Preface

What is truly special about human beings as a species? Is it that we have invented tools to increase our proficiency at gathering food and managing daily life? Is it our development of language? Perhaps it is our complex social behavior? Although we have developed these abilities to an extraordinary degree, at least compared to other inhabitants of the planet, they are hardly unique. After all, chimpanzees have been known to use tools to hunt for food or to defend themselves. Ants and termites are far better organized in their social networks, and dolphins and whales rely on their own verbal language system to communicate regularly.

What distinguishes us from other creatures is that we have developed the capacity for empathy: We are mind readers! Evolution has equipped us with the ability to reliably and accurately sense what others are feeling and to place ourselves in their shoes (or sandals). This has permitted us to decode others' body language, facial expressions, and verbal subtleties in such a way that we can usually assess whether someone is an ally and friend or a potential threat. This has made it possible for us to function more cooperatively within our social groups and to respond sensitively to members of our “tribe” who need support, reassurance, or assistance. The empathic mind is also what makes counseling work, in all its forms and permutations.

With respect to the practice of counseling relationships, we are talking about a subject so complex and challenging that it defies any simple explanation or easy answers. Dozens of models reflect their own particular emphasis or theoretical orientation, whether in the form of transference, working alliance, real relationship, empathic resonance, collaborative stance, attuned responsiveness, attachment interactions, corrective emotional experience, or immediacy, to mention only a few. Each relational conception attempts to explain, or at least to describe, the mechanisms of change that take place during the time counselors and clients spend together.

In spite of the emphasis on empirically supported treatments (or ESTs), manualized strategies, and evidence-based practice (or EBP), relatively little attention is paid to the results of the studies upon which most models are based. A consensus in the field has emerged that many specific interventions and strategies have limited impact on counseling outcomes compared to the so-called common factors, which include client and counselor characteristics and, especially, the helping relationship. In addition, counselors feel undue pressure to incorporate particular strategies that may actually act as a barrier to more successful helping efforts. We all hunger for new techniques, novel interventions, and revolutionary advances in theory development, sometimes forgetting that the power of the relationship strengthens everything else we do to help people.

This book integrates the evidence supporting relational factors in counseling in a way that is both accessible and clinically useful. In addition, we focus on the reciprocal impact of the counseling alliance—how practitioners, as well as clients, are affected as a result of the intimate encounter, for better or worse.

An Unusual Collaboration and an Improbable Partnership

This is a book about relationships. It is also a story about our own relationship, which began 15 years ago when Rick was a doctoral student, taking an advanced group course that used one of Jeffrey's texts as a primary source. It was the first book in the field in which the author felt “real” to Rick, so much so that he was determined to meet Jeffrey at the next professional conference. Their first meeting was one of unequal power, with Rick as the deferential student and Jeffrey an established academic. There were other brief meetings at subsequent conferences, but mostly polite encounters. They would not have another conversation for more than 12 years.

Meanwhile, Rick worked hard to establish his own professional identity and reputation as a scholar and counselor educator. While Jeffrey continued writing two or three books each year about relationship issues, Rick mostly concentrated on his own research agenda and teaching, specializing in inferential statistics and assessment instruments (we warned you this was an unusual partnership).

In his wisdom (or audacity), the president of the American Counseling Association, who was a long-standing friend to both of us, as well as being Rick's mentor, invited us to team up to keynote the national conference. Jeffrey's first thought—and the first words out of his mouth during the keynote speech—was, “What the heck was he thinking?” It seemed ridiculous, first of all, to invite two people to deliver a speech together about relationships in counseling but particularly so considering that their styles were so completely different, their interests almost in opposite domains, and they hardly knew one another, much less ever collaborated on anything before.

Rick and Jeffrey tried to negotiate their differing opinions about the best format and structure for this speech, which represented one of the highlights of the careers of both men. Jeffrey was far more experienced in this area, having delivered similar keynotes at other international and national conferences in the past, but that didn't mean that Rick was any less opinionated about what they should do and how they should do it. In their dialogue with one another, they eventually settled on the idea of emphasizing process as well as content, which, after all, is what counseling is all about. What can one really do in 40 minutes that makes any kind of difference to an audience of several thousand people crowded in a hot room? They decided they would try to model the kind of relationship that they wished to profile in their talk, one that was collaborative, genuine, warm, engaging, and empowering. You know, the usual.

