When Counseling Backfires

What a treasure to have so many great minds ready and willing to respond…thank you!

As a clinical professor, speech-language pathologist, and family member of persons who stutter, I’ve been on a journey to understand the experience of stuttering. The counseling piece has been particularly intriguing and approaches such as CBT, motivational interviewing, Egan’s skilled helper model, etc. Recently I read about someone’s perception of therapists who are “in the business of readjusting your internal dialogue, not accepting what you say when you give them reasoning as to why you feel the way you do.” This individual felt therapy was actually “dehumanizing.” This person’s experience was not related to stuttering therapy, but since we are concerned with a person’s internal dialogue and understand how it can often affect decisions and shape behaviors, I wonder if you all have experienced counseling “backfiring” and how you responded?

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When Counseling Backfires — 4 Comments

  1. Hi Ana Paula!
    Thanks for such a wonderful and thought-provoking question! I hope that you are well – and hope to see you in person sometime in the near future! 🙂

    From my understanding and research, many of the more traditional CBT approaches focus a lot on helping the client to ‘replace’ the negative or unhelpful thoughts that they are having with more positive and helpful thoughts. However, some of the newer approaches like Acceptance and Commitment Therapy (ACT) focus more helping the client to feel what they feel in any moment and with time possibly reframe their own thoughts.

    I haven’t had any experiences in which counseling has “backfired” per say, however, thinking about this situation, I think this is where the clinician-client relationship comes into play. I would hope that any client I’m working with would feel comfortable telling me if they felt as though therapy was not working or in line with their wants, needs, and goals. Maybe this is where regular check-ins with our clients as to how things are going may help as well. Also, I think it’s important for us as clinicians to let go of our own “plan” (so to say) when we go into any session with our clients. The therapy session is their time – and we are simply their guides. Spending some time exploring who our clients are at the core (their values) can help to ensure that the therapy is truly client-centered.

    The individual’s feedback also made me think about the importance of validating what our clients are feeling – no matter how dark, muddy, and difficult those thoughts and emotions may be. Sometimes
    I think we feel a need to ‘make things better’ (which comes from a true place of caring); however, simply sitting with our clients in those moments may be the most powerful thing we can do. Whatever our clients, or we, are feeling in a given moment is okay…even if it may not feel that way. Being totally vulnerable, open, and honest takes a lot of courage – and it can help us to move closer and closer to the person that we are at the core and that we want to show the world.

    Just some beginning thoughts! Can’t wait to hear what others have to say about this topic!

    Best,
    ~Jaime

  2. Hi, Ana Paula!

    Good to ‘see’ you on this conference! Great question and a good response from Jaime. I can’t say that I’ve ever had a ‘backfire’ situation. Rather, there have been times when, in retrospect, where I did not respond in the most helpful way to someone’s comment during a session. I try to learn from those missed opportunities, so that I am more supportive in future interactions.

    As Jaime commented, it is so important to refrain from invalidating a person’s feelings. There are no right or wrong feelings. When a client shares feelings, it is important to validate them, and engage the person in talking about the feelings/concerns in ways that support growth toward the person’s goals.

    It seems that many SLPs believe that they are counseling a client or family member when, in fact, they are giving advice, aka, telling the person what the SLP would do or thinks the person should do in the situation. I suspect most of us have been treated in this way by friends, family members or even professionals. Giving advice is not counseling, nor is it a way to facilitate ownership of both the problem(s) and the solution(s). While it may seem as if telling someone what to think or feel or how to solve a problem is helping, it does not lead to durable change in the same way that supporting the client’s experience of working through the feelings, emotions and thoughts and coming up with their own ‘ah hah’ moments.

    I’ll be interested in what others have to share on this!

    Regards,

    Lynne

  3. Hi Ana Paula,

    Thank you for your great question. I’d like to add to Jamie Michise’s insightful comments by sharing my personal experiences, as a PWS, with counseling. You might say that for me, counseling made things much worse, until it made things much better.

    My first encounter with traditional Cognitive Behavioral Therapy (CBT) was brutal. Not only did I have a stuttering problem, severe anxiety surrounding stuttering and communicating, and some deeply ingrained negative feelings and attitudes about stuttering and myself as a communicator … but all of my perceptions of these problems were dead wrong. (At least, this is how I felt at the time.) Adding a laundry list of cognitive distortions to the knot of problems I already had was demoralizing, to say the least.

    My introduction to Acceptance and Commitment Therapy (ACT) was equally fraught. As a covert stutterer, to learn that my (totally understandable) efforts at experiential avoidance were not “workable” in leading a meaningful life were terribly destabilizing. It took me a while to recover from that downward spiral. However, ACT and CBT have ultimately become my salvation, so to speak. Through ACT, I’ve learned to embrace my inner experiences less judgmentally and to tolerate some of the unpleasant ones in the service of pursuing valued outcomes. More often, I find myself living the kind of life I want to lead. This insight has allowed me to embrace CBT and to recognize that in having cognitive distortions, I am not alone. We all have them. Identifying my cognitive biases has allowed me to sidestep some potential traps and pitfalls, cultivate a more open and rational mind, and (not always, but often) lead a better life.

