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Interviewing
and Change Strategies
for Helpers 8e
Sherry Cormier
West Virginia University
Paula S. NuriuS
University of Washington
CyNthia J. oSborN
Kent State University
Australia ● Brazil ● Mexico ● Singapore ● United Kingdom ● United States
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Helpers, Eighth Edition WCN: 02-300
Sherry Cormier, Paula S. Nurius, Cynthia
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Printed in the United States of America

Print Number: 01 Print Year: 2016
In memory of Sherry’s parents, Bill and Edith Keucher,
Sherry’s spouse, Jay H. Fast,
Paula’s mother, Gwyndolyn Medley Garner,
and Cynthia’s parents, Noel and Emma Ruth Osborn;
and in honor of Dick Mitchell, Cynthia’s spouse, and Bill Garner,
Paula’s brother, with grateful appreciation and affection.
About the Authors
Sherry Cormier is Professor Emerita in the Department of Counseling,

Rehabilitation Counseling, and Counseling Psychology at West Virginia
University in Morgantown, West Virginia. She is a licensed psychologist in the
state of West Virginia. Her current research and practice interests are in counseling
and psychology training and supervision models, health, wellness, stress
management, and grief recovery. She is the mother of two 30-something daughters
and the grandmother of a 10-year-old granddaughter. She enjoys yoga, walks on
the beach, and kayaking in her Chesapeake Bay community.
Paula S. Nurius is the Grace Beals Ferguson Scholar, Professor, and Associate
Dean in the School of Social Work at the University of Washington in Seattle.
Dr. Nurius is a mental health specialist with research, practice, and teaching
addressing perception and responding under conditions of stress and trauma.
She brings particular concern for vulnerable, marginalized populations and
toward fostering prevention and resilience-enhancing interventions. Her current
scholarship focuses on childhood and cumulative life course stress, including
impacts of maltreatment, nonviolent adversity, and poverty on physical, mental,
and behavioral health disparities. She enjoys the outdoor life of the Pacific
Northwest with her husband, daughter, and schnoodle pooch.
Cynthia J. Osborn is Professor of Counselor Education and Supervision at Kent

State University in Kent, Ohio. She is a licensed professional clinical counselor
and a licensed chemical dependency counselor in Ohio. Her research, clinical
practice, and teaching have focused on addictive behaviors and counselor
supervision from the perspectives of motivational interviewing and solution-
focused therapy. Additional scholarship has addressed case conceptualization and
treatment planning skills and stamina and resilience in behavioral health care.
She enjoys reading character novels and practicing yoga, and she and her husband
together enjoy exercising and the company of their Bichon Frisé dog, Jake.
Contents
Preface xi Practicing Idiographically 48

Beyond Multicultural Competencies to Cultural
Attunement 54
Chapter 1
Ethical Practice 55
Building Your Foundation Ethical Decision-Making Models 70
Chapter Summary 71
as a Helper 1 Knowledge and Skill Builder 73
Learning Outcomes 1 Knowledge and Skill Builder Feedback 75
The Chambered Nautilus 1
A Practice Nexus for the Helping Professions 2 Chapter 3
Four Stages of Helping 2
Core Skills and Attributes 4 Ingredients of an Effective
Effectiveness and Accountability 15 Helping Relationship 76
Evidence-Based Practice 16 Learning Outcomes 76
Concerns, Critiques, and Caveats of Evidence-Based The Importance of the Helping Relationship 76
Practice 20 Empirical Support for the Helping Relationship 77
Multiculturalism and Evidence-Based Practice 21 Cultural Variables in the Helping Relationship 78
Adapting and Adopting Evidence-Based Practices 24 Facilitative Conditions 79
Innovations with Integrity 25 The Working Alliance 90
Chapter Summary 28 Transference and Countertransference 93
Knowledge and Skill Builder 29 Chapter Summary 101
Knowledge and Skill Builder Feedback 33 Knowledge and Skill Builder 102
Knowledge and Skill Builder Feedback 104
Chapter 2
Chapter 4
Critical Commitments 35
Learning Outcomes 35 Listening 105
Toward Skillful Practice 35 Learning Outcomes 105
Growing Into Professional Competence 36 Three Steps of Listening 106
Four Critical Commitments 37 Listening to Clients’ Stories 107
Diversity Issues 45 Listening to Clients’ Nonverbal Behavior 107
Multicultural Counseling and Therapy 47 Four Listening Responses 112
vii
viii Contents
The Clarification Response: Listening for Accuracy 113 Diagnostic Interviewing 198
Paraphrase and Reflection: Listening for Facts Sensitive Subjects and Risk Assessment in Diagnostic
and Feelings 114 Interviewing 199
Summarization: Listening for Patterns and Themes 126 Intake Interviews and History 201
Listening to Diverse Groups of Clients 128 Cultural Issues in Intake and Assessment Interviews 205
Distractions and Distractability: Listening to Yourself 131 Putting it all Together: Evidence-Based Assessment
Chapter Summary 133 and Conceptualization 207
Knowledge and Skill Builder 136 Model Case: Conceptualizing 207
Knowledge and Skill Builder Feedback 138 Chapter Summary 212
Knowledge and Skill Builder 213
Chapter 5 Knowledge and Skill Builder Feedback 214
Influencing Responses 139 Chapter 7

Learning Outcomes 139
Social Influence In Helping 139 Conducting an Interview
Influencing Responses and Timing 140 Assessment with Clients 215
What Does Influencing Require of Helpers? 140 Learning Outcomes 215
Six Influencing Responses 141 Assessment Interviewing 215
Sequencing of Influencing Responses In Interviews 141 Eleven Categories for Assessing Clients 216
Questions 143 Limitations of Interview Leads in Assessment 232
Information Giving 146 Model Dialogue: Interview Assessment 234
Self-Disclosure 149 Chapter Summary 242
Immediacy 156 Knowledge and Skill Builder 243
Interpretations and Additive/Advanced Empathy 159 Knowledge and Skill Builder Feedback 250
Confrontation/Challenge 163
Skill Integration: Putting it all Together! 170
Chapter 8
Chapter Summary 170
Knowledge and Skill Builder 171 Constructing, Contextualizing,
and Evaluating Treatment
Chapter 6 Goals 251
Assessing and Conceptualizing Personal Reflection Activity 251
Client Problems and Contexts 177 Where Are We Headed? 251
Learning Outcomes 177 Beginning With The End in Mind 252
Client Statements 177 Purposes of Treatment Goals 252
What Is Clinical Assessment? 177 Characteristics of Well-Constructed Treatment Goals 254
Our Assumptions About Clinical Assessment 178 Support for Goal Characteristics 258
Functional Assessment: The ABC Model and Chain Cultural Considerations 258
Analysis 186 The Process of Change 261
Diagnostic Classification of Client Issues 193 Collaborative Construction of Treatment Goals 267
Limitations of Diagnosis: Categories, Labels, and Model Dialogue: Goal Formulation 269
Gender/Multicultural Biases 196 Contextualizing Treatment Goals 273
Mental Status Examination 197 First Things First: Prioritizing and Sequencing Goals 276
Contents ix
Running Interference by Addressing Obstacles 278 Working With Resistance, Reactance, Reluctance,
Identifying Resources to Facilitate Goal and Ambivalence 346
Achievement 279 Solution-Focused Therapy 347
Evaluating Treatment Process and Outcomes 279 Model Dialogue: Deconstructing Solutions 355
What to Evaluate 280 Motivational Interviewing 357
How to Evaluate 282 Model Dialogue: Affirming, Emphasizing Autonomy,
When to Evaluate 285 and Advising only with Permission 368
Treatment Evaluation Pointers 288 Applications of SFT and MI with Diverse Groups 370
Model Dialogue: Evaluating Progress 288 Chapter Summary 372
Chapter Summary 293 Knowledge and Skill Builder 374
Knowledge and Skill Builder 295 Knowledge and Skill Builder Feedback 377
C h a p t e r 11
Chapter 9
Cognitive Change Strategies 379
Clinical Decision-Making Learning Outcomes 379
and Treatment Planning 302 An Overview of the Theoretical Framework 380
Learning Outcomes 302 Reframing 382
Treatment Planning Purpose and Benefits 302 Reframing Components 383
Common Factors and Specific Ingredients of Reframing with Diverse Clients 386
Treatment 303 Cognitive Modeling Components 386
Factors Affecting Treatment Selection 304 Model Dialogue: Cognitive Modeling 389
Evidence-Based Practice and Treatment Planning 311 Cognitive Restructuring 392
Models of Treatment-Client Matching 312 Cognitive Restructuring Components 392
Planning for Type, Duration, and Mode Some Caveats 406
of Treatment 314 Cognitive Change Strategies with Diverse
Cultural Issues in Treatment Planning and Selection 317 Clients 406
Intentional Integration of Cultural Interventions 319 Model Dialogue: Cognitive Restructuring 409
The Process of Treatment Planning 325 Integrative Interventions: Linkages of ACT and DBT
Model Dialogue: Exploring Treatment Strategies 329 with Cognitive Change Strategies 412
Chapter Summary 332 Chapter Summary 414
Knowledge and Skill Builder 333 Knowledge and Skill Builder 416
Knowledge and Skill Builder Feedback 335 Knowledge and Skill Builder Feedback 423
C h a p t e r 10 C h a p t e r 12
Models for Working Cognitive Approaches

with Resistance 336 to Stress Management 425
Learning Outcomes 336 Learning Outcomes 425
Partnering with Client Experience 336 Stress and Coping 425
Resistance, Reactance, Reluctance, and Cultural, Socioeconomic, and Discrimination
Ambivalence 336 Variations in Stress 430
Two Models for Working with Resistance 341 Spirituality Considerations 431
Research on Solution-Focused Therapy (SFT) and Problem-Solving Therapy 432
Motivational Interviewing (MI) 342 Problem-Solving Therapy Components 433
x Contents
Problem-Solving with Diverse Clients 440 Research with Diverse and Vulnerable Groups 519
Model Example: Problem-Solving Therapy 441 Virtual Reality 522
Stress Inoculation Training: An Integrative Clinical Pharmacotherapy to Enhance Exposure 522
Approach 443 Model Dialogue for Exposure Therapy 523
Stress Inoculation Training Components 443 Chapter Summary 525
Model Dialogue: Stress Inoculation 450 Knowledge and Skill Builder 526
Chapter Summary 452 Knowledge and Skill Builder Feedback 527
Knowledge and Skill Builder Feedback 459 C h a p t e r 15
C h a p t e r 13 Self-Management Strategies 528

Self-Calming Approaches Learning Outcomes 528
Terminology and Areas of Focus 528
to Stress Management 460 Steps in Developing Self-Management Programs 529
Characteristics of Effective Self-Management
The Physiology of Breathing and Stress 460 Programs 531
A Focus on Diaphragmatic Breathing 461 Self-Monitoring Overview 532
Caveats with Diaphragmatic Breathing 463 Components of Self-Monitoring 535
Muscle Relaxation 464 Model Example: Self-Monitoring 540
Muscle Relaxation Procedure 465 Stimulus Control Components 541
Caveats with Muscle Relaxation 471 Model Example: Stimulus Control 544
Model Dialogue: Muscle Relaxation 471 Self-Reward Overview 545
Meditation: Processes and Uses 472 Self-Reward Components 546
Mindfulness Meditation Procedure 475 Caveats with Applying Self-Reward Strategies 550
Caveats with Meditation 479
Model Example: Self-Reward 550
Model Example of Mindfulness Meditation 481
Self-Efficacy Overview 550
Applications of Meditation for Diverse Issues and with
Sources of Self-Efficacy 551
Diverse Clients 483
Summary 555
Chapter Summary 484
Model Example: Self-Efficacy 556
Applications of Self-Management with Diverse
Groups and Types of Problems 557
C h a p t e r 14 Guidelines for Using Self-Management with Diverse
Groups of Clients 559
Exposure Therapy for Anxiety, Self-Management as a Professional Aide for Helpers 560
Fear, and Trauma 491 Chapter Summary 561
What Is Exposure? 492
Theoretical Background for Exposure 494
Components and Processes of Exposure Therapy 497 References 565
Gradual Exposure 505 Name index 621
Intensive Exposure 512 Subject index 641
Collaborative Considerations in Conducting
Exposure 514
Caveats about Exposure 517
Preface
The eighth edition of Interviewing and Change Strategies the application of change strategies to diverse groups and
for Helpers reflects a number of changes. The new edi- the importance of culture and context in applying these
tion represents a blending of our collective expertise in and other helping strategies. Recognizing the enormous
counseling, psychology, social work, and health and hu- influence of evidence-based expectations on contem-
man services. Our partnership in these interdisciplinary porary practice, we have incorporated current findings
areas augments the book’s responsiveness to the unique into each of our chapters on various change strategies
perspectives of each discipline while also working at the (Chapters 10 through 15).
interface or nexus, addressing cross-cutting issues and Layered across all of this is the fourth area of our con-
commitments. This book is intended to be used by helpers ceptual model: critical thinking and ethical judgment.
who are trained in a variety of health and helping-oriented We focus on this area specifically in Chapters 1 and 2 and
disciplines, including counseling, social work, psychol- explore these topics again throughout the remainder of
ogy, human services, and related professions. We recog- the book because they permeate all of the decisions that
nize that terminology varies across settings. You will see helpers face at each phase of the helping process, from
the term helper as well as practitioner, clinician, therapist, establishing the helping relationship, to assessing client
and service provider used throughout the book. One of problems, setting treatment goals, and selecting, using,
the fundamental changes we have made in this edition is and evaluating change intervention strategies. Many users
in response to continued requests for a streamlined book of the text have indicated that combining major stages of
that can be used with relative ease in the parameters of the helping process with specific change strategies facili-
several quarters or a given semester. tates integration within and across courses that aim for
this bigger picture and is also beneficial for students.
Our Conceptual Foundation
Our conceptual foundation, which we describe in Built-In and Supplemental
Chapters 1 and 2, reflects four critical areas for helpers
from various disciplines: (1) core skills and attributes;
Instructional Guides: Features
(2) effectiveness and evidence-based practice; (3) diversity of the Book
issues; and (4) critical commitments and ethical practice. We have retained the specific features of the text that
The core skills that we present cut across all helping we have learned through feedback make it invaluable
disciplines and in this edition we present them in as a resource guide—and we have taken this emphasis a
Chapters 3, 4, and 5. Diversity issues and ecological step further. We have worked to distinguish this teaching
models are presented in Chapters 2, 6, and 7, and also text by providing a rich array of built-in exercises, exem-
are integrated throughout the book. Evidence-based plars, and tools to promote and evaluate student com-
assessment and its implementation in the interviewing prehension. The book balances attention to conceptual
process are described in Chapters 6 and 7. Effectiveness and empirical foundations with an emphasis on real-life
and evidence-based practice is introduced in Chapter 1 factors in practice settings and ample use of examples and
and presented again in Chapters 8 and 9. Chapters 10 how-to guidelines. In addition, consistent with the out-
through 15 give special attention to research supporting come emphasis of accreditation standards of counseling,
xi
xii Preface
psychology, social work, and human services, chapters 2. The longstanding commitment of this book to valu-
are guided by learning outcomes and opportunities to ing human diversity is commensurate with its estab-
practice with numerous learning activities and guided lished commitment to consulting and incorporating
feedback. Model cases and dialogues are given in each scientific research. In many ways, this edition reflects
chapter, as well as end-of-chapter evaluations (referred a healthy dialectic or tension between science and in-
to as “Knowledge and Skill Builders”) with feedback de- novation, empiricism, and improvisation. And it is this
signed to help assess chapter competencies. both/and approach, this practice of living and work-
In addition, we have developed a range of supplemen- ing in between polarities, that has spawned integrative
tary materials to enrich the teaching experience. These therapies such as dialectical behavior therapy (DBT),
include an instructor’s manual, a bank of test questions an evidence-based practice that we draw from through-
(which can be used by instructors for course exams or by out the chapters.
students in later preparing for accrediting exams), and 3. Chapter 1 showcases the symbolism of the cham-
PowerPoint slides for each chapter. bered nautilus featured on the cover of the book and
Brand new to this edition, MindTap® is the digital introduces readers to the practice nexus featured on
learning solution that helps instructors engage and trans- the inside cover of the book. In the first half of the
form today’s students into critical thinkers. Through chapter, the first component of the practice nexus is
paths of dynamic assignments and applications that you discussed. Specifically, four core skills and attributes
can personalize, real-time course analytics, and an acces- (self-awareness and self-reflection, mindfulness, self-
sible reader, MindTap helps you turn your students into care, and self-compassion) are presented and discussed
higher-level thinkers. Your students become practitioners as a means of promoting helper stamina and resilience.
of their own learning as they master practical skills and In the second half of the chapter, the second compo-
build professional confidence. Students will be engaged nent of the practice nexus, effectiveness, is highlighted.
in a scaffolded learning experience designed to move their In this section extensive discussion is devoted to evi-
thinking skills from lower-order to higher-order by rein- dence-based practice (EBP). This discussion includes
forcing learned skills and concepts through demonstrated criticisms of EBP as well as continued efforts to adapt
application. EBP to culturally diverse populations. A listing of
culturally adaptive interventions to EBP is provided,
along with examples of such adaptation.
New to the Eighth Edition 4. The third and fourth components of the practice
With sensitivity to the value of using a book within a semes- nexus are the focus of Chapter 2: critical commitments
ter or two-quarter framework, we have worked for a more (including ethical practice) and diversity issues. We dis-
streamlined book in this edition. We have retained the same cuss four critical commitments professional helpers are
organizing structure and skill-building components that encouraged to make to grow into clinical competence:
adopters have long valued, and provide some integrated and commitment to lifelong learning; commitment to col-
distilled content to provide an up-to-date compendium of laboration; commitment to values-based practice; and
interviewing and change practices applicable across a range commitment to beneficence. The section on diversity
of settings and clientele. Throughout, we aim to build on issues includes prominent and newer frameworks for
recent clinical evidence and to point to emerging develop- working with culturally diverse populations, such as the
ments relevant to instruction in clinical services. more idiosyncratic focus on the intersection of multiple
identities proposed by feminist multicultural scholars.
1. In this edition we increased this book’s enduring The ethical issues section includes updates from profes-
commitment to working with diverse groups. This sional codes of ethics and a new section on telepractice,
includes further attention to working with youth, with a corresponding new learning activity.
older adults, and sexual minorities, in addition to 5. Consideration of the therapeutic relationship has been
diversity implications related to gender, race/ethnicity, expanded (Chapter 3) to include the ever-expanding
religion, immigration, and disability. Although this empirical basis for various relationship conditions
book is focused predominantly on individual change toward increasing effectiveness. New additions to
(e.g., strengthening problem-solving, adaptive coping, this chapter include the additional evidence base for
self-efficacy, management of long-term problems or helper empathy, the working alliance, and relation-
conditions), we have aimed to strengthen attention ship ruptures, as well as an expanded discussion of
to the importance of context and the frequent role of microaggressions and the therapeutic relationship and
environmental sources of stress and injustices. invalidating environments.
Preface xiii
6. Chapter 4 includes an expanded discussion of the amplify the discussion of the multiple levels of processes
processes of listening as well as updated evidence-based involved in the development and operation of schemas
literature on the listening responses, particularly reflec- involved in psychological disorders. This material il-
tion of feeling. lustrates ways that biological factors such as genetics,
7. Chapter 5, Influencing Responses, includes an up- brain functioning, and physiology are systematically
dated evidence base for the influencing responses, linked with cognitive and emotional factors, which
particularly self-disclosure. It also includes a new dis- then interplay with interpersonal, environmental, and
cussion of the effects of self-disclosure and environ- behavioral factors in both the development of and in-
mental settings, technology, and information giving, tervention with psychological problems. Here we also
and a new section integrated into the chapter and the update information about schema development and
Knowledge and Skill Builder on Skill Integration. schema therapy, about new intervention findings for
8. Chapter 6 focuses more broadly now on both clinical cognitive change strategies with diverse populations,
and evidence-based assessment. The material on the and about developments of cognitive strategies with
person-in-environment model has been updated and acceptance and commitment therapy (ACT) and DBT.
the functional assessment model has been expanded 14. Stress is among the universally shared struggles of
and includes new examples and new content regard- clients. Therefore, we have emphasized stress as a criti-
ing chain analysis, which is a component of dialectical set of factors in the development of problems and
cal behavior therapy. An entirely new section on the in understanding ways that change strategies must
DSM-5 is also described in Chapter 6. This chapter address stress. In Chapter 12 we describe cultural,
also includes expanded coverage of conducting risk socioeconomic, and life course implications of stress.
assessment in diagnostic interviewing and expanded We update findings regarding neurophysiological
coverage of mental status interviewing. pathways through which stress becomes embodied,
9. Chapter 7 describes the implementation of evidence- leading to physical and mental health impairment.
based assessment in the interviewing process. This We update interventions applied with diverse groups,
chapter includes expanded coverage of clients’ indi- including attention to minority stress. We update de-
vidual and environmental strengths and resources as velopment in stress inoculation and problem-solving
well as functional analyses assessment queries. Case therapies including incorporation of emotional mind-
examples have been changed to reflect current DSM-5 fulness techniques.
diagnoses. 15. In Chapter 13 we have expanded attention to the
10. The purpose and process of developing treatment growing evidence support for stress management, par-
goals are described in Chapter 8, as are characteristics ticularly mindfulness-based practices. Here we provide
of well-constructed goals. Stage models (e.g., stages an illustration of recent applications across a range of
of change model) are introduced to assist with the se- child and adult populations as well as settings (e.g.,
quential and collaborative task of treatment planning. workplace) and contexts of helping. We also update
The process of further refining—or contextualizing— ways that mindfulness constructs and meditation are
treatment goals is likened to preparing for a journey being incorporated across a range of interventions,
and includes references to easy-to-use and evidence- including mindfulness-based stress reduction, mind-
based client assessment measures. fulness-based cognitive therapy, DBT, and ACT.
11. Chapter 9 is devoted to clinical decision-making and 16. In Chapter 14 we provide updates on extension learn-
treatment planning. Updates include an expansion of ing and increased focus on prolonged exposure ther-
client and helper factors contributing to client change, apy, including applications with military veterans and
references to the newest addition of The ASAM Crite- cultural minority groups. This chapter also provides
ria used to match clients to levels of care, and resources updates on virtual reality exposure therapies as well as
for intentionally integrating cultural interventions. additional coverage of clinical issues related to safety
12. Strategies of working through various forms of re- behaviors, return of fear, dropout, and fear tolerance.
sistance, as well as client ambivalence, are found in 17. In Chapter 15 we describe new uses of the Inter-
Chapter 10. These strategies are informed by solution- net and technological devices to support longer-term
focused therapy and motivational interviewing, two self-management interventions, which are particularly
approaches whose respective research base has been valuable for clients with special needs, when people are
expanded in this edition. more distant from services or support communities, or
13. The science underlying cognitive therapies is dem- when access to immediate help is needed. This chapter
onstrating increasing complexity. In Chapter 11 we includes numerous literature updates on each of the
xiv Preface
categories of self-management, illustrating the rapid Counselor Education and Supervision, for preparation of
growth in populations and problem foci to which they the instructor’s manual, test bank, and PowerPoint slide
are applied, including helping professionals managing resources; Kelly Martin-Vegue (University of Washington
complex and stressful work environments. MSW student) for her invaluable insights, recommenda-
tions, and contributions from a consumer perspective; and
The instructor’s manual is authored by Penny Minor, to Dr. Daniel McNeil and Dr. Brandon Kyle for their col-
a PhD degree candidate in Counselor Education and Su- laborative authoring of Chapter 14 on exposure therapy.
pervision at Kent State University and a licensed profes- We are very grateful to the staff at Cengage Learning,
sional clinical counselor in Ohio. She also developed the particularly to our current editor, Julie Martinez, for her
test bank of questions for each chapter and the assessment commitment, enthusiasm, and wisdom. The final form
that is available in MindTap. We also offer a resource of this book as you, the reader, now see it would not have
that can be used for in-class or online teaching formats: a been possible without the superb efforts of the entire
compendium of PowerPoint slides covering major points Cengage Learning team, especially our content develop-
within each chapter. (These supplements are available ers: Mary Noel, Stefanie Chase, and Elizabeth Momb. We
to qualified adopters through the instructor section of also acknowledge with gratitude the contribution of our
the Cengage Learning website. Please consult your local manuscript reviewers, who include the following:
sales representative for details.) This edition also features Akira Otani, Ed.D, Spectrum Behavioral Health Center
Cengage Helper Studio training videos in helping skills Edward Keane, Ph.D., Housatonic Community College
which Sherry Cormier and Cynthia Osborn developed Susan Adams, Ph.D., Texas Woman’s University
and produced as a part of MindTap. Jacqueline Persons, Ph.D., University of California,
Berkeley
Daniel W. McNeil, Ph.D., West Virginia University
People We Acknowledge Brandon N. Kyle, Ph.D., East Carolina University
Over the years, we have been asked, “What is it like to put To all of you: Many thanks! We could not have done
together a book like this?” Our first response is always, this without your careful and detailed comments and
“We require a lot of help.” For this edition we are indebted suggestions.
to a number of people for their wonderful help: to Penny
Minor, Kent State University PhD degree candidate in Sherry Cormier, Paula S. Nurius, and Cynthia J. Osborn
chapter
Building Your Foundation