Jeffrey was quite comfortable with this format and was used to improvising and winging it, depending on his mood and the audience responses, but Rick much preferred a clear structure. As a quantitative researcher, he was far more familiar with presenting findings supported by numbers. He loved the idea that they could write out a script ahead of time and basically get to read it on the teleprompter on stage. However, Jeffrey was insistent that the experience would be more lively, entertaining, and interesting if they tried to be with one another in such a way that it reflected what they were actually talking about.

It was when they were about to walk out on stage that Jeffrey informed Rick that he made a few changes to the slides and not to be surprised if he “went off script a little bit.” This doesn't sound exactly collaborative, but Jeffrey's intent was to help Rick loosen up a bit so they might capitalize on the strengths of their own relationship to support and empower one another. Rick was trying to calm his nerves and practicing deep breathing, so he barely registered what Jeffrey had just told him. It all became quite clear when they landed on stage and Jeffrey proceeded to ignore their prepared slides altogether and walked to the edge to talk directly to the audience. He told them that Robert Smith must have been a little crazy to pair two such radically different professionals together and then give them a little more than half an hour to talk about the most complex, multifaceted, confusing, and significant feature of what we do—forming relational connections with clients.

Then, something magical happened. Jeffrey, the consummate storyteller, launched into a tale about his latest adventures working in Nepal with at-risk girls, highlighting how this was essentially a relational intervention. He finished with a flourish, leaving the audience practically in tears, and then turned to Rick and said, “Over to you, Partner.” Rick responded with a horrified look on his face as the next slide came on the screen profiling him with the words, “I love statistics!” The audience laughed uproariously at the awkward transition, wondering how Rick would recover.

What happened next sometimes occurs in rich, collaborative partnerships when the participants decide to just trust one another and go with the flow. Rick told his own story, also off script and spontaneously created, and they both knew at that exact moment that they were going to be okay, that this would indeed work. They weren't certain what the association's president imagined would ever happen in this shotgun marriage, but it turned out just fine.

Jeffrey and Rick began their relationship in the customary and familiar configuration of unequal power that eventually was negotiated into one of mutual trust and optimal functioning, and this is what led them to coauthor this book together as a much more detailed and deep investigation of the most important subject in our profession—the most effective relationships that counselors develop and nurture with their clients, as well as with their loved ones.

Overview of What (Mostly) Follows

In this book, we address common misconceptions about what works in counseling and present strategies for further developing the counseling relationship and enhancing our own expertise and outcomes. Representing the strengths of the two coauthors—one, an empirical researcher and editor of the flagship journal in the field, and the other, a noted storyteller and writer—key facets of the counseling relationship are supported by engaging examples and stories that are integrated with existing research on counseling outcomes.

Part 1 introduces and reviews some of the basic assumptions that counselors, therapists, and researchers hold about the nature of helping relationships, including some of the discrepancies and debates in the field regarding how and why they empower change efforts. Part 2 describes some of the more practical ways relationships are used both as leverage and to facilitate trust and growth. We include chapters on some of the standard relationship interventions and also explain how relationships are embedded in a cultural and environmental context. We discuss how relationally based counseling is used to treat trauma, and how it uses storytelling structures, and we address some creative and innovative ways to enhance relational power. Part 3 moves to a discussion of how relationships operate in a counselor's personal life, such as how we are affected and influenced by our work, how we process disappointments and failures, how we deal with our own personal conflicts, and the ways we model in our lives what we teach to others.

Because of the focus on core factors that lead to successful outcomes, this book is appropriate as a textbook for a variety of courses in the curriculum including Introduction to Counseling, Theories of Counseling, Counseling Skills and Strategies, and more advanced Practicum courses. Although we have infused research and examples related to diversity throughout the book, Chapter 5, “Customized Relationships,” provides an opportunity for us to address issues of diversity with respect to the counseling relationship more directly. After all, it is the ways that we adapt and individually personalize our relationships that make them optimally potent and responsive.

Chapter 1
What Do We Know, or Think We Know, About How Counseling Works?

