Key Skills In Counselling and Psychotherapy An Introduction to Counselling and Psychotherapy: From Theory to Practice

Attending ClientI think of talking to her about it sometime but... ehm... well, I’m not sure what I would... I guess I’m not sure how I would put it or how she might... well, react I suppose. TherapistYou’re not sure how she might react if you say something, and I also notice how much you hesitated and paused in saying that; really quite tentative. ClientYes, I do feel quite tentative about it. I’m really not sure if it’s the right thing to do. Here the therapist not only reflects back to the client the expression about not knowing how ‘she will react’, but also highlights the client’s pauses and hesitations (which are linked to their concerns).

Empathy ClientIt just feels so big. I can’t even bring myself to think about it. All too much for me to think about. TherapistI have a real sense of how overwhelming this feels. Just so frightening and enormous. ClientYes, it feels so frightening. The therapist here introduces the word ‘overwhelming’ to characterise their sense of how this might feel for the client, seeking to understand the situation from the client’s perspective. The client hears this as strongly affirming their experience.

Congruence ClientI know I’ve talked about this so many times before, you must feel that we go over the same ground. I’m always talking about the same things. TherapistI am aware of sometimes feeling a frustration in revisiting things we have talked about, and I wonder if that means anything for your experience too? ClientYes! Yes, I feel so frustrated with things – I get stuck with my frustration rather than the things themselves. It’s more about what happens with my feelings isn’t it! The therapist here takes a risk in naming the client’s experience as ‘frustration’, which could easily be experienced by the client as critical. However, by linking it to the possibilities of the client’s experience too (‘I wonder if that means anything for your experience?’), the therapist creates an opportunity for the client to explore and clarify their own process a little more. Congruence always needs to concern a dynamic within the relationship, rather than merely the therapist’s own views on life.

Summarising ClientWe’ve been together for about five years now and, well... it doesn’t seem to be going anywhere. I’m not sure I want to finish it, and I can’t imagine another five years like this. It gets so boring at times and un-stimulating – I know I sound horrible saying that about him, but there you go. That’s what it feels like [sighing]... TherapistSo you’re struggling with a relationship that you can’t imagine will go anywhere but feel quite ambivalent about what to do about it. You seem to make judgements about your feelings about it too, when you say ‘I know I sound horrible’, and then you sigh? ClientYes, I suppose I do make judgements about myself. I think that’s probably something I do a lot: I have feelings about things but then give myself a hard time and don’t trust them. The therapist offers a summary of the client’s narrative, using in the process non-verbal (paralinguistic) sounds (sighing) and implied meaning (‘I know I sound horrible’) in what the client is saying. The summary includes more than just the words. This helps the client begin to explore a wider issue of self- judgement.

Paraphrasing ClientIf I got on with my manager more the job wouldn’t feel so awful. I mean... getting up in the morning I just wonder what she’s going to be like today. Seems to influence so much what sort of day I’m going to have. TherapistYour manager has a lot of influence over how you experience being at work. If your relationship with her was better, work would seem much more manageable. ClientYes, she’s quite dominant isn’t she! Stupid that one person should have such control. The therapist paraphrases the client’s narrative, sometimes using the client’s words and phraseology to do so. This provides the client with an opportunity to reflect on the meaning and implications of what they are saying and to move forward with their exploration.

Challenging ClientI’m just not any good at anything... I can’t organise and manage anything. It’s like I am incapable of doing anything well. TherapistYou say you’re incapable of organising and managing, and I think back to when you talked about how you manage your two children on your own – getting them to school so you can go to work – that sounds like a lot of managing and organising! ClientI suppose, I’d not really thought of that as meaning anything. The therapist offers a direct challenge to the client’s position by referring to things they have said previously. This is different to simply trying to make the client feel better (e.g., ‘Oh, I’m sure you can organise things well. I’m sure you can!’), which never has any real benefit.

Advanced Empathy ClientI miss him so much, I can’t hardly think of the fact that he has gone. All that time looking after him and now he’s not here. But it was so tiring, there’s a part of me as well that thinks... oh, I mean... I miss him so much all the time. TherapistThe loss is unbearable at times. And there might also be a part that feels relief from how tiring it was; difficult having those feelings? ClientYes, it is a relief as well. I couldn’t imagine saying that to anyone, I thought I’d feel so guilty. The client tentatively begins to talk about feelings that lead to guilt and shame (‘... there’s a part of me...’), but finds them too hard to express. The therapist picks up on this and, from an empathic position, helps the client begin to name the feelings ( ‘... might be a part that feels relief...’) and then acknowledges how ‘difficult’ it is to have such feelings. The client hears this ‘permission’ to name the difficult feelings.

Encouraging Strengths ClientI kind of feel stuck. Y’know, I wonder how I’ll manage and carry on with all this stuff going on. I feel so depleted in some ways. TherapistYou feel stuck and depleted, and yet you have coped with so much too. You talked about the things you do to look after yourself, which might be really important here? ClientThose things do help, yes. I forget them sometimes y’know. I forget I can do those things too. The therapist, using reflective skills, highlights the difficulty of the client’s situation but then encourages the client by referring back to a previous session when they had talked about what the client does to take care of herself. This encourages the client to recall these things and begin to draw some strength from them – this immediately begins to help with a sense of depletion, although those feelings are acknowledged too.

Highlighting ‘Edge of Awareness’ ClientWe ended up having this almighty argument – it was awful. She was going on about what I should do about stuff and... well... I just blew – lost it! Another relationship ended... again! TherapistI’m thinking about the other times when you have ‘lost it’; I’m thinking about how often it seems to be something to do with being told what to do, about not being in control? ClientOh goodness yes! Yes, it is! I hate it, I hate being told what to do. My sister always used to do that to me when I was younger – always pushing me around. I’d really get pissed about it. The client has not made any links himself concerning the arguments he has in relationships. The therapist tentatively offers a link – not in a way that interprets the client’s narrative, but rather as a way of holding similarities together for the client to reflect on them. This has a profound impact on the client, who suddenly begins to make connections.

Reflection ClientSometimes I just feel utterly hopeless. Like a big cloud descending on me – just overwhelmed. Utterly, utterly overwhelmed. TherapistLike a big could descending – utterly overwhelmed. ClientYes, it’s so smothering. The therapist uses the client’s narrative without adding anything new: they just reflect the words back for the client to hear. This helps the client to make more sense of their experience and move forward, in this instance to a sense of being ‘smothered’ by their hopelessness.

Exploration ClientI look in the mirror and I feel so disgusted. I mean, I feel so fat and ugly and the rest of my body... well... y’know, it’s awful. TherapistCan you tell me a little bit more about the rest of your body – what is it about your body that is awful? ClientI’m too tall and too fat. I think I am completely out of proportion – it’s all so ugly. While the exploration here doesn’t lead to any new insight or resolution, it does provide the client with an opportunity to be more specific about how they feel about their body. This extra detail may be important for the client and therapist to use in subsequent sessions.

Focusing ClientThere’s the job – that’s rubbish and I really hate it. It just gets me down so much. I wondered about moving away and doing something different. I’ve always fancied living in a big city and... well, do you think it would be a good idea? TherapistThe job gets you down so much. I wonder if you could tell me more about what it is about the job that gets you down? ClientThe hours are so long and I just end up feeling exhausted. I never feel that I recover from it and am always tired. I can’t enjoy the rest of my life. The client names an important area of concern and then becomes distracted by the thought of living in the city. It would be easy here for the therapist to follow that line and miss the issue about the job. Here, however, the therapist focuses the client, which helps the client be more specific about what it is they find difficult. The issues of moving may return in subsequent sessions.