    I do not know exactly how, in the end, I managed to respond to my therapeutic setbacks in a workable way, and how my experience of counseling flipped from backfiring to running more like a well-oiled machine. Somehow, despite the setbacks, I found a way to take a long view and have some faith in the process. It helped that I had compassionate, skilled people on my team. Mindfulness meditation helped. I cannot overstate the utility of learning to recognizing that thoughts and feelings do not represent a stable, unchanging “reality,” but are simply appearances in consciousness that continually come and go. No matter how bad (or good) things are in the present moment, they are bound to change in the next. When things are not going one’s way, that can be an enormously helpful realization!

    Thanks again for your question. I hope you find this digression helpful. Wishing you all the best,

    Rob Dellinger

  4. Introduction

    Before proceeding with investigating instances when counseling can backfire, let me first define what is meant by counseling.

    Counseling is a way of the client and therapist to examine:
    1. How the client thinks about himself, other people, and the world;
    2. How the client’s thoughts, feelings, behaviors, and perceptions interact with each other; and
    3. How the thoughts, feelings, behaviors, and perceptions help or hinder a client to recover from a presenting problem such as developmental stuttering.

    The client is the expert of himself or herself. It is never advisable to dismiss as invalid whatever the client thinks and feels. Whatever he or she perceives or how he behaves is a reaction to what he or she has experienced and, thus, has validity.
    On the other hand, to validate and justify Person Who Stutter (PWS) belief system to align with recovery process the therapist may employ Socratic questioning and provide the client with the most recent and pertinent information in the field of stuttering therapy.

    As a result, the client is provided with a growth opportunity: a) to learn about the universe; b) to learn about how a human body reacts to various inputs be they cognitive or experiential; and c) to learn about having fun while undergoing therapy.

    If a PWS leaves counseling without having any changes in his or her belief system, no growth has taken place. If a PWS regurgitates the beliefs enshrined in a theory, at the most he or she has been brainwashed. Neither of the two results is desirable. We really want the PWS to be able to explore various beliefs and judge for himself or herself, which ones would help and which ones would hinder recovery from stuttering. Remember that, according to Sheehan (and others), more than 90% of the stuttering iceberg is below the visible and audible water line.

    What precautions to take to prevent consulting from backfiring?

    As noted above, there are both sins of commission, when the PWS feels that his or her ideas are being dismissed out of hand and sins of omission, when no growth in the beliefs of how a PWS takes place. Let me use a case study to illustrate a proper counseling approach.

    Description of a case study

    A case study is best described by examining the thoughts of a PWS–be they beliefs, attitudes, or self-talk–that play a key role in recovery. When Ray (not his real name) contacted me to explore the possibility of recovering from stuttering, as always, I tried to capture his mindset, his self-talk, about stuttering and his being-in-this-world. I was careful neither to dismiss his feelings nor endorse them, but merely validate them as being his true feelings. Feelings do not exist in a vacuum. They are the result of firmly held beliefs. As you shall see, the initial beliefs about stuttering, those that are held when PWS first comes to therapy, are not always consistent. (Note: at this stage, while mentally recording the various beliefs, do not point out any contradictions even though you may ask for some clarification as necessary.)

    On one hand, Ray believed that he absolutely had to recover from stuttering while, on the other hand, he ”knew” that there are no “cures” for stuttering. He defined himself by his stutter. He obsessed (thought) about stuttering 24/7. Since he devoutly believed that stuttering was “awful” and that he “could not stand it”, in almost all situations he used avoidances to hide his stuttering, albeit not that successfully. He had convinced himself that people who stutter were less worthwhile than those who did not stutter. He “knew” that when people found out he stuttered they would disrespect him and devalue his opinions. He was sure people did not have anything better to do than snicker about his stuttering and talk about it behind his back. Since he had failed at a couple of stuttering therapies, he believed that he could never recover from stuttering nor eliminate any of the struggling and forcing from his speech. He was, after all, genetically handicapped, and no amount of work would make him feel better about himself and help him lead a full enjoyable life. He thought that he was doomed to always be unhappy.

    Becoming aware of precursors to stuttered speech

    However, Ray was willing through counseling to examine his thoughts, feelings, behaviors, and perceptions and learn new facts about his cognitive interaction with stuttering. When I asked Ray to differentiate between his speech when talking to himself with no pressure on him and his speech when he was desperately trying to impress people as when talking to his supervisor, Ray reported that when he was talking to his supervisor he had a difficult time with his speech, but not when talking to himself in the front of a mirror.

