CARKHUFF MODEL OF COUNSELING

Abstract research has shown that good interpersonal skills are a prerequisite for
a helping relationship to be effective. Carkhuff s helping model provides a
framework in which to examine the nature of the helping relationship. The
core helper dimensions and phases of helping are outlined. It is suggested that
by incorporating this model into occupational therapy practice the delivery of
care will be enhanced. Occupational therapy intervention, through a process of
mutual collaboration, provides opportunities for the client to be an active
participant in treatment. Clients are encouraged to be involved in purposeful
activities of their own choice in order to achieve the established goals. Caring
and helping relationships are emphasized to enable clients to reach their full
potential It is often stated that these core beliefs and assumptions are adhered
to by occupational therapists in their clinical work, regardless of the setting
and model of practice that is followed (Katz, 1988). Establishing a
therapeutic milieu is required of occupational therapists vvhen clients are
referred for assessment and treatment. The key feature of this therapeutic
milieu is the interpersonal relationship between occupational therapists and
their clients. An essential aspect of health-care is communication (Crepeau,
1991). Being able to engage clients in a meaningful relationship determines
the therapeutic process (Fleming, 1991a). The nature and quality of these
interpersonal relationships may greatly influence the outcome of treatment,
since it is only when there is a strong therapeutic relationship that there is a
commitment to the treatment process (Mattingly, 1991a; Truax & Carkhuff,
1967). Research by Carkhuff and Berenson (1977) has indicated that
ineffective interpersonal skills may actually have a detrimental effect on
clients and that therapists functioning at minimally facilitative levels do not
make a difference in treatment outcomes. It is only those people vvith high
levels of interpersonal skills that actually help people (Carkhuff & Berenson,
1977). The results of these findings have implications for occupational
therapy, since it is a helping profession. Helping professionals, by definition,
are engaged in assisting their clients to achieve change. The process of
intervention is dynamic; there is a continually changing pattern of interaction
between therapist, client and significant others (Townsend, Brintnell, &
Staisey, 1990). As members of a helping profession, occupational therapists
have a responsibility to provide quality care for the clients that participate in
occupational therapy programmes. The purpose of this paper is to examine the
interpersonal skills required to help people as defined by Carkhuff.
FIELDWORK AND CLINICAL PRACTICE
The importance of establishing rapport and communicating with clients is
emphasized in the literature since a good relationship between the
occupational therapist and the client has been identified as a factor that will
influence the effectiveness of treatment (Fleming, 1991a; Mattingly, 1991a).
Rapport enables the development of a relationship where honest and
supportive communication can take place (Furnham, King, & Pendleton,
1980; Lloyd & Maas, 1991, Moore, 1977). Rapport forms the basis for a
sound, mutually acceptable relationship between client and therapist. There is
an expectation that the therapist will know how to establish rapport and
achieve an effective therapeutic relationship with clients (Christiansen, 1977;
Fumham et al.,1980; Lloyd & Maas, 1991). Many clients, who come to
occupational therapy, do not make the decision to participate in the
occupational therapy process. Often they are referred because the referring
agency, for example health-care team, social services, education, workers
compensation, think that they would benefit from occupational therapy. This
may have a direct bearing on the attitude and behaviour of the client. Fraenkel
(1951) outlined some of the difficulties or obstacles that the occupational
therapist might face during the assessment and treatment process. For
example, clients may not be ready for therapy, may feel pessimistic tovvards
treatment in general, may feel unsure of what occupational therapy has to
offer, may have concerns unrelated to the presenting problem, or may
perceive that occupational therapy is limited to such activities as arts and
crafts vvhich they do not value. It is critical that the therapist understand the
client's feelings and expectations. Not being aware of the client's underlying
fears, concerns and needs may well result in the failure of the treatment
programme, since what is most pertinent to the client may not be addressed.
This situation more commonly occurs when the therapist applies standard
technical solutions to problems without taking into account the client's
concerns (Parham, 1987). Peloquin (1990) found that clients revealed widely
differing views of occupational therapists depending on the ways in which
therapists show competence and caring during client/therapist interactions.
Moore (1977) studied the interaction patterns of occupational therapists
during initial interviews with clients. The results of the study revealed that
the therapists spent almost half of the interview time talking. By using a short
question-answer sequence, clients were not encouraged to be self-revealing.
Discussion of subjective material was not encouraged. This study raises some
questions concerning the issue of the quality of the interpersonal relationships
between therapists and clients. Recent work has shown that inexperienced or
novice therapists focus on the diagnosis; it is only when the therapist gains
more experience that they begin to look beyond the diagnosis and see the
client as an individual (Slater & Cohn, 84 * JUIN 1993 CJOT VOLUME 60
NO 2 1991). It is now understood that the inexperienced or novice therapist
cannot attend to both concrete skills and abstract thought. In the practice
situation, they focus on one or the other (Cohn, 1989). Christiansen (1977)
conducted a study to measure the quality of empathy in occupational
therapy students. The results indicated that occupational therapy students do
not necessarily have the interpersonal skills necessary for effective helping
relationships. In
