Karyn Harvey, Ph.D. Lisa Cloud, B.S.
Who spends the most time with the consumers? The psychologist? The behavior specialist? The program manager? Or the direct care staff? We all know the answer to that question.
Every staff member working directly with consumers is trained in a variety of behavior management techniques. However, how many staff members are trained on a comparable level in counseling techniques? We propose that such training would make a crucial difference in the quality of interaction between staff and consumers. We also maintain that the degree and magnitude of behavioral interventions required would significantly decrease over time with the increased use of counseling techniques employed by the direct care staff.
Research has shown that counseling by paraprofessionals can be just as effective and, in some cases, more effective than counseling administered by professionals (Hurvitz, 1974). We contend that this is particularly the case with individuals with developmental disabilities and mental health needs. Due to the ongoing presence of the direct care staff and the accompanying opportunity for immediacy of response and discussion, direct care staff can intervene more effectively, in many cases, than the outside professional. But this potential efficacy, of course, depends on the direct care staff's ability to respond quickly and therapeutically to the emotional needs of the consumer. The ability to respond therapeutically can be trained just as behavior management techniques are trained, simply and systematically.
Many direct care staff function quite therapeutically without extensive training. These people are truly the "heros" of our field and we wish to honor them. We also believe that basic counseling techniques can be accessed relatively easily through the training plan that we propose.
This training plan is divided into three sections: 1) Basic counseling skills, 2) Counseling skills unique to working with individuals with developmental disabilities and mental health needs and 3) Supervision of direct care staff implementing counseling techniques.
Basic counseling skills universal to effective counseling and specific in application to working with adults with developmental disabilities and mental health needs covered in our training plan include: establishment of trust and rapport, active listening, empathy and goalsetting.
Building rapport is essential to any effective counseling (Kottler, 1986). It is both easier and more difficult for the direct care person working residentially or vocationally with a consumer to build a rapport based on trust: easier, because of the time and proximity together, more difficult because the direct care individual is more than likely the person helping the consumer to perform the more difficult tasks of work and living that the consumer may not always want to perform. Rapport which fosters therapeutic dialogue has to stem from a foundation of trust. The establishment of trust requires three elements: respect, reliability and attention.
Trust cannot be present unless there is a fundamental basis of respect on the part of the counselor for the fundamental humanity of the client. This is particularly true regarding the relationship between staff and individuals with developmental disabilities who are particularly sensitized to being treated with a lack of respect. Respect must be shown in a way that we label as "active respect" or treating the consumer with the courtesy and consideration that one would afford one's colleague or co-worker. The consumers that we work with are, of course, adults, and respect includes treating them as such.
In addition to respect, establishing trust must also include reliability. The counselor must be reliable to the consumer in a way that mature adults are reliable to each other. This includes keeping promises and maintaining honesty. It means only making promises that can be kept, acting reliably and avoiding deception. It is difficult to establish reliability in the day to day relationship that the direct care staff must maintain with the consumer but it is essential in order for any therapeutic work to be done.
Finally, attention must be given to the consumer on a consistent basis in order to build an effective level of trust. Behavior modification theories focus us on the effective use of attention as a reinforcer to increase positive behaviors. Attention must also be present if any kind of rapport is to be built. Of course, rapport cannot be built if the consumer feels as though the staff is more interested in conversations with co-workers about the on-goings of the night before than actually interacting with the consumer. In the residence the TV might be a focal point of attention for staff and consumers, sometimes undermining the establishment of any meaningful rapport. Distractors must be eliminated as much as possible and attention should be adequately focused on the consumer in order for trust to exist and rapport to be built.
Active listening has long been an essential ingredient of successful counseling (Egan, 1994). Listening in a manner in which the consumer feels focused on and understood can be highly therapeutic. Who better than the direct care staff member to conduct such listening? The staff is there when issues arise, when feelings surface, when interpersonal conflicts occur. The elements of active listening that our training plan focuses on are: attending, reflection and paraphrasing.
Attending means to focus on the consumer as they are speaking. This is fairly obvious but often times staff can benefit from listening training which teaches body language of listening, encouraging verbalizations and patience.