as a Helper
Learning Outcomes
After completing this chapter, you will be able to The chambered nautilus is in the family of cephalopods
1. Recognize, in writing, using dialogue from a counseling that also includes the octopus and squid. Unlike some of
supervision session, one example each of the need for its close relatives, however, the nautilus does not discard
developing the core helper skills of: (a) self-awareness and an outgrown shell in search of a larger one. Rather, it
self-reflection; (b) mindfulness; and (c) self-care and self- retains its shell throughout its adult life. As the mollusk
compassion. You also will be able to identify one specific activity grows, it forms a new and larger chamber to accommo-
for developing each of these three skills to promote stamina and date its size. In other words, it builds on its foundation.
resilience as a professional helper. In so doing, it seals off the last chamber. Its entire life is
2. Define evidence-based practice (EBP) from a list of descriptors therefore dominated by the production of one new living
provided (what it is and what it is not), identify two of its in- chamber after another, each new chamber connected to
tended benefits and at least two of its criticisms, and identify at earlier ones and a part of an ever-enlarging and stronger
least six methods for adapting EBPs for culturally diverse shell. How this is done remains a mystery. Nixon and
populations. Young (2003) state, “This process of forward movement
is not understood but does involve the repositioning of
the muscles that attach the animal to its shell” (p. 36). In
other words, the growth and development of the cham-
bered nautilus is ongoing and requires a firm foundation,
strength, determination, perseverance, and flexibility.
The Chambered Nautilus The mollusk lives in only one chamber at a time—in the
The story of the sea snail or mollusk that makes its largest and last chamber of the shell. It firmly anchors itself
home in the spiral-shaped nautilus shell is fascinating to the shell by a pair of powerful muscles. It moves around
and compelling. It captures well the primary message of the ocean depths entirely by jet propulsion and uses the
this book—change and growth. An inside and lateral, or empty chambers it once called home for buoyancy. Despite
“sliced,” view of three empty nautilus shells is showcased this buoyancy that allows it to move laterally with the ocean
on the cover of the book. We ask that you pause now to currents, the nautilus is able to travel vertical distances of up
look at the designs of all three. Spend a few moments in- to 2,000 feet per day. This is made possible by the mollusk
specting their shapes. Notice first the spiral formation of using the muscles in its body and tentacles to draw in and
each shell, which has its beginning at the center. Also no- expel seawater. It is quite the strong, resilient, and versatile
tice that the shell comprises successively larger compart- animal! This is one of the reasons the nautilus has been
ments or chambers. Each chamber was where the mollusk referred to as the “survivor” (Boyle & Rodhouse, 2005,
lived at one time. As it grew, it created a new, larger living p. 50). We encourage you to spend some time viewing some
space. It is because of these chambers that this sea creature amazing videos on www.YouTube.com of living nautiluses.
is often referred to as the chambered nautilus. Simply search by using the key words “chambered nautilus.”
1
2 Chapter 1
As we have learned more about the chambered nautilus, nautilus and its spiral-shaped shell can inspire helpers and
we cannot help but make some comparisons to helping clients alike in the process of change and growth.
professionals, and to our helping professions. We believe
skilled and effective helpers are part of a professional
community yet are also one of a kind. Each helper is his
or her own person, not a replica of a supervisor or some-
A Practice Nexus for the Helping
one working intently to be just like Carl Rogers, Aaron Professions
Beck, or Marsha Linehan. In addition, helpers make use
During the approximately 35-year history of this book,
of their buoyancy to “go with the flow” as needed, for
we have learned quite a bit from our readers and from the
example, by cooperating with clients and supervisors and
changing fields of practice, and our approach has evolved
by implementing a recently learned evidence-based prac-
as a result. In Figure 1.1 we illustrate the unique nature of
tice (EBP). At the same time, however, skilled helpers also
this text in terms of today’s practice nexus—the interrela-
know when to “go against the current.” This means that
tion, connections, and interfaces of our field. These might
they stretch themselves by doing something uncustom-
be likened to the interrelationships among the chambers
ary and perhaps uncomfortable at first, such as sitting
of the nautilus shell. The figure depicts the relatedness
in silence with a client or interrupting a client when
and connection among the four major components of
needed. Like the chambered nautilus, the professional
practice knowledge: (1) core skills and attributes; (2)
helper’s vertical travel also suggests the deliberate use of
effectiveness and accountability; (3) critical commit-
clinically trained muscles in search of new ideas and better
ments; and (4) diversity. The components come together
alternatives for clients, all the while remaining immersed
to define the central core of what you need for today’s
in the necessity of ethical practice. An example of this is
practice. So we focus on the interface—the area of over-
modifying an EBP to accommodate the cultural values,
lap among the components of practice knowledge—to
traditions, and needs of a particular client or client popu-
provide a coherent and unifying foundation. As the figure
lation, a practice consistent with the culturally affirmative
shows, each component contains specialized content that
services we discuss in Chapter 2.
you will pursue to greater or lesser degrees, depending on
Just as the chambered nautilus retains its shell and
the need. And as you specialize, you will certainly find
builds on its former living compartments, effective helpers
other components of practice that you will need to master.
use their life experiences and graduate training to build a
The totality of it all will develop over years of practice,
strong foundation on which to grow and fashion a level of
ongoing training, receiving feedback from clients and col-
expertise in their work. In so doing, they remain resource-
leagues, and self-reflection. To begin, however, you need
ful and inventive. This parallels the forward movement of
core content, an understanding of the interrelations, and
the nautilus, which involves the flexing and repositioning
practical as well as conceptual understanding.
of its muscles to adapt to new living and work environ-
ments. Professional helpers can be like the strong and
resilient nautilus by concentrating on the present moment
and the current living environment while leaning into and Four Stages of Helping
preparing for the next stage of growth. This means that
The four components of today’s practice nexus are ad-
retreating to previous chambers is not possible—they no
dressed in the 15 chapters of this book and are part of four
longer fit. Likewise, sticking to (or remaining stuck in)
primary stages of helping:
customary practice and “same-old, same-old” ways of
thinking results in a stifling work environment, in addi- 1. Establishing an effective therapeutic relationship
tion to ethical vulnerability, burnout, and ineffective care.
2. Assessment and goal setting
Just like the nautilus, we have no choice but to move on
because change and growth are constant. The spiral shape 3. Strategy selection and implementation
of the nautilus shell suggests that the mollusk can keep
4. Evaluation and termination
growing forever. This also is true for professional helpers!
We hope the skills, strategies, and interventions described The first stage of the helping process, establishing
in this book will assist professional helpers to guide their an effective therapeutic relationship with the client,
clients step by step in the construction of new, more ac- is based primarily on client-centered or person-centered
commodating, and healthier living spaces using existing re- therapy (Rogers, 1951). We present skills for this stage in
sources and strengths. Perhaps the maturing and determined Chapters 3–5. The potential value of a sound relationship
Building Your Foundation as a Helper 3
Multiprofessional
relevance
Multiproblem
applicability
Ethics in practice
Critical thinking
Core Skills
and
Attributes
Critical Interviewing
Commitments and Change Diversity
Strategies for
Helpers
Effectiveness Oppressed,
and vulnerable, and
Accountability underserved
populations
Person in
environment
Evidence-based
practice
Collaborative
practice
Figure 1.1 A Practice Nexus for Today’s Helping Professional
base cannot be overlooked. Research has consistently relationship part of therapy is necessary but not sufficient
noted that the therapeutic relationship accounts for a to help them with the kinds of choices and changes they
substantial amount of client change, approximately 30% seek to make. These clients need additional kinds of ac-
(Lambert, 1992). This is understandable given that the tion or intervention strategies.
relationship is the specific part of the process that conveys The second stage of helping, assessment and goal
the helper’s interest in and acceptance of the client as a setting, often begins with or soon after establishing a
unique and worthwhile person. It is the foundation for— therapeutic relationship. In these first two stages, the
or the container of—all subsequent therapeutic work. practitioner is interested mainly in helping clients explore
The helper’s validation of the client can be empowering, their concerns and wishes. Assessment is designed as a
generating hope the client may not have experienced in a collaborative endeavor, a joint undertaking intended to
very long time. For some clients, working with a profes- help the clinician and client obtain a better picture, idea,
sional helper who stays primarily in this stage of help- or grasp of what is happening with the client and what
ing may be useful and sufficient. For other clients, the prompted the client to seek the services of a helper at this
4 Chapter 1
time. Think of this stage as the client and helper locating the perspective of a client early on in our work, then we
the horizon for the client’s journey of change and also need to be aware of this right away. In reality, we need to
determining the compass to be used to indicate progress be intentionally evaluating effectiveness throughout the
toward reaching the client’s preferred destination. The in- helping process, sharing our observations with clients,
formation gleaned from assessment is extremely valuable soliciting their feedback, and negotiating a plan of care.
in planning strategies. It provides clarity and direction. It These four stages of helping are not discrete. Actually,
also can be used to manage resistance or occasions when there is quite a bit of flow and interrelationship among
client and helper do not agree or encounter an impasse. the four stages. In other words, elements of these stages
We describe assessment skills and strategies in Chapters 6 are present throughout the helping process, with varying
and 7. As the problems and issues are identified and de- degrees of emphasis. Change rarely follows a predict-
fined, the practitioner and client also work through the able path. Clients encounter challenges and setbacks as
process of developing outcome goals. The skill of treat- they implement new behaviors. Symptoms may not abate
ment goal formulation is described in Chapter 8. quickly or respond well to preliminary interventions. A
Strategy selection and implementation is the third revision of the initial plan of care is not uncommon.
stage of helping. The clinician’s task at this point is to help The foci and tasks of each stage of helping thus are not
with client understanding and related action. Insight can confined to that stage. This also is true of the four com-
be useful, but insight alone is far less useful than insight ponents of the practice nexus. Their interrelationship is a
accompanied by a supporting plan that helps the client constant throughout our work with clients.
translate new or different understandings into observable We ask now that you return your gaze to Figure 1.1.
and specific actions or behaviors. Insight also is a Western Two components of the practice nexus—core skills and
and individualistic concept that may not apply or be use- attributes and effectiveness and accountability—are the
ful to many culturally diverse clients. Think of this stage focus of this first chapter. The remaining two compo-
of helping as the skill-building phase when clients, like nents—critical commitments (including ethical practice)
the chambered nautilus, are learning about and using and diversity—are addressed in Chapter 2. All four com-
new or reconfigured muscles to sustain a healthier living ponents, however, are woven throughout the book. To be
environment or to construct a new one. Toward this end, more precise, the nexus of these components throughout
the helper and client select and sequence a plan of action: the four stages of helping is the foundation of the book.
intervention strategies that are based on the assessment
data and are designed to help the client achieve the des-
ignated goals. In developing action plans, it is important
to select plans that relate to the identified concerns and
Core Skills and Attributes
goals and that are not in conflict with the client’s primary Think back to when you knew you wanted to LO1
beliefs and values (see Chapters 9–15). become a professional helper. More than likely it was
The last stage of helping, evaluation and termina- at a time when others had been telling you how good a
tion, involves assessing the effectiveness of interventions listener you were. Even some might have said you offered
used—as well as the therapist’s style in facilitating the helpful advice. It was not necessarily that you went out
process of change—and the progress the client has made looking for people to help—they just seemed to migrate
toward the desired goals (see Chapters 8–10). This kind to you, asking if you could spare a moment, or, for others,
of evaluation assists you in knowing when to terminate not bothering to ask, but proceeding to divulge personal
the process or to revamp your initial action plans. Also, information and then waiting for your response. Your
clients can easily become discouraged during the change desire to become a professional helper also may have been
process, realizing that transferring the skills learned in propelled by witnessing the aftermath of tragedy in your
counseling to various aspects of their lives is a challenge. school or hometown, or even experiencing first-hand
Social supports may not be in place, necessitating the debilitating fear, trauma, and injustices. Because of insuf-
development of new and healthier relationships. Clients ficient care provided to those in need or, by contrast, the
often find observable and concrete signs of progress to be helping hand you received that allowed you to breathe
quite reinforcing. again and learn how to persist and be resilient, you vowed
Our listing of evaluation as the last stage of helping can to be a part of a solution rather than to perpetuate a
inadvertently suggest that gauging effectiveness comes problem. “Never again,” you may have said. “I want to
near the end of counseling. This is far from the truth. If help . . . and to do it right.”
we are not making effective progress in developing a col- Maybe you cannot remember a specific time or event
laborative, therapeutic relationship or in understanding that crystallized your decision to become a professional
helper. Perhaps it had to do with looking back over your The analogy of a toolbox also suggests there is some-
life and realizing that some kind of change was in order, thing that needs to be fixed or corrected and that it is
that remaining on the same life path did not portend the helper who must fix, correct, or straighten out what
much excitement or even any hope. “It’s now or never,” is wrong in clients. This is not a helpful perspective.
you may have said. “Something has to change . . . for the Reference to tools also implies that it is the tools, the
better.” instruments themselves, that are responsible for client
Regardless of the circumstances that brought you to the improvement. It is as if the tools are imbued with some
entrance of your graduate training program, you’re ready kind of power to effect change and, regardless of the client
for something different. Although questioning how this or the therapist, each kind of tool will work in a particu-
may all work out for you (in terms of time, finances, and lar way to fix what is broken. This is another example of
extent of community involvement), you are eager to get using a tool out of context. Again, we do not find this
started and venture into this professional realm. You want comparison helpful. Thinking this way negates the con-
to be a part of change—for others and for yourself. And tributions of the helper and the client!
you are ready to begin learning and to continue learning Our fourth and final reason for not encouraging the
what it takes to be a change agent. “Bring it on,” you may toolbox analogy is that it can prevent a discussion of helper
say. “Just give me the tools so that I can build my toolbox skills. Although some may liken tools or counseling tech-
and get out there to help people.” niques to helper skills, they are not quite the same. Tools
The analogy of the toolbox is one we hear often from and techniques are often regarded as external to the helper
our graduate students. It brings to mind the work of a car- (especially when learning to use a new tool), whereas skills
penter or an electrician, the professional who is equipped comprise the helper’s qualities, traits, and learned behav-
with various instruments to build something new or fix iors. To speak of tools is to speak of something other than
something that is broken. Although students and new the helper; to speak of skills is to talk about the helper. The
professionals may take comfort in having a figurative focus of the former is impersonal; the focus of the latter
toolbox that they can carry with them to each encounter is the person of the helper and how he or she has learned
with a client, we caution them to not allow this anal- to embody and demonstrate certain skills for the benefit
ogy to persist and remain prominent in their career. For of a client. A prime example of this distinction is found
one thing, a toolbox brings to mind something that is in what are referred to in person-centered therapy as the
external to you, something like an appendage that is not core conditions of the therapeutic environment: genuine-
you, that can be inauthentic. This is not to say that the ness or congruence, unconditional positive regard, and
“tools of the trade”—the strategies, interventions, guide- empathic understanding. These are discussed in greater
lines, and practice principles of the profession—are not detail in Chapter 3. Notice that these are not impersonal
important. They are! They are critical! But when they “things” or tools—they are the qualities or attributes and
are not understood and are not incorporated into the skills of the helper, how he or she relates to another person
helper’s overall practice style, their potential for misuse to create the conditions for client change.
increases. This is when they are applied out of context, It may be more accurate, therefore, to talk about the
when the helper is faithfully implementing an assess- skilled helper (Egan, 2014) or the helper who prac-
ment protocol, for example, but is not mindful of how tices what is referred to in dialectical behavior therapy
some of the standard questions have offended a particular as skillful means (Linehan, 2015). Skills refer to and
client. The open-ended question, “How do you feel?” is describe the way a helper practices and reflect how the
considered an important tool, as is the “miracle question” helper has learned, made sense of, and integrated certain
in solution-focused therapy. But when they are asked theories and techniques (or tools) of helping. In other
without understanding their purpose for a particular cli- words, skills reflect the person of the helper. A skilled
ent at a particular time, they may be interpreted by the and skillful helper is a professional, not a technician or
client as disrespectful and intrusive and may result in the what Skovholt and Jennings (2004) referred to as a “tech-
client’s early departure. Tools, therefore, are not intended nique wizard” (p. 140). Whereas learning a technique can
to be used in a mechanical fashion, only applied because take only a few hours, becoming a skilled professional
the instruction manual says so. Because of this, we do not and a wise person takes many years (see Rønnestad &
want to encourage helpers to continue to rely on tech- Skovholt, 2013). Our focus on core skills and attributes
niques they do not understand, have not yet practiced throughout this book is in effect a focus on you as the
and received feedback on, and have not incorporated into helping professional—your qualities, traits, and learned
their overall style. Doing so over the course of one’s career behaviors—so that clients derive maximum benefit from
would be disingenuous and inauthentic. services provided. It is a learning and growth process:
6 Chapter 1
from a mechanical and disjointed use of tools in the tool- orientation or operating from an evidence-based treat-
box to practicing with skillful means. Like the way the ment manual, that theory and those treatment protocols
chambered nautilus grows, this process can take place over were not developed expressly for the client with whom
many years, but its foundation begins now, with careful you are working. Rather, you are the one in the imme-
attention to matters of context and environment. diacy of the moment to determine, adapt, and deliver
We dedicate the remainder of this section to a discus- services to each client. This is what it means to move
sion of three core skills and attributes that are essential beyond rote use of tools in a toolbox to developing skillful
throughout the stages of helping: (1) self-awareness and means. The tools are no longer disconnected from you;
self-reflection; (2) mindfulness; and (3) self-care and self- they now have become part of your routine functioning so
compassion. These make possible the promotion of stam- that quality client care is maintained. This also is part of
ina and resilience, concepts that also are addressed in this the professional development process, the forward move-
chapter. Think of these as core skills and attributes from ment similar to that of the growing chambered nautilus—
which to start your journey of growth and change as a developing from mere technician to a skilled and respon-
professional helper. Just as the chambered nautilus began sive professional. The instruction manual remains; its
its development at the core or center of the spiral shell, purpose is now understood.
we believe these skills and attributes are the foundation of Just as the chambered nautilus must navigate through
your own development as a professional helper. the murky waters of the deep sea, so must practitioners
make their way through the ambiguous terrain of clinical
practice. The skills of self-awareness and self-reflection
Self-Awareness and Self-Reflection make this possible. These are practices intended to keep
Being drawn to uncertainty is one precondition for thera- the practitioner in check and also to monitor the quality of
pist development. According to Jennings, Skovholt, Goh, services extended to his or her clients. High self-awareness
and Lian (2013), helpers who “thrive . . . are comfortable and in-depth self-reflection are primary characteristics
in the seemingly paradoxical reality of searching for clarity of highly skilled, effective, or “master” therapists in the
while enjoying the ambiguity and confusion of the human United States and four other countries (Jennings et al.,
condition” (p. 239). This means that the terrain of help- 2013). Self-awareness is being highly observant of one-
ing is not clear and the journey cannot be predicted. It self, and self-reflection is a form of self-monitoring or
also means that there is no one-size-fits-all “answer book” self-regulation. Rather than being self-absorbed in a nar-
to consult so that you know what to do with clients each cissistic manner, self-awareness and self-reflection are
step of the way. Rather than getting clearer as you move skills of introspection that consider yourself from differ-
through your graduate studies, it may be that this work of ent dimensions (e.g., verbal expression, demeanor, values)
professional helping seems to be getting murkier as you go as you learn new skills and are exposed to professional
along. Two of the 20 “hazards” of practicing as a profes- guidelines.
sional helper that Skovholt and Trotter-Mathison (2011) It might be helpful to think of self-awareness and
listed illustrate this murkiness: lack of concrete results and self-reflection as consultation skills—that is, the ability
closure in our work with clients, and not knowing how to to consult your inner compass as part of the clinical
measure improvement or even effectiveness. decision-making process. Your inner compass continues
What does uncertainty have to do with the core skills to be shaped as you learn more about theory, research,
of self-awareness and self-reflection? Quite a bit! For one, and professional standards. It could be said that your in-
it means that these skills are essential because there is no ner compass is what sits on the practitioner’s stool, a stool
absolute “how to” manual out there for you to consult. Skovholt and Starkey (2010) described as having the three
In session with your clients, you are the one facilitating legs of practitioner experience, personal life, and academic
the conversation, establishing a connection with the cli- research. These three legs are sources of knowledge for
ent, assessing the case, and making decisions about client you to consult throughout your career. This must be done
care. More often than not, no other professional is in the deliberately, such as setting aside time to read a self-help
session to assume those responsibilities. You are the sole book and journal about what you have read, obtaining ad-
professional in the moment with clients. Understood in ditional supervision, or attending an experiential profes-
another way, you are the only active ingredient in that sional growth workshop. Your compass requires routine
therapeutic encounter that you can control. More than calibration, just as your stool needs to be balanced and
likely other factors are beyond your control, such as cli- leveled. Self-awareness and self-reflection are the skills you
ent characteristics and the immediate treatment setting. use to calibrate your inner compass by consulting theory,
Although you may be guided by a specific theoretical research-informed practices, supervisory directives, and
ethical and other professional guidelines. These skills also It is group-based training conducted in 2.5-hour weekly
are used to maintain balance as you operate from your sessions for 8 weeks, with an additional 1-day meditation
practitioner’s stool. retreat. Mindfulness-based cognitive therapy (MBCT)
Before reading further, we invite you to pause and for depression (Segal, Williams, & Teasdale, 2002)
participate in Learning Activity 1.1. This activity is in- and mindfulness-based relapse prevention (MBRP) for
tended to heighten your self-awareness and make use addictive behaviors (Bowen, Chawla, & Marlatt, 2011)
of your self-reflection skills. Specifically, this activity is are designed based on the work of Kabat-Zinn. A newer
designed to help you explore your reasons for entering approach is mindful self-compassion (MSC; Germer &
the helping profession, as well as what you hope to gain Neff, 2013) that teaches self-compassion skills to the gen-
from your work as a helping professional. Because this is eral public and is fashioned according to MBSR’s format.
demanding work that involves substantial personal com- Inspired by Eastern spiritual practices of meditation,
mitment, routine self-reflection is essential to effective namely Buddhism and Zen, mindfulness is understood
practice. as practicing focused attention, specifically, remaining
aware of and deliberately attuned to the present moment.
Mindfulness Although often confused with meditation, it is not.
Related to self-awareness and self-reflection is the core Rather than “zoning out” or retreating from the present
skill of mindfulness. Think of it as a specialized and dis- moment, mindfulness is “a way of living awake, with your
ciplined form of self-awareness and self-reflection. It is an eyes wide open” (Dimidjian & Linehan, 2009, p. 425).
intentional practice that is central to dialectical behavior This means that it is an attentional skill or a way of paying
therapy (DBT; Linehan, 2015) and to acceptance and attention on purpose. It therefore is not “mindlessness.”
commitment therapy (ACT; Hayes, Strosahl, & Wilson, It is a heightened state of consciousness wherein the focus
2012). Mindfulness also is a core skill in at least four of attention is on in-the-moment perceptual experience,
other approaches. Jon Kabat-Zinn’s (1990) mindfulness- making use of as many senses as possible (e.g., sight,
based stress reduction (MBSR) initially was developed sound, smell)—and also attending to visceral functioning
for persons with chronic pain and is now intended for (e.g., breathing)—to be fully immersed in the textured
persons with a variety of psychological and medical issues. detail of the concentrated now. In this way, mindfulness
Learning Activity 1.1