Let's acknowledge at the outset that there are decades of empirical research, not to mention practitioner anecdotes, to support the power, influence, and efficacy of counseling. This is true across a number of theoretical orientations, clinician styles, contexts, clinical specialties, diagnostic issues, and client problems. However, in spite of the confidence we might feel in the power of our profession to improve the quality of people's lives, as well as to address their most challenging difficulties, we are by no means all in agreement as to why it works.

In this initial overview of what we know, or at least what we believe may be the case, we review some of the consensual assumptions and common precepts about what most consistently produces the most satisfying outcomes—for both clients and their counselors.

First, a Little History

Much of the interest in the counseling relationship began with Sigmund Freud's (1933/1916–1917) early work, which was followed by many of his colleagues and disciples, investigating the mechanisms of the so-called alliance that takes place in all therapeutic work. Luborsky (1976) distinguished between two different phases in this process; the first includes the supportive and caring “holding environment,” and the second involves the client's own commitment and investment in the process. Bordin (1979) considerably expanded these ideas from a psychodynamic perspective to one that was far more encompassing and integrative. This model, which has now become known as the “working alliance,” consists of three distinct but related features: (1) agreement on goals between counselor and client, (2) collaboration on the structure and content of the sessions together, and (3) respectful and intimate bonds that develop in the relationship. It is this third dimension of relational connection that Carl Rogers (1957) researched throughout his career, emphasizing the warmth, affection, trust, authenticity, and congruence that he found so critical in his work. Complementing Bordin's work were other theorists (e.g., de Shazer, 1985; Haley, 1963; Satir, 1983) who advanced more relational strategies, spawning specializations in marriage, couples, and family counseling. Essential to these theorists was the notion that what is occurring between two people is more important than what is occurring within each person (Bateson, 1972).

All of this is part of the foundational heritage of counseling as a profession. In one sense, it is what helped distinguish counseling from other allied mental health specialties such as social work, psychology, and psychiatry; that is, we have always been (and, we hope, always be) relationally oriented in our approach. Rogers (1980), perhaps more than any other thinker, defined the anthem of the counseling profession when describing the nature of empathy as both the ability and the willingness to understand others' thoughts and feelings from their own unique point of view. He believed this could only legitimately take place when the counselor was able to enter into the private perceptual world of clients, thus enabling the counselor to sense meanings about which clients may not be fully aware.

Empathy has its origins as part of the biological and social basis for human existence. This ability likely evolved as a way for members of a community to literally feel one another's pain and provide assistance as needed. Cozolino (2006) described empathy as more like a hypothesis than an actual sensation: “Shuttling back and forth between my head and what I imagine to be in yours, I generate hypotheses about your inner state based on my own thoughts and inner experiences” (p. 231). He posited that it is our shared neural circuitry that allows us to create models of others' internal states and make assumptions based on this resonance. Using the metaphor of cellular physiology, Cozolino suggested that just as neurons have synapses between them, so too are there social synapses in the spaces between client and counselor, or any other individuals. We communicate across those spaces in such a way that they alter brain chemistry in the same way that cellular structures and compositions are changed as a result of interneuron interactions. So-called mirror neurons, in particular, allow us to feel what others feel—as if it is our own experience. This remarkable ability, as we discuss later, is one reason stories have such a profound effect on people's lives, regardless of their form. When we are watching a film, television show, opera, play; listening to song lyrics; or reading a novel, we enter into the fictional world and fully imagine ourselves living in this alternative universe that provides vicarious experiences without danger or actual threat (Gottschall, 2012; Kottler, 2014).

The Counseling Relationship and the Era of Accountability: Two Opposing Forces?

For any of us who has been in the field for a while, we may remember a time before the strict oversight of managed care and the sometimes rigid parameters of prescribed “manualized” treatments designed to provide greater accountability. This was an era when counselors and therapists were actually allowed to determine for themselves, and their cases, exactly how often sessions should be conducted, how long they should last, and what should be the focus of treatment. Although there were some abuses of this system, it was a time of greater professional freedom in which counselors and therapists determined what was in the best interests of their clients.

In recent years, two terms related to greater accountability in counseling frequently have been used: empirically supported treatments (ESTs) and evidence-based practice (EBP). ESTs refer to specific techniques and strategies that reduce symptoms based on empirically controlled studies. EBP, on the other hand, refers to any evidence that affects client outcomes (Laska, Gurman, & Wampold, 2014). The issue of evidence, therefore, is the primary concern because there is ample support to conclude that the role of the relationship in client outcome is indeed quite substantial. In addition, “evidence” can take many different forms beyond quantitatively measured dependent variables, such as the anecdotal evidence that emerges from personal and professional experience.

