Skillful Counselling: Enhance Positive Expectancy

Positive expectancy is an essential feature of skillful counselling. This is to harness the natural healing capacity, which we all possess.

Expect to get better and you more likely will

Positive expectancy triggers our in built capacity to heal – evident in the power of the placebo. But for the placebo to work – there must be expectancy that healing is possible. For only then will the mind/body’s own healing resources be activated.

To the extent that a client believes he/she will get better and has faith in the skills and experience of the counsellor, then he/she is already at first base.

Positive Expectancy – clients cannot be fooled

It is critical that clients appreciate both consciously and unconsciously that I expect improvement and recovery.

But this expectation has to be credible. Clients can rarely be fooled as we are talking about subtle body language, an unconscious tone of voice as much as anything else.

Of course, after some improvement, we both (client and therapist) can feel a naturally growing confident expectation. However, if there is no improvement within a few sessions or it is not sustained, then it is absolutely critical that I remain calm and positive.

This is to take pressure off both of us and so to be open to whatever might need to be changed in how we are working.

And when confidence is lost then so does positive expectancy. Of course this does happen and if it is genuinely lost – well then the therapy is over.

Evidence of effectiveness helps positive expectancy

The evidence of 85% client  progress has supported my confidence as a counsellor – which will then transmit to my client. I know that I am likely to help each new client who is before me for the first time. And if my client is aware of my track record then this too can help build expectancy.

Having said that, humility is also essential as arrogance and over-confidence is foolish. This will erode a genuine sense of positive expectancy.

I remember a final session with a client. She said that as I had answered the door at the first session she had felt somewhat disconcerted and unsure but that the moment we had sat down she felt fine. Now I have Multiple Sclerosis and was unsteady on my feet. She picked up on that but the moment I was in my natural counselling “place”, her uncertainty was replaced with confidence.

Normalisation is an important tool to build positive expectancy

I am always looking for opportunities to normalise or explain what may be happening for my client. This breeds confidence by taking pressure off some very weighted down shoulders. They will realise that there is an explanation and they are not going mad.

One obvious means of normalising concerns depressed clients. For them to realise that the problem is to do with excessive dreaming and that they are not going mad – can be wonderfully relieving and also build real confidence in the therapist. And there are really credible psychological explanations for addictions, anxieties, angers and so on.

And to have these repeated and repeated (or to hear again and again on a tailor made audio) can be an important part of expectancy.

Building rapport and positive expectancy

It has long been understood that an essential pre-requisite for good counselling (and indeed any healing) is to ensure the client or patient feels comfortable with and has trust in the motives, competence and humility of their therapist.

Building rapport, establishing trust and openness is the first task in counselling. At its core this requires that the client senses clearly that they are being listened to respectfully, non-judgementally and insightfully.

I am only answerable to my client. There is no strong model of therapy that needs to be defended, or an imposed way of working by the organisation that employs or accredits me.

Formalising feedback

Barry Duncan and Scott D Miller, whose work on what works in therapy has made such an impression on me, have one piece of advice for all therapists. If counsellors do this one thing, then the outcome of their therapy will improve – which is to ask formally for evaluation of the session.  I do this (mostly and not always I have to admit) using the Session Rating Scales (SRS) devised by Duncan and Miller.

Even if the therapist believes the sessions are going well it is important says Duncan and Miller to ask for feedback, as there might be something that the client would otherwise be too embarrassed or shy to communicate.

There is one final point – which is that you, the client know yourself much better than the therapist. And though you may know you need help (otherwise why are you sitting there with the “expert”), your wisdom and experience has to be part of the healing. As the great Milton Erickson said – “when in doubt I ask the client what he/she thinks we should do.”

What wisdom can you share about what you know would work for you?

Positive expectancy in conventional medicine

Conventional medicine is certainly aware of the placebo and indeed goes to great lengths to take out the placebo effect when testing for new drugs and procedures.

The ambivalence of conventional medicine to the existence of the placebo effect is surely a clue as to why conventional medicine is so rarely about healing (as opposed to body fixing) and why it can be so unsatisfactory. This mindset spills into the medical treatment of mental illness as well.

This is what the United Kingdom Parliamentary Committee on Science and Technology has to say: : “…prescribing placebos… usually relies on some degree of patient deception” and “prescribing pure placebos is bad medicine. Their effect is unreliable and unpredictable and cannot form the sole basis of any treatment on the NHS.”

Now, doctors may be happy to reject our natural healing capacity as bad medicine, but no good counsellor would dream of doing the same. It is hard not to conclude that our doctors may learn about good medicine but they pick up some very questionable healing.

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