The Practice of Collaborative Counseling & Psychotherapy: Developing Skills in Culturally Mindful Helping
Publication Year: 2013
Subject: Therapeutic Relationships
Collaborative Helping Skills is a T1 for courses in the helping professions that helps students learn the basic skills of helping. The course is a requirement for any student in counseling, psychotherapy, or social work as it prepares the student for the work they will be doing with clients. This book has a focus on developing skills that are collaborative by involving the client in the helping process/solution and it has an integrated focus on multicultural skills and social justice. The book first outlines the basic process of counseling and counselor self care, then goes into conversation and counseling, receiving, attending, listening, positive regard, empathy, and connection. Then the author moves into the basics of developing a relationship with the client as well as relating ...
- Front Matter
- Back Matter
- Subject Index
- Section 1: Preparing for Practice
- Chapter 1: Culture, Counseling, and Care
- Chapter 2: Therapeutic Conversation
- Section 2: Constructing a Foundation for Collaboration
- Chapter 3: Receiving and Listening
- Chapter 4: Building the Relationship
- Section 3: Mapping Clients' Experience
- Chapter 5: Receiving and Reading Meaning
- Chapter 6: Responding to and Confirming Meaning
- Section 4: Assessing Challenges, Preferences, and Opportunities
- Chapter 7: Defining and Describing Problems and Preferences
- Chapter 8: Assessment I: Evaluating Challenges and Competencies
- Chapter 9: Assessment II: Attending to the Wider Context
- Section 5: Promoting Change
- Chapter 10: Collaborative Influence: Achievable Goals toward Preferred Outcomes
- Chapter 11: Working with Actions
- Chapter 12: Working with Thoughts and Beliefs
- Chapter 13: Working with Emotions and Values
- Chapter 14: Working with Stories
- Chapter 15: Endings and Beginnings
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Library of Congress Cataloging-in-Publication Data
The practice of collaborative counseling and psychotherapy: developing skills in culturally mindful helping / David Pare.
Includes bibliographical references and index.
ISBN 978-1-4129-9509-2 (pbk.)
1. Psychotherapy—Cross-cultural studies. 2. Counseling psychology. 3. Ethnopsychology. 4. Counseling psychologist and client. 5. Psychotherapist and patient. I. Title.
This book is printed on acid-free paper.
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All Student Voices boxes are reproduced with consent from anonymous students.
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At last! The textbook I have been waiting for!
It's hard these days to write a counseling textbook that is fresh and doesn't read like a rehash of existing texts. David Paré has done it.
Many textbooks teach the practice of counseling to new learners by relying on basic ideas generated before the 1970s and graft more recent developments onto this foundation as optional modalities. David Paré avoids this shortcoming. He has written a text that incorporates some of the best of contemporary practices while avoiding the arbitrary cobbling together of unrelated ideas that can result in a sort of eclectic counseling stir-fry. The problem with doing this is that practices that are incompatible often get stirred in and the overall taste is spoiled.
There are also those who advocate dropping a range of practices into a ‘toolkit’ and pulling out the ones that seem most appropriate for the occasion. The problem with such an approach is that it does not represent a unified perspective which gives practitioners the opportunity to improvise in accordance with a coherent set of values. In fact practices are always linked to philosophical frameworks and these are rooted in perspectives on living that, in order to be useful, have to be espoused with some depth. Without careful learning of the framework as well as the immediate tool, practitioners can actually do damage. It is as hard to be completely eclectic in this sense as it is to be Christian, Muslim, Buddhist and Jewish at the same time. David Paré does not ask students to attempt the impossible.
David Paré does not try to be all things to all people. Instead, he draws carefully from theoretical frameworks that hang together coherently. He explains his own preferences along the way and students are therefore able to critically engage with the material as they formulate their own forms of practice. This transparency is a refreshing alternative to implausible “neutrality” that wears a mask of purported objectivity while secretly turned in one theoretical direction.
Much of the professional and academic energy in the counseling professions has been dedicated in recent years to strengthening the structure of the profession through [Page xx]establishing licensing standards, credentialling processes, codes of ethics or laws, and extending the reach of professional bodies. There has also been a concerted effort to attend to long overdue issues of diversity and social justice. As a result, concerns about the basic foundations of practice have often remained neglected. By default, counselor education has fallen back on teaching practices established long ago. It often appears to be assumed that you can just paint a coat of diversity on top of the usual basic practices and add on a few ‘evidence-based’ tools from the toolkit and all will be okay.
The problem is that the world has changed. People's lives are different from when Freud wrote and also from when Carl Rogers constructed his ‘core conditions’ for the counseling relationship. Problems people experience are constructed differently and philosophical developments have taken place that move us inot new territories of meaning and practice. Cultural forces have shifted the ground on which learning counseling has to take place.
What I like most about this book is that it recognizes these shifts. David Paré does not assume that the world has not changed in recent decades. He draws on a wide range of innovative ideas and practices well suited to addressing the challenges people face in the contemporary world, weaving them into a potent foundational mix for practice. The approach taught here actually has much to offer the cause of social justice through doing counseling itself with more understanding of the effects of power, rather than seeing social justice as mainly relevant to what counselors do outside the counseling room.
Neither does David Paré dismiss the foundations of counseling laid a generation or two ago as irrelevant. Instead he connects them judiciously with new emphases drawn from the most creative practices of recent decades and makes them relevant to students learning counseling. His effort can be summarized by saying that ideas drawn from the turn to meaning are placed alongside many well-established traditions of counselling which are reworked and retained in new formats.
Remarkably, David Paré both draws from sophisticated philosophical thought but avoids heady jargon. He speaks to the reader in a very direct, practical, and accessible way. This book guides students through the complex process of learning to be a counselor without hurrying understanding along or glossing over knotty issues. There is plenty of invitation to reflect, to loiter with a poignant metaphor, to discuss subtle nuances, and to incorporate both accumulated wisdom and vigorous new ideas into creative practice.
There are also many useful suggestions for practice exercises to use in class and invitations to discussions worth having. This book will help enthusiastic and caring practitioners become skilled, intentional and up-to-date in their practice. I am very grateful for the work that this book does, and I can't wait to share it with classes.Professor and Associate Dean, College of Education, California State University, San Bernardino September 2012
It would be difficult to marshal the staying power to complete a text like this one without the conviction that one had something new to say. This book has been a long time coming—many years in gestation and a few in the birthing phase, too. It's precisely because I believed I had something urgently worth sharing that I was able to keep at the project despite many other duties, obligations, and distractions. But I'd like to be clear that I don't see this book as a compilation of my ideas; the something new that I have taken great pleasure in articulating derives from the work of countless theorists and practitioners I have had the privilege of encountering over the past two decades.