Survey of Helper Motives and Goals injustices at some point in your life? What more do you
This activity is designed to help you explore areas of your- still have to learn about yourself as a result of such pain?
self that in some fashion will affect your helping. Take some 7. Which of your personal qualities do you believe will
time to consider these questions at different points in your serve you well as a helping professional? Why do you
development as a helper. We offer no feedback for this ac- believe this?
tivity, because the responses are yours and yours alone. You 8. What aspects of yourself (e.g., being “rough around
may wish to discuss your responses with a peer, a supervi- the edges”) do you still need to work on for you to be a
sor, or your own therapist. helpful practitioner? How do you see yourself address-
ing these traits?
1. What is it about the helping profession (e.g., social 9. How do you handle being in conflict? Being con-
work, counseling, psychology) that is attractive to you fronted? Being evaluated? What defenses do you use
or enticing for you? in these situations?
2. What do you look forward to learning and doing over 10. How would someone who knows you well describe
the next 5 years? your style of helping or caring?
3. What is anxiety-provoking to you about the work or 11. What client populations or client issues do you enjoy
lifestyle of a professional helper? working with or look forward to working with? For
4. What are you cautious or hesitant about as you con- what reasons?
tinue in the profession? 12. What client populations or client issues are difficult for
5. If you had to select one event in your life or one per- you to work with or do you foresee as being difficult for
sonal experience that contributed to your decision to you to work with? For what reasons?
pursue the helping profession you are now in, what 13. What are three primary factors that contribute to being
would that event or experience be? an effective helper?
6. What have you learned about yourself by having expe- 14. How will you know when you have been an effective
rienced tragedy, trauma, or types of personal pain and helper?
8 Chapter 1
is like stepping outside yourself, taking a meta-perspective and increased patience. These and other benefits seem to
on your own experience, so that you can consider your support Carmody’s (2009) contention that the overall
perception of the present moment with greater objectivity goal of mindfulness is the reduction of human suffering
(Neff & Pommier, 2013). (p. 272).
Mindfulness is the means by which an individual makes In both DBT and ACT, mindfulness is a skill taught to
direct contact to immediate experience, not to abstrac- clients and is a skill practiced—and lived—by therapists.
tions or concepts. Persons who practice mindfulness are You do not have to be a religious or spiritual person to
able to control or focus their attention on the present practice mindfulness. Consistent with our earlier discus-
moment. They do not control what is being attended to, sion of skill and how it differs from technique, mindful-
such as deliberately trying to change their breathing or ness is how the helper interacts with clients—or, more
rid their mind of thoughts; rather, they control how they precisely, how the helper is present with clients. The
attend to what is happening in and around them in the premise of DBT and ACT is that helpers cannot teach
here and now. In this way, mindfulness is unlike certain skills to clients that therapists do not practice themselves.
forms of prayer and is not to be confused with prayer. Manuals are available to teach clients mindfulness skills
It is not a form of communicating with or connecting (e.g., Linehan, 2015), but mindfulness cannot be learned
to a transcendent being. Furthermore, mindfulness does simply by talking about it or lecturing on it. Mindfulness
not seek to make something happen, such as relaxation must be practiced in session and modeled by the therapist.
or preventing certain kinds of behavior (e.g., fighting). The therapist who is purposefully attentive to the client
Dimidjian and Linehan (2009) state, “Mindfulness has as in the immediacy of the counseling session is modeling
its goal only mindfulness” (p. 425). for the client the skill of mindfulness. The therapist who
Mindfulness is the polar opposite of multitasking. It routinely practices mindfulness in and outside of therapy
does not mean, however, doing nothing or being nonpro- also is able to guide the client through the process of learn-
ductive. It does mean intently focusing on one thing at a ing and continually practicing mindfulness.
time and doing so in the present moment. This requires
effort! Although not intended to make something hap- Mindfulness Skills In DBT, there are six specific mindful-
pen or to control that which is the focus of attention, ness skills divided into “what” and “how” skills. The three
research suggests that persons who consistently practice “what” skills are observing, describing, and participat-
mindfulness experience a greater sense of control over ing; the three “how” skills are remaining nonjudgmental,
their feelings and mood, their behaviors (e.g., not acting focusing on one thing at a time in the present moment,
on impulses), and their attitudes (e.g., more hopeful). For and being effective. Observing is the act of noticing what
example, primary care physicians trained over 1 year in is in your awareness, using your sight, hearing, or tactile
mindfulness skills reported improved personal well-being, senses, for example. It does not label or categorize what is
including decreased burnout and improved mood (Kras- observed; it is simply the act of paying attention to what
ner et al., 2009). They also experienced greater changes is taking place around you and what is being experienced
in empathy, a finding that seems to fit Greason and inside you in the here and now. The skill of describing
Cashwell’s (2009) survey of counseling student interns. requires a kind of stepping back from the experience to
They found that these students’ high mindfulness scores identify what has been observed. This may include nam-
predicted greater empathy and greater self-efficacy. Coun- ing the colors, sounds, and tactile sensations (e.g., soft,
seling students who had taken a graduate level course that rough, warm temperature) observed and experienced.
focused on mindfulness and self-care reported similar The third “what” skill is participating and refers to fully
benefits (Christopher & Maris, 2010) and also spoke of immersing yourself in the activity of the present moment.
the positive effects of mindfulness specific to their work This has been described as throwing yourself into and
with clients, such as increased calm and comfort with si- becoming one with an activity or experience, and doing
lence and reduced fears of inadequacy and incompetence. so without reservation or self-consciousness. This means
It appears that even though mindfulness is not prac- that participating has the quality of spontaneity. Take, for
ticed for the specific purpose of changing mood, behavior, example, the act of walking. When done mindfully, fully
or attitude, the practice of mindfulness results in positive participating in walking means attending to your move-
changes in these areas of functioning. Think of these ments and the sensations as you walk, focusing on the act
changes as positive side effects or the benefits of mindful- of walking, and immersing yourself in the activity.
ness. Davis and Hayes (2011) reviewed additional ben- As its name implies, the three “how” skills of mindful-
efits of mindfulness from the research literature, including ness describe how the three “what” skills are used. First,
relationship satisfaction, improved physical functioning, observing, describing, and participating in the present
moment is to be done nonjudgmentally. This means not your attentional “muscles” so that you can tune in to your
evaluating the experience as either bad or good. This immediate experience, using your sensory resources. It’s a
practice is similar to that of accepting, a core skill in ACT. way of becoming acquainted with you—with where you
It means assuming a noncritical or neutral stance by dis- are and who you are in this present moment! Mindfulness
carding the need to control what is, even that which has that is effective becomes a welcome, inviting, and mean-
been experienced as unpleasant. To walk nonjudmentally ingful activity, not a scary, suspicious, or worthless one.
means to not ruminate on your movements or to experi- Each of the six mindfulness skills is not to be taken
ence them as “stupid,” “difficult,” or “painful.” It does lightly. The skills also are to be used carefully with clients,
mean accepting your experience as is, and continuing to not in a haphazard fashion or only because mindfulness
walk with your full attention on the present moment, may be regarded as a popular clinical perspective and
the second “how” skill of mindfulness. This means not practice. Again, mindfulness practice requires discernment
walking and thinking about your destination at the same and effort! To help you practice your mindfulness skills,
time. This would be doing two things at once—a practice we invite you to participate in Learning Activity 1.2.
inconsistent with remaining in the present moment by Even if you have learned about mindfulness prior to read-
doing one thing at a time. The third “how” skill of mind- ing this book, we ask that you pause to “flex” and “tone”
fulness is being effective, which is doing what works or your mindfulness muscles. Think back to the mollusk that
what is helpful. Being mindful is not about doing what makes its home in the nautilus shell—to continue to grow
is right and avoiding what is wrong. It also is not about and expand, it uses its muscles continuously. Doing oth-
following orders or simply going through the motions erwise would result in shriveling up or being swept away
(like pulling out tools from a toolbox!). It is about using by the tide. If you are new to mindfulness practice, we ask

Mindfulness Practice visuals on your hands, such as the blood vessels below the
You can engage in this practice by yourself after reading skin, markings on the skin, or rings that appear on the in-
through the activity. It can also be done in a group with one side of your fingers. Simply use your eyes to scan the open
person volunteering to lead the practice, reading aloud the palms of your hands, the hands that have lifted objects for
following activity. you, opened and closed doors, helped you write and type,
Find a quiet spot where you know you will not be dis- and held the hand and cupped the face of a loved one.
turbed for approximately 10 minutes. Turn off or mute any Now take one of your hands and its fingers and touch the
mobile devices you may have around you. Sit down in a surface, the palm, of the other hand; notice how this feels.
comfortable position, either on a chair or on the floor. Sit Glide your fingers and its palm across the palm and the fin-
upright, with your feet firmly touching the floor (if sitting gers of the other hand. Simply notice the touch, how your
on a chair), or, if sitting on the floor, extend your legs, or open hand feels when gently touched by one or several
cross them with one of your ankles resting comfortably fingers of the other hand. Describe this sensation without
on the knee or thigh of the other leg. Take three or four judging it as good or bad. Suspend any criticism. Hold off
deep breaths in through your nose, noticing how it feels on assigning to the sensation any positive evaluation as
for the air to come in through your nostrils, and also notic- well. Simply give a name to how the motion, the sensation,
ing how your chest expands as it takes in new oxygen. As feels. Keep the motion of your fingers on the other palm
you breathe out through your nose, notice how your chest slow, gentle, and deliberate so that you are able to notice
subsides and the motion of air in your throat and nostrils. the detail or the intricacies of the sensation. Continue do-
Now take your hands and rest them on your thighs, ing this for a few moments, doing your best to remain
palms up. Keep them separate for now. Notice the palms of focused on the activity in the here and now.
both of your hands, the lines or “creases” that make up the To close this activity, take three or four deep breaths,
inside of your hands. Observe the length and the direction holding for just a moment each time before breathing out.
of these lines, notice how they change as you bend your As you gaze again at the palms of your hands and glide
fingers slightly and then extend your palms. See the detail your fingers of one hand over the palm of the other, remind
of the lines, and how they criss-cross, as you move your yourself of your uniqueness, that these hands are yours
hands slightly in the light. Pay attention to the detail across and one of a kind. Offer a word of gratitude to both hands,
the surface of your palms. As you do, remind yourself that thanking them for being a part of you, making you unique,
these palms and these fingerprints are yours and yours and for working for you. This might even include a warm
alone—unique and one of a kind. Now notice any other shake between your two hands or a gentle clap.
10 Chapter 1
that you enter into this exercise with an open mind, ready only in the United States but also in other countries.
to try something new—a skill we believe is central to all For example, the Canadian Code of Ethics for Psycholo-
forms of helping. You will have the opportunity to practice gists (Canadian Psychological Association, 2000) regards
yet again your mindfulness skills in Chapter 4, so think of self-care as an activity that fulfills the ethical principle
this activity as a warm-up! of responsible caring. In its Ethical Framework for Good
Practice in Counselling and Psychotherapy, the British As-
Developing Skilled Intuition We believe the deliberate sociation for Counselling and Psychotherapy (2013) lists
practice of mindfulness can assist new helpers in making self-respect (the practice of “fostering self-knowledge and
the transition from relying on only intuitive judgments care for self ”) as one of six ethical principles. Professional
(decisions that are automatic, involuntary, and almost ef- associations and accrediting bodies based in the United
fortless) to incorporating deliberate judgments (decisions States also have recognized the importance of professional
based on controlled, voluntary, and effortful activities). self-care. For example, counseling programs accredited by
Although acting on your intuition or gut may have some the Council for Accreditation of Counseling and Related
appeal because it is thought of as genuine or authentic Educational Programs (CACREP, 2009) must include in
practice, it also suggests a dismissal of learned theory their core curriculum “self-care strategies appropriate to
and skills. Think about it. If all it took to be an effec- the counselor role” (Standard G.1.D.). In addition, the
tive helper was the use of instinct and gut, why would National Association of Social Workers (NASW, 2008)
graduate studies be necessary? The truth is that effective has a policy statement supporting the practice of profes-
helping requires the application of genuine yet sophisti- sional self-care, describing this practice as “a core essential
cated skills—skills that have been learned, practiced, and component to social work practice” (p. 269).
revised over a period of time. If you hear a supervisor tell That self-care is an ethical imperative for all profes-
you to “just go with your gut,” or “stop using your head sional helpers suggests four things: (1) it is not simply
and simply use your instinct,” ask him or her to explain. a personal matter or quality; (2) it is not an indulgence;
It may be that your supervisor is encouraging you to (3) it is not optional; (4) it is not automatic; and (5) it
integrate the skills you have learned (“head knowledge”) is not to be practiced in a shallow or superficial man-
into your natural style of interpersonal communication. ner. As a reflection of ethical conduct, self-care is a set
His or her recommendation may be for you to practice of learned behaviors that must be demonstrated during
what Kahneman and Klein (2009) described as skilled graduate studies and throughout one’s professional career.
intuition, or the testing of your cue recognition skills. Just because you care for others does not automatically
They proposed that skilled intuition develops only in an mean that you are able to care for yourself. More than
environment of regularity (e.g., meeting with clients on a likely, it is because you care for others that you are prone
routine basis and receiving supervision consistently) that to not care for yourself adequately. It may be that for far
makes it possible to validate your observational skills or too long you have prioritized the needs of others over your
cue recognition (e.g., discerning symptoms from client own, set aside your own goals to accommodate the goals
presentation). of others, and sacrificed your own well-being to preserve
We believe that mindfulness is a form of skilled intu- your prize-worthy reputation as the devoted child, faith-
ition. In this case, what your supervisor may be trying ful spouse and partner, loving parent, generous friend,
to tell you is that in session with your clients, you must helpful neighbor, and dutiful employee. Although these
attend to the present moment in a more focused and de- are qualities many of us aspire to and would hope to have
liberate manner, accepting what is without trying to force included in our eulogies and obituaries, they come with a
change. Now, that requires skill, doesn’t it? Maybe that price. And in the role of professional helper, you cannot
explains the practice of skillful means! afford what it costs to care for others while simultaneously
ignoring caring for yourself.
Self-Care Baker (2007) stated that “self-denial or self-abnegation
Another core skill for helpers is self-care (Norcross & is neglectful not only of our real self-needs, but ultimately
Guy, 2007). Although mindfulness is a form of self-care of the well-being of our clients” (p. 607). In other words,
(Wise, Hersh, & Gibson, 2012), self-care is a broader self-care must become routine practice for helpers for
concept and practice and has been identified as an ethi- the sake of client well-being and remaining effective as a
cal imperative for counselors (American Counseling As- clinician—and we believe this practice must begin during
sociation, 2014), psychologists (Wise et al., 2012), and graduate studies. It is meant to prevent helper impairment
social workers (Lee & Miller, 2013). This is true not and inadvertent client maltreatment. Its purpose also is to
strengthen helper resilience and well-being. Self-care was one’s career. Concentrating only on active coping strate-
identified by a group of 24 mental health practitioners gies at work, they noted, may actually “exacerbate the
from diverse ethnic backgrounds in the United States and psychological tiredness of the worker” (p. 85). Engaging
Canada as an adaptive response and an essential practice in relaxing activities during one’s leisure time is therefore
to “detoxify from frequent forms of racial microaggres- important because these “off-the-clock” activities serve to
sions they experience in their jobs” (Hernández, Carranza, address the emotional exhaustion that has been found to be
& Almeida, 2010, p. 206). Self-care activities described the primary culprit of burnout (see Wallace & Brinkerhoff,
by this group included physical exercise, meditation, visu- 1991). It is assertive self-care over the career life-span that is
alizations, massage, acupuncture, chiropractic treatment, essential (Skovholt & Trotter-Mathison, 2013).
thinking positively and avoiding negative thoughts, and
taking pride in their ethnic heritage. Self-care thus has a Self-Compassion
dual purpose: prevention of ineffective or even harmful A newer concept applied to professional helpers is that of
client care (i.e., doing no harm, the ethical principle of self-compassion. It is a form of self-care, but it is a broader
nonmaleficence), and promotion of beneficial care (i.e., concept that encompasses self-care. Self-care refers to
doing good, the ethical principle of beneficence). specified behaviors, whereas self-compassion is an overall,
In your work as a professional helper, you have no foundational, and transformational attitude or perspective
choice! You must practice self-care. And this is not self- (Patsiopoulos & Buchanan, 2011) that could be said to fuel
indulgent, selfish, or narcissistic behavior. It also is not to self-care activities. Borrowing from Buddhist philosophy,
be practiced in a shallow or superficial manner “‘dumbed Neff (2003a) proposed self-compassion as a healthier and
down’ to socializing and recreational pursuits” (Putter- more constructive self-attribution than self-esteem because,
baugh, 2015, p. 54). Rather, as a stipulation for living unlike self-esteem, self-compassion does not compare self
and working as an effective professional helper, self-care to others and does not endorse the processes of separa-
is a deliberate, purposeful practice that involves quiet and tion and individuation in human development. Rather,
deep reflection on our lives. self-compassion balances concern for self with concern
How do you practice self-care? In a recent study of psy- for others, meaning that self-compassion fosters concern
chology graduate students, Myers et al. (2012) found that for others, and vice versa. In recent research, Neff and
three self-care behaviors predicted lower perceived stress: Pommier (2013) reported a significant association between
(1) engaging in better sleep hygiene; (2) having strong so- self-compassion and concern for others.
cial support; and (3) regulating emotion through cognitive There are three components of self-compassion (Neff,
reappraisal (changing the meaning of an emotion-filled 2003a; Neff & Pommier, 2013):
situation) and suppression (changing emotional expres-
1. self-kindness, or self-understanding rather than harsh
sion, as in not acting on anger). Surprisingly, physical
judgment or self-criticism;
exercise and mindfulness practice did not predict reduced
levels of perceived stress, which the researchers attributed 2. common humanity, the recognition that all humans
to varying opinions on the benefit of these behaviors and are imperfect, that they fail and make mistakes, so that
lack disciplined engagement in these behaviors by gradu- one feels connected to—rather than isolated from—
ate students. In Turner et al.’s (2005) study of psychology others in the midst of personal struggles; and
interns, engaging in pleasurable activities outside of the
3. mindfulness, referring to the acceptance of painful
internship, using humor, getting a sufficient amount of
emotions and thoughts while not overly identifying
sleep, and engaging in physical exercise were activities re-
with them.
ported to be beneficial. When working at the internship,
these same graduate interns reported that consulting with Note the integral role of mindfulness in self-compassion.
fellow interns, obtaining clinical supervision, diversifying We contend that mindfulness sustains self-compassion,
internship activities, and setting realistic internship goals making it possible for persons to be kind to themselves
were beneficial self-care activities. because of their humanity. Said in another way, it is the
Turner and colleagues (2005) encouraged graduate in- heightened and concentrated awareness of one’s self in
terns to be intentional about participating in self-care strat- the midst of current activity and surroundings (includ-
egies because “self-care is a life-long process and not limited ing people)—accepting what is without changing what
to the internship year” (p. 679). Similarly, Jenaro, Flores, is—that cultivates self-compassion.
and Arias (2007) emphasized the importance of an appro- Neff (2003a) defined self-compassion as being open
priate balance between work and private life throughout to and moved by one’s own suffering, assuming an
12 Chapter 1
understanding and nonjudgmental attitude toward one’s exhausting at times. It is! Skovholt and Trotter-Mathison
own shortcomings and failures, and recognizing that one’s (2011) said this loud and clear in their listing and descrip-
own experience is part of the common human experi- tions of not one but 20 hazards of practicing as a helping
ence. This suggests that self-compassion promotes humil- professional. Among these are: (1) providing constant em-
ity rather than self-centeredness or narcissism. At the pathy, interpersonal sensitivity, and one-way caring; (2)
same time, it also demonstrates resilience and a striving realizing that one’s effectiveness is difficult to measure and
toward psychological well-being. These hypotheses were thus remains elusive; and (3) working with clients who
supported when Neff (2003b) first administered to under- are not “honor students” and whose readiness to change
graduate students the Self-Compassion Scale she developed. lags behind our own hopes and desires for them. These
As expected, she found an inverse correlation between and other consequences of “emotional labor” (Wharton,
self-compassion and symptoms of depression and anxiety, 1993) may lead to burnout and compassion fatigue, or
as well as rigid perfectionism. From this same study, self- what Stebnicki (2009) referred to as empathy fatigue.
compassion was associated with greater life satisfaction. In Counselors who volunteered to help victims of natural
subsequent studies, self-compassion was found to predict disasters were found to have twice the rate of compassion
mental health among adolescents and young adults (Neff fatigue and vicarious traumatization compared to other
& McGehee, 2010; Neff, Kirkpatrick, & Rude, 2007), counselors (Lambert & Lawson, 2013).
suggesting that self-compassion might be thought of as Burnout is a general term that describes emotional
resilient humility or humble resilience. depletion, a lack of caring or empathy for clients, and
Specific to professional helpers, Patsiopoulos and Bu- a diminishing sense of personal accomplishment. The
chanan (2011) identified six overlapping dimensions of first two aspects of burnout describe what Skovholt and
self-compassion from their interviews with 15 Canadian Trotter-Mathison (2011) termed caring burnout, whereas
counselors. With an average of 14 years of psychotherapy the third aspect of burnout, loss of meaning and purpose
practice, these counselors defined self-compassion as: (1) in one’s work, is what they characterized as meaning burn-
being gentle with yourself; (2) being mindfully aware; (3) out. In broad terms, burnout can be understood as a lack
having a sense that as humans “we are all in this together”; of resilience and constricted coping abilities. Jenaro and
(4) the importance of speaking the truth to yourself and colleagues (2007) characterized burnout “as an answer to
others; (5) the development of spiritual awareness; and chronic labor stress that is composed of negative attitudes
(6) having an ethic of professionalism. Specific practices and feelings toward coworkers and one’s job role, as well
of self-compassion used during therapy sessions included as feelings of emotional exhaustion” (p. 80). Compassion
assuming a stance of acceptance (e.g., recognizing the fatigue can signal the onset of burnout and is regarded
limits of helping, making appropriate self-corrections), as mental and physical exhaustion resulting from taking
mindfulness (i.e., nonjudgmental in-the-moment atten- better care of others than you do of yourself. Empathy fa-
tiveness) and not knowing (i.e., counseling from a nonex- tigue can also be a precursor to burnout and describes the
pert stance), and participating in a caring and supportive practitioner’s diminished capacity to listen and respond
work team as colleagues or supervisees. Counselors also empathically to clients whose stories convey acute and
described the importance of scheduling breaks in between cumulative psychosocial stress (Stebnicki, 2009, p. 804).
therapy sessions and ending appointments on time as We may not have been fully briefed about the hazards
deliberate acts of self-compassion. According to the coun- of practicing as professional helpers before we submitted
selors in this study, these practices served to enhance their our own versions of informed consent and signed up for
well-being, effectiveness in the work setting, and therapeu- this career. It may not be until later in one’s formal train-
tic relationships with clients. ing (e.g., during practicum and internship) that a novice
The self-compassion website (http://self-compassion helper actually experiences some of the stresses and strains
.org) established by Dr. Neff posts updates on self- that are part of this work. But knowing about all the chal-
compassion research, includes informational videos, and lenges may not have kept us away anyway, and perhaps
provides information on trainings and workshops. One some attraction to the challenge of this work spurred us to
of these is the 8-week Mindful Self-Compassion program seek out this particular profession in the first place. It also
(Germer & Neff, 2013). may be that we are hardier than we realize and that it takes
only a few reminders of our competence here and there—
including some client success stories—to keep us going.
Promoting Stamina and Resilience Realizing that our experience of strain and exhaustion is
Given the many facets of practicing as a professional not attributable to one thing or person but more than
helper, it is understandable how such a lifestyle can be likely to an accumulation of factors over time, including
ones beyond our control (e.g., vague and ambiguous ex- to shift attention from a deficiency or pathological per-
pectations in the work setting), can ease our tendency to spective (i.e., “burnout prevention”) to a strengths-based
self-blame. Likewise, reframing our goals as helping clients or competency-based orientation (i.e., “stamina promo-
manage or otherwise live with concerns rather than fixing, tion”). Stamina is likened to resilience, endurance, and
curing, or even solving difficulties may help us remain flourishing – not despite hardship but in the midst of
invested in this important work. There are additional and challenges. Each suggestion for stamina corresponds to
specific things we can do to help cultivate our resilience the seven letters in the word stamina, thus creating the
and stamina for providing professional care to others. acronym STAMINA. These are presented and described
Osborn (2004) identified seven salutary suggestions for with examples in Table 1.1.
stamina for those who serve in the helping professions. Although stamina and resilience are close cousins,
These recommendations are intended to assist helpers we differentiate the two by thinking of stamina as the
not only remain vigilant about the hazards of professional fuel for resilience. Resilience therefore refers to a set of
helping, such as compassion fatigue, but also maintain specific skills that Tjeltveit and Gottlieb (2010) stated
their resolve for rewarding work. Based on a review of the can be taught and then “marshaled when psychothera-
scholarly literature and reflections on her clinical practice, pists are faced with difficult situations” (p. 100). Spe-
Osborn’s recommendations comprise a proactive rather cifically, resilience develops from social relationships
than a reactive or preventive approach and are intended and support networks (e.g., clinical supervision), but
TABLE 1.1 Seven Ingredients of Helper Stamina

