonal learning among the members. The therapist elicits the expression of negative affect and assists members to identify and resolve conflict.

Behaviour that is incongruent with the group's goals is confronted if necessary. The leader should avoid labelling individuals in terms of specific roles or rigidly identifying with members subgroups. The most important trait in helping groups to move on to the next stage seems to be in each memeber's ability to listen and understand, accept and respect the multifaceted nature of varying personalities and perspectives within the group (Bernard, Burlingame, Flores, Greene et al., 2008).

Stage 3 - Norming

In Tuckman's Norming stage, interpersonal relations are characterised by cohesion. This is because group members have reached a consensus of group dynamics and norms that allows for both the commonalities and unique individual qualities of each group member. As such, group members are engaged in active acknowledgment of all members' contributions, in community building and maintenance of group norms, and in solving any group issues that arise. Members are also more willing to change their preconceived ideas or opinions on the basis of facts presented by other members, and they actively ask questions of one another creating friction and conflict. Leadership is shared, and cliques dissolve. When members begin to know and identify with one another, the level of trust in their personal relationships contributes to the development of group cohesion.

It is during this stage of development (assuming the group gets this far) that people begin to experience a sense of group belonging and a feeling of relief as a result of resolving interpersonal conflicts. The major task of stage three is the information flow between group members. Information flow is where they share feelings and ideas, solicit and give feedback to one another, and explore actions related to the task, all in the context of demonstrated trust between group members. As a consequence, creativity is high. Interactions are characterised by openness and sharing of information on both a personal and task level. Members feel good about being part of an effective group.

At this stage, the group therapist's interventions aim to maintain a balance between support and confrontation. The primary role is to facilitate the working process around feedback, promoting insight and encouraging problem solving in an ongoing manner. A derailment of the group process during this stage may suggest that the group members are revisiting a previous developmental issue (Bernard, Burlingame, Flores, Greene et al., 2008).

Stage 4 - Performing

The Performing stage is not always reached by all groups. If group members are able to evolve to stage four, their capacity, range, and depth of personal interaction expands to a constructive and vibrant interdependence. In this stage, people can work independently, in subgroups, or as a total unit with equal facility. Their roles and authorities dynamically adjust to the changing needs of the group and individuals at the time. Stage four is marked by interdependence in personal relationships, acceptance of individual differences and problem solving in the realm of task functions. It is at this stage the group should be most productive.

Individual members have become self-assuring, and the need for group approval is in the past. All members feel accepted and an authentic sense of belonging so they do not have to focus time and energy on to these needs anymore. Members are both highly task oriented and highly people oriented. There is unity, group identity is complete, group morale is high, and group loyalty is intense as the group has reached maturity. The task function becomes genuine problem solving, leading toward optimal solutions and optimum group development. There is support for experimentation in solving problems and an emphasis on achievement.

The overall goal is productivity through problem solving and work. At this stage of performing, the group therapist focuses more on letting the group run itself whereby the therapist focuses mainly on facilitating member to member empathy and assist the members to acknowledge and amplify individual differences (Bernard, Burlingame, Flores, Greene et al., 2008).

Stage 5 - Adjourning/ temination

Tuckman's final stage, adjourning, involves the termination of task behaviours and disengagement from the group relationships. A planned conclusion usually includes recognition of participation and achievements and an opportunity for members to say personal goodbyes. Concluding a group can create some apprehension or a minor crisis. With ending in sight, the group may experience upheaval, sadness, anxiety and anger. The termination of the group is a regressive movement from giving up control to giving up inclusion in the group. The members may experience the ending of therapy as a profound relationship loss especially if the group has become a significant source of psychological support. Defensive efforts of denial will alternate with periods of productive work.

The most effective interventions at this stage are those that facilitate task termination and the disengagement process. The role of the group therapist at this stage is to assist members to express their feelings about adjourning the group process while also attending to any unfinished business prior to the conclusion of the group. The group therapist may also facilitate a systematic review and evaluation of the group progress and encourage planning for a post group period. The therapist must also facilitate opportunities for group members to express proper goodbyes (Bernard, Burlingame, Flores, Greene et al., 2008).

