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Chapter 5 | The Helping Interview: Skills, Process, and Case Management
Creating The Helping Environment
The human services professional needs to create an environment that is conducive to a facilitative helping relationship
The professional needs to pay attention to a number of areas, including the following:
Comfortability: Assuring that a comfortable office environment is provided.
A fostering environment: The helper needs to embody the personal characteristics necessary to foster a positive helping relationship
Nonverbal communication: The helper needs to know how to attend nonverbally to the client.
Office Environment
The office where you work should elicit positive attitudes from people and send clients a message that they are welcome.
Not all Human services professionals have offices, but regardless of where you work, it’s the Human Services Professional's responsibility to ensure the environment in which they work is as conducive as possible to form and maintain a positive working relationship.
If the Human Services Professional does have an office, he or she should consider the following:
Nonglare lighting.
Comfortable seating.
Obstructions (e.g., large desks) between yourself and your clients.
Personal Characteristics of the Helper
The personal characteristics that a Human Service Professional brings to the helping relationship can either foster or destroy a helping relationship.
Common attitudes that would be destructive to a helping relationship include the following:
Being critical
Being disapproving
Being disbelieving
Scolding
Threatening
Discounting
Ridiculing
Punishing
Rejecting
In contrast, characteristics and attitudes that can foster a positive helping relationship include the following:
Relationship building
Empathy
Genuineness
Acceptance
Cognitive complexity
Wellness
Competence
Cross-cultural sensitivity
Importance of Nonverbal Behavior
Words account for 7% of what is being communicated, voice intonation accounts for 38%, and body language accounts for approximately 55%.
Nonverbal behavior is a major aspect of how we communicate with others.
How we present ourselves nonverbally can significantly add or detract from our overall relationship with our clients.
Personal space is mediated at least somewhat by culture, age, and gender; individuals vary significantly in their degree of comfort with personal space.
Human Service professionals must allow for enough personal space so that the client feels comfortable, yet not so much that the client feels distant from the helper.
It is important for each of us to be sensitive to our clients’ boundaries, our own boundaries, and limits to touch set by our professional code of ethics.
Brammer and MacDonald suggest that physical contact with a client should be based on four factors.
1: The helper’s assessment of the needs of the helpee.
2: The helper’s awareness of his or her own needs.
3: What is most likely to be helpful within the counseling relationship?
4: The risks that may be involved as a function of agency policy, customs, personal ethics, and the law.
The Human Service Professional in today’s society must be acutely sensitive to client responses to nonverbal behaviors.
Counseling Techniques
A wide arrange of traditional helping skills have been shown to be important in building strong relationships between the professional and the client, such as the following:
Listening
Empathy
Silence
Encouragement
Affirmations
Modeling
Self-Disclosure
Questioning
Information giving
Advice Giving
Providing alternatives
Confrontation
Collaboration
Listening Skills
There are two kinds of listening, listening with one ear and listening with ones non-ear.
Listening with ones non-ear is a state like that of a tranquil pond, a lake that is completely quiet, and when you drop a stone into it, it makes little waves that disappear.
Effective listening helps to build trust, and convinces the client you understand him or her.
Effective listening also helps encourages the client to reflect on what he or she has just said, ensures that you are on track with your understanding of the client, and can facilitate information gathering from your client.
Good listening skills entail not talking; most people want to be heard, not given advice.
Hindrances to Listening
Our own prejudices, biases, and unfinished business can prevent us from fully hearing another person.
Knowing ourselves is the first step we can take toward hearing another accurately.
Here are some tips to help us effectively listen
Calm yourself down. Before meeting with your client, calm yourself down—meditate, pray, jog, or blow out air, but calm your inner self.
Stop talking, and do not interrupt. You cannot listen while you are talking.
Show interest. With your body language and tone of voice, show the person you are interested in what he or she is saying.
Do not jump to conclusions. Take in all of what the person says, and do not assume you understand the person better than he or she understands himself or herself.
