Enhancement of the Working Alliance: A training program ... - IOS Press

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Journal of Vocational Rehabilitation 20 (2004) 107–125 IOS Press

Enhancement of the Working Alliance: A training program to align counselor and consumer expectations Linda R. Shawa,∗, Brian T. McMahonb , Fong Chanc and Elizabeth Hannold a a

University of Florida, FL, USA E-mail: [email protected] b Virginia Commonwealth University, Richmond, VA, USA c University of Wisconsin-Madison, WI, USA

Abstract. Working Alliance has been described as a collaborative process characterized by shared goals, tasks and attachment bonds The development of a strong working Alliance is desirable in a rehabilitation system that embraces full and meaningful involvement from consumers. It has been suggested that the Working Alliance is dependent upon four factors that include congruence between counselor and consumer expectancies regarding counseling. This article describes a training protocol to help counselors develop awareness and specific skills aimed at consumers achieving greater congruence in expectations early in the rehabilitation counseling process. The protocol utilizes both didactic and experiential instruction and includes values clarification activities, use of the Expectations About Rehabilitation Counseling (EARC) Scale, and a conflict resolution approach to expectation convergence. Training protocols, materials, and processes are presented along with discussion regarding the impact of the training protocol on participating counselors. Keywords: Rehabilitation counseling, Expectations about Rehabilitation Counseling (EARC) Scale, consumer-counselor work relationships

1. Introduction There is, perhaps, no other public human service agency with an historic emphasis on outcomes equal to that of the state-federal vocational rehabilitation (VR) program. Almost since its inception, counselor success has been measured almost exclusively in number of Consumers placed into employment – generally referred to within the VR system as the number of “26 closures”. Not only has individual counselor perfor∗ Linda R. Shaw is an associate professor and Elizabeth Hannold is a doctoral candidate, Department of Rehabilitation Counseling, University of Florida. Brian T. McMahon is a research professor, Departments of Physical Medicine/Rehabilitation and Rehabilitation Counseling, Virginia Commonwealth University. Fong Chan is a professor, Department of Rehabilitation Psychology and Special Education, University of Wisconsin-Madison.

mance been assessed along this single criterion, but agency success and funding allocations have also been directly tied to number of successful placements. The use of the “26 closure” as the sole criterion of success came under fire in the mid ‘70s as counselors were required to comply with the federal mandates that required them to serve greater numbers of individuals with severe disabilities [6,31]. Such concerns were most often addressed with quotas that set minimums for numbers of individuals with severe disabilities served or other approaches, such as weighted measures [30]. Despite these experiments in broadening the criteria for success, the “26 closure” has continued to reign supreme as the representation of counselor and agency success. It is all the more interesting, then, that the State VR system, with its historic emphasis on outcomes

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has, in recent years, come under increasing criticism for a lack of accountability in effecting quality outcomes. This criticism has evolved from a number of social and economic forces that have converged to create demands for increased accountability, including the consumerism movement, the escalation of health care costs, the trend toward privitization, and the disability civil rights movement. The disability civil rights movement of the 1970’s succeeded in creating a whole generation of individuals with disabilities who demanded not only that counselors secure placements for them, but that those placements constitute meaningful work consistent with their personal interests, abilities and life goals. Increasingly, vocal proponents of consumer-focused rehabilitation demanded that counselors must actively involve individuals with disabilities in the rehabilitation process from start to finish and that all counselor activities should be guided by the consumer’s own perceptions about what activities would best address their needs. Chan et al. [8] suggest that the implementation of this “consumer-directed” model in the day to day activities of rehabilitation has been implemented somewhat poorly and with considerable difficulty for most counselors. To maximally involve the consumer in his/her own rehabilitation is not always easy, nor is it always comfortable to share power. A study by Murphy and Salomone [28] helps to elucidate the difficulties counselors often experience in trying to meet expectations for “26 closures” while also actually involving their consumers in rehabilitation-related decisions and activities. They interviewed 7 State VR counselors and 12 of their severely disabled clients. A qualitative analysis of the interview transcripts revealed that while the counselors agreed, in principle, that consumer involvement was a laudable goal, they often indicated that their consumers were too “needy”, too uninformed, or cognitively unable to be full participants in vocational decision-making. Counselors voiced frustration with “over-assertive” consumers, believing that such consumers should accept that in some cases, it is in the consumer’s best interest to rely on the counselor’s professional judgment. Interestingly, Murphy and Salomone also found distinct differences in the expectations of counselors and their consumers. They concluded that greater attention needs to be given to nurturing the development of a healthy relationship between counselor and consumer, characterized by shared power and decision-making. More recently, Patterson et al. [29] utilized a nominal group process to examine barriers to choice within the VR system. The 21 VR counselors

