Objectives

At the end of this topic you will be able to:

• explain and demonstrate attending behaviour
• discuss the importance of the physical surroundings where counselling takes place
• recognise that listening is a wholistic process
• utilise observational skills to accurately track messages
• discuss the role of silence in the therapeutic relationship
• identify some problematic issues which may occur
• apply what you have learned in this and previous topics to commence the counselling process by introducing yourself to your client and putting them at ease
• identify any client groups which cause you discomfort at this stage.

Introduction

In previous topics we have discussed the therapeutic alliance and the use of self in the counselling relationship. The opportunity now arises to put these concepts into practice through knowledge and application of attending skills and observation.

What is attending?

To ‘attend’ means ‘being there’ with your client wholistically. This occurs when we:

• really listen to our clients needs, feelings, thoughts and emotions
• respond appropriately to verbal cues (verbal tracking) (Ivey & Ivey, 2005)
• become skillful in observing and interpreting non-verbal communication cues from our client
• desist from using the counselling relationship as a forum for our own issues and concerns
• use our bodies to communicate support (Sullivan, 2008)
• ensure a safe and confidential environment where clients feel free to talk
• put our own emotional responses on the back burner, to be examined and understood later
• are emotionally present with our client with a genuine willingness to hear their message in whatever way it is conveyed (verbally or non-verbally)
• listen for what is not being said, as well as what can’t be said (Sullivan, 2008)
• feel comfortable with natural gaps in conversation and become aware of the therapeutic use of silence (Corey, 2005).

Listening and the therapeutic relationship

The process of effective listening, attending, and the use of verbal and non-verbal communication occurs within the therapeutic relationship. Attending is therefore much more than the words, artifacts and mannerisms we use; it is a wholistic approach to a collaborative and healing alliance. Although certain techniques and skills are foundational to this process, if we are not really ‘with’ our clients they will leave without feeling heard. ‘Not being heard’ may be a common scenario for many clients, it is quite a negative experience for this perception to arise with clients as they leave their first session with their new counsellor.

Erich Fromm (1994) asks us to appreciate and practise therapeutic listening as an art, with its own rules and norms. His rules and norms for the artistic practice of listening are:

• the complete concentration of the listener
• the listener must be free from anxiety and greed
• his/her imagination works freely and is able to be concretely expressed in words
• empathy is present – and strong enough to feel the experience of the other as if it were one’s own
• the therapist must have the capacity to love. Not in the erotic sense, but the ability to reach out to another without losing oneself
• real understanding will only occur when loving and understanding are not separated. Otherwise this listening process occurs only on a cerebral level and does not allow a true and honest connection between counsellor and client.

Isn’t use of the imagination really just an old-fashioned furphy used by tired old existentialists who are out of touch with the issues of the modern world? Do we have any imagination left at all in this climate of instant sensory gratification? Imagination is alive and well, according to recent research into the relationship between counselling and neuroscience (Cappas et al. 2005, cited in Sullivan, 2008) which has found that stimulating neural areas in the brain through imagery as applied in the counselling process (e.g. visualisation, the miracle question, re-storying, role playing social skills, imagery for pain management) has actually produced adaptive neuronal changes and made a difference to clients’ feelings of wellbeing which are scientifically measurable. Sullivan asks us to see attachment and bonding as the ‘seed bed of therapeutic nurturance and change’ (p. 65). In attending to our clients holistically, we need to use all our faculties to really listen, including our bodies and brains. Siegel (2006, cited in Sullivan, 2008) presents a triangulated model of wellbeing:

1. empathic relationships
2. coherent mind
3. integrated brain.

Bearing in mind that the process of observation, attending, listening and building the therapeutic relationship is interwoven, continuous and omnipresent, there are however practical steps which can be taken to provide a positive experience. The creation of a supportive physical environment and the development of practical techniques and the use of appropriate questions which demonstrate your complete attention to your client will ensure you get off to a good start.

Techniques to promote a positive attending environment

(a) Creating a comfortable environment

The creation of a healing setting was identified by Frank & Frank (1991, cited in Hubble, Duncan & Miller, 1999) as being one of the essential components of all effective therapies. The setting is of course more than just the physical environment and includes all the components of the therapeutic alliance – however, a suitable physical setting provides a good environment in which to work together. Remember all these points to ensure your client starts to feel at ease.