Some group members may require further follow-up and treatment. This will need to be assessed accordingly. It is important to note that termination will have pathological issues if the group members formed dependant relationships rather than interdependent relationships. Thus, for effective termination to take place, the group therapist needs to ensure from the start that relationships formed are healthy and functionally interdependent rather than excessively dependant.

References:

Bernard, H., Burlingame, G., Flores, P., Greene, L. , Joyce, A. et al., (2008). Clinical practice guidelines for group psychotherapy. International Journal of Group Psychotherapy, 58, 455-542.

Source: www.mentalhealthacademy.com.au

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Group Development Stages - AIPC Article Library

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Like all groups, therapeutic groups change and evolve over time. Knowledge of group development can help the group therapist distinguish if members reflect personal and individual or group developmental issues. Furthermore, knowledge of how members cope in the face of group developmental issues can aid the therapist in formulating specific interventions at those times (Bernard, Burlingame, Flores, Greene et al., 2008).

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Small group techniques: ways to develop activities based on stages of group development

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Anxiety levels at the termination stage of group counseling

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Anxiety levels at the termination stage of group counseling

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At this stage, experiences that are important to the health of individual group members are liable to arise at this stage of the group’s development.

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Drop-out from psychotherapy is common and represents a considerable problem in clinical practice and research.

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Best practices guidelines for group counseling

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Best practices guidelines for group counseling

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Counselor Preparation at the working stage

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Counselor Preparation at the working stage

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Counselor termination

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When preparing for a symphony, a conductor will often tell the musicians that the last note is as important as the first; after all, the last note is what the listeners will take with them. For that reason, the final note of a symphony requires just as much artistry, thought and attention as the first note.

Much like the final note of a symphony, counseling termination requires a great deal of creativity and attention to detail. Although termination is an often neglected concept in the counseling literature, it is supremely important.

Termination is the term most commonly used to describe the process of finalizing or ending a counseling experience. Yet that word conjures up images of abrupt endings or even death, so we wish that a better phrase could be identified to describe counseling endings and transitions. Perhaps the words finale or commencement, or even the euphemism new beginnings, would better capture the termination process.

Many if not most of our clients have experienced traumatic or adverse life experiences. Thus, the termination process can be particularly triggering and take on an even more significant meaning for these populations. Because of its importance, we believe that the termination process merits a closer look.
Ethics and termination
Ethically, it is a counselor's duty to prepare clients for the counseling termination process and to terminate services when clients are no longer benefiting from counseling. Therefore, counselors ought to be thinking about termination, even at a first session.

When the time comes to end the therapeutic relationship, it is natural for there to be feelings of grief and loss and even an adjustment period. Some clients may struggle to negotiate healthy boundaries and the termination of relationships. Furthermore, clients who have experienced abuse or trauma may be especially sensitive to relationship transitions.

Ending a therapeutic relationship requires a great deal of thought. If done ethically and competently, termination can help solidify counseling gains, empowering clients to integrate their experiences and bravely face their next chapter in life. Termination can also help model healthy boundaries and a natural and appropriate end to a relationship. Effective termination provides clients with an opportunity for continued personal growth, whereas ineffective termination can actually harm clients.
Preparing clients for termination
To best prepare clients for termination, it is essential that counselors proactively address termination. Ideally, termination should be introduced during the informed consent process. In fact, by openly discussing termination from the beginning of counseling, counselors may help galvanize client motivation because clients will see counseling as something temporary that can be used to help them reach a defined set of goals.

By weaving the idea of termination into informed consent, counselors can also encourage and elicit client feedback regarding the progress being made in counseling. Thus, clients will be liberated from the fear of "disappointing" their counselor by raising the idea of ending counseling once they feel they have received what they needed from the counseling experience. Remaining transparent about termination, from the initiation of counseling, can help clients invest in reaching their goals while concurrently empowering them to voice when they feel they are ready to end counseling.
Counselor adjustment to termination
Just as clients often experience a tangle of feelings around the end of a counseling relationship, counselors themselves can have emotional reactions to termination. As counselors, we invest much time, emotional and intellectual energy, and dedication to helping our clients. After all, the lifeblood of the counseling profession is based on building a warm connection with those we serve. As a byproduct of this relationship process, counselors do indeed develop emotions and thoughts regarding their clients. Consequently, when the counseling relationship ends, there is an adjustment period for counselors too.