Many of us might agree that that there have been times when the obsession with empirically supported interventions for specific presenting complaints has been taken a bit too far. Wampold (2001) has been particularly critical of the role ESTs have garnered in counseling practice and estimated that techniques account for less than 1% of actual client outcomes. Nevertheless, all of us today are expected to provide some evidence that what we are doing is helpful to others. To understand what we know and what we think we know, it might be helpful to explain how we got to this point.

Hansen, Speciale, and Lemberger (2014) provided a historical retrospective on the debate between ESTs and the role of the relationship in counseling. ESTs have roots in the biological premise of behavior espoused by Freud and behaviorism as exemplified by B. F. Skinner and others. As you are probably well aware, our profession has been fighting for respectability as a scientifically supported discipline that is grounded in research. Although humanistic ideologies, exemplified in the work of Carl Rogers, Abraham Maslow, Victor Frankl, and others, provided a counterpoint to the influences of behaviorism and psychoanalysis, the medical model also exerted a lot of pressure on nonmedical practitioners to utilize their Diagnostic and Statistical Manual of Mental Disorders ([DSM] American Psychiatric Association, 1952), which emphasizes ESTs for specific diagnostic entities and configurations of symptoms.

The DSM, originally published in 1952, was developed by psychiatrists in collaboration with the pharmaceutical industry. Although the latest incarnation of this “bible” invites input from other helping professionals—notably, psychologists—it is still heavily shaped by the medical profession, which treats conditions such as depression, anxiety, and other emotional disorders essentially as diseases ([DSM, 5th ed.; DSM-5] American Psychiatric Association, 2013). There has also been a noted preference for any therapeutic approach, such as cognitive–behavior therapy (CBT), that can be “manualized” and empirically tested. Needless to say, relational factors, which are often both indistinct and difficult to measure, have been relegated to categories of “nonspecific” or “common” factors.

Components of Successful Counseling Relationships

Debates and arguments, if not an actual war, have been waged among therapeutic practitioners regarding which approach or model is best. This has been going on for decades, with some arguing that the best way to help people is by focusing on their internal beliefs, or their innermost feelings, or their dreams, or their past unresolved conflicts, or their behavior, or the social constructions of the larger culture, and so on. At one time, these debates may have been useful, but we are pleased to report that more recent efforts have focused on what all (or most) successful counseling efforts have in common. In other words, instead of trying to figure out which single theoretical model is best for all clients, in every context and situation, regardless of their complaints, social environment, family configuration, and cultural background, attention has now turned toward those features that seem relatively universal across the spectrum of variables. The key question now is, “What are the common factors in counseling approaches that seem to be most important and useful?” Once these significant variables have been identified, the corollary question explores just how relatively important each of these factors might be. In the language of researchers, this is described as the “percentage of variance.”

Identification of Common Factors

Many years ago, Jerome Frank (1971) published a seminal book about the nature of persuasion and influence within helping encounters. He viewed the various therapeutic approaches as “cults” in the sense that each had a rigid ideology that seemed impervious to compromise. Rather than necessarily accepting that what their proponents insisted was operative as a therapeutic ingredient in each conceptual framework, Frank settled on what he considered to be universal features of healing, such as the client's expectations, the counseling relationship, and the importance of faith in the process. Since that time, a number of other researchers (e.g., Duncan, 2014; Lambert, 1986, 2013; Norcross, 2011; Wampold, 2001) have investigated these common factors. In one early review (Grencavage & Norcross, 1990), five recurring themes were identified that are still considered important today: (1) what the client brings to sessions in terms of motivation, beliefs, personal characteristics, and expectations; (2) the counselor's personal characteristics; (3) the ways sessions are specifically structured to meet clients' needs and interests; (4) the change processes that are emphasized and accessed; and, finally, (5) the quality and kind of relationship that is established and maintained. In subsequent studies and reviews, this last feature—the relationship—has been found to be just as important as any technique that may be used.