Ingredients of Helper STAMINA Definition Examples
Selectivity ●● Intentionally choosing and concentrating ●● Setting limits on yourself and maintaining
your efforts in only certain areas, such as healthy boundaries with others
limiting your areas of expertise (e.g., clients, family members)
●● Undertaking daily activities and long-term ●● Modifying high and perhaps unrealistic
endeavors with care and focused attention expectations you have of others and
yourself
●● Not trying to “do it all” or be a “jack of all
trades”
Temporal sensitivity ●● Being mindful of the constraints on your ●● Joining with clients in the present
time and working within these limits moment
●● Using time wisely ●● Beginning and ending counseling
●● Focusing more on current resources and sessions on time
circumstances compared to past or even ●● Engaging in mindfulness practice
future challenges
Accountability ●● Practicing according to justifiable, ethical, ●● Routinely consulting and learning from
theoretically guided, and research-informed colleagues and supervisors
guidelines ●● Attending quality workshops and
●● Able to understand and to verbalize to professional conferences
others (e.g., clients, treatment team ●● Reading professional literature
members) decisions made and actions
taken
●● Credibility
●● Practicing self-regulation or operating
from an internal locus of control within the
parameters of professional standards
Measurement and management ●● Protecting and preserving those things ●● Engaging in routine self-care activities
that are important and valuable to you during the workday and your personal
●● Holding onto and accentuating the time
resources associated with choices you ●● Engaging in personal therapy
have made in your personal and ●● Limiting the amount of your volunteer or
professional life pro bono services
●● Generating realistic goals with clients
●● Clarifying with your supervisor your exact
role and responsibilities
(continued)
14 Chapter 1
TABLE 1.1 Seven Ingredients of Helper Stamina (continued)

Ingredients of Helper STAMINA Definition Examples
Inquisitiveness ●● Curiosity about other people and intrigue ●● Practicing idiographic client care
about how they function ●● Referring to diagnoses as conditions
●● Fascination with human development and clients have, not who they are
change ●● Suspending judgment
●● Honoring client uniqueness and originality ●● Engaging in routine self-reflection
●● Routinely soliciting feedback from clients
Negotiation ●● Flexibility and adaptation ●● Engaging in collaborative and
●● Engaging in give-and-take without coconstructive conversations with clients
necessarily giving-in and colleagues
●● Responding to and cooperating with ●● Remaining open to new ideas from
others while simultaneously remaining colleagues
steadfast to and upholding professional ●● Revising over time long-held beliefs and
guidelines and standards practices that are no longer helpful
●● Becoming more assertive on a treatment
team to advocate for a particular client’s
needs
Acknowledgment of agency ●● Salutary or strengths-based orientation ●● Assessing and promoting client strengths
●● Recognition and promotion of human and resources
instrumentality, intrinsic motivation, and ●● Conveying hope to clients
resilience ●● Living a life worth living
●● Remaining confident in the undeniably ●● Implementing a recovery plan
persistent strength, resourcefulness, and ●● Pursuing with diligence a new area of
will of the human spirit expertise
●● “Blooming where I’m planted”
Source: Osborn, C. J. (2004). Seven salutary suggestions for counselor stamina. Journal of Counseling & Development, 82, 319–328.
because it is multidimensional, Tjeltveit and Gottlieb Once you have paused to reflect on his words (per-
(2010) also defined resilience as a set of relatively stable haps rereading his reflections), what thoughts come to
personal characteristics (e.g., virtues). Using the acro- mind about your intended style of helping? What wisdom
nym DOVE, they identified four assets that enhance might he be conveying to you as you prepare for the work
therapist resilience while decreasing therapist vulner- and lifestyle of a professional helper? How would you
ability to ethical misconduct. These therapist assets propose to offer help to this man at this time in his life?
or dimensions of resilience are: having a Desire to What would you tell him if you were working with him?
help others, creating and making use of available Op- In addition, what ingredients of stamina and resilience
portunities for personal enrichment and professional might you need to make use of intentionally as you work
development, consulting and revising core Values, and with this father? What aspects of temporal sensitivity or
approaching Education as lifelong learning. Among negotiation, for example, might be especially helpful to
their eight recommendations for cultivating resilience you? What further education would you need to pursue?
to “move toward ethical excellence” (p. 108) are en- As we ourselves read and reflect on his words, it seems
gaging in regular self-assessment and seeking psycho- that this father’s loss cannot be “fixed” and that he resents
therapy and structured supervision. the well-meaning advice others have offered. As much as
The need for helper stamina and resilience is evident in we’d like to think of ourselves as problem-solvers, we real-
the reflections of a bereaved father that Neimeyer (1998) ize that some hurts and pains simply cannot be “solved.”
shared and that are presented in Box 1.1 on page 15. This father may experience living in the metaphoric three-
This man’s story underscores the importance of walking sided house for some time, and no one can build a fourth
alongside and waiting with our clients rather than trying wall for him—that is, his son will never be restored, will
to “fix” them or “solve” their concerns. Before reading not be brought back to life. This father and all the clients
further, take a moment to read this father’s reflections. we work with are in charge of constructing their own lives
Having read this father’s reflections, you may need to (the ethical value or principle of autonomy that we must
pause for a moment. Some of what he has to say is not honor when working with them); they are the carpen-
easy to hear. His grief is quite evident. ters. As professional helpers, we may be likened to their
Box 1.1 Story of the Three-Sided House

Steve Ryan, a bereaved father, wrote the following meta- I need shelter once again. The storm now travels within me,
phoric account of his life in the aftermath of the death of and there is no shelter from the tempest behind doors or
his 2-year-old son, Sean, from complications following a walls.
kidney transplant. Who can show me how to build here now? There are no
I am building a three-sided house. architects, no experts in designing three-sided houses. Why
It is not a good design. With one side open to the is it then that so many people seem to have advice for me?
weather, it will never offer complete shelter from life’s cold “Move on,” they say, quite convinced that another house
winds. Four sides would be much better, but there is no can replace the one I lost . . . I grow weary of consultations
foundation on one side, and so three walls are all I have to based on murky insight, delivered with such confidence.
work with. . . . [And yet] among those who wish to see my house
I am building this place from the rubble of the house I rise again[,] there are real heroes too. People who are not
used to own . . . It had four good walls and would, I thought, daunted by the wreckage. It is not a pleasant role for them
survive the most violent storm. It did not. A storm beyond to play because the dust clings to those who come to see
my understanding tore my house apart and left the frag- and it will not wash off when they go home . . . Above all
ments lying on the ground around me . . . And so I must they know how difficult this task is, and no suggestion
rebuild. Not, as so many onlookers would suggest, because comes from them about how far along I ought to be.
Source: Neimeyer, 1998.
apprentices or at times consulting architects, but they Think of your clinical skills and your self-care activities as
themselves know best the constructed and reconstructed the provisions needed for the arduous journey of service
lives and houses that will fit them. delivery in an age of accountability and EBP. Only by
In addition, clients need helpers who are “not daunted mobilizing learned skills will you be able to hold yourself
by the wreckage,” helpers who are able to deal with and accountable for the client care you provide.
make meaning from the “dust that clings” to them from
the stories they (i.e., the helpers) have witnessed and in-
directly participated in. Our clients deserve helpers who
can demonstrate what Kenneth Minkoff characterized as
Effectiveness and Accountability
“the courage to join them [clients] in the reality of their Today’s practice continues to be highly influenced by
despair” (see Mental Illness Education Project, 2000). regulatory requirements and ethical expectations regard-
Incorporating the seven ingredients of stamina (see ing accountability. Use of empirically supported practice
Table 1.1) and the four dimensions of resilience (DOVE; and evidence-based decision-making has become part of
see Tjeltveit & Gottlieb, 2010) may assist you in temper- training accreditation requirements as well as work site
ing the effects of this demanding work, work that is not expectations, although certainly not without issue. It is
for the faint of heart. Specifically, we encourage you to expected that in the next 10 years helpers will need to
establish your own board of advisers with whom you can demonstrate the evidence base of practice decisions and
consult on a regular basis. These persons would include outcomes and use practice guidelines in standard therapy,
trusted friends, family members, a supervisor, respected while at the same time conducting short-term and brief
colleagues, and your own therapist. Surrounding yourself therapy (Norcross, Pfund, & Prochaska, 2013). It is for
with such a support system is essential. this reason that Putterbaugh (2015) reinforces the impor-
As you read the next section of this chapter, you may tance of deliberate and purposeful practitioner self-care.
understand our decision to discuss core skills and at- Recent health care reform in the United States stipulates
tributes—self-awareness and self-reflection, mindfulness, that all practitioners will need to demonstrate increased
self-care, and self-compassion, as well as stamina and accountability for their work. In effect, this means that we
resilience—prior to discussing issues of effectiveness, ac- as clinicians need to demonstrate that our work is safe and
countability, and evidence-based practice (EBP). Just as makes a difference in the lives of our clients. Goodheart
clients need to be equipped with certain skills (e.g., mind- (2011) made clear that insurers are now making decisions
fulness) before they can be expected to manage stressors about allocating funds for treatment services based on a
and other symptoms effectively, professional helpers need review of client outcomes rather than what had been a
to demonstrate core skills before they can be expected to utilization review. This means that helpers increasingly will
deliver effective services. As we have already discussed, need to provide evidence that clients have improved while
these core skills include self-care and self-compassion. in treatment for services to be reimbursed. This certainly
16 Chapter 1
raises ethical concerns, but it also suggests that, more than The Staying Power of EBP
ever, professional helpers will need to deliver services that It is evident that EBP is here to stay. The Evidence-based
are consistent with current and established guidelines. No Behavioral Practice project (www.ebbp.org) claims that
longer can personal experience suffice as the sole or primary “all major health professions now endorse the policy of
standard for justifying treatment decisions (Beutler, 2009). evidence-based practice.” Many of these same organiza-
Although the helper’s personal experience influences how tions have developed what are known as evidence-based
he or she makes treatment decisions, it is only one source clinical practice guidelines, what Hollon et al. (2014)
of influence. As discussed earlier in the chapter, Skovholt define as “a systematic approach to translating the best
and Starkey (2010) identified it as one of three sources of available research evidence into clear statements regard-
knowledge that inform clinical expertise, with the other ing treatments for people with various health conditions”
two being professional experience and academic research. (p. 214). The use of such guidelines in treatment planning
Together, these represent what they referred to as the three is discussed in Chapter 9.
legs of the professional helper’s learning stool. A one-legged Many states have adopted the practice of evidence-
stool will not suffice! All three must be securely in place to based policymaking, which includes performance-based
supply a firm foundation and a balance of practice. budgeting. This entails cost-benefit analysis so that only
programs that have demonstrated effectiveness continue
to receive state funding. These programs include child
Evidence-Based Practice welfare and corrections. Fourteen states facing economic
difficulties have partnered with the Results First Initiative,
The delivery of evidence-based practice (EBP) or the LO2 a project of the Pew Charitable Trusts and the MacArthur
provision of empirically supported services is the expecta- Foundation, to help them identify ineffective programs
tion of contemporary clinical and behavioral practice, not to budget only proven programs (see www.pewtrusts.org).
only in the United States but also in many other coun- One of these states is Illinois, whose governor established
tries. Thyer (2009; Thyer & Myers, 2011) noted that the in February 2015 a criminal justice commission to reduce
major contributors to EBP, particularly in medicine and the state prison population by 25 percent by the year
social work, were British and Canadian. Some might say 2025. To do so, “evidence-based programming” will be
it is only recently that U.S. health care providers are catch- pursued such as diversion programs (i.e., drug and spe-
ing up with their Canadian, European, and Australian cialty courts, intensive probation).
counterparts. This may be true in light of recent health Straus, Richardson, Glasziou, and Haynes (2010)
care reforms in the United States, primarily the Patient argued, however, that evidence-based medicine is not
Protection and Affordability Care Act signed into law in necessarily a cost-savings endeavor because “providing
March 2010 by President Obama and upheld twice by the evidence-based care directed toward maximizing patients’
U.S. Supreme Court. This means that translating research quality of life often increases the costs of their care and
findings into everyday clinical practice and substantiating raises the ire of health economists” (p. 8; emphasis added).
treatment decisions made in the throes of an emergency This serves as a reminder that EBP should not be regarded
or during routine work are now the global norm for health as strictly or only a way to save money; rather, EBP should
care providers. be used to provide quality care. In the context of eco-
Although psychologists have been at the forefront of EBP nomic realities, the point is to use limited resources wisely.
in the United States since the 1980s, what Thyer (2009) As Miller, Zweben, and Johnson (2005) noted, “It makes
referred to as science-informed practice is not new to social good sense to give priority to [evidence-based treatments],
work. He explained that it was this positivist focus that dis- particularly within this era of fiscal austerity. We owe it to
tinguished social work from its beginnings in the late 1880s our clients to provide the best treatment that we can offer
as faith-based ministerial outreach and as a charitable orga- them within available resources” (p. 274).
nization. “Scientific charity” and “scientific philanthropy”
actually were two of the original names for the social case
work movement in the United States, leading Thyer (2009) Discredited Therapies
to reinforce that “the principles of EBP are congruent with Some have stated that rather than identifying so-called best
central core descriptions of social work dating back to the practices or effective practices, EBP has helped to iden-
beginnings of our field” (p. 1117). Yet it has been the psy- tify treatment interventions that are not effective (with-
chology profession in the United States that in many ways out effect or inert) or are potentially harmful. As Beutler
has framed the current conversation about EBP. (2009) indicated, “It appears to be easier to identify a
bad treatment than a very good one” (p. 310). Although Affirmative Therapies
defining what exactly constitutes harm and what is directly As with SFT, affirmative therapies developed specifi-
responsible for harm in psychotherapy is a complicated cally for lesbian, gay, and bisexual (LGB) individuals (see
endeavor (Dimidjian & Hollon, 2010), it seems that one Chernin & Johnson, 2003; Kort, 2008), transgender and
contribution of EBPs is that they have been able to weed gender nonconforming individuals, and lesbian, gay, bi-
out certain practices—despite their recognition, appeal, and sexual, and transgender (LGBT) couples and families (see
popularity—that actually have been found to be harmful to Bigler & Wetchler, 2012) have yet to establish a strong
service recipients (i.e., clients are worse off after receiving research base and to be recognized as an EBP (see Johnson,
these interventions than before). These practices include 2012). This has not thwarted their promotion by various
rebirthing therapy, boot camp interventions for juvenile professional associations (e.g., the American Psychological
offenders, critical incident stress debriefing, and drug abuse Association’s 2009 Resolution on Appropriate Affirmative
and resistance education (or DARE; see Lilienfeld, 2007, Responses to Sexual Orientation Distress and Change Efforts;
for a listing of additional potentially harmful treatments). see APA, 2011) and their depiction as synonymous with
Treatments such as these are regarded as discredited thera- culturally competent therapy (Johnson, 2012). The APA
pies (Norcross, Koocher, Fala, & Wexler, 2010; Norcross, (2012) also has developed Guidelines for Psychological Prac-
Koocher, & Garofalo, 2006), therapies that have undergone tice with Lesbian, Gay, and Bisexual Clients and guidelines
testing over time and have been found not to make a dif- for working with transgender persons are forthcoming.
ference or to exert a negative effect, in other words, to exert It is because affirmative therapies endorse a strengths
harm (e.g., exacerbated symptoms at follow-up, or even or empowerment perspective (see Boes & van Wormer,
death as a direct result of treatment). It is thus important 2009) and represent a humanistic and nondiscriminatory
to recognize the reasons for EBP because helpers who do practice that they are viewed today as the ethical alter-
not “may fail to appreciate how readily they can be fooled native to so-called conversion therapies. Conversion or
by ineffective or harmful treatments” (Lilienfeld, Ritschel, reparative therapies have been determined to cause more
Lynn, Cautin, & Latzman, 2013, p. 884). harm than benefit to LGB individuals and to society as a
Avoiding the use of discredited and harmful therapies whole because they reinforce stigma and prejudice. The
or interventions actually is an ethical imperative. Sec- APA (2011) has referred to “the emerging knowledge on”
tion C.7. of the ACA Code of Ethics (2014) stipulates the culturally affirmative therapies as “a foundation for an ap-
types or quality of techniques, procedures, or modalities propriate evidence-based practice with children, adoles-
counselors are to use with clients. Specifically, only those cents, and adults who are distressed by or seek to change
practices “grounded in theory and/or have an empirical or their sexual orientation.”
scientific foundation” (Section C.7.a.) are to be consid- The APA (2011) policy statement on affirmative
ered. Furthermore, Section C.7.c. is explicit in its state- therapies illustrates very well Thyer and Myers’s (2011)
ment that “Counselors do not use techniques/procedures/ contention that “EBP involves not just a consideration
modalities when substantial evidence suggests harm, even of research evidence but also of other factors...such as
if such services are requested.” individual clinical expertise, patient preferences, values
Discredited therapies must be differentiated from and circumstances, and no one of these elements is af-
therapies that have yet to be tested or whose effects forded primacy over the others” (p. 18). In other words,
remain unknown or inconclusive—therapies that may determining what constitutes the “evidence” for an EBP
be inert, beneficial, or detrimental but for which con- should not be confined to the outcomes of randomized
sistent and substantial evidence from methodologically clinical/control trials (RCTs). Perhaps this is what Good-
sound investigations is absent. Solution-focused therapy heart (2011) meant in her statement that EBP does not
(SFT) is one example. Although it is a popular therapy privilege certain types of data. Although RCTs are consid-
that has been practiced for more than 30 years, in many ered the gold standard in medical research, the clinician’s
countries SFT has not been subjected to the rigorous expertise, the client’s culture and preferences, and ethi-
testing that other therapies have undergone, such as cal standards of professional associations must also serve
motivational interviewing (MI). Unlike MI, SFT has prominent roles in determining the “evidence” of an EBP.
not gained the recognition as an EBP. Recent efforts
to examine the effects of SFT in more sophisticated
ways are encouraging (see Franklin, Trepper, Gingerich, Defining EBP
& McCollum, 2012), and we discuss these research It should be apparent by now that there are many ways
findings—and those of MI—in Chapter 10. to define EBP. Given our review of the research literature
18 Chapter 1
and the proceedings of professional associations, we en- been referred to as empirically supported treatments, or
dorse the APA definition: EBP is “the integration of the ESTs (Chambless & Hollon, 1998)—is a static noun. This
best available research with clinical expertise in the con- implies that EBPs are fluid and susceptible to revision and
text of patient characteristics, culture, and preferences” cultural adaptation, whereas ESTs are absolute fixtures that
(APA Presidential Task Force on Evidence-Based Practice, are resistant to change and can be mistaken for the once-
2006, p. 273). Derived from the definition of evidence- and-for-all solution for all clients.
based medicine (see Straus et al., 2010), this definition of Given these distinctions, it is extremely important that
EBP highlights the essential contributions of clinicians as an emerging professional helper you see yourself as an
and clients to what is considered evidentiary practice. In influential ingredient in the process of client change. This
other words, EBP is not—or should not be—a top-down means that you not look to a specific treatment, technique,
mandate from researchers to clinicians, but rather is—or or tool as the sole answer to or the only source of healing
should be—a dynamic discourse among clients, clinicians, for your clients. Thinking that all that is needed for client
and researchers. This exemplifies the contention made by improvement is your selection of the best tool from your
Thyer and Myers (2011) that EBP is a process and there- toolbox is thinking like a magician and investing power
fore is a verb, not a noun. This notion of process seems to in a magic wand. In this era of EBP, magicians and magic
be supported by Goodheart (2011) when she described have no place. Rather, the focus is on you as a skilled
EBP as that which incorporates new clinical phenomena, practitioner and your use of skillful means, which includes
research, theory, and professional consensus (e.g., ethical your ability to: (1) learn from and work in a collaborative
codes) to provide clients with individualized and benefi- fashion with each of your clients; (2) consult and critique
cial care. She and colleagues (Wampold, Goodheart, & empirical research findings; (3) understand the standards
Levant, 2007) also stipulated that EBP is not prescriptive of professional ethics; (4) participate in and contribute to
but descriptive and serves as a guide in that EBP offers constructive dialogues with your clinical supervisor and
recommendations for the selection and implementation other skilled practitioners in your profession and in related
of treatment services. Lilienfeld et al. (2013) discussed professions; and (5) adapt your therapeutic style over the
other misconceptions of EBP. These are listed in Box 1.2. course of your career based on what you have learned from
Note that our discussion here is about evidence-based prac- these various constituents (i.e., clients, research literature,
tice, not evidence-based treatment. This is a very important professional standards, supervisors and colleagues). It is
distinction (LaRoche & Christopher, 2009; Littell, 2010; this focus on skillful means—in the context of EBP—that
Thyer & Pignotti, 2011; Westen, Novotny, & Thompson- we suspect contributed to Beutler’s (2009) (re)definition of
Brenner, 2005). The former is inclusive of client and helper psychotherapy as “[t]he therapeutic management, control,
factors (e.g., client cultural diversity), treatment interven- and adaptation of patient factors, therapists’ factors, rela-
tions and setting, and research findings (consistent with tionship factors, and technique factors that are associated
the 2006 APA definition); the latter is concerned only with with benefit and helpful change” (p. 311).
interventions or techniques—the tools that we discussed
earlier in this chapter that are external to the helper and
therefore do not equate with helper skills. Furthermore, as Becoming Familiar with EBP
Thyer and Myers (2011) noted, EBP is a dynamic process, To help you develop and calibrate your skillful means—
a verb, whereas evidence-based treatment—or what have your therapeutic management, control, and adaptation
Box 1.2 Eight Misconceptions of Evidence-Based Practices