Ideally, this adjustment period would include a space for self-supervision, with counselors objectively evaluating their performance and efficacy with the client. Counselors can identify potential growth areas and reflect on their professional strengths as part of this process.

Before engaging in such objective evaluation, however, counselors may need to sort through their residual feelings of loss. These feelings may be further complicated by countertransference. If, for instance, a counselor's personal experience aligned with that of the client who recently terminated, the counselor's emotional reaction may be intensified. If there is a positive prognosis for the client, the termination process may catalyze feelings in the counselor of fulfillment, competency and even confidence. If, however, the client terminates abruptly or has a less than favorable prognosis, the counselor may experience feelings of incompetence and disillusionment, especially if the counselor's lived experiences mirror those of the client. In these instances, counselors must make processing their emotions around termination a priority.

Although it is imperative to cultivate self-awareness surrounding countertransference throughout the counseling relationship, monitoring countertransference at termination may be especially important. Counselors ought to be cognizant of their emotions and willing to process these emotions, whether positive or negative, at the end of a counseling relationship.

In summation, while clients often experience grief and a sense of loss at the conclusion of the counseling process, counselors may also have emotional reactions to the termination process. Counselors should monitor these reactions, discuss them in supervision, consult with peers, and seek personal counseling if necessary to ensure that even as they adjust to the loss of a therapeutic relationship with a client, the quality of the services they provide to their remaining clients remains top-notch. Being aware that termination is a two-way street that affects the counselor-client dyad allows counselors to more effectively understand, and thus cope with, the emotions and thoughts that ending a therapeutic relationship may stir up.
Client ambivalence around termination
Even when counselors introduce the discussion of termination in the initial stages of the counseling relationship, it is natural for many clients to experience some anxiety and disillusionment with the idea. After all, the counseling relationship may be one of the only times, if not the only time, in their lives when they have experienced safety, trust, compassion and care. Given that these virtues are basic human needs, it makes sense that clients may be reluctant to end the counseling relationship.

Some clients may manifest this reluctance by continually raising "new" issues or concerns anytime the possibility of termination is mentioned. Clients may even return to the behaviors that led them to counseling initially. For example, a client who self-injures and works toward abstinence over the course of counseling may engage in self-injury again as the idea of termination nears. Rather than viewing this as a counseling failure, counselors should remember that, like counseling itself, termination is not linear.

At its core, termination involves the ending of a relationship, likely resulting in feelings of grief and loss. Thus, space should be made for clients to experience, rather than avoid, those feelings that come with the natural ending of a relationship. Encouraging clients to utilize the coping and emotional regulation skills they have gained over the course of counseling can assist in managing the emotions surrounding termination. This action also helps to reinforce the learning that occurred throughout the counseling process. Walking alongside clients as they grieve the loss of the counseling relationship allows them to experience the conclusion of a relationship in a nurturing and empathetic environment and helps them develop so that they can better manage future losses and transitions.

Counselors should continually assess for termination readiness when working with clients. One way to do this is to ask clients questions such as, "Do you think you are benefiting from counseling?" and "How will you know when our time here together is coming to an end?" Questions such as these set an expectation that counseling will end and serve to empower clients to help determine when it will conclude. By trusting clients and actively listening to their experiences and sense of how they are (or are not) benefiting from counseling, counselors help clients prepare for the termination process.
The termination process
When it comes to the actual process of termination, counselors can take many different approaches with clients. The interests and developmental level of clients and the content of counseling should all be considered when planning termination activities. Termination is often an ideal time to incorporate active, engaging and creative interventions that encourage clients to engage in active learning and reflection upon the counseling process as a whole.

Often, as termination nears, client engagement and enthusiasm in counseling diminish. By using active and creative termination interventions, counselors can inject new enthusiasm into the last several counseling sessions. Clients tend to more readily remember counseling interventions in which they are interactively involved.