• Comfortable seating – an armchair is particularly supportive if available.
• Even temperature.
• No glaring sun in client’s eyes.
• Shake hands, unless you assess your client may feel uncomfortable or it is culturally inappropriate.
• Glass of water and tissues available; some counsellors also offer tea or coffee.
• Provide information to the client about your service, e.g. a brochure or a short explanation from you if no written material is provided.
• Ask client if they have any questions at the outset.
• Inform client of confidentiality and any costs involved.
• Ensure you introduce yourself by first and second name, give a (very brief) background if you wish – remember the session is for the client, not an opportunity for a ‘captive audience’ to hear an exhaustive list of your professional accomplishments.
• Explain briefly what counselling is, and what it is not.
• Identify the length of this session, and further sessions if appropriate.
• Ask the client what brings them to see you or a similar opening sentence with which you are comfortable. Avoid starting the session with ‘how are you?’ This is an over-used greeting – clients expect you to really care how they are and use of this phrase may not convey the level of genuineness you hope to convey.
• You may wish to ask whether the client has attended counselling or a similar therapeutic process in the past, and whether this was a positive or negative experience.

Although you will be continuously gathering data and assessing your client throughout the first meeting, the purpose of this meeting is to start building a therapeutic alliance, create an atmosphere of collaboration and allow the client to leave with a sense of hope for the future.

(b) Development of attending behaviour

Egan (2002) developed some simple steps to assist with developing attending/observational skills. The acronym SOLVER can be usefully employed as a checklist to develop and improve attending behaviour.

1. SSquare-on or facing position. Generally being turned toward the person you are interacting with is an indication that you are involved with them and that you want to be with them. However, sitting at a 90 degree angle, basically sitting side by side, is less threatening than squarely facing the person. Some people find square-on intimidating – sitting on an angle means that you are close enough to touch them if it is appropriate and required.
2. OOpen posture. Crossed arms or legs can be signs of being ‘closed off’ and show lessened involvement or expression of openness to the other person. This does not have to be taken too literally, most women for example sit cross-legged. It is important, however, that your overall body language is giving an ‘open’ impression.
3. LLean slightly forward. This will reinforce the open body posture and shows attentiveness. The opposite, leaning back, can indicate boredom or that the person is not ‘with’ you anymore.
4. VVerbal components and responses. Or as described by Ivey & Ivey (2005) – verbal tracking. This indicates that we are following the client’s story. It also acts as a feedback mechanism for the counsellor to ensure we understand the content and feelings expressed by the client.
5. EEye contact. This should be established and maintained at a comfortable level. If you find yourself looking away frequently then this could tell you something about your own discomfort with closeness, or your reluctance to be with this particular person. However, it is important to note that the discomfort could also be a cultural issue, as many cultures consider prolonged eye contact rude and intrusive. Certainly it is important not to ‘stare the client down’, but to maintain a level of eye contact which is comfortable for both of you.
6. RRelax.Try to be relaxed whilst engaging in these behaviours. If you are very self-conscious about every step of what you are doing, it will distract you from the main purpose – that of focusing on the client.

In applying the above skills, we are of course seeking to exemplify the core conditions of empathy, unconditional positive regard, genuineness and concreteness. We may feel that being aware of the need for skill development interferes with our authenticity. Some of these behaviours may at first feel unnatural or contrived, but with practice, relaxation will eventually occur. If you can be truly open to the rewards of the therapeutic alliance, as you practice your skills they will become more part of you. It will not be long before your role playing client gives you very positive feedback!

Non-verbal communication

There are many resources available on non-verbal communication and much of this content will be familiar to you already. In the counselling context an understanding of non-verbal communication is vital to attending, observation and building rapport. The following components of non-verbal communication impact on the attending process:

• Proxemics – space and distance
• Kinesics – body motion, including gestures
• Chronemics – time
• Artifacts – things made by humans
• Oculesics – eye contact
• Haptics – relaying information through touch
• Olfactics – odour
• Paralanguage – rate of speech, word emphases, volume, tone of voice (Zaremba, 2003).

So even by the simple act of thoughtfully placing an artifact (vase, box of tissues) in your counselling space, you are communicating good will towards your client.

Heightened cultural awareness will assist in the observation/attending process. Let us now consider what other messages we may receive from our client.