Actively listen. Focus on the client and pay attention. Many people do not realize that listening is an active process that takes deep concentration.
Concentrate on feelings. Listen to, identify, and acknowledge the person’s feelings to him or her.
Concentrate on content. Listen to, identify, and acknowledge what the person is saying.
Maintain appropriate eye contact. Be willing to look directly at your client, but also be sensitive to how eye contact might make some clients feel uncomfortable.
Have an open body posture. Show, by your body language, that you are inviting the client to talk (e.g., do not sit there with your arms crossed).
Be sensitive to personal space. Obtain a sense of the optimal distance needed between you and your client for effective communication.
Do not ask questions. Do not ask questions except if they are used to clarify content (e.g., “Can you repeat that—I didn’t hear exactly what you said”). (See Activity 5.1.)
Empathy: A Special Kind of Listening
Empathy is also one of the most important counseling skills.
Early Greek philosophers noted the importance of listening to another person from a deep inner perspective.
Lipps is given credit for coining the word empathy from the German word Einfühlung.
Carl Rogers is the person who has had the most impact on our modern-day understanding of the use of the word empathy.
The state of empathy, or being empathic, is to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the “as if” condition.
Robert Carkhuff developed the five-point scale to measure empathy shown below.
In the training of helpers, it is suggested that they attempt to make Level 3 responses because such responses have been shown to be effective for clients.
Making good empathic responses (Level 3 or above) can be taught in a relatively short amount of time and such responses, whether given by paraprofessionals or professionals, are beneficial to clients.
Good empathic responses can sometimes be confused with active listening or reflection of feeling.
It’s important to make sure your empathy is naturally empathic and not mechanistic.
Silence
Silence is a powerful tool that can be used advantageously by the helper for the growth of the client.
Silence Helps both the client and the helper.
For the Client, it allows them to reflect on what he or she has been saying.
For the helper, it allows them to process the session and formulate his or her next response.
Silence shows the client that words can sometimes be used to divert a person from his or her feelings.
Silence can cause client anxiety which has its ups and downs.
On one hand, the anxiety could push the client to talk further about a particular topic.
On the other hand, the anxiety could cause a client to drop out of the helping relationship.
Determining how much silence there should be between when the client stopped talking and when the helper responds varies and should depend on both the helpee and the helper.
The value of silence is somewhat culturally determined; research has shown that typical pause time varies between different cultures.
Encouragement and Affirmation
One’s need for support doesn't end in childhood; adults still need unconditional love from their family, life partners, animals, peers, and even in some cases, their all-forgiving deity or god.
Clients often arrive to the helper with “hurts” from their past, which continue to infiltrate their life, causing issues such as low self-esteem.
Hurts can cause depression and anger that, in some cases, have lost their origins.
Such feelings can cause the client negativity and, in some cases, an attitude towards the world that can make these individuals our hardest clients to work with.
Often these clients need affirmation of self and an attitude that says “you can do it.”
Human service professionals must be able to see beyond the hurts, the depression, the anger, and the attitude.
Human service professionals must be able to see the potential in their clients.
Human service professionals can express this positive attitude toward clients through encouragement and affirmation.
Affirming a client entails reinforcing the client’s existing way of being, whereas encouragement is reinforcing the client’s ability to perform a task.
The human service professional must be aware that too many affirmations or too much encouragement can lead to client dependency issues.
Encouragement and affirmation, when done appropriately, can be important tools in helping clients integrate a more positive attitude about life.
Modeling
Human service professionals are constantly modeling behavior for their clients.
The ways in which human service professionals model behaviors can have a powerful effect and dramatically influence our clients’ change process.
When modeling occurs in very subtle ways, clients learn new behaviors simply as a by-product of being in a helping relationship.
The ways in which human service professionals model behaviors can have a powerful effect and dramatically influence our clients’ change process
Modeling can be an effective change strategy for clients, but so can self-disclosure.