Staff can be trained to reflect back to consumers the content that they have heard in order to encourage further consumer selfdisclosure. This involves restating to the consumer in snipets what they have just stated. Such as "There was no one home when I came home yesterday and I was scared." says the consumer and the staff replies "You were scared.", thus encouraging the consumer to continue.
Paraphrasing can be easily taught and facilitates increased selfdisclosure as well as insight. In paraphrasing the listener restates, in his or her own words what he or she has just heard, such as "So you came home, you saw your counselor wasn't there and you felt scared; you saw you were all alone." This restating can afford the consumer increased insight into his or her own story and can be very effective for facilitating further self-understanding.
According to Egan ( 1994) Empathy is far deeper than mere sympathy; it is the communication of the sense of being in the other's shoes. Not only feeling sorry for those shoes but actively envisioning and communicating a sense of what those shoes must feel like. Empathy is clearly an essential ingredient for effective therapy in any therapeutic relationship (Howell, 1982). Individuals respond to genuine empathy. Empathy is a powerful tool when working with individuals with developmental disabilities and mental health needs. So many of these individuals have not experienced genuine empathy in their lives. Sympathy may be available, but rarely do others make the leap to understand how these individuals must actually be feeling and take the time to communicate that understanding. Once that empathy is felt and communicated it becomes a very effective therapeutic tool.
Goal-setting is critical to the successful therapeutic intervention (Egan, 1994). The consumers that we work with are constantly working with us on goals: community living goals, personal care goals, vocational goals, behavioral goals, etc. Often behavioral goals are of a personal and interpersonal nature. However, therapeutic goals can be set, similar to behavioral goals but with more emphasis on process rather than outcome. When therapy is conducted in an ongoing manner such process oriented goals naturally arise. For example, if Susan is upset about not seeing her Mom that weekend the counselor may reflect her feelings, empathize with her and then gently guide her towards setting more realistic expectations where her Mom is concerned. This goal to not depend on the not entirely "dependable" mother is not written down and listed with objectives; it is, rather, an outcome of the empathetic, counseling-oriented dialogue that Susan has engaged in with her counselor. The counselor keeps this issue in mind and continues to guide Susan towards more emotional independence.
Working with individuals with developmental disabilities and mental health needs on a direct care level in a therapeutic manner means flexibly applying the above covered principles when possible. Difficult individuals can be successfully maintained in both residential and vocational programs when behavior management techniques are combined with paraprofessional counseling. There are five factors unique to ongoing direct care counseling: therapeutic moment, redirection into self, in-vivo processing, communication between paraprofessional and professional and kindness.
When staff are with consumers throughout the day or evening, moments arise when a new emotional understanding can be achieved. This may be a moment when an emotionally charged event occurs or some emotionally relevant content is experienced. It may also be a moment within the social interaction during which the consumer feels challenged in some way and needs assistance to respond appropriately. For example, when Susan hangs up the phone after her mother apologizes for not picking her up, staff can be there to listen to her feelings about the phone conversation. By paraphrasing, reflecting, and using active listening techniques the staff can help Susan to talk about her feelings rather than act them out. The therapeutic moment arises in the course of direct care work frequently. Intervening in a timely and sensitive manner can provide a tremendous amount of support to the consumer.
In the heat of the moment we all can, at times, blame others for our discontent. Since we are the ones feeling it, we are the ones able to work through and change such feelings as well. A consumer in the throws of an emotional moment of blame, anger and despair can be redirected inward by the sensitive direct care staff. The consumer can be encouraged to accept responsibility for his or her own feelings and cognitively reframe a situation in order to gain a sense of control and/or well being. For example, Susan can be told, "Susan, look at your mother, she's the one who missed out, you had a fun weekend and she missed being with you." Or "Susan, it's understandable that you're angry, but this has happened before. Maybe next time we'll ask her not to call us unless she's really coming. Maybe next weekend you can invite a friend from the day program over instead." Susan is redirected towards her own ability to control her responses and emerge victorious.