I won't fill this early preview of what lies ahead with a detailed account of what those novel ideas and practices are—there is plenty of space ahead for that—but let me provide you with a brief glimpse. The idea for the book sprung from my noticing that none of the counseling skills textbooks I was acquainted with through my role as a counselor educator paid sufficient tribute to the dazzling array of innovative approaches to counseling and therapy I was familiar with through my role as a counseling practitioner keeping up with contemporary work in the field. I noticed the textbooks were still informed by a highly individualistic view of people, whereas so many forward-looking practitioners had moved well beyond that perspective.
As you will see in the pages ahead, that single shift to a view of person-in-context sets off a domino effect of other important shifts that distinguish this book in may ways from traditional counseling texts. For starters, counseling is unveiled as a cultural practice, and clients are seen as cultural beings. That move away from individualism precipitates a lessening of the focus on individual pathology because it opens up a view of people's taking on the diverse contextual challenges of their lives in a variety of resourceful ways. Counseling comes to be seen less as an exercise in correcting dysfunction or promoting personal growth [Page xxii]and more as a cross-cultural collaboration capitalizing on people's unique knowledges and competencies.
The book is divided into sections that roughly parallel phases of the work, with the first section devoted to preparation for practice. Chapter 1 provides a tour of some of the key new ideas I referred to above; it may be worth returning to from time to time as the issues highlighted there become foregrounded through the practices outlined in later chapters. This first chapter introduces one of two counselors, Maria, whose therapeutic conversations will be featured in transcript form throughout the text. Maria is represented in each of the ongoing scenarios—as both a counselor to Jorge and a client of Daniel. She is included in both roles as a reminder that like clients, counselors face ongoing challenges themselves that hover in the background of the work they do.
The second section of the book is devoted to constructing a foundation of collaboration. Chapter 3, on receiving and listening, emphasizes the critical importance of skills that are less overt but fundamental to creating a safe and receptive context for sharing. The fourth chapter examines the role of the therapeutic relationship, which has been repeatedly shown to play a crucial role in effective helping.
Section 3 of the book takes on the task of mapping the client's experience, reminding readers to be mindful of cultural diversity and to approach each new client with an attitude of open-minded curiosity. Achieving shared understanding is a subtle art that includes both receptive and expressive skills. The section is divided by these, starting with skills for reading experience, followed by skills for conveying that reading back to clients to coordinate meaning making.
The fourth section of the book focuses on assessment. This is where some of the more striking divergences from some other texts appear. Whereas assessment typically emphasizes a scoping out of personal deficit, these chapters provide ideas for separating persons from the challenges they face, a practice that diminishes the focus on pathology and opens space for more optimistic and productive conversations. Chapter 7, about defining problems and preferences, reminds readers that assessment should never lose sight of what people are striving for because clients' hopes and aspirations are the compass for the work. The following two chapters expand on assessment practices that situate challenges in context and keep a view of client competencies alongside an account of what is troubling them.
The book's final section, about promoting change, moves into the more proactive task of joining persons in making shifts in the ways they act, think, feel, and make meaning of their lives. The section begins with the topic of collaborative influence, an orientation to practice that facilitates change while keeping the client at the center of the process. The chapters to follow in this section offer a diverse range of practices for joining clients in making changes in particular areas. The chapters portray possibilities for creatively linking practices associated with dominant contemporary models of counseling and [Page xxiii]psychotherapy. Chapter 14, “Working With Stories,” is particularly integrative because it demonstrates opportunities for bringing together gains made in the various domains of living, making meaning of changes, and reflecting on what they say about clients' values, skills, and identity. The book's final chapter, “Endings and Beginnings,” emphasizes that the termination of work with a counselor is the beginning of a new era of living for clients—cause for both thoughtful reflection as well as acknowledgment and celebration.
As the book unfolds, you will notice some other features worthy of mention. The chapters include boxes designated as “Student Voices”—passages written by graduate students in the thick of their counselor training. These will give readers cause for reflection as they witness accounts of counselors' experience both resonant with, and different from, their own. The chapters are also interspersed with further opportunities for contemplation: watch for the gray boxes that invite reflection on personal experiences tied to the material at hand. The text is also broken up at times with boxes focusing in on particular elements and presented in the form of vignettes, in-depth explanations of key concepts, tables and charts, and so on. Each chapter closes with a pair of other features: sets of questions for discussion, and activities for bringing an experiential element to the learning.
Writing this book has been a rewarding experience for me, consolidating my respect for the infinite diversity and resourcefulness of the people I encounter as a practitioner. I hope it serves to invigorate your own practice.
The chapters to come reflect my journey as a student, therapist, counselor educator, researcher and supervisor. The ideas and practices that fill these pages derive from the many sources cited throughout the text, of course, but also from countless interactions with colleagues who have stoked my curiosity and inspired me to further exploration and learning.
I'd like to pay a particular tribute to the late Michael White. His work courageously challenges the taken for granted and has been profoundly inspiring to me and thousands of others. Thanks as well to his colleague David Epston, whose unwavering energy and optimism have given birth to so many joyful practices and who generously provided feedback to earlier drafts of this book. Michael White and David Epston belong among the pantheon of seminal contributors to counseling and psychotherapy. I would also like to acknowledge the clear-eyed and steady vision of Cheryl White, David Denborough, Jill Freedman, Gene Combs, Harlene Anderson, Ken Gergen, and Mary Gergen, prime movers behind international communities of theorists and practitioners devoted to countering oppressive practices and celebrating the knowledges of diverse peoples.
I'd like to mention fellow teachers and writers who have served as mentors, intellectual role models, and conversational partners over the years. Thank you to Don Sawatzky, my original mentor who set me on my path, and to Stephen Madigan, whose riveting Vancouver conferences provided so much early learning. I'm grateful to the Waikato community, which inspired me at the time the idea for this book was hatched: Kathie Crockett, Wendy Drury, Wally McKenzie, Gerald Monk, and John Winslade. Mishka Lysack welcomed me into his Ottawa community and joined me in growing that community over the years. Glen Larner teamed up with me at a great distance on an edited volume. Tom Strong did the same and continues to be a continual source of inspiration through his prolific writings. André Gregoire provided thoughtful commentary on earlier drafts and [Page xxv]has nourished me over the years through our ever-animated bilingual discussions. Jim Duvall, Texan “Jimbob” to my “Slim,” has shown me how therapist training and guitar picking can go hand in hand. And Vikki Reynolds continues to energize me with her moral courage and passionate solidarity.