Evidence-based practices (EBPs): 5. Neglect evidence other than that obtained from
1. Stifle innovation and the development of new treat- RCTs
ments and practices 6. Are unnecessary because all treatments are equally ef-
2. Require “cookie-cutter” and “one-size-fits-all” ap- fective.
proaches to treatment 7. Are inherently limited because therapeutic changes
3. Do not include nonspecific influences or common fac- cannot be measured or quantified
tors in therapy 8. Are erroneous because human behavior defies predic-
4. Do not generalize to clients who have not participated in re- tion with certainty
search studies, including randomized controlled trials (RCTs)
Source: Lilienfeld et al., 2013
of various clinical factors—we encourage you to consult As you learn more about a specific practice and its
the lists, registries, and reviews of EBPs that are avail- interventions on one of these lists, you may wish to
able currently from a number of professional organiza- compare it against each of the nine ideal features of a
tions. Although EBP lists have been criticized (Beutler & mental health intervention proposed by Bond, Drake,
Forrester, 2014; Thyer & Pignotti, 2011; Wachtel, 2010), and Becker (2010). According to their definition, the
we believe they offer professional helpers the opportunity ideal features of a mental health intervention are that it
to learn more about and to scrutinize approaches heard should:
about only in passing. They also may provide helpers
1. Be well defined
with information not offered to them by superiors during
mandated training on a recently instituted EBP. 2. Reflect client goals
Seven online sources are presented in Table 1.2. These
3. Be consistent with societal goals
include reviews of EBPs. The contents of these electronic
sources are updated periodically as new research findings 4. Demonstrate effectiveness
are introduced or new selection criteria implemented,
5. Have minimum side effects
so it is best to check these sites every few months to
determine what, if any, changes have been made. Bear 6. Have positive long-term outcomes
in mind that none of these lists is exhaustive and that
7. Have reasonable costs
each site may use different criteria for what it deems
to be an EBP. Therefore, we recommend that you use 8. Be relatively easy to implement
your critical thinking skills as you read the reviews of a
9. Be adaptable to diverse communities and client
selected intervention or practice on one of these lists.
subgroups
Read carefully the purported benefits as well as the criti-
cisms. Look for how often and how recently each prac- In addition to consulting the lists, registries, and re-
tice has been reviewed and updated. Take careful note of views of EBPs, professional helpers will soon be con-
how the practices listed attend to cultural factors, such sulting evidence-based clinical treatment guidelines
as the availability of treatment materials in languages (see Hollon et al., 2014) mentioned earlier in this sec-
other than English and the flexibility of extending or ab- tion. Described as recommendations for psychological
breviating services to accommodate specific client needs interventions for specific disorders, Goodheart (2011)
and preferences. reported that these guidelines are intended to “facilitate
TABLE 1.2 Registries, Lists, and Reviews of EBPs

Registry Name Sponsoring Group Date Established Website
National Registry of Evidence- Substance Abuse and Mental Health 1997 www.nrepp.samhsa.gov
Based Programs and Services Administration
Practices
Cochrane Reviews The Cochrane Collaboration 1995 www.cochrane.org/cochrane

-reviews
Research-Supported Society of Clinical Psychology, 2008 www.psychology.sunysb.edu

Psychological Treatments Division 12 of the American /eklonsky-/division12
Psychological Association
What Works Clearinghouse U.S. Department of Education 2002 http://ies.ed.gov/ncee/wwc
Social Programs that Work Coalition for Evidence-Based Policy 2001 http://evidencebasedprograms.org
The Campbell Collaboration The Campbell Collaboration 2000 www.campbellcollaboration.org

Library of Systematic Reviews /library
Results First Clearinghouse Pew-MacArthur Results First Initiative 2015 www.pewtrusts.org/en/multimedia