in their study identified a number of barriers that contributed to an inability to maximally promote consumer choice. Several of these barriers related to discrepancies between consumers’ and counselors’ expectations about what the consumer was capable of accomplishing and what the VR system could or should do for them. For example, counselors’ greatest barriers included “lack of knowledge of vocational rehabilitation system,” and “balancing consumer expectations with reality” (p. 207). Unfortunately while a review of the literature reveals many articles about the importance of consumer empowerment, involvement and autonomy in the rehabilitation process, there are few concrete suggestions for counselors about how to accomplish this aim. Even counselors who received specific training on counseling interventions to explore consumer goals and expectations during their pre-service educational programs can easily lose sight of the importance of giving serious attention to promoting consumer choice, when that choice is perceived as being unrealistic or unattainable. Given high caseloads of ever-increasingly severely disabled individuals and ongoing pressures to effect successful placements, it is not surprising that counselor competence in promoting consumer choice may become eroded. 1.1. The working alliance Based upon the foregoing discussion, it would seem that what is needed is a model that focuses on successful outcomes, but also incorporates a counselor-consumer dynamic of shared involvement, power, and commitment to the goals of rehabilitation. Such a model might create a framework for the development of practical suggestions for the counselor that focus not only on outcomes, but also on a rehabilitation process more likely to ensure outcomes considered to be successful closures by the agency, counselor and consumer alike. The Working Alliance is a useful way to conceptualize those characteristics that comprise a positive counseling relationship. The Working Alliance has been described as a collaborative process characterized by shared goals, tasks, and attachment bonds [3]. The Working Alliance has been shown to be a strong predictor of successful outcomes, including consumer satisfaction, participation in counseling, behavior change and a wide variety of therapeutic gains [1,19,22,26,39]. This conceptualization of the successful counseling relationship with its emphasis on collaboration and mutual participation would seem to hold particular rele-


vance for VR counselors for whom issues of inclusion, empowerment, and promotion of autonomy have become central to the definition of a healthy counseling relationship [18]. 1.2. Counseling expectations Al-Darmaki and Kivlighan [1] have theorized that the Working Alliance is based upon four factors, one of which includes congruence between counselor and consumer expectancies regarding counseling. Research suggests that the construct of consumer expectancies is essential in the establishment of a successful working relationship [1,37]. Other studies have linked early termination in counseling either to low expectations [2] or to discrepancies between the consumer’s expectations and their actual experiences [37]. Chan et al. [8] suggest that discrepancies between counselor and consumer expectations might be particularly amenable to change, as compared to the other factors that contribute to the strength of the Working Alliance. They further suggest that this concept is very important to VR counselors and consumers, although it rarely is addressed within this service delivery system. The importance of consumer expectations within VR was echoed by Koch [21] in her qualitative study of the preferences and anticipations of consumers. She concluded that: each participant in the study had his or her own unique set of clearly stated preferences regarding VR services, counselor characteristics, meetings/appointments with the counselor, counselor role, consumer role, and VR goals; however, their anticipations were often quite unclear. The expectations with which each consumer enters the VR process are likely to have far-reaching implications for individualized rehabilitation planning, and the consideration of consumer expectations at all phases of the VR process promotes the delivery of responsive, consumer-driven services. For these reasons, the impact of consumer preferences, anticipations, and preference-anticipation ambiguities on the rehabilitation process is an area ripe for further investigation (p. 85). Given the potentially strong relationship between congruence of expectancies, the development of a healthy Working Alliance and positive outcomes, it appears that counselors would be well-advised to spend time early in the counseling relationship to examine the nature of the expectations of both themselves and their consumers, and to attempt to bring the expectations of

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both parties into some sort of “alignment”. The literature seems to suggest that if one could examine the expectations of counselor and consumer at the outset of rehabilitation and then devise a means for bringing any areas of divergence into closer alignment, it would increase the chances of the development of a stronger working alliance, thereby improving the chances of achieving successful outcomes. The remainder of this article will describe an intervention developed by the researchers intended to achieve this result.