fact, some of the scores were quite low which tends to support the idea for
further interpersonal skill development of occupational therapists. Another study
which examined the level of empathy of occupational therapy students was
conducted by Wise and Page (1980). Although hypothesized that occupational
therapy students would show an increase in empathy after their initial contac
with clients following their first clinical experience, this did not occur. Why
did client contact
not make any actual difference to the students' levels of empathy? It would
appear that client contact alone is not sufficient to ensure the development of
interpersonal skills. Instead, it may be necessary to teach interpersonal skills to
the students before having any client contact, so that they would be better able
to show empathic understanding to their clients. Later studies on empathy,
such as the one conducted by Lloyd and Maas (1992), found that empathy in
clinical
fieldwork was not positively regarded; rather assertiveness in communication
with clients was more
highly valued. For a number of years concern has been raised that academic
programmes do not prepare students adequately for clinical practice (Cohn,
1991). It was found by Cohn and Frum (1988) in a survey of fieldwork
locations, which was completed by fieldwork educators and academic fieldwork
co-ordinators, that there existed a discrepancy between theory and fieldwork.
Fieldwork experience is a vital component of students' educational programme.
Being in a clinical
situation enables students to put into practice the theories and skills they have
learned in their academic work (Cohn, 1989). This concern about the
discrepancy between academic programmes and preparation for fieldwork
experiences, coupled with the fact that studies have found that students focus
on a technical or skills oriented approach to treatment intervention, raises a
number of issues. The primary issue is in what way can students be better
prepared for the challenges facing them in fieldwork. Recent work in the
United States (Cohn, 1989; Fleming, 1991b; Mattingly, 1991b; Schwartz,
1991) has emphasized the importance of understanding the
process of clinical reasoning. By gaining an understanding/knowledge of
how and why clinical decisions are made, a more integrated way of looking
at clinical practice is provided. Clinical reasoning is based on the therapist's
knowledge of treatment procedures, interactions with clients, and being
perceptive about the changing nature of the therapeutic process (Cohn, 1989).
The experienced therapist will take into consideration pertinent aspects about the
client during therapy
situations, and look at this in conjunction with medical, physical, and psycho-
social features, thereby looking at the client as an individual (Slater & Cohn,
1991). It is important that students in the fieldwork experience are able to
engage in becoming proficient in technical skills, for example, the correct
splint to use with a particular disability; but, equally important, is gaining an
understanding about the clients' life experiences (Crepeau, 1991). In other
words, for students
to view the whole person, they need to learn about the client's beliefs and
values and to gain an appreciation of what the disability has meant to that
individual's life (Schwartz, 1991). It is only by providing such an integrated
approach to treating clients that their needs and, most importantly, what they
see as relevant to them are being met, that quality care is provided.
Implications of the findings from work that has been conducted into
occupational therapy practice over the years, seem to indicate a need towards
greater emphasis being placed on experiential learning, examination of current
practice, and the development of effective interpersonal skills. One such way in
which this could be achieved is to incorporate, at an early stage in the students'
academic preparation, a strong component on interpersonal skills and to
ernphasize how this
contributes towards forming an effective therapeutic relationship. A shift
needs to be made from just teaching facts concerning interpersonal skills to
providing students with opportunities to utilize these skills with each other and
in therapy situations. Additionally, when students are learning about disability
and treatment skills and techniques, there should be a focus on looking at the
impact that disability has on all spheres of an individual's life. A number of
approaches can be used in the
academic setting, namely, the use of video, discussion of case histories, and
utilizing experienced therapists. Video-taped therapy situations enable students
to examine the process of intervention by experienced therapists. Once
students themselves have the opportunity to work with clients, their
involvement should be video-taped as this provides immediate visual feedback
about their interactions. Preparing case histories, that go beyond outlining
methods of intervention and goals of treatment, provide opportunities for
students to consider how the illness/disability has affected the individual's
life. Experienced therapists can not only be mentors and role models to students
JUNE 1993 85 CJOT • VOLUME 60 • NO 2 but share with them their
experiences in differing
therapy situations. By looking at occupational therapy practice more critically
and emphasizing an experiential approach to interpersonal skills acquisition,
this will encourage the development of clinical reasoning, thereby ensuring
better quality care. According to Carkhuff (1969), interpersonal awareness
promotes therapeutic effectiveness. This can be related to the therapist gaining
a greater understanding of self and of others. There is an expectation that
helping takes place during a helping relationship. Yet it can be seen that there
needs to be a shift in focus to enable students to be more empathic and
understanding of what their clients' needs are. If a helping relationship is to
be truly helpful, more attention needs to be paid to interpersonal skill
development. Without
the necessary functional helping skills required to establish rapport and to
maintain a meaningful relationship, it is difficult to be as effective as one could
be. Carkhuff (1969) suggested that systematic skills training focusing on the
skills needed to deliver help to clients is an important step towards overcoming
this deficit.