Of course, it isn't any kind of relationship that is considered helpful to clients but rather the sort that has some particular qualities. Although certain clients may need or prefer more or less structure, as well as a number of other facets, it consistently has been found that the best helping relationships have a high degree of perceived and experienced empathy—clients feel understood, respected, and cared for by their counselors. Clients feel that there is a true partnership in terms of collaboration on their goals. In addition, the best relationships provide opportunities for ongoing sharing of input and feedback so that constant adjustments can be made as the process, stage, and needs inevitably evolve.

We will save you the trouble of wading through the overwhelming evidence, supported by countless research studies, that clearly demonstrates the importance of the counseling relationship by summarizing the key principles that we describe and apply throughout this book:

In all of its many manifestations, the relationship is central to all that we do in counseling.
Although we may be fascinated and drawn to study theories, models, and different approaches to counseling, it turns out that the particular choice we make is much less important than the kind of relationships we negotiate with clients.
Most counselors identify as integrative or pragmatic or eclectic, especially as they gain experience. What holds together all the different ideas they have incorporated is the way they are uniquely blended within the context of a helping relationship.
It would be far more useful to spend less time and energy learning new techniques and mastering new models and, instead, to become far more proficient and skilled at developing solid relationships with clients, regardless of their issues and background.
Issues of power, marginalization, privilege, and cultural background are not just facets of the relationship that should be considered but remain central components of any helping effort.
Successful relationships in counseling—or, for that matter, in any helping encounter—can take place in a variety of settings and contexts but still retain many similar features, which are personalized and adapted for each client.
Positive outcomes are most often associated with high levels of empathy, rapport, and relational engagement.

As we have stated, the relationship is a key component of any helping effort, perhaps even the most significant feature, but it is also not nearly enough. In asking the crucial question, “What leads to lasting change, both within counseling and in daily life?”, a number of other factors have been identified that play an important role (Bohart & Tallman, 1999; Gianakis & Carey, 2008; Higginson & Mansell, 2008; Kottler, 1991, 2014; Lambert, 2013; Norcross, 2011; Paul & Charura, 2014b). We summarize the most active ingredients within constructive helping relationships in the following section.

What Makes a Difference in Promoting Change in Counseling?

Positive expectations and hope
Lifestyle changes
Disclosure and processing of content
Permission to explore new areas
Feeling understood and heard
Emotional arousal
Facing fears
Validating and normalizing feelings
Collaborative goal setting
Constructive risk-taking
Reduction of stress
Honesty and directness
Rehearsal of new skills
Task facilitation
New insights and understandings
Sensitive confrontation
Challenge of dysfunctional beliefs
Suggestions for resolving problems
Modeling new behavior
Creation of meaning
Public commitment of intentions
Social support
Reframed narrative
New options and alternatives
Secondary gains eliminated
Responsibility for consequences
New resources accessed
New solutions generated
Understanding past behavior
Planning for the future
Interpretations of behavior
Tolerance for ambiguity/complexity
Inviting and responding to feedback
Flexible adjustments over time
Integrity and mutual respect
Follow-up and accountability

Even with all of these additional variables that usually operate in complex and interactive ways, we may still conclude that relationships are the principal forum by which healing, growth, and change take place in counseling. These are not static entities; helping relationships are multidimensional and occur on different levels and within culturally specific contexts. Regardless of their setting, they are designed to maximize power and influence within a collaborative partnership, although each successive stage in the relationship requires a different kind and level of engagement. There may be differences of opinion between the client and the counselor as to the origin, source, and meaning of the presenting problems, but eventually a consensus is reached that further enhances the relational connection. As we mentioned earlier, the best of these relationships are characterized by agreement on goals and methods, open communication, mutual respect, and caring.

Common Factors and Outcome Variance

Before discussing further conceptualization of common factors theory, it may be beneficial to identify what is meant by outcome variance, which is a statistical term that reflects a percentage of impact, influence, or effect, usually expressed in relation to a normal distribution. This is often the way researchers choose to discuss what contributes to particular outcomes. For example, Michael Lambert (1986, 2013) followed Frank's original ideas to identify the four common factors that were believed to contribute the most to successful counseling cases. It was found that 40% of the outcome was determined by factors related to the client, 30% by the relationship, 15% by the client's hopeful or pessimistic expectations, and the last little bit (15%) the result of the counselor's preferred theory and techniques. Pretty interesting, isn't it? Although we may hungrily attend workshops and classes, read books, scour the Internet, and watch videos searching for the latest hot interventions, our efforts might be much better focused on strengthening our relationships with clients and harnessing their own resources.