An Ottawa-and-area community of practitioners has been a constant source of inspiration and support. May it continue! My deep gratitude goes out to Aimee Anderson, Don Baker, Lynn Bloom, Bonney Elliott, Karen Hill, Margaret Kelly, Rena Lafleur, Alice Layiki-Dehne, Marc Leger, Heidi Mack, Karen McRae, Mego Nerses, Christine Novy, Maureen Parker, Linda Smith, Noah Spector, Pamela Story-Baker, and Francine Titley.
Thanks to those who contributed feedback and reflections for the text and help with the accompanying videos, including Mohamoud Adam, Emely Alcina, Mary Alexandrou, Cristelle Audet, Magda Baczkowska, Janet Balfour, Patricia Bernier, Shaofan Bu, Kevin Chaves, Katie Crosby, Jessica Diener, Christy Etienne, Tara Findlay, Maria Franchina, James Galipeau, Cheryl Gaumont, Frances Hancock, Victoria Homan, Samantha Johnson, Lauren Joly, Genevieve Killulark, Peter Kiriakopolis, Tracie Lee, Nicole Lewis, Tapio Malinen, Gaya Mallya, Talia Nadler, Julia Paré, Jill Peckham, Jessica Poloz, Chelsea Purcell, Peggy Sax, Melanie Stubbing, Jacqui Synard, and Tina Wilston.
I'd like to tip my hat to my good humored and ever supportive colleagues at the University of Ottawa: Cristelle Audet, Nick Gazzola, Diana Koszycki, André Samson, David Smith, Anne Thériault, and Tracy Vaillancourt. I had special hands-on help pulling the manuscript together from Sheena Sumarah and Jessica Chew Leung, assistants who patiently juggled multiple inquiries and diligently dug up obscure sources. Thanks to the SAGE team including Lisa Brown, Barbara Corrigan, Lauren Habib, Elizabeth Luizzi, Laura Barrett, Adele Hutchinson, Anupama Krishan, and in particular, Kassie Graves. Kassie, you were always available for consultation and reassurance while gently steering the process forward; it's been a real pleasure working with you.
My final words of acknowledgment go to my children Casey and Liam and my wife Susan Peet, who have spent recent years witnessing my preoccupation—sometimes to the point of distraction—with what turned out to be a formidable project. Susan, I'm not quite sure how I would have pulled this off without you. I am forever grateful.[Page xxvi]
Absent but Implicit:
The unspoken expression of value and purpose that can be read between the lines of client accounts or problems and difficulties.
The ability to account in the sense of being able to provide a rationale for what counselors say and do. This involves being transparent with clients about what informs questions and statements and giving clients an opportunity for input into the therapeutic direction.
Sometimes referred to as personal agency, associated with what is called free will: volition, deliberate choice. Agency can be contrasted with passivity and the notion of determined action.
An interpretation, account, description of events in contrast to the problem version and more in line with client preferences, hopes, values, and so forth. Exceptions can be understood as threads of alternative stories. An alternate story is sometimes referred to as a subordinate story line because it is (initially) in the shadow of a dominant problem-saturated account.
Self-talk arising in the moment in response to situations. The term is generally associated with problematic thoughts.
Co-construction of Meaning:
In dialogue, meanings that are not merely shared between conversational partners but are also constructed in the moment. When there is more than one person participating, the meaning is, in effect, co-constructed.
A thought/belief or the process of thinking. See Chapter 14 for reflections on how cognition has different associations than thought/belief.
Supporting clients to move toward their preferred outcomes, rather than versions of health or wellness prescribed by the counselor, or a [Page 426]theory, or society at large. This form of influencing is decentered and involves leading from behind.
Explicitly or implicitly inviting the client to correct the counselor's reading of what the client intends to convey. If there were no power differential involved, this step would be less necessary because it could be assumed clients would instantly object to what they took to be misreadings of their experience.
Indicating a complex concept, the word that is used to characterize both the social groupings we inhabit and the discourses and practices that are predominant within those social groupings.
An orientation to conversations that invokes a rich description of experience from the other. Curiosity leads us to approach conversations the way an anthropologist approaches an unfamiliar culture. It translates into questions that seek to evoke a fuller depiction of the meanings and traditions of the other.
A conversational practice that involves exploring the origins of thoughts and ideas, tracing them back to their cultural origins. The practice externalizes in that it helps separate people from problematic identity claims not previously questioned or challenged.
Two-way conversation that evolves and transforms on the basis of contributions from both conversational partners. Dialogue is mutually responsive, co-constructive talk.
Both a noun and a verb: as a noun, a belief, story, or body of knowledge that circulates within the wider culture or within a specific subculture or institutional context; as a verb, discourse is performed as well. People engage in discourse with each other, and therapeutic conversations are prime sites for constructive discourse.
All accounts of problems are also accounts of people's taking initiatives in the face of challenges and obstacles, exercising skills and abilities amid constraints, expressing implicitly what they hope for and value. Double listening involves listening as an ally, keeping an ear open for traces of all of these in a client's account.
The ability to identify what is of most consequence for the client. This requires care-filled listening and often a reading of what is not overtly spoken but lies between the lines.
In simple terms, an instance when the problem is absent. Assuming the client has been part of naming what is problematic, this implies an exception [Page 427]is a preferred development. Making further meaning of exceptions, they can also be understood as personal initiatives or expressions of agency. They are examples of people's taking steps aligned with their values and intentions.
To be contrasted with the facts of the matter, one's lived reality. The facts may stay the same, but experience is changeable, a function of the meanings made of events.
Initially coined by White and Epston (1990), a linguistic practice that separates clients from problems and reduces blame and totalizing.
An unquestioned opinion, view, or perspective about one's identity, relations, life in general, and so forth that is influenced by cultural stories or discourses.
Jointly settling on language, including metaphors and turns of phrase, that is useful and resonant for discussing the issues at hand. This involves arriving at ways of speaking about things that are close to the experience of the client. These may include extensions or spins from the counselor so long as they are negotiated with the client.