Regardless of the specific intervention used, termination is an ideal time to incorporate an optimistic, empowering and future-oriented approach. Counselors can compassionately empathize with clients who are reluctant to terminate while concurrently encouraging them to see the end of counseling as a new adventure in which they can apply the skills they have learned throughout counseling. Assuming such a tone as a counselor assists clients in developing a future-focused orientation. This may help propel them through the natural grieving process that often accompanies the ending of a counseling relationship.
Creative termination activities
A variety of creative termination techniques can be used with clients. Ideally, the counselor can dedicate several sessions to fully processing and exploring the termination process. A few examples of creative termination activities follow.

One-way trip for trauma: This activity can be used with clients who have worked on trauma issues or those who have worked to let go of something while in counseling. Clients can take the materials that they have accumulated throughout the counseling process that are associated with their trauma narratives - writings, journals, worksheets, illustrations, etc. - and either rip them up, color over them, or simply fold them neatly.

After the materials are collected, counselors should provide clients with a small box or container (these are easily obtained from everyday recycled products or by purchasing them in bulk on the internet). Next, clients can be given a variety of tape. Clients then
place their trauma narrative materials into the container, tape the container shut, and decorate the container as they see fit. At this point, counselors can process with clients how their traumatic past need not dictate their future. Clients can then discuss how leaving the counseling relationship symbolizes their having processed and worked through their trauma.

This intervention can also be paired with a "new beginning" celebration to signify the start of a new chapter in clients' lives. Although shifting the language from "termination" to "new beginning" may seem like nothing more than a euphemism, the language is immensely important. Helping
clients who have a history of trauma understand that they do indeed have a future, despite the pain and hopelessness they have endured in the past, is a powerful intervention.

Sticker chart/memory book: Younger clients may struggle to fully grasp the concept of termination or to engage in metacognitive reflection on the counseling process as a whole. Thus, with these clients, more developmentally appropriate and artistic interventions are often indicated. For instance, a sticker or picture chart could be maintained throughout the counseling process, with clients placing a sticker on the chart each time they come to counseling. Clients can even draw pictures, along with using the stickers, to illustrate a "story" of their time in counseling. As termination approaches, clients can further illustrate their chart, review what they have learned so far, and place more stickers on the chart signifying their achievements in counseling.

Another effective approach is working together with younger clients to create a memory book with pictures, words, stickers and decorations that will help them remember their time in counseling in a more concrete manner. Both of these interventions allow child clients to take a tangible item with them as they end the counseling process.

Aloha lei (hello-goodbye) activity: Counselors can explain to clients that the word aloha means both hello and goodbye. Counselors can then discuss with clients that every end is the start of a new beginning, as is the case with the end of counseling.

For the activity, paper flowers can be cut out (clients can select the color of the materials to enhance autonomy). Clients can write effective coping skills, memorable counseling experiences, or other notable takeaways on the flowers. Next, punch a hole in each flower and thread them along the string. Family members or caregivers can also be involved in the process (with client consent), adding their own flowers to the lei. The lei can then be given to the client as a parting gift. This intervention involves creativity and metaphor in a way that summarizes the counseling experience while actively involving the client.

Building blocks: This activity can be tailored to clients of any age. During the final session, counselors can bring a number of building blocks, Legos, Jenga blocks, or other toy blocks to session. Clients can then construct a tower or creation of their choosing. Each block in the creation can represent a powerful moment in counseling, a coping skill clients now possess, or another skill clients have learned during counseling.

As the height of the tower increases, clients may become anxious, especially as the tower begins to lean. If the tower ultimately falls, the counselor can explain that, given the clients' fundamental skills - the skills they assigned to each block - the tower can be rebuilt. This intervention helps clients understand that even if they experience the inevitable "falls" of life, they possess the fundamental "building block" skills to rebuild. This intervention is a tactile and empowering activity for the end of counseling.

Goodbye letter: There are many variations of a goodbye letter that can be used as the counseling process comes to a close. Counselors can provide a letter template with certain blanks to be filled in, or they can simply provide a blank piece of paper on which clients can write their own letter. Adding prompts or sentence stems for clients to complete can add a degree of structure to the letter.

There is flexibility in terms of the letter's point of view. Goodbye letters can be written from client to counselor, from counselor to client, or even from the perspective of the process of counseling itself being personified. Possible writing prompts include "One thing I remember from counseling is ..." or "The most memorable moment of counseling was ..." Although counselor creativity can yield limitless possible prompts, it is important that the goodbye letter be narrowed to focus on the most relevant moments of the counseling process. It is also important to keep the activity strengths-based (as is the case with any termination activity).