Although these estimates are widely cited, not everyone agrees that they are set in stone. In fact, although the numbers conveniently add up to 100%, they were not derived from statistical analyses but represent best guesses from reviewing previous studies. Nevertheless, this does act as a reminder that the “Holy Grail” will not be found in any magical technique that has so far eluded us but rather in the less glamorous job of making our relationships with others more engaging and productive.

We wish we had learned this lesson long ago because each of us has spent many years as workshop junkies, not to mention lifetime students and scholars, searching for the next best thing that would render everything else obsolete. Perhaps like you, we have watched the masters in the field work their magic in demonstrations and then tried (often unsuccessfully) to imitate them. It took a long time to discover that what they did was unique to them and not easily replicated.

Subsequently, many others have attempted to sort out these variance percentages as precisely as possible. Duncan (2014), for example, honed in on clients' contributions to outcomes in counseling, including their initial motivation to seek help, available support system, particular complaints and problems, life experiences, resilience and hardiness, and what they want and expect from the sessions. However, many other factors are random, mysterious, or difficult to measure in the first place. In addition, none of this addresses the other important features such as the counselor's unique personality, approach, and signature style. It is, therefore, our view that many of these treatment effects ultimately can be connected to some relational components, either directly or indirectly. This is very good news because there are so many things that we cannot control, or even change much, such as what the client originally brings to counseling.

We may all agree that the relationship is key, perhaps the ultimate force and factor that determines the result of helping. However, that still doesn't explain the many paradoxes within counseling relationships that we may not immediately recognize because we live within them so much of the time (Kottler, Sexton, & Whiston, 1994). For instance, counseling is said to be based on reasonably equal, collaborative negotiations, yet it is pretty clear that most of the real power is lodged in the counselor's authority and position no matter what we claim otherwise. Likewise, counseling is conceptualized as being intimate and highly personal, even though it is also professional and distant at times with very clear boundaries. It is conceived as a rather spontaneous encounter but is often highly prescribed and ritualized. It is supposed to be real and genuine but is actually at times somewhat manipulative and filled with all kinds of distortions and projections. It is designed to foster independence but does so, in a way, via dependence in counseling. It is also advertised as safe and secure but can be somewhat dangerous, given that its structure is designed to produce changes. Finally, counseling is based on universal principles that have been supported by research and practice, yet it is adapted differently based on the cultural and individual context of the client and the counselor and their negotiated relationship.

Why Don't You Believe Us?

Despite all of the evidence reported, especially numerous studies indicating that client outcomes are predicated on the quality of the client–counselor relationship, it often seems problematic for practitioners and students to actually believe this and take it to heart. Most of us were originally trained to believe in the power of theories and techniques, taking classes mandated by accreditation standards. We offer specific classes that focus on particular approaches, skills, and interventions, and certainly these are important, but the subtext is that this is where all the action resides. This focus continues despite all the evidence and research that affirms that specific theories and techniques account for a very small part in client outcomes.

From early in a counselor's training, faculty and supervisors may instill the belief in the magic pill—that there is a technique or an intervention that will transform the client with a few sessions of active listening or disputing irrational beliefs. Such a belief is further strengthened by managed care and external funding agencies that emphasize these supposed ESTs.

Embracing regimented, manualized treatments that emphasize situation-specific techniques implies that almost anyone could do counseling with minimal training, if they just follow the template. The reality is that such practices can undermine the effort and hard work it takes to establish a deep and meaningful relationship with clients that is designed to empower the work that we do together. Such a relationship requires deep, deep listening, hovering attention, and intense concentration to capitalize on whatever is happening in the ever-changing moment. Counselors are required to take time to truly understand a person and to demonstrate that understanding through a genuine, accepting, and caring interaction.

Unfortunately, providing evidence of the client–counselor relationship through traditional research techniques such as clinical trials is difficult. The establishment and growth of a relationship is a unique process between two (or more) people that is not easily reduced to successive, incremental, invariant steps. Nevertheless, each of us is saddled with the responsibility of answering the ultimate question, “How do you know that what you are doing is actually working?”, and each of us is required to provide reasonable evidence to support that claim.

Relationships in Counseling and the Counselor's Life