Self-Disclosure
As human service professionals, we are helpers and caregivers
Human service professionals are not in the business to take or to have their own needs met.
Always keeping a check on when and why we are self-disclosing is extremely important for this reason.
Self-disclosure is defined as “verbally, nonverbally, on purpose, by accident, wittingly, or unwittingly.”
Although self-disclosure can have the potential for harm it can also be an important tool, research has shown that when one person is open in a relationship, the other person is more likely to be open.
However, Self-disclosure needs to be done sparingly, at the right time, and as a means for promoting client growth rather than just satisfying the counselor’s needs
A general rule of thumb is that if it feels good to self-disclose, don’t because you are likely meeting your needs more than the needs of the client.
The following is a list of guidelines concerning the use of self-disclosure provided by Hill and Knox.
Disclose infrequently.
The least appropriate disclosure is about sexual issues.
The most appropriate disclosure is about professional issues.
Disclosure is best used to normalize situations, validate reality, build the relationship, or offer alternatives.
Avoid disclosures for your own needs or disclosures that are intrusive, blur boundaries, interfere with the flow, or confuse the client.
The best disclosures are ones in which the information given by the helper somehow matches that given by the client.
Some clients respond better to disclosures than others—know your client.
The Use of Questions
Questions can be used effectively to uncover patterns, gather information quickly, induce self-exploration, challenge the client to change, and move a client along quickly to preferred goals, but their overuse can lead to dependency as the helpee will come to expect solutions from the helper.
In addition, questioning may not be as helpful as an empathic response in allowing a client to delve deeper into one’s self.
Open Versus Closed Questions: Open questions are stated in a manner that allows clients to respond in a variety of ways, whereas closed questions tend to limit client responses.
Tentative Questions: A tentative question is much more akin to an empathic response and is more facilitative when trying to build a relationship with a client and for client self-exploration.
Solution-Focused Questions: Based on the work of solution-focused theorists, these types of questions focus on problem-free times in one’s life and positive change.
Preferred goals questions: These questions are generally asked near the very beginning of the helping relationship to assess what the goals or hope of counseling would be.
Evaluative questions: These questions help clients distinguish behaviors that have led to preferred goals from those that have not.
Coping questions: Coping questions focus on past behaviors that have been successful in dealing with problems.
Exception-seeking questions: These questions help clients examine times when they have not had a problem in their lives so that they can explore how they previously lived a problem-free life.
“Why” Questions: Generally, asking a “why” question is not recommended because people often feel interrogated and put on guard when asked why they felt or did something.
If you are going to ask a question, keep the following in mind:
Are you aware you are about to ask a question?
Have you weighed carefully the desirability of asking a question?
Have you examined your tendency to use questions and why you use them at all?
Have you considered alternatives to asking questions?
Will the question(s) you are about to ask inhibit the flow of the interview?
Offering Alternatives, information Giving, and Advice Giving
Offering alternatives, information giving, and advice-giving are three ways of facilitating client movement, all of which assume the helper possesses some information that he or she can give to the client to foster positive change; however, all three of these options can also damage the helping relationship.
In order of least to most potential to cause harm, it is the following:
Offering alternatives: This type of response has the least potential for harm because it does not presume there is one solution to the problem.
Information giving: This kind of response sets up the helper as the expert, thereby increasing the potential for the client to become dependent on the relationship.
Advice giving: This type of response is generally value-laden, carries with it the potential for developing a dependent relationship and may mimic control issues from the client’s family of origin.
Confrontation: Support with Challenge
The confrontation that is facilitative revolves around giving feedback without being judgmental, critical, or aggressive.
To achieve this goal, it is important to first spend time trying to understand the client's life circumstances, often by using good listening and empathy skills.
This is followed by challenging the client, which may include making a high-level empathic response, suggesting alternatives, and pointing out discrepancies.
Making a level 4 response can be very effective in helping the client see hidden parts of him or herself.
In the case of higher-level empathy, such a confrontation should be attempted only if there is a base of caring; otherwise, the client may respond by becoming defensive.