Observation of messages from your client

In all fields of enquiry we learn from observation – observing changes in colour in a chemical compound, observing redness in the skin when applying remedial massage techniques, observing a patient’s verbal report of symptoms when taking a medical history – in counselling we observe and learn by attending and listening to our client with all our senses and with reference to all the components of the non-verbal communication process.

As you observe your client telling his/her story at your initial meeting, you will be gathering data and making assessments. You will be wondering about their readiness for the process and their psychological-mindedness. Sedgwick (2001) explains that we need to make an assessment of our client’s ability to deal with pain, how much he/she can take at one time and what has worked or not worked in the past. Data gathering takes place within the unconscious emotional dialogue which occurs between the therapist and client.

Incongruence between language and non-verbal communication gives vital clues to your client’s state. For example, a client may explain that he/she has totally recovered from a certain painful experience, but you notice that their voice has become very soft, they are unconsciously wringing their hands or perspiration has appeared on their brow. Your knowledge of the veracity of non-verbal messages alerts you to this incongruence and you and your client can make decisions in relation to the need to address such issues later.

We are all aware that communication is a two-way process. Observation, attending and listening therefore includes attention to our own responses. Whilst listening to the client, it is equally important to check your own responses to their story. It may help you clarify what is happening, and at the same time, whilst listening you are also giving ‘messages’ to the client. If that sounds confusing, remember that listening involves many levels of activity. Egan (2004: 80–89) points out four different levels of listening, which include:

• listening to the words, the story
• listening to the non-verbal and body language
• listening for meaning
• listening to your own reactions to the stories.

We probably pay attention to the first three levels automatically, when we really listen to someone. As a counsellor you need to do that with awareness, so you can pick up discrepancies, new perspectives or even solutions the client is volunteering. As we learned in use of the self in the counselling relationship, we are part of the healing process, and our reactions to our clients’ stories are an important component of the therapeutic process.

Use of silence

Many members of Western society are uncomfortable with silence. Our culture is full of noise, both loud and intrusive and not so obvious ‘white noise’. Some of us perform at optimum level listening to loud music, others delete any type of noise from our surroundings to facilitate concentration on a task. Members of our society who follow a path of devotion, meditation, and prayer may be more at ease with silence. However, within the therapeutic relationship, silence has its place, and learning to be observant and attentive to our clients requires us to listen to silence as well as words and body language. Sharpley (1997) found that clients particularly valued silence when they were confronting the discrepancies between actual behaviours and the way they sought to behave and, later, when developing plans to change behaviour. Moments of silence allow the client to reflect on what has been occurring in the dialogue, and if not interrupted, occurrences of important insight can occur. Polster (1995, cited in Corey, 2005) instructs therapists to build skills in allowing clients the opportunity to ‘flesh out a flash’ (p. 202). If clients have been using elusive language to gloss over their life struggles, allowing time for pregnant pauses allows the client to clarify meaning.

Silence is therefore more valuable during the working and decisional stages of the session. It was also found that long silences in the initial rapport-building stage may cause the client to feel that there is lack of leadership from the counsellor. Some theoretical perspectives suggest that there should be little leadership from the counsellor, even in the beginning stages of the therapeutic alliance. What do you think?

Silence can have negative connotations as well. The counsellor or client can be bored or distracted. The client may be feeling hostile and has chosen not to put those feelings into words at this time. There may be hesitancy on both sides to communicate on a deeper level (Corey, 2009).

Silence can also indicate the inability of the client to speak of unbearable pain (Sullivan, 2008).

Whilst it will be very useful for your practice to have an understanding of the therapeutic effects of silence, in your ten-minute assessment for this unit, the inclusion of periods of silence may not allow you to sufficiently demonstrate your microskills. Your understanding of this concept will be demonstrated by your ability to allow your role-playing client to speak without your need to ‘jump in’ too quickly with your next question or statement. In longer assessments and indeed in real life, you will certainly have the opportunity to employ this therapeutic technique.