Survivor tree: Survivor trees can serve as a creative intervention to foster and celebrate resilience in the final stage of the counseling relationship. They can be either simple or complex, depending on the clients' developmental abilities. Survivor trees may be drawn out to explore clients' areas of growth (the branches), clients' future hopes and aspirations (leaves and buds), coping skills that clients have learned in order to stay grounded (the trunk and roots), and even what struggles clients have worked through in counseling (dead leaves beneath the tree).

As the tree grows and expands on the paper, the counselor can weave in the idea that trees survive multiple seasons every year. Some seasons leave barren branches, whereas other seasons are rife with leaves and buds. Nevertheless, the tree survives and continues to bloom, even after a cold or barren season. Clients can then reflect how their resilience has allowed them to overcome previous barren seasons. They might also reflect on how the skills they learned in counseling can help engender resilience during future difficult seasons of life. Taking the example of the tree eventually blooming despite the adversity of winter, clients can explore how they can go forth in life and bloom beautifully, no matter the adversities they face.

Making a case for counseling: With this activity, clients are invited to create a "case" and fill it with various objects to help them summarize and conceptualize their experience in counseling. Depending on the client's interests, the case can take on a variety of forms (e.g., a purse, an athletic shoebox, a favorite cereal box). Client autonomy can be reinforced by allowing clients creative license in decorating and designing their cases.

Clients can be encouraged to include various objects in the box that they find important and valuable to the counseling process (e.g., a grounding stone, a worksheet with coping skills, a journal). Furthermore, clients can create decorative scraps of paper to add to the box. These papers can include notable moments in counseling, emotions surrounding the counseling process, skills learned, or other tools with which the client can face the future trials and travails of life outside of the counseling relationship. If family members or significant others are involved in the counseling process, they can also add items to the client's case (if the client agrees to their participation). This intervention is relatively open to interpretation and can include myriad creative avenues to help clients gain closure.
New beginnings
Regardless of the specific intervention used, termination is a vital part of the counseling process. During termination, counselors should convey a great deal of warmth and compassion to clients, while simultaneously aiming to empower them and promote their self-worth.

To reiterate, it is important to understand that semantics matter. The word termination conjures up brutal images of loss. In truth, the end of counseling is really the start of a new beginning; it is as if one chapter is closing and counselors are handing the pen off to clients to write their own next chapters. In so doing, counselors play their role in helping to ensure that the next chapter will be a good one.

The end of counseling, just like the end of a symphony, is not simply the end. Rather, it is a resounding note that acts as a gateway to new beginnings.
****
Victoria Kress is a professor at Youngstown State University and a licensed professional clinical counselor supervisor, a national certified counselor, and a certified clinical mental health counselor. She has published a number of journal articles on counseling termination and further addresses the topic in her textbooks, Counseling Children and Adolescents and Treating Those With Mental Disorders. Contact her at victoriaEkress@gmail.com.

Marissa Marie is a licensed professional counselor working at Youth Intensive Services in Youngstown, Ohio. She uses trauma counseling with those who have been involved in the sex trafficking industry. Contact her at mgray@youthintensiveservices.com.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.
**** Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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Counseling termination and new beginnings - Counseling Today

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When preparing for a symphony, a conductor will often tell the musicians that the last note is as important as the first; after all, the last note is what the listeners will take with them. For that reason, the final note of a symphony requires just as much artistry, thought and attention as the first note.

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Ending any relationship for most of us is not something that comes easily, or is second nature. In fact, ending a relationship may be one of the most difficult things we do in our lives. Many people simply don't know how to handle the feelings accompanying the loss, and so it can be a very trying and stressful time even under the best of circumstances.

Most psychotherapy relationships end mutually, however, which makes them a little bit easier to handle. But not much. No matter what reason the relationship may be ending - the natural end of a course of therapy for a specific mental disorder, you or your therapist moving, a change in insurance coverage - here are some tips to make the transition easier for you.

10 Tips When Ending Psychotherapy
1. Understand The Process.
While many therapists are good about explaining the termination process, some are not. Termination starts with a discussion about whether it might be a good time to end therapy. Although it's usually begun by the therapist, sometimes clients will get the ball rolling too (especially if they feel like they're no longer "getting anything" from therapy).