Collaboration
Collaboration involves showing that you respect the client’s opinion by eliciting feedback from the client about perceived progress in the helping relationship, by hearing criticism about your skills, and by being willing to adjust the direction of the helping relationship, if necessary.
Collaboration can occur throughout the helping relationship and is often most useful at transitional points.
Collaboration includes the following:
The use of one’s basic skills (e.g., listening, empathy) to offer a summary of what has been discussed thus far.
Asking the client, through the use of questions, how he or she feels about the helping relationship thus far.
Asking the client, through the use of questions, about the direction he or she would like to take in the helping relationship.
Sharing with the client one’s own thoughts about which areas might be important to focus upon.
Having an honest discussion concerning any discrepancies between numbers 3 and 4, which leads to a mutual decision about the helpfulness of the helping relationship thus far and the direction to take in the future.
Using Helping Skills Wisely
The helper’s use of skills is most facilitative when the helper feels at ease with a variety of skills and can reach into his or her bag of skills and choose those most conducive to client growth.
An effective helper is intentional in his or her delivery of helping skills and, prior to making responses, can quickly and deliberately choose the most effective skills and tools.
The Stages of The Helping Relationship
All helpers will face and need to address, identify and deal with the following:
Addressing technical issues unique to the first session (e.g., meeting times, length of session, payment issues, and frequency of sessions).
Identify client concerns, develop goals, and assist their clients in working on identified goals.
Face issues of trust.
Deal with termination.
The addressed commonalities can be Broken down into 5 stages.
Stage 1: Rapport and Trust Building
Stage 2: Problem Identification
Stage 3: Deepening Understanding and Goal Setting
Stage 4: Work
Stage 5: Closure
The use of a written professional disclosure statement has become increasingly popular, which include information that is as follows:
Limits of confidentiality.
Length of the interview.
Purpose of the interview.
Professional credentials.
Limits of the relationship.
Professional’s theoretical orientation.
Legal issues of concern to the professional and the client.
Fees for services.
Agency rules that might affect the client (e.g., reporting a client’s use of illegal drugs).
After providing the disclosure statement to the client, it is critical to obtain informed consent from the client in written form.
Informed consent indicates that the client has been given this information and agrees to participate in the helping relationship.
Clients should be informed that they may withdraw consent at any time except where denied by court order and should be able to ask questions before agreeing to the services.
The building of a trusting relationship and the ability to do an assessment of client problems are signs that you are moving into the second stage, in which you and your client will validate your initial identification of the problem(s).
During the third stage, the client will allow you to confront him or her, ask probing questions and give advanced empathic responses.
You can increasingly push the envelope and move into the client's inner world.
It is always crucial to maintain sensitivity to the client’s needs and to maintain a supportive and nurturing base when moving between all stages.
Moving too fast will cause the client to rebuff your attempts to expose his or her inner world.
During the fourth stage, the client begins to work on the issues that were identified and agreed upon between the helper and the client.
During the fifth stage, the client accomplishes some or most of his or her goals, and both client and helper will logically think about ending the helping relationship.
Because the helping relationship is one of the few intimate relationships that is time limited, clients and helpers will inevitably have to work through their feelings of loss about the ending of the relationship.
Case Management
case management is generally defined as the overall process involved in maintaining the optimal functioning of clients.
Case management includes the following:
Treatment planning.
Diagnosis.
Monitoring the use of psychotropic drugs.
Writing case reports.
Managing and documenting client contact hours.
Monitoring, evaluating, and documenting progress toward client goals.
Making referrals.
Follow-up.
Time management.
Treatment Planning
Treatment planning comprises the accurate assessment of client needs that results in the formation of client goals.
Ideally, assessment involves a myriad of information-gathering activities that can include the following:
The clinical interview.
Personality testing.
Ability testing.
The use of informal assessment instruments such as observation, reviews of records, and personal documents.