2. Counselor-Consumer Expectation Convergence Intervention The Counselor-Consumer Expectation Convergence Intervention was designed to identify the expectations of counselors and consumers and to bring them closer into alignment. The intervention consists of two primary activities, followed by an evaluation. The first activity consists of pre-training activities, which result in the generation of an Expectations About Rehabilitation Counseling (EARC) Expectation Discrepancy Profile that identifies areas of convergence and divergence between the expectations of counselors and consumers early in the process of vocational rehabilitation. Additionally, counselors complete a values exploration checklist prior to training called the Vocational Rehabilitation Expectations Modification Questionnaire (VREM-Q). The second major activity comprising the intervention involves the development and delivery of Expectation Convergence Training, designed to help counselors utilize the EARC to reduce divergent expectations in a manner that empowers and fully respects the views and needs of the consumer. Each of these two major activities is described more fully below. 2.1. Pre-training activities 2.1.1. Expectations About Rehabilitation Counseling (EARC) Profile The EARC is an instrument developed by the researchers to determine the expectations of both Counselors and Consumers early in the VR process. The instrument has both a Counselor and a Consumer version and measures the degree to which the Counselor and Consumer agree with a number of different possible expectations. Counselors and consumers are asked to indicate the degree to which they agree with a number of expectations using a five-point Likert scale, from Strongly Disagree (1) to Strongly Agree (5). The devel-

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opment and content of the EARC is discussed in detail in another article within this special issue [7]. The first step in the pre-training part of the intervention involves a process of orienting VR Counselors by requesting that they read some background materials explaining the theoretical rationale for discovering the expectations of themselves and their Consumers. Counselors are then asked to identify Consumers with whom they have just started working and ask them if they would like to complete the EARC-Consumer Questionnaire. Participating Counselors are asked to arrange to have the EARC administered to the Consumer at their third session, and then to self-administer the EARC-Counselor Questionnaire. Both of the Questionnaires are then returned to the researchers. Chan et al. [7] developed a computer program to score the instruments and report counselor and Consumer scores in a manner that clearly identifies areas of similarity and areas with discrepancies between the counselor and consumer dyads. Appendix A provides an example of a typical report generated by the computer program. The items are arranged within four counseling expectancy subscales labeled on the report as (a) Counselor Behavior; (b) Consumer Behavior; (c) Clinical Rehabilitation Service Needs; and (d) Vocational Service Needs. Counselor and Consumer Raw Scores are provided for each of the four subscales, and a discrepancy score is calculated for each, based on a norm group of 78 counselor-consumer pairs. A cut off score is provided along with each discrepancy score. The report also lists the individual items that comprise each of the subscales and provides the raw scores of counselors and consumers on each. The EARC Profile reports are then returned and interpreted to the Counselors during the Expectation Convergence Training, described more fully below. In addition to completing the EARC, participants are also asked to complete a questionnaire called the Values Related to Expectation Modification Questionnaire (VREM-Q), a values-exploration tool, prior to attending the training. The VREM-Q is not a formal measurement instrument, but rather was intended to encourage discussion among participating VR Counselors about their values related to the VR process, consumer expectations, and expectation alignment. Comprised of a series of statements requiring true or false responses, the VREM-Q reflects the themes of rigidity/flexibility, balance of power issues, cultural beliefs, Consumer characteristics, and VR policy/job issues. A copy of the VREM-Q is reprinted as Appendix B. The questionnaire is intended to better enable VR Counselors to answer such difficult questions as, “What should/can

I expect from this consumer?” “Who should do the compromising when my consumer and I reach an impasse?” and “What issues do I feel are most important for this consumer?” Furthermore, the awareness and self-understanding gained through this values exploration process is believed to be a necessary precursor for considering how to bring discrepant counselorconsumer expectations into alignment. The completed counselor and consumer versions of the EARC and the VREM-Q are mailed to the principal investigator prior to the training workshops and are scored. Counselor/Consumer EARC Scoring Profiles are then generated for each Counselor-Consumer pair. Additionally, the responses to the VREM-Q are tabulated for discussion purposes during the training. 2.1.2. Expectation convergence training protocol The investigators developed a training program specifically for DVR counselors, intended to give them the necessary tools to help them bring expectations between themselves and their consumers into closer alignment. The training consists of an Introduction and four segments. The content of each of these segments is described below.