Negative outcomes when attending

Despite our best intentions and prior planning, sometimes our first session with our client does not ‘gel’. Some of these issues are complex, and some are easier to overcome. If you feel uncomfortable after your client has left, consider whether:

1. the physical surroundings were unsuitable, i.e. too hot, too cold, too stuffy. Be aware that even if you are physically comfortable, your client may not be. Humans come in diverse shapes and sizes and their physical comfort is affected by stress and anger levels, hormones, time of life, physical illness, etc. If you work in an air-conditioned area, check whether the temperature is suitable for your client – many people are too cold in air-conditioning. Physical discomfort impacts significantly on the therapeutic alliance as the body automatically seeks a state of homeostasis. Particular client groups (e.g. persons who have been incarcerated) may not be comfortable in an ‘office-like’ environment. A Vietnam veteran will prefer to sit in a chair where he can clearly see the door. There is often an option to move the interview outdoors or to a more informal sitting area. Ensure you have investigated such options before starting your interview.
2. you omitted to introduce yourself. In our attempts to ensure the physical comfort of our clients and to impart all the wonderful information we have about our counselling service, it is surprising how many times we can overlook this very basic component of the attending process. Even if your client knows your name from the referral source or reading it on your brochure, he/she may be wondering how to address you – should your first name be used, or should the client call you ‘sir’, ‘m’am’ or ‘Dr’? Of course not, but do they know this?
3. you have unintentionally committed a cultural faux pas. It is vital to read widely on cultural issues. You need to dress and sit in a manner which will not cause offence to your clients. Use appropriate levels of eye contact and be aware of proxemics – merely placing chairs too close together, or a table between you and our client, may significantly impede the communication process. Again, cultural reflexivity, preparation and a genuine appreciation for the richness of human diversity assists in working well with all client groups.
4. there has been a language mismatch. Can the client understand what you are saying or are you disempowering him/her by using jargon or unsuitable vocabulary? Have you suggested that he/she join a D&A support program? Are you using words which delineate your higher educational level? Have you shown offence (through direct disapproval or a fleeting facial expression) at your client’s use of coarse language? What are your boundaries re language? Do you need to communicate these to your client – if so, how will you do this without adding to the power imbalance inherent in the therapist/client relationship?
5. your feelings of unease relate more to yourself than the client. Why? Return to your process of self-analysis to understand what has triggered your emotional response.

The best way to ensure client comfort and ease when building rapport is to ‘check in’ with your client. It is important to build skills to chat easily and informally so that you can ascertain your client’s level of comfort and attend to any cultural issues. We are not expected to know and understand every nuance of every background of each client – in many circumstances we can frame a respectful question to build our knowledge of diversity. As human services workers, we are mandated to a continuous process of self-awareness and self-reflection to ensure that issues of power inherent in the counselling process do not exacerbate our clients’ stories of oppression and adversity.

So, those were perhaps some of the problematic issues in the initial rapport building phase which can be improved with a little more thought and awareness. We have considered some ruptures in the therapeutic alliance in Topic 4, and the process of reflexivity needs to commence at our first meeting (or our first phone contact). During your first meeting with your client, your observation and examination of your own responses may alert you to the following:

1. The counsellor’s challenges in truly approaching the client with ‘unconditional positive regard’.
2. The client’s inability to verbally express why they are there. It is important not to pressure the client to be clear when they present in a state of existential unease. At this point it may be useful to reassure the client that this it is not necessary to provide a ‘list of problems’. You may wish to give (more) information on the therapeutic alliance and some of the outcomes which may be expected. Counsellors working from a narrative or solution focused perspective may suggest that clients can be informed at the outset that it is not necessary for client and counsellor to unearth underlying conflicts but rather that the process of counselling will identify, validate and strengthen the client’s inner resources (Milner & O’Bryne, 2002). The story will unfold in the client’s own time.

Summary

In this topic we have explored the listening process and learned some practical techniques to observe what our clients are telling us both verbally and non-verbally; and to attend to our clients through manipulation of the physical environment and the SOLVER model. We have seen that attending is a comprehensive process requiring the attention of our whole selves, including our body and brain. We have understood that creation of a true and honest therapeutic alliance causes positive changes in neural pathways which can be scientifically measured.

The therapeutic use of silence has been introduced, and we have continued on our research journey towards culturally appropriate practice. We have practised our observational skills on our friends/colleagues and attempted our first introduction to our client. We have continued our process of self-analysis by thinking about any client groups with whom we may not be able to work.

In the next topic we will build on our therapeutic technique by considering useful ways to gather data and make assessments through questioning.