CARKHUFF'S HELPING MODEL

Background
Rogers (1957) coined the phrase "the necessary and sufficient conditions for
therapeutic personality change" (p.95) in which he advocated that the core
conditions of congruence, unconditional positive regard, and empathic
understanding are essential for an effective
counselling relationship. He further hypothesized that "significant positive
personality change does not occur except in a relationship" (p.96). The client-
centred approach (Rogers, 1951) is based on two main assumptions: 1) the
inherent capabilities of the individual to understand the factors in his or her life
that are causing unhappiness and the capacity to overcome these factors; and
2) therapeutic change will take place if the therapist can establish with the client
a relationship that is caring and understanding. Family and friends may be
understanding and helpful but wha distinguishes a therapeutic relationship
from other relationships is that it is "an extension through time of qualities
which in other relationships tend at best to be momentary" (Rogers, 1957,
p.101).
The pioneering work of Rogers greatly influenced Truax and Carkhuff
(1967) who developed reliable scales to measure the core ingredients of the
psychotherapy relationship. Their work generated a renewed interest on
interpersonal therapist skills and served as an impetus for further research. One
of the issues that concerned Truax and Carkhuff (1967) was that research
tended to focus predominantly on the dynamics of personality and
psychopathology. The emphasis was on whether or not the client made
changes in therapy and on the mode of therapy used. Very little attention was
given to the interpersonal skills of the therapist in promoting therapeutic
change. The question they then asked was "what are the essential characteristics
or behaviours of the therapist or counselor that lead to constructive change in
the client" (Truax & Carkhuff, 1967 p.24). In order to answer this question
Truax and Carkhuff conducted and evaluated a large number of outcome
studies. Their findings supported their hypothesis of the importance of the
therapist qualities such as empathy, respect, genuineness, and concreteness
in effecting client change (Truax & Carkhuff, 1967). When a therapist or
helper intervenes in another person's life, the effect may be either
constructive or destructive. The result of the helping relationship depends, to a
large extent, on the level of the therapist's interpersonal skills and the nature of
the therapeutic
relationship that is established. If a therapist has good interpersonal skills, the
result will be helpful or constructive. On the other hand, if the therapist has
poor interpersonal skills, the result will not be helpful and may, in fact, actually
cause harm to the client (Carkhuff & Berenson, 1977; Truax & Carkhuff,
1967). This may occur, for example, when the therapist is not perceptive to
how the client is feeling; the client may be a danger to themselves or to others
or be non- compliant with treatment.

The Core Dimensions

Carkhuff and Berenson (1977) outlined the core dimensions of a helping
relationship; these being empathy, respect, genuineness, and concreteness.
They developed 5 point scales to assess these core dimensions, with level 3
being the minimally facilitative or effective level of functioning. The helping
relationship in this instance does not necessarily refer to what takes place in
counselling or psychotherapy but in any situation where one person has
exhausted his or her own resources and comes to another person for help. The
core dimensions are shared by all interactive processes regardless of
theoretical orientation. The levels in which an individual functions with
others
reflects his or her attitudes and understanding.

Empathy

Empathy involves being with the other person, or to put it more simply, seeing
the world through his or her eyes. The helper's level of empathic understanding
is related to the client's improvement in therapy. The helper needs to be able
to suspend judgement, tolerate anxiety and communicate understanding to the
client. Carkhuff and Berenson (1977) stated that "it is the
manner of the helper, not his theory or technique that communicates
understanding and fosters growth" p.9. 86 • JUIN 1993 CJOT • VOLUME 60 •
NO 2

Respect

It is suggested that in order to respect the feelings and experiences of another,

one must have self-respect. The communication of warmth or positive regard
establishes a base for empathy. Respect is communicated to the client when
the helper shows commitment, understanding, and spontaneity. Respect is a
vital link between helper and client (Carkhuff & Berenson, 1977). It has been
found that helpers whose communication shows warmth and understanding
have the greatest success in helping (Carkhuff & Berenson, 1977; Truax &
Carkhuff, 1967).