    “Even when I am merely thinking about speaking with my supervisor my mind starts to race and a series of beliefs (self-talk) about me and stuttering swirl in my head. Then, immediately before I start to talk, I get a sinking feeling in my stomach as well as real anxiety about me having to talk. As per your suggestion, I tried to capture if there were any connections between my beliefs and my speaking performance. The careful examination led me to conclude that the struggled, forced, disfluent speech originated with my beliefs and self-talk. There appears to be a preconscious if not subconscious connection. I only need to start to think about a speaking situation which I evaluate as “dangerous” or difficult and a myriad of demands emerge including the demand for perfect fluency. Then when I start to talk, the next thing I remember is that I am in a forced, struggling stutter over which I seem to have no control.” Ray concluded with wondering if all this self-talk and panicked emotions were not a precursor to his forced, struggled, loss-of-control stuttering.

    Framework for examining self-talk and beliefs

    We both chuckled when I told Ray that within a couple sessions he had discovered what it took me years: To understand that the below surface mass of Sheehan’s iceberg may prove to be a valuable insight into what keeps the stuttering going. If one is to recover from stuttering the below surface beliefs and ideas need to be adjusted. For the next week, I asked him to read some of Clark’s book, “SOS Help for Your Emotions”. The next time he came back he was sold on REBT. We agreed that we would use the tools provided by REBT to help him recover from stuttering. (Note to the reader: It is very important that the client more or less discovers by himself the role self-talk and emotions play in propagating stuttering.)

    Scientific method

    Ray understood that different beliefs cause different emotional reactions and different degrees of stuttering. Since Ray had earned a degree in computer science and, he was very well acquainted with the scientific method and he immediately saw that the value of a belief is based on the three questions: 1) Do we have empirical evidence to back up this belief? 2) Is the belief logical? and 3) Is it helpful to recover from stuttering? Unlike Ray, some PWS need through Socratic questioning to discover the scientific method.

    Belief and attitude justification

    In the next couple sessions Ray, with my guidance, came up with what attitudes/questions he wanted to study. He quickly caught on that some beliefs were unhelpful and some of the feelings were unhealthy. Before proceeding, I asked Ray to come up with the definition of unhealthy negative emotions. After some more or less abortive attempts Ray concluded that the unhealthy negative emotions cause a great deal of unnecessary mental anguish and use up energy that could best be used to recover from stuttering. When asked which beliefs or self-talk was unhelpful, Ray quickly answered that any self-talk or beliefs that resulted in unhealthy negative emotions, in the long run, were unhelpful.

    Questions that led Ray to recovery from stuttering

    Ray and I brainstormed and came up with the questions that needed to be resolved to recover from stuttering. The questions and answers are in the first person, as Ray wrote them in his journal. He wrote what he believed to be the answers under each question. We discussed the helpfulness of each of the belief answers. As time went on, he reworded the questions and answers. He edited the content and wording to reflect his idiosyncratic way of expressing himself. I encouraged him to combine questions so that he could review them daily but without losing any of the content. Here are the questions and the answers:

    Do I, Ray, really want to really commit time, energy, and money to recover from stuttering?
    Yes, I can devote an hour a day recovering from my stuttering. I am going to depend a lot on reading and occasional contact with Dr. Neiders.

    Do I really need to perform well and be accepted by everyone?
    No, I am a forever fallible messed-up human being, who will sometimes be approved by others and sometimes be rejected by others regardless of whether I stutter or not.

    What does it mean to me to accept my stuttering?
    It means that I can acknowledge that I have a stutter and work on lessening the impact of stuttering on the rest of my life.

    Is stuttering really “awful”?
    Although it sometimes seems so, stuttering really is only inconvenient, not awful.

    Does stuttering make me worthless?
    No, stuttering cannot make me worthless.

    Do people base their opinion of me solely on my speech?
    Hardly.

    Does stuttering condemn me to be a bad communicator?
    No. Winston Churchill who stuttered was one of the best orators ever.

    Do my past failures at recovery from the stuttering guarantee that I will never recover from stuttering?
    No.

    Is it too hard to work on recovering from stuttering?
    No, it is only hard.

    Does stuttering really prevent me from enjoying life?
    No. Using last week as an example, I enumerated 10 things that I really enjoyed.

    Is it really unbearable to tolerate when somebody makes fun of my speech?
    No, I have been learning how to ignore bullies and idiots.

    Do I really have to take my speech so seriously?
    No. My friends and I have really enjoyed goofing around where the butt of the joke sometimes is my speech.

    Does my speech really need to be perfectly fluent?
    No, I don’t know any law in the universe that says I have to be perfectly fluent.

    Is it really so hard to use easy bounces? (This is the technique that I, Gunars, use as a swiss army knife to help a client do voluntary stuttering and change forced, struggling blocks into forward moving easy disfluencies.)
    Nope. No. Hell no!

    Can I stand stuttering?
    Yes, I have stood it so far, haven’t I?

    Conclusion

    Although it is possible, nay probable, that the therapist will commit some errors of commission and omission in counseling, just because we are forever fallible messed-up human beings. None of the missteps should have serious repercussions. As long as we teach using the Socratic method and encourage PWS to learn and express their answers using their terminology, counseling should not backfire.

    Gunars

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