Distinguished by Harlene Anderson and Sue Levin (Anderson, 1997; Levin, 2006) from mere listening. Hearing involves dialogue—it is a mutual negotiation of meaning, a striving for a shared understanding.
Marks practice as conscious and ethical, guided by rationales for the actions taken, both verbal and nonverbal. When we practice with intentionality we do more than simply respond from the gut—we make decisions about the impact of our actions on the clients who consult us.
Leading From Behind:
Keeping close to client meanings, evoking the client's values and preferences and relying on these as a compass for the direction of the work.
Mapping the Influence of the Problem:
Asking questions that help to elaborate the effect of the problem on the client in various contexts.
Matching Client Language:
Speaking in a manner that promotes mutual understanding by adjusting to the client's vocabulary and level of language use.
A person's subjective experience in relation to a word, event, or series of events. Although words come to some extent with some predetermined meanings, the product of cultural consensus, each person puts their own spin on the meaning as well, as in, What does love mean to you? The meaning of an event or series of events is more than the facts of what happened; instead, it is the sense made of them, the story told about them, by the person in question.[Page 428]
Thinking about thoughts, adopting a reflexive posture in relation to one's cognitions.
Characterizing both lives and identities in the sense that many interpretations or meanings can coexist, with different versions’ assuming dominance at different times.
Strong's (2001) term for the meanings, knowledges, beliefs, values, discourses, theories, and so forth, the counselor brings to the conversation.
Also known as story—akin to a web of meanings in that it brings continuity and coherence to what otherwise can be experienced as discontinuous and discrete events. It is in narrating experience that we ascribe meaning to it. Narratives are never neutral because they always foreground some elements and background others. They are expressions of subjectivity, and although they can be understood as conceptual frames or viewpoints, they can also be performed: In this sense they are meaning in action.
A stance involving the deliberate suspension of preunderstandings (professional theories and models, personal biases, hypotheses, etc.) in the service of the client. Not knowing is an orientation to the other rather than a statement of the degree of one's personal knowledge (Anderson & Goolishian, 1993).
Gurevitch's (1989) term, used in a manner similar to Anderson's (1997) not knowing. This implies not a literal ignorance but a stance of openness to surprise and further discovery.
Strong's (2001) term for the meanings co-constructed with the client, the product of dialogue between My House and Your House.
Defining a client in terms of deficit, sickness, deviance, and so forth; developing formal labels of pathology and using these to categorize clients and make sense of their experience; ascribing purportedly causal links between a client's traumatic experience and their perceived deficits.
When making sense of people's experience in storied terms, the thematic continuity between the events as they recount them. Plot is a web of meaning that coheres otherwise disparate events.
Not so much a quality that resides in an individual as a function of a relationship. In this sense, power exists between people. A position of power in relation to another may mean greater leverage or access to resources, a louder voice, more weight being assigned to one's utterances, and so forth. Power with suggests a sharing of the advantages of power to the other's advantage, whereas power over suggests imposition of meaning or abuse of power to the other's detriment.[Page 429]
The dominant account of a client's life and identity shared by a client who is struggling with life challenges. Problem-saturated stories tend to render exceptions difficult to discern—one of various ways to explain the utility of a therapist's second pair of eyes.
Periodically taking stock of the unfolding conversation, providing a summary of the most recent portion of the exchange. Effective recapping captures meaning: It includes the facts but is also rich with descriptions of the client's experience of those facts. Recaps contain a mixture of restating and paraphrasing.
Holding a mirror up to one's practice, life as it were—being mindful and self-aware, observing what one is doing and reflecting on it critically.
The quality of being attentive to the other person in the relationship and responding in accordance with what the other brings forward (Paré & Lysack, 2004). The metaphor of coordinating with a dancing partner captures a sense of the skills associated with relational responsiveness.
The process or practice of choosing one's words and actions in consideration of the words and actions of the other person in a relationship.
Using the client's language in responding to their utterances. Typically in restating we seek to capture both content and process—an experience-near description of the client's experience.
See Global Belief.
A counselor's sharing with the client details about the counselor's personal life, emotional experience, and so on.
In effect, things we tell ourselves: the thoughts that arise, most often automatically, in response to events.
The use of questions to invite someone to reflect on their position, weighing out its consequences, playing out an argument to its conclusion, and so forth.
Providing an account of an entire conversation by way of achieving closure or introducing a new conversation. Like recaps, summaries include factual detail but are also rich with descriptions of the client's experience of the facts. Summaries contain a mixture of restating and paraphrasing.
Closely related to a not-knowing orientation: telegraphing to the client that the counselor's understandings are not closed or final and that the [Page 430]counselor's view of the client's experience is always open to the client's scrutiny and correction.
Also known as a cognition, something we tell ourselves. A thought is to a global belief somewhat like a sentence is to a story.
Defining something or someone in fixed and delimited terms, making out some perceived quality or feature to be the all of the client or thing. Pathologizing is typically a totalizing process.
Usually of identity, a bounded and fixed description that leaves no room for other versions, other possibilities—often problem or pathology focused.
Tracking the Story:
Asking clarifying questions to ensure that you have the details right. These may be factual details, but more important, they are meanings. Meanings are what experience is made of and comprise thoughts, feelings, values, hopes, fears, and so forth.
Unpacking Resonant Language:
In this sense, to explore words that appear to have special significance for the client in more detail, to open up the language further, to tease out a richer and fuller description.
Strong's (2001) term for the meanings, knowledges, beliefs, values, discourses, theories, and so forth that the client brings to the conversation.
Appendix 1: Assessment[Page 431]
In many instances, agencies have staff members specifically devoted to an intake assessment that precedes linking clients to therapists. This arrangement can be used to link clients with appropriately skilled practitioners, but it also leads to counselors’ inheriting one particular take about their clients before they even meet them. Working with prior assessments calls for a skillful balancing act: It involves taking a cue from pregathered facts and thus saving a certain amount of time while simultaneously inviting clients to recount their stories face to face so that counselors hear clients’ experience in the clients’ own words.
Alternately, counselors may be called on to conduct formal assessments themselves at the front end of their work with clients. In some cases, the structure of these assessments may be rigidly predetermined; in other instances, practitioners have some leeway as to what they will include in assessment documentation. This appendix (adopted from Madsen, 2007) supplies ideas for possible sections to include or characteristics to look out for in conducting assessment. The following are a couple of points worth noting about assessment: (a) It is ongoing, and the picture inevitably expands and changes with repeated conversations with clients, and (b) assessment is not just about what information is committed to paper; it is about how counselors position themselves relative to the people with whom they work. The notes below deliberately manifest an orientation that centers client preferences and highlights their competencies and resources.