As a situation is occurring staff can enable the consumer to understand and express how he or she is feeling about the situation. A staff member may help a consumer to label and understand their feelings initially and then to express them. For example, when Susan hangs up the phone and then flings a plate across the kitchen table the staff member might ask Susan (if Susan is not flinging more plates) "Susan stop and tell me how you are feeling right now." Staff may have to be assertive in order to enable Susan to label and express her feelings. The more Susan can verbally express and process her feelings the less they will need to be expressed behaviorally.
We do not advocate para professional counseling as a complete substitute for professional therapy or, of course, behavior management or psychiatry. However, we do assert that there are times when emotional issues may be inappropriately treated as psychiatric or behavioral. That is when the direct care staff trained in counseling can provide crucial input to the behavior specialist or psychiatrist as to the impact of certain emotionally based issues.
In addition, therapy with a professional is far more effective, we assert, when the professional is communicating consistently with the therapist. Therapy in a vacuum with only the consumer's input is often limited at best. The more the para professional shares his or her work and the consumer's insights, needs and issues with the therapist, the more relevant and appropriate the therapist's approach to the consumer will be. In the ideal situation the therapist can provide crucial input and guidance for the counseling that the direct care person is doing.
The direct-care person can, in turn, provide critical information about and insight into the emotional life of the consumer relevant to therapy.
The relationship between the professional and the para-professional both working with the consumer is a crucial partnership.
Kindness is to regard others with care and concern, forgiveness and sensitivity, awareness and respect. We don't always encounter a lot of this on our planet, but when we do, it can have a profound and long-term impact. Frequently, the consumers that we serve have not experienced much kindness in their lives. Whatever kindness they do experience can be tremendously encouraging.
Granted, we cannot train people to be kind, but at least that direction can be set and that standard pointed to. The actions and approach to kindness can be trained. Kindness does not mean an absence of limits. Rather, we refer to an underlying compassion based on the awareness that those whom we serve are not so different from us and, if not for a twist of fate or turn of Karma, might have been us, as we might just as easily have been them. Treating others as we would have them treat us if we were the consumer is the guidepost for kindness and we contend that counseling by paraprofessionals for individuals with developmental disabilities and mental health needs should be directed by that guidepost.
Supervision encompasses three separate functions: administration, support and education (Shulman, 1992) Within the para professional counseling approach that we propose, both support and education from the supervisor concerning the application of basic counseling techniques are essential. Of course, support and education must be based on training in counseling techniques. The model which we propose for techniques to be taught is ideally presented by a professional trained in counseling skills. We envision supervisors and staff participating in such training together, with extra training provided for management in the support and education of direct care staff implementing counseling techniques.
Support begins with belief. If, through training, the supervisor can understand the effectiveness of counseling on the direct care level, that understanding can be naturally transformed into support of counseling-based activities on the direct-care level. Ideally, clinically trained individuals can provide guidance to the supervisor in the supervision and direction of direct care counseling. Support can also be in the form of the supervisory functions including encouragement, motivation and rewards for counseling-based activities. The management style of the given supervisor can be adapted to support and promote counseling-based activities. We do not advocate a specific style, we advocate supervisory support, in the style best employed by the supervisor, of counseling-based direct care intervention.
As stated above, training from a professional in the counseling skills reviewed in this paper, for both the supervisor and the direct care staff, is the essential foundation upon which counseling activities are based. It is also the foundation for supervisory education. Education is an ongoing process, through one on one supervision and staff meetings the supervisor can continue to remind staff of counseling-based approaches to situations as they arise. Based on material presented from this paper we hope to equip direct-care personnel to intervene therapeutically with consumers they serve and supervisors to support and promote such intervention.
Egan, G. (1994). The Skilled Helper. Pacific Grove: Brooks/Cole Publishing Company.
Howell, W. S. (1982). The Empathetic Communicator. Belmont, CA: Wadsworth.
Hurvitz, N. (1974). Similarities and differences between conventional psychotherapy and peerself help groups. In P.S. Roman & H.M. Trice (Eds.), The Sociology of Psychotherapy. New York: Aronson.
Kottler, J.A. (1992) . Compassionate Therapy. San Francisco: Jossey-Bass.
Shulman, L. (1992) Interactional Supervision. Washington D.C.: NASW Press.
For further information contact:
Karyn Harvey, Ph.D.
9104 Red Branch Road
Columbia, MD 21045