INTRODUCTION Participants are introduced to the conceptual bases for the training and an overview of the training is provided. Pre-training information about the relationship among congruence of expectations, Working Alliance, and outcomes is reviewed. Each participating counselor receives a copy of the Expectation Discrepancy Profile, developed from the EARCs that have been previously completed by the counselor and a consumer, and submitted prior to the training. The Profiles are quickly reviewed and explained, and participants are advised that they will be using the Profiles later in the workshop to identify counselor-consumer discrepancies in expectations and to work with the consumer toward bringing expectations into closer alignment. At the conclusion of the introductory portion of the training, participants are introduced to a case study that is used to illustrate the skills required of counselors throughout the process. Participants view a videotape of a role-played intake interview with the counselor and the consumer in the case study that is referenced throughout the training. SEGMENT #1: VALUES EXPLORATION AND CLARIFICTION


This training segment focuses on the underlying values that might affect individuals’ expectations toward one another in the rehabilitation counseling relationship, with a particular focus on assisting counselors to examine their personal values as these may impact expectations. The participants’ scored VREM-Qs are returned and data is presented which summarizes the responses of the group to each of the items. Participants are then asked to note those items in which their responses are discrepant from the larger group or which show marked variability in their responses. Next, participants are separated into facilitated discussion groups to process any of these items with fellow counselors. The discussion addresses such issues as rigidity vs. flexibility, balance of power, cultural beliefs, consumer characteristics, and matters of occupational policy and practices. Following the small discussion groups, participants are invited to summarize their discussions in the larger group for processing by the entire class. This segment also includes information about the formation of initial impressions and their power, expectations based on different worldviews/cultures, and the importance of values self-examination. SEGMENT #2: EXPECTATIONS CLARIFICATION AND MODIFICATION In this section, the EARC Profile for each counselorconsumer dyad is discussed in detail. Participants are taught how to interpret the Profile for themselves and with consumers. Each of the subscales representing an Expectancy Domain is explained and participants are oriented to the meanings of the raw scores, discrepancy scores and cut scores. The counselors’ attention is directed to those subscales where the discrepancy score is greater than the cut scores, and the counselor is advised that this suggests that there are substantial differences in expectations within that Expectancy Domain. Participants are directed to examine the individual item analysis for additional information on the specific areas of divergence between their consumers’ expectations and their own. Counselors are advised to attend to any items where the counselor’s and consumer’s rating is in opposite directions, or where there is at least a two point discrepancy between counselor and consumer scores. For example, in the EARC Profile appearing in Appendix A, “John Kounselor” and “Jane Konsumer” have a Discrepancy Score of “12” in the Consumer Behavior Subscale, with a cut score of 10. In the training workshop, John Kounselor’s attention would be directed to this area and he would be directed to examine the item