Source: Adapted from Madsen, W. (2007). Collaborative therapy with multi-stressed families, (2nd ed.). New York: Guilford Press.[Page 432]Identifying Information
This section is for basic contact information and client demographics. It should include cultural characteristics, broadly speaking—for instance, age, ethnicity, sexual orientation, class, and so on. Sometimes these factors are only highlighted when clients are from a nondominant group, which further entrenches social hierarchies. As seen throughout this book, persons’ lived experience is inextricably related to their cultural contexts. Gaining an understanding of clients’ multiple cultural identities is a key aspect of assessment.Description of the Client in Context
This provides a picture of the client in relational and contextual terms. It's often useful to include a genogram here (see Chapter 9), which is useful for tracking family and other close relationships as well as providing background to current circumstances (dates of births and deaths, divorces, graduations, and other key milestones). This section is valuable for noting any key community supports as well, including friends, neighbors, and social agencies. As seen in Chapter 8, knowing the contexts clients inhabit tells us what they are responding to. This could include various forms of abuse, conditions of poverty or violence, and so on. Foregrounding these helps to render people's actions more sensible because it clarifies the circumstances of their lives.Presenting Concerns
Client concerns—sometimes referred to as presenting problems—are at the heart of the assessment process. Given that counseling is about addressing distress or some expressed need, the presenting concern is a description of which forms these take. How this is documented can vary immensely, from dry depictions of deviations from some arbitrary norm (“the client demonstrates significantly flat affect”) to descriptions that foreground clients’ concerns in their own words (“Josh says the ‘spark’ he felt when he first went back to school ‘has been snuffed’ and that he feels a ‘heaviness’ throughout his body on most days, particularly in the evenings”).
A useful addition to this section is a separate account of the presenting concern as related by a referring source, which may come in the form of a diagnosis. It can be enlightening to determine how this description corresponds to or differs from how clients describe their concerns. As seen in Chapter 9, it is also useful to learn about the client's response to the referral source's description of the presenting problem(s).[Page 433]Client Preferences and Competencies
The flip side of presenting concerns, client preferences tell us, What does this person hope for? What is their image of a better life? The picture of client preferences is usually directly tied to presenting problems (i.e., the absence of the problem), but skillful questioning can also uncover rich descriptions of preferred territories of living (see Chapter 7).
Client competencies are gifts they can draw on to get to those preferred territories and are well worth noting. This can include skills applied in relation to specific concerns such as the use of humor to defuse family tensions. But people are “weirdly abled” (Freeman, Epston, & Lobovits, 1997) in all kinds of delightful ways, and learning about these abilities not only renders a richer picture of who they are but also uncovers resources that might prove useful in all kinds of unexpected ways.Context of Presenting Concerns
This section fleshes out a picture of how the concern operates in various domains of the client's life. It includes details about where and when the problem presents itself and how the client and those around him or her respond to it. In addition to actions, the context includes emotions, thoughts, and beliefs as well as the broader meaning making the client does in relation to the problem. Questions here uncover the “life support systems” of problems—situations, locations, people around whom the problem thrives, for instance. They also highlight the support systems that account for exceptions to the problem—the contexts in which clients’ preferred ways of being are able to thrive.Client Experience with Helpers
Asking about their experience with helpers conveys to clients that their subjective experience of services is of key importance. Learning about how previous work has unfolded is useful for two other reasons. First, it provides insight into what has not gone well, reducing the chances of duplicating ineffective or distressing interactions that might get the therapy off to a poor start, not to mention hampering the development of a productive relationship. Second, information about the client's successful experience with other care providers helps to avoid reinventing the wheel because it provides a detailed account of interventions that may well prove useful in the current circumstances.[Page 434]Relevant History
All of the preceding information in this appendix provides a rich backdrop to soliciting an account of clients’ relevant history. Relevant is a key word here: There is always an infinite amount of information that could conceivably be gathered; it is more useful to foreground events directly related to the presenting concerns. This should include both accounts of the negative repercussions of problems and also accounts of success in relation to problems. As the word history suggests, this section is about capturing a time line of events from a time before the problem became a problem to the current day.Medical Information
It is not uncommon for relational, emotional, and cognitive experience to be affected by medical issues. Gathering medical information involves identifying illnesses or conditions that may have repercussions for the client's broader well-being as well as keeping track of medications currently and previously taken.Mental Status
The content of this section is frequently required by licensing regulations and includes categories such as appearance and behavior, general orientation, thought content and organization, attention, concentration, intellectual functioning, memory, judgment and insight, and mood and affect. These categories are focused on the individual, and the information recorded here makes a lot more sense in the context of the other information gathered as part of the broader assessment.Risk Factors and Safety Factors
Counselors and therapists have a responsibility—ethical, legal, and regulatory—to ensure that clients are not at risk of perpetrating serious harm on themselves or others. Gauging the likelihood of this occurring is typically part of an overall assessment. Appendix 2 explores risk to others (violence and abuse), and Appendix 3 deals with risk to self (suicidality). A useful adjunct to determining which risks are at play is to also look for indications that clients have means of countering risk within their behavioral, emotional, and cognitive repertoires—what might otherwise be called “signs of safety” (Turnell & Edwards, 1999; Turnell & Hogg, 2007).[Page 435]Diagnosis
In many jurisdictions and work settings, assessment is linked to the practice of diagnosis. I almost wrote “inescapably linked,” but as Madsen (2007) points out, some practitioners abstain from diagnosis on the basis of objections to its potentially stigmatizing influence and disillusionment with its clinical utility. Chapters 8 and 9 address the topic of diagnosis in a variety of ways. A shorthand summary of that discussion is that for some clients, diagnosis comes with a sense of relief that their suffering apparently has an explanation; at the same time, a diagnostic category renders a thin description of people, directing attention to what is not working, and obscuring that which is. It's important to ensure diagnoses do not define clients.