Database /data-visualizations/2015/results
-first-clearinghouse-database
20 Chapter 1
the integration of science into practice, offer a framework with caution. Although EBP in social work is, accord-
for clinical decision making, provide benchmarks for eval- ing to Thyer (2009), differentiated from “impulsive
uating treatments, benefit patients by promoting quality altruism, the efforts of faith-based social missionaries,
improvements and discouraging harmful practices, iden- or unsystematic secular efforts aimed at helping others”
tify gaps in research and care, and give clinicians flexible (p. 1116), EBPs as a whole are not “magical answers
tools to support their work” (p. 341). She stipulated that for complex questions [or] over-simplistic approaches
these guidelines are decision aids and are not to be viewed to complex problems” (Sexton & Kelley, 2010, p. 85).
as prescriptive protocols or a substitute for clinical judg- Healthy skepticism is in order. This includes inspecting
ment. Unlike practice guidelines that are practitioner- what is meant by “evidence.” For example, should only the
focused, these treatment guidelines are client-focused. findings from randomized clinical/control trials (RCTs)
constitute the evidence for treatment practice? Or should
findings from studies conducted in applied settings (e.g.,
Concerns, Critiques, and Caveats a community mental health agency) following normal,
routine clinical procedures also be included? The first
of Evidence-Based Practice type of research comprises studies conducted in the most
EBP has become big business. You will likely find fre- ideal experimental conditions (e.g., controlled and manu-
quent references to practices or interventions that are alized treatments, random assignment, selected clients
“evidence-based” as you scan the issues of recent schol- and helpers), usually comparing one type of treatment
arly journals, peruse the titles of new books for profes- to another or to a control group (e.g., clients on a wait
sional helpers from a variety of publishing companies, and list), or both. These are referred to as efficacy studies. The
browse the listings of workshops offered at professional second type of research comprises effectiveness studies and
conferences. As we mentioned, this appeal of EBP is due does not adhere to the strict (or some might say “sterile”)
in part to the belief that adopting an EBP will save time laboratory research standards of RCTs. Effectiveness stud-
and money, apparent in the mandates of state legisla- ies exemplify what has been referred to as “pragmatic,
tive bodies in the United States. Morales and Norcross utilitarian research” (Sanchez & Turner, 2003, p. 126)
(2010) also discussed the trend among federal agencies and may emphasize more idiographic than traditional
that, to be considered for grant funding, applications nomothetic subject research. A concern about efficacy
must include an intention to implement one or more studies is that their findings may not easily transfer to
EBPs. Third-party payers and other funding sources— actual, everyday practice (Beutler & Forrester, 2014). In a
as well as accrediting bodies—thus have been known similar vein, a concern about effectiveness studies is that
to latch onto certain evidence-based treatments because their findings may not be generalizable to other practitio-
they are viewed as cost-effective and hence “successful.” ners, treatment facilities, or clients. Hence, the evidence
Short-term cognitive behavior therapy, for example, may derived from the research question, “What works for
be heralded by certain insurance companies as the “best” whom under what conditions?” may have limited utility
treatment for all their providers to practice because, in the from either an efficacy or an effectiveness perspective.
long run, it is not as protracted or long-term (and hence In addition to the overreliance on RCTs (i.e., efficacy
expensive) as, say, certain types of expressive-supportive studies) as the gold standard for determining what con-
therapies. However, marketing EBPs as the solution stitutes an EBP, EBPs have been criticized for confining
to cash-strapped state and federal budgets exemplifies themselves to a single diagnostic category. It is true that
what Gambrill (2010) described as propaganda. In other many EBPs were developed for clients presenting with
words, it is misleading. It reflects a one-size-fits-all ap- specified diagnostic disorders. For example, motivational
proach (see Bernal, Jiménez-Chafey, & Rodríguez, 2009) interviewing (MI) is an EBP for persons with substance
that Wachtel (2010) described as “the Walmart approach use disorders, and dialectical behavior therapy (DBT) is
to mental health care” (p. 264). As we stated, Straus et al. recognized as an EBP for persons with borderline person-
(2010) noted that evidence-based medicine actually is not ality disorder. According to Wachtel (2010), the solitary
an effective cost-cutting tool. For certain interventions to diagnostic confinement of EBPs dismisses the majority of
be effective, they noted, longer and more intensive care persons with more than one disorder (i.e., comorbidity)
may be necessary. We believe this is also true for mental and does not account for persons in therapy who do not
health and addictions treatment. fit the minimal criteria for any mental health or substance
The hype surrounding EBP therefore requires careful use disorder (i.e., at a subthreshold for a diagnosis). These
scrutiny and the EBP bandwagon must be approached are valid concerns. However, a greater number of EBPs
now are being applied to persons presenting with a range perhaps have helped to keep the focus on what is in the
of concerns. Seeking Safety (Najavits, 2002), for example, best interest of the client, including prioritizing client
is intended for persons with a history of trauma and experiences of treatment by soliciting their feedback (see
substance-related problems. Likewise, DBT now is con- Lambert, 2010). Third, discussions about evidence-based
sidered appropriate for persons with multiple diagnoses practices appear to have ushered in a more integrative or
(e.g., eating disorder, substance use disorder, and bipolar both/and perspective about client care, consistent with
disorder) and concerns (e.g., chronically suicidal), and MI the APA (2006) definition of EBP. One example of an
has expanded its application to include persons with a va- integrative approach to EBP is that of cultural adaptation,
riety of health problems such as diabetes, high cholesterol, an overdue initiative given that racially and ethnically
and obesity (Rollnick, Miller, & Butler, 2008). diverse participants historically have not been included
EBPs also have been criticized for an overreliance on in RCTs (Bernal & Sáez-Santiago, 2006; Comas-Díaz,
manuals. It is true that many if not most EBPs have a 2006; Whaley & Davis, 2007). We discuss the role of
treatment manual and perhaps a separate training man- culture in EBP in the following section.
ual. To be included in the U.S. Substance Abuse and
Mental Health Services Administration’s (SAMHSA) Na-
tional Registry of Evidence-Based Programs and Practices
(NREPP), for example, recognized programs need to have Multiculturalism
developed training and support resources, implementa-
tion materials (e.g., treatment manual), and quality as-
and Evidence-Based Practice
surance procedures, all of which are ready for use by the Traditional psychotherapy and EBPs for the most part
public. The development and use of a treatment manual have been developed, validated, and promoted by white
is an example of internal validity, allowing the interven- European Americans for use with a predominantly white
tion to be distinguished from and compared to other European American client population. The research to
treatments in RCTs. Treatment adherence is referred to support these approaches has been conducted with a
as fidelity and allows researchers to determine whether similarly privileged client population—that is, white Eu-
the intervention being tested was faithful to its design or ropean American, middle class, and heterosexual. The
purpose. The concern about treatment manuals is that evidence to substantiate that these approaches are appro-
the practice can become “manualized,” resulting in an priate for culturally diverse and nondominant/minority
approach that is too rigid and objectifies clients (Littell, group clients therefore is lacking, and implementing an
2010). Clinicians themselves can feel “manualized”—that EBP for clients for whom the EBP was not developed
is, feel coerced and confined to one type of treatment— could potentially harm ethnic minority clients (Bernal
resulting in a restriction of their autonomy, flexibility, et al., 2009). Thus, the challenge is to conduct method-
and creativity. According to Overholser (2010), adhering ologically sound research of culturally specific practices
to a treatment manual can compromise clinical expertise, and interventions and adapt existing EBPs to fit the needs
such as inhibiting clinical judgment/decision-making and of culturally diverse clients. Doing both represents the in-
complex reasoning skills. This is a valid concern and ex- herent tension or dialectic of EBP: maintaining scientific
plains Barkham, Hardy, and Mellor-Clark’s (2010) prefer- soundness/rigor while ensuring clinical relevance. This
ence for practice-based evidence or the pursuit of effective dialectic is evident in Morales and Norcross’s (2010) con-
care based on the “evidence” from routine clinical practice tention that “Multiculturalism without strong research
(consistent with effectiveness studies), whether or not a risks becoming an empty political value, and EBP without
treatment manual is followed. This illustrates the practice cultural sensitivity risks irrelevancy” (p. 823).
of what Scott and Lewis (2015) refer to as measurement- Morales and Norcross (2010) describe the relationship
based care wherein client feedback is routinely solicited. between multiculturalism and EBP as transitioning from
A resolution to these criticisms and concerns of EBP is “strange bedfellows” to “fast friends.” This suggests that
premature. We suspect that the controversies surround- cultural adaptation of EBPs or the integration of EBP and
ing EBPs will continue for some time. Although it is multicultural therapy is a promising initiative. However,
frustrating for helpers and researchers alike (perhaps for Hwang (2009) noted that this focus must shift from sim-
different reasons), we believe there has been merit in this ply being a set of abstract ideas about cultural competence
controversy over the past 20 to 25 years. For one thing, to an emphasis on developing specific helper skills and
the debate has opened lines of communication between strategies that can be implemented effectively with cul-
practitioners and researchers. Second, such conversations turally diverse clients. This is not an easy task. It does not
22 Chapter 1
mean simply using existing EBPs with culturally diverse In their work with American Indians and Alaska Na-
clients. And it involves more than a helper simply learning tives, BigFoot and Schmidt (2010) acknowledged that
about a particular cultural group of which the client is a CBT principles complement many traditional tribal heal-
member or matching culturally diverse helpers with cli- ing and cultural practices such as storytelling and express-
ents of their same cultural group (e.g., African American ing emotions in ceremonies. Bennett-Levy et al. (2014)
helpers working with African American clients). Accord- reported that Aboriginal Australian counselors trained
ing to Helms (2015), EBPs must be culturally responsive in CBT found CBT useful with their Aboriginal clients
by considering client and helper racial socialization (e.g., for several reasons. These included that CBT: (a) is prag-
racism), client responses to EBPs, and client-helper cul- matic (simple interventions can be effective for complex
tural dynamics. problems); (b) highly adaptable and useful as a preven-
tive measure (e.g., mental health hygiene); (c) provides
structure that maintains focus; and (d) is empowering
Culturally Adapted EBPs and promotes self-agency. One CBT method reported to
Considerable attention has been given to what are referred be most useful with clients was the use of visual diagrams.
to as culturally adapted EBPs. This involves systematically Aboriginal counselors also found that CBT enhanced
modifying, supplementing, or sequencing an interven- their skills and confidence, as well as their well-being (i.e.,
tion (e.g., thought-stopping technique) or intervention protecting from burnout).
protocol (e.g., cognitive behavior therapy for anxiety) to Specific examples of culturally adapted EBPs based
accommodate or to be compatible with the client’s cul- on CBT principles include: Aguilera et al.’s (2010)
tural patterns, meanings, and values (Bernal et al., 2009; 16-week group CBT in Spanish for adults with depres-
Morales & Norcross, 2010). According to Bernal and sion; Nicolas, Arntz, Hirsch, and Schmiedigen’s (2009)
Sáez-Santiago (2006), this includes, among other things, 8-week adolescent Coping with Depression Course for
a consideration of: (a) interdependent value systems (i.e., Haitian American adolescents; BigFoot and Schmidt’s
family system) rather than individualistic value systems; (2010) program for American Indian/Alaska Native chil-
(b) spirituality in the healing process; and (c) poverty. dren who have experienced trauma, Honoring Children,
Benish, Quintana, and Wampold (2011) emphasized Mending the Circle (see www.icctc.org), an adaptation of
understanding and explaining illness from the client’s trauma-focused CBT (Cohen, Mannarino, & Deblinger,
cultural milieu and adapting interventions to fit this ill- 2006); and Cunningham, Foster, and Warner’s (2010)
ness explanation. Their research found that when helpers adaptation of multisystemic therapy (MST; Henggeler,
were able to do this, racial and ethnic minority clients Schoenwald, Borduin, Rowland, & Cunningham, 2009)
benefitted more from culturally adapted EBPs than from specifically for African American youth and their caregiv-
conventional psychotherapy approaches. Aguilera, Garza, ers (e.g., parent, grandparent) to address the adolescents’
and Muñoz (2010) further noted that adaptation is a delinquency and substance misuse. In all three of these
fluid process that must take into account not only broad culturally adapted programs, importance is placed on:
ethnocultural values (e.g., family system) but also local (a) the use of culturally and clinically relevant language
and specific elements that are part of each client’s social (e.g., reference to proyecto personal or “personal project”
reality (e.g., level of acculturation, substance use, access rather than “homework”); (b) maintaining a strength fo-
to health care). cus; (c) routinely soliciting feedback from clients and their
caregivers or other family members about the helpfulness
Culturally Adapted CBT of therapy (including the formation of an advisory board
comprising cultural experts to help develop a culturally
One EBP, cognitive behavior therapy (CBT), has been relevant program before it is implemented); and (d) prac-
adapted to various cultural groups because of what Hays ticing reinforcement of positive behaviors, validation, and
(2009) noted as the “remarkable number of assumptions” empathy among therapists as well as among clients (e.g.,
(p. 355) shared by CBT and multicultural therapy. These promoting simpatía or healthy social interactions among
include the emphasis on: (a) tailoring treatment to the group members).
unique strengths and needs of each client; (b) empower-
ment; and (c) conscious processes (e.g., observed behav-
iors) that can be verbalized and assessed fairly easily. The Evidence for Culturally Adapted EBPs
latter emphasis, she stated, is suitable for persons whose Evidence suggests that cultural adaptation of therapeu-
primary language is not English or who do not share belief tic approaches results in significant client improvement
systems that are common among European Americans. across a range of presenting concerns and conditions
and according to a variety of outcome measures (Benish 6. Engaging in outreach efforts to recruit underserved
et al., 2011; Griner & Smith, 2006). But as Morales and clients
Norcross (2010) contend, adaptation presumes that the
7. Providing extra services to increase client retention
helper “is competent in the cultural and linguistic aspects
(e.g., child care, transportation)
of the client and has experience in integrating these vari-
ables in a culturally competent and congruent manner” 8. Orally administering written materials for illiterate
(p. 826). This means that a prerequisite for the cultural clients
adaptation of any EBP is competence in multicultural 9. Conducting cultural sensitivity training for profes-
counseling and therapy and, specifically, the ability to sional staff
understand and empathize with the client’s unique cul-
tural identity and context. This means, for example, that 10. Providing referrals to external agencies for additional
helpers should not assume that all tribal and native people services
have similar traditions, a reminder offered by BigFoot 11. Understanding and explaining illness from the cli-
and Schmidt (2010). This also means that helpers are ent’s cultural beliefs and adapting interventions to
able to appreciate the meaning each client has rendered to this illness explanation
the intersection of his or her multiple identities, such as
age, gender, sexual orientation, and race/ethnicity. These From their meta-analysis of outcomes reported in
overlapping “selves” comprise the client’s own cultural these studies, Griner and Smith (2006) found, overall,
identity (a concept we discuss in more detail in Chapter 2), that clients improved significantly as a result of having
requiring the adaptation of any EBP to be tailored to received at least one culturally adapted intervention.
that particular client. This constitutes an idiographic EBP One noteworthy finding was that groups of same-race
adaptation rather than a nomothetic EBP adaptation. The clients who received services tailored specifically to their
former is tailored to a specific client, whereas the latter cultural group (e.g., older Cuban Americans seeking
is considered applicable to persons who are members of help for depression) improved considerably more than
a certain cultural group, such as lesbian, gay, bisexual, clients who were in mixed-race treatment groups (e.g.,
and transgender (LGBT) persons or persons of Latino/ African American and Hispanic adolescents attending
Hispanic descent. Duarté-Vélez, Bernal, and Bonilla the same facility and receiving services for substance
(2010) provide a helpful clinical example of an idiographic abuse). This reinforces the contention that optimal ben-
adaptation of an EBP (in this case, CBT) for a gay Latino efit is derived when services are tailored to a specific
adolescent male who was raised in a Christian home. cultural context. Greater improvement was also found
Griner and Smith (2006) reviewed 76 studies published among older clients compared to younger clients (pos-
through 2004 to determine the effectiveness of culturally sibly due to the protective effects of lower accultura-
adapted treatment interventions. They identified 10 com- tion levels among older clients) and when clients were
mon types of cultural adaptations used in these studies. matched with a therapist based on language (other
To their list we have added (number 11) the one recom- than English) compared to clients who were not as-
mended by Benish et al. (2011): signed to therapists who spoke their native language.
An unexpected finding was that clients matched with
1. Explicitly incorporating cultural values/concepts into the therapists of their own race or ethnicity fared no better
intervention (e.g., storytelling of folk heroes to children) than clients who did not work with a therapist of their
own race or ethnicity. The failure of client-therapist
2. Matching the client and helper according to race or
ethnic matching by itself to effect positive change in
ethnicity
clients is consistent with previous studies, however
3. Providing services in the client’s native language (e.g., Knipscheer & Kleber, 2004), and suggests that
(other than English) therapist multicultural competence and organizational
cultural competence (referred to as cultural congruence
4. Providing services in a treatment facility specifically
by Constantino, Malgady, & Primavera, 2009) is a mul-
targeting clients from culturally diverse backgrounds
tifaceted construct.
(e.g., Africentric programming for African American
To investigate the effects of cultural adaptations of
youth in a substance abuse treatment facility)
specific interventions and EBPs in general, research meth-
5. Collaborating/consulting with individuals familiar ods other than RCTs need to be used (Helms, 2015).
with the client’s culture (e.g., family members, elders, One is the participatory action research method used
tribal leaders) with Aboriginal Australian counselors by Bennett-Levy
24 Chapter 1
et al. (2014) and praised by Hays (2014). Other research innovations are unreliable and imperfectly designed, a
methods include naturalistic, quasi-experimental process- concern raised by De Los Reyes and Kazdin (2008) with
outcome studies (e.g., assessing in-session client-helper respect to inconsistent findings among evidence-based
behaviors through audio or video recording or third-party interventions. They noted, however, that “some evi-
live observation and rating) and single-case or N = 1 stud- dence, although inconsistent, is clearly better than none”
ies. As an example of practice-based evidence, McMillan (p. 50). Innovations also require prospective users to acquire
and Morley (2010) described the process of conducting new technical knowledge and skills—a time-consuming
single-case quantitative research, which necessarily in- and often costly endeavor—and to change their roles,
cludes repeated measurement of client concerns and goals routines, and norms. Practitioners accustomed to meet-
after baseline. We discuss these assessment practices in ing clients in an office setting, for example, would likely
Chapters 7 and 8. have difficulty transitioning to and adopting the EBP of
BigFoot and Schmidt (2010) described the cultural multisystemic therapy (MST) because MST services are
adaptation of EBPs as “the blending of science and indig- provided to adolescents and their caregivers in their natu-
enous cultures” (p. 855). They posited that the success of ral environments, such as their school and their home. In
this blending or integration “is the translation of not just addition, the decision to adopt an innovation is typically
language but also core principles and treatment concepts made by persons in authority. We discussed this earlier
so that they become meaningful to the culturally targeted in the chapter with respect to state legislative bodies in
group while still maintaining fidelity” (p. 855). the United States limiting funding only to those state-
supported agencies that implement EBPs. The final rea-
son innovations are difficult to implement, according to
Klein and Knight, is that organizations (e.g., treatment fa-
Adapting and Adopting cilities, schools, local communities) are a stabilizing force
Evidence-Based Practices and therefore any change that disrupts stability, status
quo, and homeostasis is not necessarily “welcomed with
Most EBPs began as innovations in that they represent the
open arms.” This might explain why certain discredited
integration of two or more therapies. For example, dia-
practices (e.g., DARE) continue to be popular despite the
lectical behavior therapy (DBT) is an adaptation of CBT
evidence that they are ineffective and potentially harmful.
in its incorporation of Eastern philosophy, namely Zen,
It also might explain why some in the scientific commu-
and mindfulness practice. The balance of behavior change
nity remain skeptical of culturally adapted EBPs because
and acceptance—the fundamental tension or dialectic of
they did not derive their evidence from RCTs.
DBT—is a treatment goal and reflects the innovative style
The likelihood of adopting an innovation, such as an
of DBT. Although DBT is an EBP for borderline person-
EBP, increases when it meets certain criteria. In his sem-
ality disorder, it must continue to undergo adaptation for
inal book, Diffusion of Innovations, sociologist Everett
it to be relevant and remain clinically useful for helpers
Rogers (1995) identified five attributes of an innovation
and clients alike (see Dimeff & Koerner, 2007). This is
that, when perceived by members of a particular group
true for all EBPs. If, as Thyer and Myers (2011) noted,
(e.g., clinical team), determine whether or how quickly
EBP is a verb or a dynamic process rather than a static
the innovation will be adopted and implemented into
noun, and if, as Wampold et al. (2007) stipulated, EBPs
routine practice. The five attributes of an innovation are:
are guidelines rather than absolutes and mandates, then
EBPs must be subjected to ongoing modifications (e.g., 1. It must be perceived as having a relative advantage; that
cultural adaptations) that are able to demonstrate benefi- is, it must be viewed as being better than or an improve-
cial effects for clients and their families using a variety of ment on current practice. This advantage might be the
sound measures. Only in so doing will EBPs shed their perceived convenience, prestige, or cost of an EBP.
notoriety as reflections of what Wachtel (2010) termed “a
2. It must be perceived as being consistent with the
poverty of imagination” (p. 254). It is from the (healthy)
adopter’s experience, values, and goals; in other words,
tension between science and clinical practice/expertise
for a helper to use an EBP, it must be compatible or
that innovations and future EBPs are born.
resonate with his or her own values and beliefs as
As innovations, adopting EBPs and implementing them
well as previously introduced ideas and practices (e.g.,
into routine clinical practice (a process known as diffusion
theoretical orientation, cultural competence).
or technology transfer) is not a simple task. Klein and
Knight (2005) discussed several reasons why innovations 3. It must be easy to understand and use; it must be per-
are difficult to implement. Among these are that many ceived as simple rather than as complex.
4. Potential users must be able to sample or try it out on practitioners. They have become familiar practices in
a limited basis before making a decision. This is the certain sectors, and the concepts that undergird and
innovation’s attribute of trialability and can be lik- guide their respective approaches are not new. However,
ened to test-driving a car before making a purchase. only in recent years have assertive community treat-
A trial period is designed to dispel uncertainty about ment (ACTx) and dialectical behavior therapy (DBT)
a new idea. gained wide prominence. An integration of ACTx
and DBT also has been proposed (Reynolds, Wolbert,
5. The benefits of adopting an innovation must be visible
Abney-Cunningham, & Patterson, 2007). We discuss
to others. This is the attribute of observability. In the
each of these EBPs briefly and encourage you to com-
case of EBPs, this is not limited to reading or hear-
plete Learning Activity 1.3 on page 26 once you have
ing about research findings; it also includes—perhaps
familiarized yourself with ACTx and DBT.
more so—helpers being able to directly witness and
testify to the beneficial effects of the EBP for their
clients. This appears to support the efforts of practice- Assertive Community Treatment
based evidence. According to Bond, Drake, Mueser, and Latimer (2001),
Researchers and health care administrators cannot ex- assertive community treatment was first developed in the
pect helpers to automatically and enthusiastically embrace 1970s as an intensive and holistic approach to the treat-
EBPs simply because “the research says so.” Rather, adopt- ment of persons with severe and persistent mental illnesses
ing and then implementing these practices is a process (e.g., schizophrenia, bipolar disorder). (In this chapter we
that requires time, involvement of and collaboration with abbreviate assertive community treatment as ACTx to dif-
clinical staff, provision of staff support (e.g., training, on- ferentiate it from the acronym ACT that designates accep-
going supervision, financial compensation), and evidence tance and commitment therapy mentioned earlier in the
beyond research findings. Just as clients engage in a pro- chapter.) Key features of ACTx (see Box 1.3 on page 26)
cess of personal change—moving through various stages are that integrated services (e.g., medication management,
of readiness to change over time—practitioners also par- vocational rehabilitation) are provided not by one person
ticipate in a professional change process when introduced but by a group of professionals (e.g., substance abuse
to new practices. Miller et al. (2006) likened this process counselor, case manager, nurse) who work as a team. All
to learning any new skill, which often entails three aids: team members, therefore, share responsibility for caring
ground school or basic training (e.g., graduate school, for the same clients. It is highly unlikely that persons with
reading, attending workshops), practice with feedback, severe and persistent mental illnesses initiate and maintain
and coaching or supervision to reinforce correct practice active involvement in formal services. Therefore, the ma-
and cultivate enhancement. We believe that researchers, jority (approximately 80%) of ACTx services are delivered
clinical directors, and supervisors need to engage practi- in the field or in vivo (i.e., in the community rather than
tioners (as well as the systems or organizations they repre- in a clinical setting) to engage and remain connected
sent) in a similar stage of change process when attempting with persons challenged by a multiplicity of concerns
to disseminate innovative approaches. and prone to frequent relapses and overall instability. In
As you learn more about EBPs in your coursework and this manner, ACTx is regarded as a proactive, assertive,
in your clinical practice (e.g., from in-service training, pro- and persistent treatment approach. It is a “living-systems”
fessional workshops), we encourage you to consider each alternative to hospital and residential care (see Ellenhorn,
EBP you are introduced to according to the five attributes 2015) that often is described as “a hospital without walls.”
that Rogers (1995) identified. For example, be willing to Specific ACTx services target what some might con-
ask, “How is this EBP intended to benefit clients in ways sider basic client needs, such as obtaining housing, food,
that that are currently not available?” and “Will I be able to and medical care as well as managing finances. Although
explain this EBP to clients in a way they can understand, in it resembles case management, ACTx is different from
a way that is simple and not confusing to them?” and far more comprehensive than intensive case manage-
ment in that a range of services is delivered directly to
the client (rather than linking the client to other service
providers) by members of a team (rather than one case
Innovations with Integrity manager). In addition, ACTx services are tailored to the
Two therapies recognized as EBPs exemplify the benefit individual client, include individual counseling and crisis
of a comprehensive and integrative perspective result- intervention, and are unlimited. The most encouraging
ing from ongoing discussions between scientists and and compelling aspects of ACTx are that it has been
26 Chapter 1

Compelling Evidence Exercise 6. ____ Learning that after 6 months of implementing
This activity is intended to assess your own motivations for ACTx and DBT, our facility saved the county mental
adopting and implementing an evidence-based practice. It health board several thousands of dollars due to
can also be used as a classroom activity to generate discus- our clients needing fewer psychiatric hospital bed
sion. As you complete the activity, consult the five attri- stays.
butes of an innovation identified by Everett Rogers (1995) 7. ____ Hearing the stories of (and even being able to
that are listed and defined on pages 24–25. interact with) clients of other treatment facilities who
Consider for a moment that you are on the clinical staff of have participated in ACTx and DBT and are now man-
a community-based mental health facility primarily serving aging their symptoms fairly well.
a low-income population, many of whom have severe and 8. ____ Receiving training from prominent researchers
persistent mental illnesses (e.g., schizophrenia, personality dis- who have studied ACTx and DBT for a number of years.
orders). In response to the accrediting body’s new policy that 9. ____ Learning that I will be provided with a mobile
all accredited treatment facilities adopt and deliver evidence- phone (at no expense to me) so that I can be on-call 24
based practices as standard service, you have been informed hours once per week.
that you will soon become a member of a new assertive com- 10. ____ Knowing that my current caseload will be reduced
munity treatment (ACTx) team and will need to attend training and that all members of the ACTx team (approximately
in dialectical behavior therapy (DBT). Given what you know six to eight) will assume responsibility for the same
about ACTx and DBT, what “evidence” will convince you that clients (approximately 50 to 60).
these two treatment approaches will be worth the investment
11. ____ Knowing that DBT is a highly structured approach
of your time and energy? What information will compel you to
that holds clients accountable for their behaviors while
adopt and begin implementing these two practices?
validating their experiences and circumstance in a
Check all of the following that apply, and add two of your
nonjudgmental and empathic manner.
own reasons, too.
12. ____ Learning that after 6 months of implementing
1. ____ Learning about research findings from published ACTx and DBT, approximately one-third of the clients
clinical trials that justify both ACTx and DBT’s designa- our team serves have taken their medications as pre-
tion as evidence-based practices. scribed and have not been actively suicidal.
2. ____ Knowing that I will be receiving close supervision 13. ____ Learning that client-helper collaboration is a pri-
and training tune-ups in the first few months of using ority in ACTx and DBT, and this resonates or fits with my
these two approaches. own belief system of effective therapy.
3. ____ Receiving training from seasoned practitioners 14. ____ After 6 months of implementing ACTx and DBT,
who themselves have used both ACTx and DBT. hearing one of my previously hostile and unstable clients
4. ____ Learning that my salary will remain the same and describe a recent incident in which he was able to keep
that I will have to pay for half of the DBT training costs. his cool after practicing one of his mindfulness exercises.
5. ____ Knowing that I will be part of a team of other clini- 15. ____ ________________________________________
cal staff who will meet at least once per week not only to 16. ____ ________________________________________
review client cases but also to offer one another support.
found to contribute to reduced psychiatric hospital stays, The Assertive Community Treatment Association (www
increased housing stability, and engaging and retaining .actassociation.org) was founded in the late 1990s and
clients in mental health services (Bond et al., 2001). sponsors an annual conference.
Compared to case management or to a standard treat-
ment, a review of research found that ACTx services Dialectical Behavior Therapy
specifically for homeless persons increased their engage- Dialectical behavior therapy (DBT) was developed by
ment in medical, mental health, and substance use treat- Marsha Linehan (2015) as a highly structured, multi-
ment services (Nelson, Aubry, & Lafrance, 2007). Early modal treatment program for suicidal clients meeting
engagement and retention in ACTx also was found for the criteria of borderline personality disorder (BPD). It
older persons with severe mental illnesses (Stobbe et al., is informed by cognitive behavior theory, biosocial the-
2014). For helpers (specifically case managers), the ben- ory (i.e., biological irregularities combined with certain
efits of ACTx participation include a decrease in burnout dysfunctional environments), and Eastern philosophy,
and an increase in job satisfaction (Boyer & Bond, 1999). namely Zen. Although DBT is now regarded as an EBP
Box 1.3 Key Principles and Practices of Assertive Community Treatment (ACTx)
●● Multidisciplinary staffing ●● Focus on everyday problems in living
●● Integration of services ●● Rapid access
●● Team approach ●● Assertive outreach
●● Low patient-to-staff ratios ●● Individualized services
●● Locus of contact in the community ●● Time-unlimited services
●● Medication management
Source: Bond et al., 2001.
for the treatment of BPD, recent adaptations of DBT have one experience is “wrong” and the other is “right.” Rather,
expanded its application to persons with eating disorders both have validity, and in her work with a professional
(Wisniewski & Kelly, 2003; Wisniewski, Safer, & Chen, helper this woman would strive to acknowledge and ac-
2007), comorbid personality disorders (i.e., paranoid cept both experiences, live with the tension or paradox
and obsessive-compulsive personality disorders; Lynch & (i.e., “not fit to live” vs. someone deserving of love), and
Cheavens, 2008), and comorbid substance use disorders arrive at a synthesis of the two polarities (e.g., “I have been
(i.e., substance use and borderline personality disorders; violated and I am a survivor worthy of love”).
Lee, Cameron, & Jenner, 2015), whether or not BPD or As a comprehensive approach, DBT offers an array
suicidal intent is present. For adolescents with repeated of behavioral strategies, including problem-solving, skills
suicidal and self-injurious behavior, DBT has been found training, contingency management (e.g., behavioral
to be effective in reducing those and depresssive behaviors contracting), exposure-based procedures, and cognitive
(Mehlum et al., 2014). DBT also has been modified for modification. These are complemented by what Linehan
deaf individuals (O’Hearn & Pollard, 2008), an example (2015) refers to as acceptance-based procedures, such as
of a culturally adaptive EBP. validation, mindfulness, and distress tolerance. Validation
DBT is based on behavior theory and includes the prin- and problem-solving strategies form the core of DBT,
ciples of acceptance, mindfulness, and validation (Neacsiu, and all other strategies are built around them. Validation
Ward-Ciesielski, & Linehan, 2012). Although it is highly conveys to the client that the choices he or she has made
structured and calls for the implementation of specific and the behaviors he or she has engaged in make sense and
helper skills and client behaviors, DBT is not a rigid or are understandable, given the client’s life situation (i.e.,
prescriptive approach, and it fits well with the helper history, current circumstances). Problem-solving is un-
skill of flexibility discussed earlier in the chapter. Helpers dertaken only after validation has been conveyed (it may
are instructed to provide individualized care and there- need to be repeatedly conveyed), and it includes clarifying
fore tailor specific practices to the needs of each client. the primary concern at hand and then generating alterna-
For example, for persons with bulimia nervosa, Hill, tive solutions. One such strategy, chain analysis, involves
Craighead, and Safer (2011) incorporated appetite aware- the development of “an exhaustive, step-by-step descrip-
ness training into the first 4 weeks of DBT and modified tion of the chain of events leading up to and following
the DBT diary card to include appetite monitoring. the behavior . . . [so as to examine] a particular instance
A guiding premise of DBT is that a convergence or of a specific dysfunctional behavior in excruciating detail”
synthesis of what appear to be opposing forces is possible. (Linehan, 1993a, p. 258). This exercise not only informs
This process of balancing and regulating conflicting feel- the helper about the client’s cognitive schema (e.g., the
ings and behaviors is what is meant by dialectical in the specific details that are remembered) but also teaches the
name DBT. Take, for example, an adult woman with a client important self-observational and self-assessment
history of sexual and physical abuse who has attempted skills, as well as the connections among many different
suicide on several occasions (symptoms or characteristics variables, and it teaches that the client has the ability to
often associated with BPD). Although she may interpret exert control over those linkages and create new patterns
the violations she experienced as “proof ” that she is “not of behavior.
fit to live,” she also has a strong desire to experience an in- We believe that both ACTx and DBT warrant further
timate connection with another human being, to be loved consideration by practitioners and scientists/researchers
(a need that might be interpreted by some as an “attach- alike. They not only have compelling empirical evidence
ment disorder” or traits of “dependency”). It is not that to justify their continued practice but they also have
28 Chapter 1
practical appeal (i.e., they make sense, can be imple- expansion of the shell, the ever-expanding and larger
mented in everyday practice settings), and this is not compartments, is symbolic of the growth and change of
always the case with evidence-based practices. the helping profession. Specifically, think of the adapta-
tions being made to evidence-based practices (EBPs) so
that they will be relevant to a wider and more diverse
client population. Our helping professions and our way
CHAPTER SUMMARY of practice must expand! We cannot limit our work only
to certain privileged groups of persons. This is not only
We end this chapter as it began, with the story of the cham-
disrespectful and discriminatory—an affront to persons
bered nautilus. Before you complete the two activities at
who, by no fault of their own, are disadvantaged and
the end of the chapter, we ask once again that you pause to
have experienced disenfranchisement for perhaps their
inspect the cover of the book. Think of this as another mind-
entire lives—but also stifling. By this we mean that help-
fulness activity! Once you have the book cover in sight, focus
ing professions that remain locked into “same-old, same-
your gaze on the center of one of the three spirals, where the
old” ways of thinking and practicing become irrelevant
life of the mollusk began. Notice that as the mollusk grew
and obsolete. Choosing to remain in the same compart-
and built new and bigger living spaces or compartments,
ment or chamber almost guarantees one’s demise. That
those chambers remained connected to and wrapped them-
is why—as with the chambered nautilus and individual
selves around its center, its beginning. It did not distance
professional helpers—helping professions must continu-
itself or grow away from its center—it embraced it.
ally expand. This includes continuing to adapt EBPs to be
Likening the story of the chambered nautilus to your own
culturally relevant to an ever-widening and more diverse
change and growth as a professional helper, consider the
population.
center of the shell’s spiral as your own beginning and foun-
Our intent and hope is that the remainder of the chap-
dation as a professional helper, a foundation that includes
ters in this book will assist you in your efforts to grow and
the core skills and attributes we discussed in this chapter,
change as a helping professional, all the while remaining
the skills of self-awareness and self-reflection, mindfulness,
fastened to and informed by your firm foundation. Keep
and self-care and self-compassion. You will learn more skills
the story of the chambered nautilus front and center as
and expand your repertoire as you continue in your career,
you move through the book and through your career.
but our wish for you is that you remain connected to these
core skills—that you embrace and wrap yourself around Visit CengageBrain.com for a variety of study
these skills and build your practice on them. tools and useful resources such as video exam-
As you return your gaze to the visual of the chambered ples, case studies, interactive exercises, flash-
nautilus on the cover of the book, also consider that the cards, and quizzes.
1 Knowledge and Skill Builder