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analysis within that subscale. John Kounselor would be asked to note that there is a general tendency for the consumer to have rated the items that reflect positive expectations about the consumer’s behavior more highly than the counselor rated them. Additionally, there are two-point differences between several specific items within that subscale: items # 41, 9, 35, and 5. The counselor’s attention is drawn to these items and he is instructed to consider them in light of what he has learned thus far about the consumer with whom he is working. Additionally, the counselor is instructed to skim all of the individual items to identify areas of obvious convergence and divergence. Counselors are asked to make note of such areas, particularly any that suggest a significant discrepancy in any individual expectation. In the case of John Kounselor, for example, items # 21 and 33 within the vocational service needs subscale may merit consideration, as it would appear that the consumer’s expectations for job placement services and job seeking skills training are considerably lower than the counselor’s. The trainer also discusses the meaning of “neutral” (3) ratings, suggesting that many consumers may rate an item as neutral when they simply do not know what to expect. Consequently, the counselor may wish to attend to those items and determine whether items rated in this manner may be areas of uncertainty for the consumer. Participants are then taught a sequence of behaviors designed to assist them in working collaboratively with Consumers to minimize discrepancies. This process is termed The Primary Expectancy Alignment Process (PEAP). The PEAP involves the following steps: 1. Explanation of the process to the consumer, emphasizing that some things can be modified and some cannot. Counselors convey their intent to fully understand the consumer’s needs, to ensure that the consumer understands the concerns of both the counselor and agency in order to come to a mutual understanding about what each may reasonably expect. 2. Identification of areas of significant divergence 3. Engagement in the process of open discussion characterized by consumer elaboration of expectations – Counselor communication of empathy and respect for consumer views – Counselor follow-up to establish values, life issues, past experiences and/or other factors affecting consumer’s stated expectations

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4. Engagement in process of open discussion characterized by counselor elaboration of expectations – Counselor’s rationale, including discussion of such issues as counselor’s style, clarification of relevant agency rules, restrictions, procedures, etc. – Counselor education regarding any consumer misperceptions or misinterpretations 5. Reconsideration of both counselor and consumer expectations with modifications, as appropriate 6. Process of brain-storming to determine all possible options for bringing still-divergent consumer and counselor expectations into alignment 7. Discussion about how counselor and consumer may develop productive relationship despite divergent expectations, as necessary. At this point in the training, participants view a videotaped case study that illustrates a counselorconsumer pair engaged in the PEAP. At the conclusion of the videotape, participants are asked to break into groups of three to engage in role-plays in which each acts in the roles of counselor, consumer, and observer. In each role-play the counselor plays him/herself, and orients the person playing the consumer to his/her role, based upon what he knows about the consumer upon whose responses the EARC Profile is based. The counselor-consumer pair then complete a role-play wherein the counselor attempts to successfully utilize the PEAP. The Observers’ role is to provide feedback regarding counselor effectiveness in implementing the principles of the PEAP. At the completion of the roleplays, the group processes the experience as a whole. In summary, counselors are asked to focus on the EARC profile of a given consumer, to compare the profile with their own EARC profile, and to analyze the areas of concordance and divergence in expectations. They are then instructed in a process of mutual selfdisclosure and exploration in an effort to fully understand the dynamics of divergent expectations. SEGMENT #3: AGREEMENT

COUNSELING RELATIONSHIP

In order to maintain the mutual understanding achieved through the PEAP, participants are encouraged to utilize a Counseling Relationship Agreement (CRA). The CRA is introduced as a contract, similar in concept to the Individual Plan of Employment (IPE) that focuses exclusively on commitments made by both

the parties to maintain clear communication and promote a collaborative working relationship. Participants are provided a CRA for the Case Study Couple to illustrate how the CRA should “flow” from the PEAP. Participants are then provided a template for the development of the CRA (see Appendix C) and are asked to develop a CRA that would seem appropriate to the process in which they had engaged to this point. After completing the CRA, counselors are re-paired with the individual who played the role of their consumer, and the consumer reacts to the CRA. Again, the experience is processed with the entire group. Counselors are encouraged to utilize the agreement as a yardstick to measure their success in developing productive relationships with consumers, and are provided with practical suggestions for utilizing the tool in this manner. SEGMENT #4: CONSUMER ORIENTATION AND SOCIALIZATION Participants are introduced to the concepts of consumer orientation and socialization by conceptualizing the process as “Expectation Discrepancy Prevention”. The important elements of a pre-counseling orientation are reviewed and methodologies for achieving a thorough and meaningful orientation are discussed. Written guidelines for socializing consumers to the VR counseling relationship are provided to participants. Among the critical topics for inclusion are: 1. Goals of the Agency 2. Track Record/Expectation of Success 3. Benefits and Risks of participation in VR Process 4. Eligibility Criteria & Process 5. Financial Obligations/Limitations 6. Timelines 7. Individual Plan for Employment 8. What constitutes a good counseling relationship? 9. The Counselor’s and Consumer’s Role 10. Counselor/Consumer Rights & Responsibilities 11. Counseling “Style” 12. Missed/Late Appointments 13. Working through disagreements or dissatisfaction with Counselor The relation of the orientation and socialization process to the development of convergent expectations is discussed, and participants are encouraged to examine how they might modify their own orientation processes to make them more effective in establishing healthy,