Goal setting should be collaborative, and the goals selected should be attainable.
Progress toward goals should be monitored and the pace adjusted, if necessary.
Diagnosis
A diagnosis is a natural outgrowth of the assessment process that can occur in many ways.
The DSM has become the most widespread and accepted diagnostic classification system of emotional disorders and has become increasingly important for a number of reasons, including:
Enhancing communication among professionals.
Increasing accuracy of diagnosis.
Determining treatment plans.
Providing information for insurance companies that need a diagnosis if they are to pay for treatment.
As many as 25% of children and adults each year struggle with a diagnosable mental disorder.
Approximately 50% of adults in the United States will experience mental illness in their lifetime.
Although human service professionals may not be asked to make a diagnosis, they will frequently see clients' diagnoses; it is important that they understand how such diagnoses are made and their purposes.
Psychotropic Medications
Psychotropic medications can be used as an adjunct to counseling in the treatment of many disorders.
These medications are often classified into five groups which includes the following:
Antipsychotics
Mood-stabilizing drugs
Antidepressants
Antianxiety agents
Stimulants
it is important for human service professionals to have a basic working knowledge of psychopharmacology
In many cases, helpers will consult with or refer to a physician, generally a psychiatrist, who can assess the client and prescribe appropriate psychotropic medications.
Although human service professionals cannot prescribe medications, they should have some basic knowledge of these drugs so they can understand the treatment plans developed by other professionals and know when to refer clients for medications.
The 1950s is when the first modern-day psychotropic medications were introduced.
Case Notes
A client’s record consists of a complete file of the individual’s concerns, progress during treatment, final disposition, and other pertinent information.
Ethics codes and recent laws suggest clients can have access to most of their records; these notes usually aid the helper.
A good set of case notes can do the following:
Be used in court to show that adequate client care took place.
Assist helpers in conceptualizing client problems and making diagnoses.
Help determine whether clients have made progress.
Help determine whether clients have made progress.
Assist helpers in remembering what their clients said.
Be part of the process through which insurance companies and government agencies approve the treatment given to clients.
Be a determining factor, in this age of accountability, regarding whether an agency will receive funding.
A variety of case reports might be required depending on the agency ranging from daily case notes to quarterly summaries, termination summaries, and even reports that aid in educational and vocational planning.
SOAP format is an approach to writing case notes that has recently gained popularity
SOAP stands for Subjective, Objective, Assessment, and Plan.
SOAP notes often include the following:
Demographic information (e.g., DOB, address, phone, e-mail address, date of interview)
Reason for the report
Family background
Pertinent background information (e.g., health information, vocational history, history of adjustment issues/emotional problems/mental illness)
Mental status
Assessment results
Diagnosis
Summary
Recommendations
Managing and Documenting Client Contact Hours
For accountability reasons, it is essential that human service professionals find a credible way of meeting the increasing demand of regularly meeting with all their clients.
This sometimes means using some creativity, such as running special groups (e.g., medication review groups) and working additional evening hours.
The documentation of these contact hours has become crucial because reimbursement by insurance companies, as well as by local, state, and federal funding agencies, is often based on the precise documentation of contact hours.
Most agencies today have some mechanism for documenting client contact hours.
Monitoring, Evaluating, and Documenting Progress Toward Client Goals
Documentation of progress towards client goals is increasingly being reviewed and is a significant key to getting funding renewed.
The simplest way to document progress toward goals is to make a note in the client’s chart highlighting the initial goals and outlining the client’s progress.
Documentation has become vital in demonstrating the progress that the helper has made toward achieving goals, the efficacy of the work of the helper, and the success of the agency as a whole.
Making Referrals
Some reasons for making a referral are as follows:
Needing assistance with parenting skills
The client needs a substance abuse support group to help them with their problem.
A professional is leaving the agency, and the client needs a referral as to where they should go for support.
Helpers also make referrals because they do not feel sufficiently competent to work with a particular client or because the client has reached his or her goals and is ready to move on to another type of helping relationship.