Part One thought he canceled because he realized he got what he
Part One is designed to help you recognize the need for the needed in that first session. We have been learning about
core helper skills of self-awareness and self-reflection, mind- brief therapy in my advanced theories class, you know,
fulness, and self-care and self-compassion, consistent with so I thought getting right to the issue and moving things
Learning Outcome 1. It is also intended to highlight specific along in the session was a good thing.
activities to develop each of these three skills to promote Dr. M.: But unless you asked the client directly at the end of
your stamina and resilience as a professional helper. the session, or followed up with him after he canceled, you
Read through the following dialogue between a counsel- don’t really know whether he got what he needed.
ing student and her practicum supervisor. In what the coun- Jasmine: Yeah, I guess that’s true.
seling student says or in what the supervisor says, identify Dr. M.: Have you been able to watch your counseling sessions
one example (three examples total) of the supervisee’s need over the past 2 weeks?
for: (1) self-awareness and self-reflection; (2) mindfulness; Jasmine: Actually, no. I haven’t had a chance. It’s been real
and (3) self-care and self-compassion. For each of the three crazy at work and I’ve had to babysit my two nephews
needs you identified, locate an example of a specific activ- because my sister’s work schedule changed. And on top
ity that either the supervisor mentioned or the counseling of everything, I’ve been applying for an internship posi-
student verbalized. You can write the identified needs and tion for this fall. The deadline, you know, for getting a site
the corresponding activities on a separate sheet of paper, is next week. And I need to graduate this December. My
or simply circle or underline the text in your book. Compare mom’s counting on it!
your responses to those provided on pages 33–34. Dr. M.: You have a lot going on right now. And you’re trying to
Jasmine is a full-time clinical mental health counseling meet the expectations that others have for you. How are
student who also works part-time as a server at a popular you managing everything?
fine dining restaurant in town. She is in her second semester Jasmine: Just doing what I need to do to get by. I’m pretty
of practicum and her clients are primarily traditional age col- good at multitasking!
lege students seeking services at the university counseling Dr. M.: Well, there’s only so much that any one of us can handle
center. Jasmine is directly supervised by Dr. Sarah Morton, a at one time. Too many things on one plate—or a serving
full-time professor in the counseling program who teaches tray—can turn into a stumble or a fall. I imagine you know
practicum. Because it serves as a practicum site, the uni- well from work that you can carry only so much on a tray
versity counseling center is equipped with video recording at one time.
equipment and Dr. Morton routinely views the video record- Jasmine: I’ve gotten pretty good at balancing heavy loads—
ings of Jasmine’s counseling sessions. even with one hand.
In a recent individual supervision session, Dr. Morton Dr. M.: It sounds to me, though, that things have gotten
(Dr. M.) and Jasmine discuss specific skills Jasmine has dem- unbalanced for you recently, kind of lopsided. I have this
onstrated and skills she needs to improve. They also discuss image of you rushing around from one place to another.
how these skills are needed inside and outside the counsel- And in your last two or three counseling sessions, you’ve
ing room. seemed distracted—sitting on the edge of your seat
for most of the session, not allowing for silences, and
Dr. M.: You use your time well in session, Jasmine. You know providing quite a few suggestions—advice—to clients
how to begin a session and how to bring it to a close. without first inviting them to come up with their own
You also provide your clients with a wealth of information ideas. This is part of what I mean by needing to pace
related to resources on campus. You know this university yourself better.
pretty well! Jasmine: But they’re obviously coming in for help. I mean, the
Jasmine: Well, I did go to undergrad here, and being at the two I saw last week actually asked me what they should
restaurant where I am, you have to be efficient. I mean, you do. How can I not tell them? And it just seems like a waste
can’t be lazy, especially when the customers are paying of time to sit there in silence, staring at each other. . .or
top dollar for their meals. the floor.
Dr. M.: Sounds like you’re kept on your toes at work. Now, in Dr. M.: Be careful that you’re not doing all the work in session.
session with clients, I’d like to see you pace yourself a little This is one example of being lopsided. It really isn’t our
better. Sometimes it seems like you’re in a hurry to get the job as helpers to figure things out for clients—as much
session over with. And I wonder, especially with the new as they may want us to, you know, give them answers. It
client you saw last week, if he felt bombarded with all of would be like you deciding for each of your customers
the resources on campus you gave him—all in the first ses- what they should eat. No menus necessary! Not only does
sion. I noticed that he canceled for this week. this go against the philosophy or ethic in counseling of a
Jasmine: Hmm. I thought that session went fine. He really client-helper partnership and also helping clients make
didn’t seem bothered by what I had to say. And I just decisions for themselves—the idea of empowerment—it
(continued)
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“Why—why, he said he might call Tuesday evening. Of course if you
had rather he didn’t—”
“I told you I hadn’t any objections, provided he doesn’t come too
often. Asked you to drop in at the Tobias Eldridge place, I suppose?”
“Ye-es. Yes, he said something about it; but I told him I couldn’t do
that.”
“Good girl.... Well, all right. Good-night.”
She bent over his chair back and kissed him.
“I think it is very sweet of you to let him come here at all,” she said. “I
—I don’t see how you can—considering who he is.”
“Who he is?... Humph!... Well, he is a friend of yours and I don’t want
to stand between you and your friends. Besides—which is what you
mean, of course—he is a Cook and when I deal with one of them I
always feel safer if he is where—”
He did not finish the sentence. “Where—? What were you going to
say?” she asked.
He was fearful that he had already said too much. “Nothing, nothing,”
he said. “Good-night, dearie. I must finish my letter.”
The letter was to Mrs. Jane Carter, in Boston, and he did finish it
before he went to bed.
Bob came on Tuesday evening and again Foster Townsend left the
young people alone in the library. The stay this time was longer. He
came again on Friday and on the following Tuesday. Townsend said
nothing, but he thought a good deal. He began to wish that he had
followed his own inclination and forbidden the pair of young idiots to
see each other at all. His questions to Esther, put very guardedly,
seemed to warrant the belief that, so far at least, her feeling toward
Griffin was merely that of friendship; but friendship at that age was
dangerous. It must be broken off—and soon.
CHAPTER X
MRS. CARTER had not yet replied to his letter. He wrote another,
stating his case more succinctly and intimating that he expected
compliance with his wishes. He even dropped a hint concerning her
obligation to him, something he had never done before.
“It may upset your plans a little,” he wrote, “and I suppose you feel
that you can’t shut up that house of yours and turn your other
lodgers adrift. Well, I don’t ask you to do that. Find some one who
can handle the craft while you are away and I will pay the bill. I have
heard you say that it was the dream of your life to go where I am
planning to send you. Here is your dream come true. You like the girl
and she likes you. You are the only one in sight that I should feel
safe to trust as skipper of a cruise like this one, with her aboard. You
have always declared that, if ever you could do anything for me, you
would do it if it killed you. Well, this won’t kill you. It may do you
good. If anything can shake the reefs out of that Boston canvas of
yours I should say this might be the thing. You will sail freer
afterwards and you will have something to talk about besides the
gilding on the State House dome. Let me hear from you right away.”
He did not hear, however. Another week passed and he had not
heard. Bob Griffin called twice more during that week. And on
Sunday, after service, while Foster Townsend stood on the church
steps chatting with Captain Ben Snow, from the corner of his eye he
saw Esther and Bob talking together and noticed, quite as clearly,
the significant glances and whisperings of his fellow worshipers as
they, too, watched the pair.
Harniss was beginning to talk, of course. Neighbors had seen Griffin
entering the yard of the mansion evening after evening. Curious
eyes had remained open later than was their custom to note the hour
at which he left that yard. And they were noting that, whereas the
said hour was in the beginning as early as nine-thirty, it was now ten-
thirty or, on one occasion, close to eleven. “What is Cap’n Foster
thinking about?” people wanted to know. “Elisha Cook’s grandson
coming to that house! Doesn’t the Cap’n realize what is going on? If
he don’t somebody ought to tell him.”
Nobody did tell him; no one would have dared. Various reasons for
his permitting the visits were suggested. For the most part these
reasons were connected with the lawsuit. Perhaps Griffin had
quarreled with his grandfather. That might be why he had hired
Tobias Eldridge’s shanty and was spending his days there instead of
in Denboro, where he belonged. Perhaps he and Elisha Cook had
had a row and Bob had deserted to the enemy. He might be giving
Townsend inside information which would help the latter and his
lawyers. Perhaps Townsend had bought the boy off. He had money
enough to buy anybody or anything, if he cared to use it.
Millard Fillmore Clark, as an “in-law” and a possible though but
remotely possible, source of information was questioned. Mr. Clark’s
replies to all queries were non-committal and dignified. One gathered
that he knew a great deal but was under oath to reveal nothing.
“You let us alone,” he said, loftily, “We ’tend to our business and we
generally know what that business is. Wait a little spell. Just wait.
Then I guess you’ll see what you do see.”
The few who dared drop a hint to Reliance left unsatisfied. Mrs.
Wheeler, who boasted that she made it a point to give her custom to
the “native tradespeople” whenever possible, was one of these few.
She had graciously permitted the Clark-Makepeace millinery shop to
fashion for her what she called a “garden hat,” and she dropped in at
the room in the rear of the post office building ostensibly to see how
the fashioning was progressing. After the usual preliminaries of
weather, health and church matters had been touched upon, she
broached another subject.
“I hear Captain Townsend’s attractive niece has developed a new
talent,” she observed, with a smile. “I always supposed music was
her specialty. Now I understand she has taken up painting.”
Reliance looked up from the garden hat, which was in her lap. Then
she looked down again.
“Has she?” she asked, calmly. “I didn’t know it.”
Mrs. Wheeler smiled once more. “So they say,” she affirmed. “She
has developed a fondness for art.”
“Is that so.... Don’t you think the bow would look better on the side
than right in front, Mrs. Wheeler?”
Considering how very particular—not to say fussy—the lady had
hitherto been concerning that hat she seemed surprisingly indifferent
to the position of the bow.
“No doubt,” she said, carelessly. “Arrange it as you think best, Miss
Clark.... Yes, Miss Townsend seems to be devoted to art at present
—or, at least, to an artist. Ha, ha! I know nothing of it, of course, but I
have heard such a rumor.”
Abbie Makepeace, who was a little deaf although she would never
admit it, put in a word.
“You can’t put too much dependence on what Maria Bloomer says,”
she declared. “She’ll say anything that comes into her head. All them
Bloomers are alike that way.”
Their patron regarded her coldly. “I said ‘rumor,’ not Bloomer,” she
corrected.
“Oh! Yes, yes, I see. One of Seth Payne’s roomers, was it? He’s got
a houseful of ’em this summer, so they tell me. Why, there’s a couple
there from somewheres out West—Milwaukee—or Missouri, or
somewheres; begins with a M, anyway. They’re awful queer folks.
Take their meals at Emeline Ryder’s and Emeline says she never
had such cranky mealers at her table, before nor since. Why, one
day, so she says, the man—I do wish I could remember his name—
found fault with the beefsteak they had for dinner; said ’twas too
tough to eat. Now, accordin’ to Emeline ’twas as good top of the
round steak as she could buy out of the butcher cart, and she’d
pounded it with the potato masher for half an hour before she put it
in the fryin’ pan. She lost her patience and says she: ‘Now, look
here, Mr. ——’. Oh, dear, dear! What is that man’s name? Funny I
can’t remember it. What is it, Reliance? Do tell me, for mercy sakes!”
Reliance could not remember, either, but she suggested various
names, none of which was exactly right. Mrs. Wheeler departed in
disgust before the matter was settled. Miss Makepeace commented
upon the manner of her exit.
“What made her switch out that way?” she inquired, in surprise.
“Acted as if she was out of sorts about somethin’, seemed to me.
Don’t you suppose she liked the hat, Reliance?”
Reliance smiled. “It wasn’t the hat that brought her here,” she
observed. “That woman was fishin’, Abbie.”
“Fishin’! What are you talkin’ about? Fishin’ for what?”
“For what she didn’t get. She wouldn’t have got it from me, anyhow,
but you saved me the trouble of tellin’ her so and, maybe, losin’ us a
customer. Do you remember that man in the Bible who wanted bread
and somebody gave him a stone? Well, that Wheeler woman wanted
news and what she got was a tough beefsteak. Serve her right.
Much obliged to you, Abbie.”
Abbie had not listened to the last part of this speech. Now she
clapped her hands in satisfaction.
“There!” she exclaimed. “I’ve got it at last. When you said somethin’
about a stone it came to me. Stone made me think of brick and brick
was what I wanted. That man’s name is Clay. Tut, tut! Well, I shan’t
forget it next time.”
That evening, when Esther came down to supper, it seemed to her
that her uncle was in far better humor than he had been for some
time. During the past week he had been somewhat taciturn and
grumpy. She suspected that matters connected with the lawsuit
might not be progressing to his satisfaction, but when she asked he
brusquely told her that was all right enough, so far as it went,
although it went almighty slow. Then her suspicions shifted and she
began to fear that, perhaps, he did not like Bob’s calling so
frequently. He had never offered objections to the calls, greeted the
young man pleasantly and usually left the pair together for the
greater part of the evening. Nevertheless—or so she fancied—his
greetings were a trifle less hearty now than they had been at first.
And, on the morning following Griffin’s most recent call, he said
something at the breakfast table which was disturbing. She had
thought of it many times since.
“Well,” he observed, after the maid had left them together, “how is
the great picture painter these days? Getting to be a pretty regular
visitor, isn’t he? Coming again Tuesday night, I suppose? Eh?”
Esther, taken by surprise, colored and hesitated.
“Why—why, I don’t know, Uncle Foster,” she faltered. “He didn’t say
he was.”
“Didn’t need to, perhaps. Probably thought you might take it for
granted by this time. Tuesdays and Fridays on his calendar seem to
be marked with your initials. Those other young chaps who used to
drop in here once in a while appear to have sheered off. I wonder
why.”
Esther looked at him. He was smiling, so she smiled also.
“If you mean George Bartlett,” she said. “He has gone back to
Boston. His vacation is over. And Fred Winthrop is—well, I don’t
know why he doesn’t come, I am sure. I don’t like him, anyway.”
“Perhaps he guessed as much. You do like this Griffin, I take it.”
Esther had ceased to smile. “Why, yes, I do,” she declared. “I told
you I did. He is a nice boy and I do like him. But, Uncle Foster, I don’t
see why you speak this way. If you think—”
“There, there!” rather testily. “I said, in the beginning, that I wasn’t
going to think anything. You and I agreed that we wouldn’t have any
secrets from each other, so why should I think?”
“You shouldn’t. Uncle Foster, if you don’t want Bob to come here—”
“Sshh! I told you he could come—if he didn’t come too often.”
“So you do think he is coming too often?”
“I didn’t say so. I was just wondering what his grandfather might be
thinking about it. He has told the old man, of course?”
He had not and Esther knew it. Bob had announced his intention of
telling his grandfather of his friendship with Foster Townsend’s niece,
but he had put off the telling, waiting, he said, for a favorable
opportunity. Townsend, keenly scrutinizing the girl’s face, read his
answer there.
“Well, well,” he added, before she could reply. “That is his business,
not yours nor mine, my dear. Only,” he said, with a grim chuckle, “I
shall be interested to hear how Elisha takes the news.”
It was this which had troubled Esther ever since. And now Tuesday
evening had arrived and, in an hour or two, unless her surmise was
very wrong indeed, Bob himself would come. If he had not told Mr.
Cook he must do so at once. She should insist upon it.
She thought about this during supper, but afterward, when they were
together in the library, her uncle made an announcement that drove
every other thought from her mind. He seated himself as usual in the
big easy-chair, but he did not pick up the newspaper which lay upon
the table. Instead he thrust his hands into his pockets and looked at
her.
“Esther,” he said, “I’ve got some news for you. You’re going to be
surprised. How long will it take you to get ready to start for Paris?”
She stared at him in utter amazement.
“To Paris!” she repeated.
“Um-hum. That is what I said. To Paris, France. How long before you
can get ready to start for there? I hope not too long, because now
that it is settled you are going the sooner you get away the better.”
She caught her breath. He must be joking—he must be. Yet he
seemed quite sincere.
“To Paris?” she cried. “Why, Uncle Foster! What do you mean? Are
we going to Paris—now?”
He shook his head. “Not quite such good luck as that,” he answered,
with a sigh. “I had intended that we should go together. I had
promised myself that cruise with you and I had counted on it. But I
can’t get away for a while. My lawyers say they need me here and
that I can’t be spared. But there’s no reason why you shouldn’t go.
Ever since that concert I have heard nothing but what a fine voice
you’ve got and that it ought to be cultivated up to the top notch. Paris
is the place where they do that kind of cultivating and there is where
you ought to be. No use wasting time. I have been tempted to be
selfish and keep you here along with me. I’ve thought up every
excuse for keeping you, but they aren’t good enough. The minute
this blasted suit is tried—or settled—or put off again or something, I’ll
take the next ship and come to you as quick as it will take me. But
you must go now. And I’ve got exactly the right person to go with
you,” he added, earnestly.
She would have spoken, have protested perhaps, but he held up his
hand.
“No, wait,” he commanded. “Just wait and listen. It’s all planned,
every bit of it.”
He went on to tell of the plan. The person who was to accompany
her, who was to be in charge of everything, was Mrs. Jane Carter of
Boston. She was very fond of Esther and the latter was equally fond
of her. She was wise and capable and refined and educated; she
was everything which a companion for the finest girl in the world
should be. He and she had been in correspondence for some time.
Mrs. Carter was to leave her house and her lodgers in charge of a
friend and was prepared to start within two or three weeks, if
necessary.
“You and she can spend the summer traveling together, if you want
to,” he went on. “There will be arrangements to make, and lots of
things to find out about before you begin with your studies. You’ll
have a good time—and I’ll have as good a time as I can until I can
get over there with you. There! that’s the plan. Pretty good one, too, I
think. What do you say to it?”
She did not know what to say. The suddenness of its disclosure, the
surprise, the conviction by this time forced upon her that her trip
abroad was to be an actual, immediate reality and not the vaguely
marvelous dream which had been in her mind for so long, were too
overwhelming to permit her to think at all, much less speak or
reason.
In the endeavor to answer, to say something, she turned toward him
and caught him off his guard. He was regarding her with a look of
love and longing, which touched her to the core. It vanished as he
saw her look and he smiled again, but she sprang from the rocker
and, running to his side, put her arms about his neck and pressed
her cheek to his.
“Oh, no, Uncle Foster!” she cried. “No, I can’t do it. It is wonderful of
you to plan such a thing for me. It is just like you. You are—oh, you
are— But I can’t go. It would be too selfish. I can’t go and leave you
—all alone, here at home. It wouldn’t be right at all. No, I’ll wait until
we can go together.”
He took her hand in his and held it tight. “Oh, yes, you will, dearie,”
he declared. “You’ll go because I want you to. I’ll be lonesome
without you. Good Lord, yes! I’ll be lonesome, but I can stand it for a
while. You’ll go. I want you to go. It is all settled—Eh? Confound it!
there’s the bell. Who is coming here to-night? I don’t want to see
anybody.”
She, too, had heard the bell and she knew who had rung it. She had
forgotten, but now she remembered. She withdrew her hand from
her uncle’s grasp:
“It is—I suppose it is—” she began; and then added, impulsively:
“Oh, I wish he hadn’t come!”
Foster Townsend looked up at her.
“Eh?” he queried. “Oh, yes, yes! I forgot. Tuesday night, isn’t it. Well,
all right; you and I can finish our talk to-morrow just as well.... Here!
Where are you going?”
She was on her way to the door.
“I am going to tell him I can’t see him to-night,” she said.
“No, no! Don’t do any such thing. Of course you’ll see him. You’ve
got some news for him, too. He’ll be surprised, of course—and
delighted, maybe.”
There was an odd significance in the tone of this last speech which
caused her to turn quickly and look at him. At that moment Bob’s
voice was heard in the hall and, an instant later, he entered the
library. One glance at the pair made him aware that he had
interrupted a scene of some kind. Esther’s eyes were wet and her
manner oddly excited. Her “good evening” was almost perfunctory
and she kept looking at her uncle instead of at him. Foster
Townsend, also, seemed a little queer. His handshake was as off-
hand as usual; Bob never considered it more than a meaningless
condescension to the formalities. That there was behind it any real
cordiality he doubted. Esther’s uncle could scarcely be expected to
love him; that was natural enough, considering whose grandson he
was. And there was an occasional tartness or sarcasm in the
Townsend speech and a look or two in his direction from the
Townsend eyes, which confirmed his suspicion that, although
Captain Foster, for some reason, permitted him to call at the
mansion, he was far from overjoyed to see him there.
To-night—or perhaps he imagined it—the sarcasm was even more in
evidence.
“Hello, Griffin!” said the captain. “How are you?”
Bob thanked him and said that he was well.
“That’s good. Painted any more pictures to give away, lately?”
Bob smilingly shook his head.
“Not yet,” he said.
“That so? Haven’t sold any either, I suppose?”
“No, sir.”
“Humph! Kind of dull times in the trade, I should say. Take you a
good while to make a million at that rate, won’t it?”
“I’m afraid so. But I shall be satisfied with a good deal less than a
million.”
“So? You aren’t as grasping as some of your family, then.”
Bob thought it time to change the subject. He turned to the other
member of the trio.
“How are you, Esther?” he asked. “Any news since I saw you?”
Esther absently replied that there was no news. Her uncle laughed.
“She doesn’t mean that, Griffin,” he declared. “There is some news,
big news. We were just talking about it when you came in. Weren’t
we, Esther?”
“Why—why yes, Uncle Foster, we were.”
“Yes, we were. Well, I’ll leave you to tell it. Good-night.”
He turned toward the hall door. She had not forgotten the look she
had seen upon his face that instant when the smiling mask had
fallen. It had shown her a little of his real feeling, something of what
the sacrifice of her companionship meant to him. She had never
loved him as she loved him now.
“Oh, don’t go away, Uncle Foster,” she begged. “You’re not going to
bed so soon. Stay here with us. We want you to. Don’t we, Bob?”
“Certainly, of course,” agreed Bob. Townsend shook his head.
“Can’t,” he declared, cheerfully. “I’ve got another letter to write Jane
Carter and I want it to go in the morning mail. Good-night, Esther.
Good-night, Griffin.”
He went out and the door closed. Esther remained standing, looking
after him. Bob grinned. Then he drew a long breath.
“Whew!” he exclaimed in evident relief. “That storm blew over
quicker than I thought it would. The way he lit into me when I first
came—and the queer way you both looked and acted when I walked
into this room—made me wonder what had happened. What is up,
Esther?”
She did not answer. His grin became a laugh.
“Did you hear him give me that dig about painting pictures to give
away?” he asked. “And that other one about not being grasping as
some one else in the family? That was a whack at grandfather and
the lawsuit, of course. I thought I might be in for a row, but he was
pleasant enough when he said good-night. I wonder—”
She surprised him then.
“Oh, don’t!” she broke in, impatiently. “Don’t! He is the best, the
kindest man in the whole world. Don’t you dare say he isn’t.”
He looked at her in astonishment. Then he whistled.
“Great Scott!” he exclaimed. “Don’t take my head off. I didn’t say he
wasn’t good and kind and all that. I think he is. I rather like him, as a
matter of fact; even if he doesn’t like me.”
She turned upon him. “Now why do you say that?” she demanded. “If
he doesn’t like you why does he let you come here—to this house?
You haven’t any reason to say he doesn’t like you.”
“Maybe not. Perhaps he does like me. I hope he does. I want him to.
As for his letting me come here to see you, I must say it’s mighty
decent of him. I doubt if I should, if I were in his place—considering
who I am. Come, Esther, don’t pitch into me this way. What have I
done?”
She smiled then. “Oh, you haven’t done anything, Bob,” she said. “I
am just—oh, excited and upset, that’s all. Uncle Foster has just told
me the most wonderful thing. He is going to let me do what I have
wanted to do for years and—and I ought to be very happy. I think I
should be if it weren’t that I know how terribly lonely he is going to be
without me.”
“Without you! What do you mean by that? Are you going
somewhere? Is this the big news he was hinting at? Why, Esther!
You aren’t going away, are you?”
She sat in the rocker. He was regarding her anxiously. She nodded.
“Yes, Bob,” she said, gravely. “I am. I am going abroad to study. I
didn’t know a word about it until a few minutes ago. Uncle has
planned it all. I am going with Mrs. Carter and—”
He interrupted. “What!” he cried. “You are going abroad?... When?”
“I don’t know exactly. But very soon.”
“How long are you going to stay there?”
“I don’t know that, either. A year at least, I suppose. Perhaps longer.”
“Indeed you are not!”
“Why, Bob Griffin! What do you mean?”
“I mean—well, never mind now. I guess I don’t know what I mean.
Or, if I do, it can wait. Tell me all about it. Tell me!”
So she told him, told as much of the plan as her uncle had told her.
He listened without speaking. At the end she said: “If I weren’t for
leaving him I should be so wildly happy I shouldn’t know what to do.
But, oh, Bob, I know what letting me go means to him. And he had
planned to go with me. He and I have talked ever so many times
about going to Paris together. Now he can’t go. That miserable suit
and the horrid lawyers are keeping him here. But because he thinks I
ought to go he is sending me and not thinking of himself at all. He
will be perfectly wretched without me. I know it. I almost feel like
saying that I won’t go until he does. Perhaps I ought to say it—and
stick to it. What do you think?”
He did not reply, nor did he look at her. She bent forward to look at
him.
“Why, Bob!” she cried. “What is the matter?”
He shook his head. “I wonder if you think your uncle is going to be
the only wretched person in this neighborhood?” he muttered. “Do
you think that?”
“Why—why, I suppose Aunt Reliance will miss me.”
He looked up then. “How about me?” he asked.
“You! You?... Why—why, Bob, I don’t believe I thought of you.”
“I don’t believe you did. I am afraid you didn’t. But do you imagine I
shall be—well, altogether joyful?”
She could not answer. For, all at once, she was thinking of him. It
seemed strange that she had not done it before. She had not
realized that her glorious trip meant the end of their companionship.
If not the end, then at least a year of separation. And suddenly, with
the realization, came a new feeling—a rush of feelings. She gasped.
“Why—why, Bob—” she faltered.
He had risen and was standing beside her, bending over her.
“Esther,” he pleaded, desperately, “do you suppose I shan’t be
completely miserable if you go away and leave me? Why—why, you
know it! You must know it! What do you suppose my knowing you
and—and being with you, like this, means to me? Esther, doesn’t it
mean anything to you—anything at all?”
She was beginning to comprehend what it did mean. But she knew
she must not think it. It was impossible—it was insane—it was—
“Oh, don’t, Bob! Don’t!” she begged. “You—you mustn’t—”
“I must. I’ve got to. It may be my only chance. Esther, don’t you care
anything about me? I thought—I was beginning to hope— Oh,
Esther, you are the only girl in the world for me. I love you.”
“Bob! Bob! Don’t!”
“I do. I love you. Say you love me! Say it! Say it!”
She had risen to her feet. Some wild idea of escape—of running
from the room—was in her mind. But his arms were about her.
“Say it! Say it, dear!” he pleaded.
“No, no! I mustn’t! You mustn’t—”
“You do love me? You do, don’t you, Esther?”
“Oh, I don’t know! I— Oh, of course I don’t! I mustn’t! Let me go.”
“No, I shan’t let you go until you tell me. You do care for me, dear?
Tell me you do.”
“No, Bob.... Oh, please let me go!”
She was crying. He released her and stepped back from the chair.
For an instant he stood there and then, lifting his hands and letting
them fall again in surrender, turned away.
“Oh, well!” he sighed, miserably. “Well—there! I see how it is. I was a
fool, of course. I ought to have known. I am sorry, Esther. Forgive
me, if you can.”
She had sunk down into the rocker once more and was sobbing, her
face buried in the cushion upon its back. He spoke again.
“I hope you can forgive me,” he begged. “I didn’t mean to say those
things to you—yet. Some day of course, after you had known me
longer—and—but I had no idea of saying them now. It was your
telling me you were going away—for years—and leaving me— Well,
it drove me crazy, that’s all. I am sorry. Of course I don’t blame you in
the least. There is no reason why you should care for me—and
plenty why you shouldn’t, I suppose. I don’t amount to much, I
guess. Don’t cry any more. I am awfully sorry I hurt your feelings.”
The head pressed against the cushion moved back and forth.
“You haven’t hurt them,” she murmured, chokingly. “I don’t know why
I am crying. I—I won’t any more.”
She sat up, fumbled for her handkerchief, and hurriedly wiped her
eyes.
“Then you do forgive me?” he urged.
“There was nothing to forgive.... No,” earnestly. “No, Bob, you
mustn’t. Please don’t!... I—I think you had better go now.”
He took a step toward the door. Then he paused and turned.
“Then it is all over, I suppose?” he said. “You don’t care for me at
all?”
Her lips opened to form the No which she knew must be said, which
she had determined to say. But when her eyes met his the resolution
faltered—broke.
“Don’t ask me, Bob, please!” she begged, in desperation. “I—I— Oh,
even if I did, what difference would it make? It is perfectly impossible
—you and I— You know it is!”
He was at her side again and this time he would not be denied. He
held her close and kissed her. Then he stepped back and laughed
aloud.
“That is all I wanted to know,” he cried, in triumph. “You do care. That
is enough. That is all that matters. Now let’s see them keep us apart!
You are mine—and you are going to be mine, always, forever and
ever, amen. Ha! Now let them try to stop it!”
She regarded him in wonder.
“You can laugh!” she exclaimed, reproachfully.
“You bet I can laugh! I was beginning to think I never should laugh
again, but now— Ha! They may send you to Paris or to Jericho, it
doesn’t make any difference now, Esther—”
But she held out her hands imploringly.
“Please go now, Bob,” she urged. “I must think this all over, before—
before we talk any more. I must. It is—oh, it is all as crazy as can be
and I must think it over by myself.... You will go now, won’t you, for
my sake?”
He hesitated. Then he nodded.
“Certainly I will, if you want me to,” he said. “But no matter how much
you think it doesn’t change the fact that we love each other and
belong to each other. That is settled.... Good-night, dearest. I’ll see
you Friday evening, of course. And then we can talk, can’t we.”
She shook her head. “I don’t know,” she replied. “I don’t know what I
may have decided by that time. I am not sure that I am doing right in
letting you come on Friday—or any more at all. I am not sure of
anything.”
“I am. And I shall be thinking, too. This Paris business—well, I may
have something to say about that. I have an idea of my own—or a
part of one. It has just this minute come to me. I’ll tell you about it
then. Good-night.”
When Esther tiptoed up the stairs to her room she devoutly hoped
that her uncle’s door might be closed. She simply could not face him,
or speak with him. She dreaded those keen eyes of his. The door
was open, however, and he called to her.
“What!” he cried. “That young fellow gone so early? He’s been
standing longer watches than this lately. What’s the matter? Anything
happened?”
She did not pause and she tried hard to make her tone casual.
“Oh, no,” she answered. “Nothing has happened. Good-night, Uncle
dear.”
He chuckled to himself. In spite of her care there had been a tremor
in her voice. He guessed the reason, or thought he did. She had told
Griffin of the European trip and he—and perhaps she—had come to
realize that it meant the end of their association. Well, that is exactly
what he intended it to mean. No doubt they both regretted the
parting. Never mind. Esther would soon get over it. Better a trifling
heartache now than a big one later on. She should not marry Elisha
Cook’s grandson if he were the only man on earth. His own
heartache at the thought of losing her for a time was soothed by the
certainty that once more he was having his own way.
CHAPTER XI
ESTHER’S hours of sleep that night were few indeed. She was
happy one moment and miserable the next. Bob loved her—he told
her so. And she loved him, she was sure of it now. But did they love
each other enough? Were they sufficiently certain of that love to go
on to face its inevitable consequences, regardless of what those
consequences must mean to themselves and to others? For if they
were not, both of them, absolutely sure, those consequences were
too tremendous to be faced. Her uncle had permitted friendship
between Elisha Cook’s grandson and herself—the fact of his doing
so was still an unexplainable mystery to her—but she was certain
that he would never consent to their marriage. And Bob’s grandfather
would be equally resolute in his opposition. It was one thing to say,
as Bob had said, that the family feud had no part in their lives. It had.
She loved her uncle dearly and she knew that he idolized her. She
owed him a debt of gratitude beyond the limits of measure. Only one
reason could ever be strong enough to warrant her risking the end of
their affectionate association and the repudiation of that debt. If she
were certain that she loved Bob Griffin—really loved him and would
always love him—then nothing else mattered. Except, of course, the
same certainty of his enduring love for her. But were they certain?
They had known each other such a short time.
And there were other considerations. Her future with her beloved
music, the career she had dreamed. She had no money of her own.
Bob had some, but not a great deal. He was almost as dependent
upon his grandfather as she was upon Foster Townsend. Might not
his chances for fame and success as an artist be wrecked if he
married her? She must think of that, too. There was so much to think
of. She thought and thought, but morning brought no definite
conclusion except one, which was that she must continue to think
and, meanwhile, there must be no plighted troth, no engagement, no
definite promise of any kind between them. She would tell Bob that
when they next met. If he really loved her he would understand and
be willing to wait, as she would wait, and see.
She came downstairs early and found that her uncle was an even
earlier riser. He had gone out to the stable, so Nabby said, but
would, of course, come in to breakfast when called. And he had
already told Mrs. Gifford of Esther’s coming trip abroad. Nabby was
excited and even more voluble than usual.
“I suspicioned there was somethin’ up,” she declared. “He’s been
nervous and uneasy for over a fortni’t. And cranky—my soul! He was
like a dog with one flea, you never could tell the place he’d snap at
next. Varunas noticed it too, of course, and he was consider’ble
worried about it. Honest, I cal’late Varunas was beginnin’ to be afraid
that your uncle was losin’ his mind or somethin’. ‘He’s touched in the
head, I do believe,’ he said. ‘If he ain’t why does he allow that
grandson of ’Lisha Cook’s to come here so twice a week reg’lar? A
Cook don’t belong in this house and you know it, Nabby. What is he
let come here for?’
“Well, I didn’t know why, of course, but I never see Foster Townsend
yet when he didn’t have a reason for doin’ things and I spoke right up
and said so. ‘When Cap’n Foster gets ready to put that Griffin boy
out he’ll do it,’ I told him. ‘You say yourself the cap’n don’t act natural
these days. Well, maybe there’s the reason. Probably he don’t really
like that young feller’s ringin’ our front doorbell any better than you
do, and he’s just waitin’ for a good excuse to tell him so.’ That’s what
I said, but I wan’t so terrible satisfied with what I said and Varunas he
was less satisfied than I was.
“‘Hugh!’ says he, disgusted. ‘When I see Foster Townsend waitin’ for
an excuse to do what he wants to, then I won’t guess he’s gone
crazy, I’ll know it. When he sets out to tell the President of the United
States, or the minister, or Judas Iscariot, or anybody else, to go to
Tophet he tells ’em so and then thinks up the excuse afterwards. You
bet he ain’t actin’ natural! Nabby Gifford, if Foster Townsend don’t
need a doctor, or a keeper or somethin’, then I do. This kind of goin’s
on is too much for me!’”
Having contributed this conversational gem from the Gifford family
treasury, Nabby paused. Possibly she expected Esther to offer some
explanation of the Griffin visits. If so she was disappointed, for
Esther said nothing. Nabby picked up a fork from the breakfast table
and then put it down again.
“Well, anyhow,” she continued, “be that as it will or must, as the
sayin’ is, your uncle has acted queer for quite a spell and ’twan’t until
this very mornin’ that he give me the least hint of why he was doin’ it.
When he told me no longer than twenty minutes ago, that he had
been layin’ his plans for you to go over to live along with them—er—
heathen in foreign lands—when he told me you was goin’ and he
was goin’ to stay here to home alone—I got my answer, or part of it
anyhow. The poor soul is about crazy with lonesomeness at the very
idea. That’s what ails him. Are you really truly goin’ to go, Esther?”
Esther nodded. “Uncle says I must,” she replied. “He wants me to go
on with my singing and my music and he can’t go himself—at
present.”
She went on to tell of the proposed trip, of Mrs. Carter, and the
details as she had been told them by Townsend.
“Goodness knows I don’t want to leave him,” she said, “but he insists
that I must. He has arranged for everything. I tried to say No, but he
won’t listen. He will have his own way, as he always does, I suppose.
I know how lonesome he will be. I shall be almost as lonely without
him,” she added.
Nabby seemed to be thinking. There was an odd expression upon
her face.
“You don’t suppose—” she began, and stopped in the middle of the
sentence.
“I don’t suppose what?” Esther asked.
“Oh, nothin’! It’s silly, I guess. I just wondered—it come across my
mind—if it might be he was sendin’ you off so’s to get you away from
—well, from this Bob Griffin.... Humph! No, ’tain’t likely he’d do that,
because—”