Linking a range of symptoms to a category in the Diagnostic and Statistical Manual of Mental Disorders (text revision) (American Psychiatric Association, 2000)—the most recent edition at the time of this writing—is a critical step in connecting clients with medications to relieve their distress. But although psychopharmaceuticals can contribute substantially to improving quality of life, they are also massively overprescribed in North America (Duncan, Miller, & Sparks, 2004; Gergen, 1990; Paris, 2010; Strong, 2009; Whitaker, 2010). In situations wherein diagnosis is required as part of assessment, it is useful to remember that assigned categories do not represent the totality of experience but are rather conceptual tools for action and part of a broader picture of a person's life. As discussed in Chapter 9, engaging clients in critical reflection on diagnostic labels signals the importance of their subjective experience and helps them to understand the diagnosis within their own frames of reference.
Appendix 2: Signs of Abuse[Page 436]
To provide help for young people who are being abused or are at risk of abuse, it's important to identify the abuse at the outset. There are various reasons why a young person may not name the abuse explicitly. They may fear reprisal, or they may be trying to avoid the inevitable disruption of their lives or the lives of their family that would accompany disclosure; they may be silent out of loyalty; they may have the impression that the abuse is normal or otherwise not worthy of reporting; they may be convinced that they won't be believed.Reporting Abuse
It is not uncommon for practitioners, especially those new to practice, to be reluctant to report when they learn of or strongly suspect abuse, for some of the following reasons:
- lack of understanding of the dynamics of abuse,
- belief that it may be an isolated incident,
- lack of knowledge of reporting requirements and procedures,
- fear of reprisals from the family toward the child,
- concerns about disrupting a therapeutic relationship,
- belief that nothing will happen anyway,
- belief that the child can be helped without reporting, and
- respect for the family's right to privacy.
The reporting of abuse is a legal responsibility. It is entrenched in legislation and associated with the ethical duty to protect, which is reflected in a wide variety [Page 437]of ethics codes, though the codes may vary somewhat in the fine print. It's helpful to remember that legislation and protocols regarding abuse are designed to protect young persons and are not founded on punitive premises. The safety of whoever is at risk should be the primary consideration in guiding decisions concerning abuse or suspected abuse. As in any situation that involves risk, it is always a good idea to consult with colleagues both to generate multiple perspectives and for support.
Although definitions vary from jurisdiction to jurisdiction, abuse generally falls into four categories: physical abuse, sexual abuse, emotional abuse, and neglect. The signs of these are diverse, and any purported indicators are not evidence that abuse is occurring; however, certain patterns of presentation deserve further inquiry. This appendix differentiates these four categories and provides some preliminary notes on recognizing abuse.Emotional Abuse
The word abuse typically conjures up images of physical or sexual violence, but significant harm can be perpetrated on young people without physical contact. Some level of emotional abuse is involved in all types of maltreatment of a child, but it can also occur alone. Emotional abuse is the persistent emotional maltreatment of a child and can take various forms. It might involve conveying to children they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It might also include deliberately silencing children or relentlessly belittling what they say or how they communicate. Although family members or caregivers are most often associated with emotional abuse, it can also arise in peer interactions (Kochenderfer-Ladd & Ladd, 2001). The term bullying has become commonplace to describe forms of abuse perpetrated by peers in face-to-face scenarios (Craig & Pepler, 2007) and increasingly through the Internet—a phenomenon known as “cyberbullying” (Keith & Martin, 2005).
Emotional abuse might include having dramatically unrealistic developmental expectations of a child: demanding the completion of tasks far beyond their current capability or severing them from social interaction or learning opportunities out of an inflated impulse to protect them from purported harm. It could also include witnessing severe emotional maltreatment or physical or sexual abuse.
When meeting with young persons and their caregivers, counselors sometimes witness abusive interactions right in the room; more often, however, it is things said or done that suggest patterns of emotional maltreatment may be occurring on [Page 438]a regular basis. It's important to remember there is no uniform way a young person might be expected to present if being subjected to emotional abuse or any other form of abuse for that matter. Indications that deserve further attention include suicide attempts, extreme aggressiveness or passivity, or an apparent delay in emotional or psychological development.Physical Abuse
Physical abuse involves physical mistreatment or physical injury of a child. It could include such actions as throwing, kicking, burning, or cutting a child; striking a child with a closed fist; shaking a child under age 3; interfering with a child's breathing; and threatening a child with a deadly weapon.
Further inquiry is warranted when children present with unexplained bruises, bites, burns, broken bones, or black eyes. Likewise if parents or caregivers offer conflicting or unconvincing accounts of the injuries or refuse to offer an explanation altogether. If parents or caregivers describe children as “evil” or advocate harsh physical discipline, it is worth learning more about what is going on at home. And of course here as with any form of abuse, a previous history of abuse is reason to be vigilant for signs of maltreatment or violence.Sexual Abuse
Sexual abuse involves the inappropriate sexual touching of a minor. It could include intentionally touching the child, directly or through the clothing, and it could also include permitting, compelling, or encouraging a child to engage in sexually touching someone else. This sort of activity should be distinguished from the touch of a parent or caregiver for the purposes of providing hygiene, child care, and medical treatment or diagnosis.
This form of abuse could also include involving children in looking at pornography or witnessing sexual activity as well as enlisting young people in the production of pornography or grooming them for sexual exploitation—for example, through the Internet. Although adult males are the most frequent perpetrators of sexual abuse, it can also be committed by women and other children.
Among the signs that warrant further inquiry, a child has difficulty walking or sitting, suddenly refuses to participate in gym or physical activities, demonstrates developmentally incongruent sexual knowledge or behavior, or becomes pregnant or contracts a venereal disease (particularly if underage).[Page 439]Neglect
Though no less consequential, neglect differs from the other categories in that it focuses more on what is not done by caregivers. Neglect is the persistent failure to meet a child's basic physical and/or psychological needs, to the extent it is likely to result in the serious impairment of the child's health or development. Neglect can occur during pregnancy as a result of maternal substance abuse. With children, neglect could include a caregiver's failing to
- protect a child from harm or danger;
- provide adequate food, clothing, and shelter;
- ensure that the child receives adequate supervision; and
- provide access to appropriate medical care or treatment.
Neglect can also include a failure to provide or respond to a child's basic emotional needs and is frequently but not necessarily associated with caregiver substance abuse. Judgments of the scope of care need to take into account contextual factors such as family income: Poverty may lead to reduced resources without constituting neglect.
Abandonment is another aspect of neglect. This involves deserting a child and leaving them without necessities of life such as food, water, shelter, clothing, hygiene, and medically necessary health care. Criminal activity or incarceration of a parent or guardian does not necessarily suggest abandonment, but a pattern of criminal activity or repeated long-term incarceration may be associated with abandonment of a child.