Reguardless of the reasoning for a referral, the manner in which it is done is critical as such the following should be done during the referral process:
Note during the onset of the helping relationship what would happen should the client need to be referred.
Discuss the reason for making the referral with the client and obtain his or her approval.
Obtain, in writing, permission to discuss the client with another professional, even if that involves simply sharing the client’s name with another professional.
Monitor the client’s progress with the other professional
Ensure that confidentiality of client information is maintained in the referral process
Follow-Up
Follow-up is an important part of case management and can be accomplished in a variety of ways such as the following:
Phone call
Email
Letters
Surveys
A follow-up can be done within a few days of the relationship ending up to a few weeks.
Follow-up serves a variety of purposes, including the following
Checking whether the client would like to return to the helping relationship or would like to follow up with a different helper.
Allowing the helper to assess if the client’s change has been maintained.
Giving the helper the opportunity to look at the most successful techniques.
Offering an opportunity to reinforce past change.
Offering a mechanism whereby the helper can evaluate the services provided.
Time Management
Time management has become crucial if helpers are to avoid burnout.
Time management can be useful in planning activities and help the professionals ensure that all their clients are attended to within a reasonable period of time.
Time management also helps professionals remember meetings, appointment times, and other obligations.
Ethical, Professional, and Legal Issues
Confidentiality of Records and Clients’ Rights to View Their Records
Clients generally have a legal right to view their records, and increasingly they have been exercising these rights in schools and agencies.
It has generally been assumed that parents have the right to view records of their children.
The Health Insurance Portability and Accountability Act (HIPAA) ensures the privacy of client records and limits sharing of such information.
HIPAA restricts the amount of information that can be shared without client consent and allows clients to have access to their records, except for process notes used in counseling.
Process notes are generally written notes used to help the counselor remember salient points of a session.
Such notes should be distinguished from progress notes, which clients do have a right to access and include such things as type of treatment plan, diagnosis, medications, prognosis, and frequency of treatment.
The Freedom of Information Act of 1974 allows individuals to have access to any records maintained by a federal agency that contain personal information about the individual.
Every state has passed similar laws governing state agencies.
The Family Educational Rights and Privacy Act (FERPA) assures parents the right to access their children’s educational records.
FERPA generally excludes process notes from the category of educational records.
Exceptions to Confidentiality
clients should have the expectation that the information they share with their helper will be kept confidential, However, some exceptions to this rule exist, such as the following:
If a helper shares client information with a supervisor as a means of assisting the helper in his or her work with the client.
If the court subpoenas a helper’s records.
If a client gives permission, in writing, to share information with others.
Human service professionals do not have the legal protection afforded to licensed professionals through privileged communication.
Privileged communication is the client’s legal right not to have information shared with third-party sources, especially the court.
If a client asks that a human service professional not share information requested by the court (e.g., case notes), the practitioner will probably have to go against the client’s wishes.
Security of Case Notes
Due to the importance of client records, and because federal law requires it, records should be kept in a secure place and should be accessible only to the limited few people who have permission to view such records.
Client records should be kept secure, if in written form, with a locked cabinet and, if digital, to be encrypted and password protected.
NOHS (2015b) ethics code: Human service professionals protect client records' integrity, safety, and security. Client information in written or electronic form that is shared with other professionals must have the client’s prior written consent except in the course of professional supervision or when legally obliged or permitted to share such information. (Appendix B, Standard 8)
The Effective Human Service Professional: Looking for Feedback from Others
Effective human service professionals are open to hearing both positive and negative feedback about their helping skills.
The professionals should want to “stretch” and be willing to take a critical look at how they interact with clients.
The Human Services professional should want to try new approaches to working with clients and be willing to feel vulnerable in the learning process.
Human service professionals saqhould actively seek out supervision and consultation from experts in the field and view the learning of helping skills as a process in which they continually grow and adjust their approach to best meet the needs of their clients