After the discussion, if both parties have agreed to end therapy, a date is chosen, usually many weeks out. In the sessions between the initial decision and the chosen end date, the therapist spends time discussing how the client is feeling about the end of psychotherapy. Goals of therapy are discussed, and the progress made on those goals. The therapist will also often review the techniques learned in therapy, and strategies to ensure the client can rely on those techniques and tools in the future without the therapist's help. A final session ends the process.
2. Bring It Up Early.
Most experienced psychotherapists are trained to start the termination process early - far earlier than most clients are probably used to or even comfortable with. Some therapists may start talking about it as far out as 10 or 12 sessions from the end (especially for longer-term therapy). This is a good thing. It gives you time to get comfortable with the idea, and it gives your mind time to get anxious - anxiety that can then be dealt with in your continuing psychotherapy sessions.
3. Pick A Final Session Date.
This is connected to bringing it up early: Your therapist should work with you on picking the date of your last session. It's best to choose this date together, to ensure it's not too early (for you) or that it doesn't interfere with some other commitment either one of you may not know about. Such a date also acts as a mutual goal the both of you will work toward in your remaining sessions.
4. Let It Out.
Ending a psychotherapy relationship is just as difficult as ending any relationship in your life. That means you're likely going to experience mixed emotions about the end of your relationship with your therapist. That's fine, but it's even better if you find a way to express those feelings to your therapist. Sometimes the end of therapy brings up a new issue that hasn't yet emerged in session. This gives you time to work on these things - if work is needed - while there's still time.
5. Anger And Anxiety Are Normal.
It's perfectly normal to feel anger, anxiety, or a host of other emotions after your therapist has suggested it might be time to end the relationship. Express them. Write them out. Twitter them, or post them on your Facebook page. Whatever works for you, find a way to share these things with your therapist (and if not your therapist, some other outlet that gives you a sense of relief).
6. Ask Questions If You Have Them.
Sometimes the end of therapy brings up questions about the future. What if I relapse? Who do I call? Can I start therapy with you in the future if the need arises? Any books or support groups you recommend to help me with everyday coping? Can you give me a referral to another psychotherapist you recommend? Sometimes we get flustered or feel embarrassed to ask such questions at the end of therapy. Try to find a way to ask any questions you might have, since this may be the last chance you have to have a mental health professional's opinion or help with them.
7. Knowing If You're Not Ready.
Some people may not be ready to end therapy. You should talk to your therapist sooner rather than later if this is the case for you. You also have to try to separate out the feelings of "I'm not ready to do this" vs. "This is making me very anxious, but it feels like it's the right time." Just because talking about ending the relationship makes you feel anxious or uncomfortable doesn't mean it isn't right. But if you're not ready to end it - because, for instance, you believe you have more work to do or more to learn - say so. Most therapists will respect your sense of whether it's "right" or not and continue working with you.
8. It's Done Face-To-Face.
The final session, as with most psychotherapy, is done face-to-face. Although some clients end up canceling their last session (with the sentiment of, "Why bother? We're done, so let's be done with it already"), it's best to stick with it and attend the last session even if you don't feel like it. Like ending any (hopefully!) positive relationship, it's usually best to have one last final goodbye. It helps with "closure," as therapists like to say.
9. The Final Session.
There is no "normal" way a final session goes - each therapist has his or her own way of doing it. It may involve a sort of encapsulating the months (or years) of therapy spent together, and ensuring the client is ready to move on in his or her life. Especially long-term or close therapeutic relationships may end with tears and a hug (if both parties agree). Shorter-term, solution-focused therapy will often end more business-like, with a handshake and best wishes.
10. Termination Is Not The End.
Although the word suggests an ending, termination really is the start of a new beginning for you. You are once again on your own in the world without the comfortable and safe weekly check-in with your therapist. And while that initially may be a little scary or sad, it marks another stage or transition in your life that you can embrace if you choose.

As the old saying goes, all good things must come to an end, and that includes psychotherapy too. Rest assured, however, that if you need to return to therapy in the future, a good therapist will be waiting for you.
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