Among signs to look out for in relation to neglect or abandonment are the following: a child is frequently absent from school, begs or steals food from classmates, or lacks clearly needed medical attention or clothing.
It is important to emphasize that this appendix is intended to provide some preliminary descriptions of forms of abuse to support novice counselors in beginning to think about it and look out for it. None of the indicators described here prove abuse is occurring, and as mentioned elsewhere, the decision to act on suspicions of abuse should always be done in consultation with colleagues and, when appropriate, with clients as well.
Appendix 3: Assessing for Suicidality[Page 440]
The questions of how to anticipate and respond to suicidality are prevailing concerns of counselors in training, and appropriately so, given the responsibility to protect clients from self-harm. Nevertheless, it is important to remember that suicide is a very rare circumstance among clients, and counselors are typically surrounded by experienced colleagues and supervisors who can and should be consulted whenever questions of suicidality arise. In addition, specialized training in assessing risk of and responding to suicidality is widely offered and is a recommended adjunct to basic counselor training—both for the skills and knowledge it adds to a practitioner's repertoire and also for the reassurance that comes with being prepared for circumstances. This brief appendix provides a snapshot glimpse at the issue of suicidality and is not intended as a substitute for either collegial consultation or specialized training.Risks and Indicators of Suicidality
The prevailing taboo about talking about suicide extends to sharing with others that one is considering taking one's life. Clients who are suicidal will only occasionally announce this outright. It is important for counselors to anticipate the risk of suicidality by evaluating the context of clients’ situations and by reading into clients’ comments. Among contextual considerations that suggest increased risk of suicide are the following:
- a history of suicide attempts or self-harm or a family history of same;
- psychiatric disorders, especially mood and psychotic disorders;
- substance abuse; and[Page 441]
- severe triggering events (job or financial losses, relationship ruptures, death of loved ones, etc.).
Of course these alone do not suggest a risk of suicide; some clients in these circumstances may be at no risk of self-harm. Assessing risk is a holistic process that involves attending to various cues. The preceding list becomes far more significant when coupled with the following:
- expressions of hopelessness or despair,
- selling or giving away possessions,
- dramatic mood swings,
- intense anger or rage,
- severe illness,
- significant social isolation, and
- physical or sexual abuse.
It's important to be fully open to exploring the topic of suicidality; if counselors are reticent, they convey the message to clients that they should keep their feelings under wraps. Instead, direct and explicit language acknowledges that self-destructive impulses are not abnormal, and it sends the signal that it's okay to share these and explore them further. A common misconception is that talking about suicide will impart the idea to a client or increase the chances that a client will follow through; there is no evidence to support this. There are many ways into this conversation that involve picking up on what the client has said or shown without needing to resort to a highly literal question such as,
Because suicide is subject to such widespread taboo, and because the emotion associated with it is hard to stay present to, it's best to gradually but systematically explore the topic with clients, picking up on their cues rather than raising suicide [Page 442]in an abrupt manner that might cause them to blurt out a denial. Nevertheless, the answer concerning whether someone is contemplating taking their own life is critical, and it's important to persist with questioning if the client responds in a manner that does not rule out the possibility.Suicide Inquiry
Most people have concluded at some time in their life that life is not worth living. This alone does not constitute active suicidality, however, and it is important to pursue a further inquiry when clients indicate they have been considering serious self-harm or suicide. The following are key considerations:
- Suicidal ideation. Suicidal ideation includes thoughts and feelings about taking one's life. Gauging the extent of these is an important first step. How often do they think about killing themselves, for how long at a time, and how intense are these thoughts and feelings? Tools such as scaling questions (see Chapter 9) are useful here for assessing the scope of suicidal ideation.
- Suicide plan. Does the client have a specific plan for killing themselves? This includes inquiring into when they anticipate doing this and at what location. Have they taken steps to prepare for this? Have they rehearsed the scenario or engaged in related nonlethal injurious behaviors?
- Lethality of method. Does the client have a particular idea about how they might take their life? How lethal is this method (e.g., firearms vs. over-the-counter pain medication)?
- Access to means. Another important question is whether the client has access to the means by which they intend to kill themselves. Does their plan involve firearms or prescription medications? If so, do they have access to a gun and ammunition? Have they stockpiled pills?
- Intent. To what degree does the client seem seriously to be contemplating these steps? Are they ambivalent or determined to die? What circumstances (such as family or loved ones) may be contributing to hesitation?
Alongside apparent intentions to commit suicide, many clients also display a range of protective factors that diminish the risk substantially. Commitment to their families—especially children—or pets can fortify their determination to see [Page 443]out the bad patch they are in. Perhaps they indicate future plans that they continue to cherish despite their dark mood. They may have a strong social network available to support them. Protective factors may also include religious beliefs that discourage suicide or coping abilities that have seen clients through previous difficult circumstances.Responding to Suicide Risk
There is no formal, fail-safe protocol for deciding that a suicide risk is imminent and in need of an active response. The most important thing is to consult with a supervisor or experienced colleagues to make a judgment call about how to respond. Clients too may be part of this consultation in cases in which the counselor determines that they are in a position to participate in decision making about their welfare. In these cases, clients should be engaged directly about the scope of the risk they are facing and steps they can take to reduce it. One option is to widen the circle by inviting clients to recruit friends and family into a circle of active support. It can also be useful to solicit an active commitment from clients to contact you or someone close to them before they act on any self-destructive impulses. This agreement might also include arrangements for limiting access to means of self-harm.
As clients will know, based on the discussion about the limits of confidentiality at the outset of therapeutic work, the risk of suicide is one of the rare circumstances that may occasionally call for the breaking of confidentiality. Nevertheless, this should be explained again in circumstances wherein the counselor chooses to inform someone directly about a client's suicidal state. In this case, the disclosure of information is motivated by the intention to protect clients from harm. Conveying this will often temper client concerns; nevertheless in some cases a client may feel their right to their own self-determination is being violated. This is an example where the counselor's ethical and professional obligations trump the client's expressed wishes.
Typical persons to contact in these circumstances include a spouse, roommate, or close family member. In situations in which suicide seems particularly imminent, it may be necessary for one of these key persons to accompany the client to a hospital emergency room or psychiatric intake.
Appendix 4: Mindfulness, Meditation, and the Breath[Page 444]What is Mindfulness?