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Full Ebook of Interviewing and Change Strategies For Helpers Sherry Cormier Online PDF All Chapter

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Interviewing and Change Strategies for

Helpers Sherry Cormier

Motivational Interviewing Helping People Change and

Job Interviewing For Dummies Pamela Skillings

Scientific American Mind Zoe Cormier

Curbing Corruption Practical Strategies for Sustainable

Choices: Interviewing and Counselling Skills for

Building Gender Equity in the Academy Institutional

Interviewing: A Guide for Journalists and Professional

Interviewing: A Guide for Journalists and Professional

Australia ● Brazil ● Mexico ● Singapore ● United Kingdom ● United States

Content Developer: Elizabeth Momb

Cengage Learning is a leading provider of customized learning solutions

Cengage Learning products are represented in Canada by Nelson

To learn more about Cengage Learning Solutions, visit www.cengage.com

Printed in the United States of America

Sherry Cormier is Professor Emerita in the Department of Counseling,

Cynthia J. Osborn is Professor of Counselor Education and Supervision at Kent

Preface xi Practicing Idiographically 48

Influencing Responses 139 Chapter 7

Models for Working Cognitive Approaches

C h a p t e r 13 Self-Management Strategies 528

Building Your Foundation

Figure 1.1 A Practice Nexus for Today’s Helping Professional

Learning Activity 1.1

Learning Activity 1.2

TABLE 1.1 Seven Ingredients of Helper Stamina

TABLE 1.1 Seven Ingredients of Helper Stamina (continued)

Box 1.1 Story of the Three-Sided House

Box 1.2 Eight Misconceptions of Evidence-Based Practices

TABLE 1.2 Registries, Lists, and Reviews of EBPs

Cochrane Reviews The Cochrane Collaboration 1995 www.cochrane.org/cochrane

Research-Supported Society of Clinical Psychology, 2008 www.psychology.sunysb.edu

What Works Clearinghouse U.S. Department of Education 2002 http://ies.ed.gov/ncee/wwc

The Campbell Collaboration The Campbell Collaboration 2000 www.campbellcollaboration.org

Results First Clearinghouse Pew-MacArthur Results First Initiative 2015 www.pewtrusts.org/en/multimedia

Learning Activity 1.3

1 Knowledge and Skill Builder

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