Genuineness
There needs to be congruence between how a helper says what he/she says and
how much his/her personality is revealed. In other words, do the helper's
statements reflect his/her true feelings. The relationship between client and
helper has to be genuine since this is a foundation for the entire helping
process. Facilitative genuineness is non destructive; it is not a license to be
rude or harmful to the client. If the helper's only genuine responses are negative
in regard
to the client, the helper should employ his/her responses constructively as a
basis for further inquiry for the helper, the client and their relationship. As an
example, if the client said: "You're just like all the others; you don't really care
a damn about me", an appropriate response would be something like: "You
question my motives?" By framing negative responses constructively, the client
is encouraged to look more deeply at him/herself and the relationship with the
helper. Being genuine means not playing the role of a therapist and maintaining
a facade as the client will
perceive this and be less genuine in turn (Carkhuff & Berenson, 1977).

Concreteness
The material used by the helper must be personally meaningful and relevant
to the client. Being specific is important in that the helper stays attuned to the
client's feelings and expressions which leads to greater accuracy on the part of
the helper. Any misconceptions can be readily clarified. It also serves to ensure
that the client attends specifically to problem areas and not to
digress away from the task at hand (Carkhuff & Berenson, 1977). Phases of
Helping - Client Learning The helping process constitutes the basis of a
helping model. The first component of the helping process is client learning.
(Carkhuff & Berenson, 1977). Client learning involves three phases, that is,
the clients' exploration of where they are in relation to their world, their
understanding of where they want or need to be, and, finally, the action required
to achieve where they want to be. A feedback loop is in operation i.e. they
receive feedback from their action, which encourages further exploration,
increased understanding or awareness thereby leading to more effective action
(Aspy, 1986).
Exploration
Exploration by the client is a key element in the helping process. It initiates the
helping process for the client. The initial contact and development of the
process of exploration enables both the helper and the client to gain an
understanding of where the client is at present (Carkhuff, 1980). It has been
found that if the helper raises or lowers the level of his or her interpersonal
skills, most clients will adjust their levels of exploration accordingly (Carkhuff
& Berenson, 1977).
Understanding Exploration is the first step in the learning process but the client
needs to move beyond the exploratory phase in order to gain understanding.
Understanding occurs when the client knows or understands him or herself, or
in other words, has gained insight. Insight, however,
does not occur systematically. The material that has been explored needs to be
built upon. In this manner the individual is encouraged to take ownership of the
problems and associated feelings (Carkhuff, 1980; Carkhuff & Berenson,
1977).

Action

Once the client has taken ownership of his/her problems and feelings, he/she
can act upon them. The helper guides the client in developing a relevant
course of action. New behaviours can be tried out in the process of
implementing the course of action (Carkhuff, 1980; Carkhuff & Berenson,
1977). Phases of Helping - Helper Skills The second component of the
helping process is helper skills. The helper serves to guide the client through
the phases of learning. A number of helping
skills are required to facilitate the client's learning. The helper skills of
atttending, responding, personalizing, and initiating need to be present.

Attending
Attending skills which involve attending physically, observing, and listening
form the basis for responding skills, which in turn, will facilitate client
exploration. The environment should be arranged so that it provides for a
maximum level of involvement and motivation by the client. Attending
physically also requires that the helper face the client directly to indicate
attentiveness. Eye contact should be made and distractions should be ignored
(Carkhuff, 1980).

Observing

the client enables the helper to gain information about the client's physical,
emotional, and intellectual status. The helper is able to assess the degree of
congruence between the client's behaviour and content of his/her speech.
Observing the client and his/her behaviour
and actions will give the helper an idea about the client's weaknesses and
resources (Carkhuff, 1980). Listening involves suspending judgement while
paying attention to both content and feeling. It is important to let the client
know that he/she is being heard (Carkhuff, 1980).

Responding
The helper must respond to both the content and feeling of the client's speech.
The client may talk about the problem but may not share his/her feelings
concerning the problem. Testing this out with the client promotes further
exploration (Carkhuff, 1980). Helper responsiveness together with client
exploration forms the basis for client personalizing which promotes
selfunderstanding.

Personalizing
The meaning of the problem, feelings, and goal need to be personalized. The
situation is individualized for the client which means that he or she is
accountable. Being accountable leads to the formulation of goals that are
specifically relevant to the individual (Carkhuff, 1980). Helper personalizing
and client understanding are the basis for helper initiating which then leads to
client action.

Initiating
The goal that is established must be concrete and have observable and
measurable steps. The helper assists the client in developing an action plan and
in initiating steps to the goal. A schedule is worked out. Expectations of both
the client and helper are outlined (Carkhuff, 1980).

CONCLUSION
Occupational therapy, as a helping profession, has an ethical responsibility for
providing clients with quality of care. With previous research suggesting that
not all helping relationships are beneficial, it becomes a matter of concern as to
the effectiveness of occupational therapists in their interactions with clients.
Carkhuff's helping model, with its humanistic orientation, appears to
complement the philosophical beliefs of occupational therapy. This model
offers a way of
examining the development of functional interpersonal skills which could be
easily incorporated into occupational therapy academic and clinical education.