Mindfulness as a construct, a practice, and a psychological process has its roots in Eastern psychology and more specifically the “contemplative science” (Wallace, 2001, p. 211) of Buddhism. A central observation of this tradition is that despite cultural variations that help to account for the infinite variety of human experience, we all encounter certain inevitabilities, such as pain, illness, ageing, and eventually death. As a result, we suffer.
The Buddhist response to the ubiquitous phenomenon of suffering is multifaceted; however, mindfulness plays a central role and has much to offer to counseling and therapy (Germer, Siegel, & Fulton, 2005). Mindfulness suggests a different approach to dealing with problematic experience than the proactive, adversarial one associated with challenging or disputing problematic cognitions detailed in much of Chapter 12. Mindfulness relieves suffering not by changing phenomena but by altering one's relationship with them (Germer et al., 2005). Germer (2005b) puts it this way:
Mindfulness is a skill that allows us to be less reactive to what is happening in the moment. It is a way of relating to all experience—positive, negative, and neutral—such that our overall level of suffering reduces and our sense of well being increases. (p. 4)
One way to get at the meaning of the term mindfulness is to consider the absence of mindfulness that is a familiar feature of most people's days. Here are examples of this:[Page 445]
- eating a sandwich while working on a computer or communicating on a mobile device,
- being introduced to someone and taking no notice of their name,
- driving a car while ruminating about something that happened yesterday, and
- failing to notice a child's newly developed skill because of preoccupation with tomorrow's meeting.
What these examples share is what they are lacking. They portray an absence of awareness of, and attention to, the present moment. Being mindful is often equated with being awake (Kabat-Zinn, 2005) and can be contrasted with the automatic way we frequently engage in our daily activities. The word mindfulness has a variety of meanings as it is commonly used, including (a) a theoretical construct, (b) the practice of cultivating mindfulness such as meditation, and (c) a psychological process of being mindful (Germer et al., 2005).
Another key feature of mindfulness is nonjudgment. To orient to experience with mindfulness is to see it, hear it, feel it, smell it, taste it, imagine it, remember it, just as it presents itself, with no ambition to change it or make it better. It is what it is. Putting these together, Germer et al. (2005) characterize mindfulness as (a) awareness, (b) of present experience, (c) with acceptance.
As you can see, this orientation is less about change and more about presence without judgment to whatever presents itself. Judgment is a form of scorecard that constantly ascribes differential value to aspects of experience. Mindfulness dispenses with that scorecard to make room for experiencing what is before us in its fullness. In fact, if one were to distill a single key finding of Buddhist psychology, it is that dissatisfaction arises from attaching to experience. Attachment—sometimes called grasping—is something we all do a great deal of the time and is associated with both pleasurable and aversive phenomena. It happens when we grasp onto a pleasurable experience and wish it will go on forever, and it happens when we cling to the desire that an aversive experience will end. Either way, attachment leads to dissatisfaction or suffering. The central Buddhist premise and a key insight of mindfulness practice is that the relief of suffering is associated with letting go, or perhaps more accurately, letting be.Meditation and the Breath
Meditation is a practice common to all of the major spiritual traditions. It takes many forms but generally involves directing attention inward while sitting, standing, walking, or lying down. In the tradition of mindfulness, which has been taken [Page 446]up with vigor in the West in recent years (cf. Hanson, 2009; Kabat-Zinn, 2005; Kornfield, 2000; Levine, 2011), attention is turned to the rising and falling of the breath, typically at either the nostrils or the diaphragm.
The key role of the breath in inducing relaxation, focus, and equanimity has been thoroughly documented for thousands of years and is most fully developed in the multifaceted discipline of yoga. Herbert Benson, a medical researcher at Harvard University, played a seminal role in drawing North American attention to the benefits of breath work and meditation when he demonstrated their role in influencing the autonomous nervous system and lowering blood pressure (Benson, 1975). Another medical practitioner, Jon Kabat-Zinn (cf. 1990, 2005), has more recently contributed to the meteoric rise of interest in mindfulness in the West and has been influential in the development of approaches to psychotherapy that borrow from mindfulness traditions (cf. Germer et al., 2005; Hayes, 2004; Linehan, 1993; Segal, Williams, & Teasedale, 2002).
There are many approaches to meditation deriving from a wide variety of traditions. Some involve attention to mental images or the recitation (aloud or silent) of words or phrases. As mentioned, the breath is a key resource in most traditions and, like the heartbeat, represents an uninterrupted backdrop to all living moments. In the traditions associated with mindfulness, the breath is an anchor rather than the one-pointed target of focused concentration found in some meditation approaches. It acts as a stabilizing home base to come back to when the mind boards a “train of thought” (Paré, Richardson, & Tarragona, 2009) and loses the quality of reflexive self-awareness. Returning to the breath supports the purpose of attending to the full scope of experience, moment by moment. Breath work is therefore the means to a greater end: the cultivation of a nonjudgmental, compassionate relationship with all that passes across the field of awareness:
Mindfulness meditation encourages a gentle focus on immediate present experience, observing bodily sensations, mental impressions, feeling states and so on as they appear moment-to-moment. Attention is directed with kindness and equanimity towards whatever objects of mind or body appear. As each impression arises it is not clung to nor pushed away but simply experienced and let be, making space for the next impression to arise and fall away. There is a quieting of the interpretative and conceptual mind, a deliberate quest for a non-discursive lived experience. Narrative creation, which relies on imagination and memory, is muted as meditators seek to reduce the proliferative thinking and rumination that often fills the mind. (Percy, 2008, p. 358)
The mental states achieved by meditation contribute to a temporary alteration of autonomic nervous system indicators such as heart rate and oxygen consumption [Page 447]among various others and have been shown to have a favorable impact on sleep patterns, concentration, blood pressure, and a range of other factors (Benson, 1975; Kabat-Zinn, 2005). Recent research indicates the changes are more than transitory: Improvements in brain scanning and other technologies have demonstrated that the brain is malleable and subject to transformation well into adult life (Hanson, 2009; Siegel, 2012). The phenomenon of neuroplasticity suggests that mindfulness practice encourages the proliferation of particular neural connections along with the atrophy of others.
Mindfulness therefore offers a range of helpful possibilities for therapeutic work, both through encouraging a gentle attention in the moment during therapeutic conversations and through supporting clients in the development of their own meditation practices. Mindfulness practice also contributes to therapists’ skills in listening and attending (Baer, 2003; Hick, 2009) and can play a central role in professional self-care.
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