mutually shared expectations. The importance of professional disclosure is emphasized and participants are provided with a sample disclosure statement completed by the counselor in the case study (see Appendix D). Participants are then asked to develop their own selfdisclosure statements. Following completion of their own statements, participants review one another’s selfdisclosure statements and provide feedback.

2.2. Field testing and evaluation of the counselor-consumer expectation convergence intervention The training protocol was field tested on two separate occasions. The training was provided to 42 VR counselors in Wisconsin and North Carolina in a one-day workshop format. Although the training was provided as a field test rather than an experimental research study, we were interested in obtaining information about the nature of the counselor and consumers’ subsequent relationship development. Consequently, in a one-month follow-up, we asked the counselors who had participated in the workshop to complete the Working Alliance Inventory (WAI)-Counselor Form on the specific consumers they were trained to work with in the training workshop. We also asked the consumers to complete the Consumer Satisfaction Scale (CSS). Thirtyone counselors and consumers returned the questionnaires. Campbell and Stanley [6] described this approach as a one-shot case study in a pre-experimental design. The WAI was developed by Horvath and Greenberg [19]. It is a self-report measure. The counselor short form used in this study consisted of 12 items and three subscales, each representing three dimensions of the working alliance (Bond, Goals, Tasks). A sevenpoint Likert type scale is used to rate the levels of agreement or disagreement for each of the 12 items. The internal consistency reliability of the WAI counselor short form is estimated to be 0.95 [22]. The items were modified to reflect working relationship in a rehabilitation rather than a counseling/psychotherapy context. The Cronbach’s alpha of the WAI counselor short form was computed to be 0.88 for this study. Ju and Thomas [20] developed the CSS to measure consumers’ satisfaction with their interaction with counselors and with the services provided by their counselors. The CSS consisted of 20 statements and measured consumer satisfaction with the counselor on seven dimensions: (a) time of appointment and counseling time; (b) communication

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between Counselor and Consumer; (c) counselor accessibility; (d) job placement and employment counseling; (e) counselor’s perceived warmth and empathy; (f) joint planning; and (g) services the counselor provides. Consumer satisfaction is evaluated using a 4point Likert type scale with a value of 4 representing the highest degree of satisfaction and 1 representing the lowest degree of satisfaction. Ju and Thomas [20] reported a Hoyt internal consistency reliability coefficient of 0.91 and a a test-retest reliability coefficient of 0.56 for the CSS. In this study, the Cronbach’s alpha was computed to be 0.88. The mean WAI factor-based score of 5.9 (SD = 0.6) on a 7-point Likert scale for counselors in the intervention group is relatively high. The mean CSS factor-based score for the consumer was 3.4 (SD = 0.5) on a 4-point Likert scale. Participants in the field test were also asked to complete training evaluation forms indicating their general satisfaction with the training. Mean scores on the items ranged from 3.24 to 3.92 on a 4-point Likert scale. The evaluation also included a general comments section. A sampling of some of the kinds of comments received included such statements as: “The small groups and role play made me aware of how different our expectations can be from the Consumer;” “I liked the multimedia format for education and the ability to openly learn and discuss issues;” “I’m going to share it with my manager to present to the agency for use and I’ll definitely review the information and do it with my Consumers;” “this really stresses how important the needs of the Consumer are and how we can strive to meet those needs;” and “This has made me more sensitive to the importance of the relationship between the Consumer and myself.”

3. Discussion This training protocol is based upon the assumption that expectations, specifically the convergence of counselor and consumer expectations, are of substantial importance in the formation of a productive Working Alliance, an assumption supported by the professional literature. The use of an instrument to identify discrepancies between counselor and consumer expectations, and the implementation of a training protocol to assist counselors in reducing discrepancies constitutes an attempt to provide counselors with a practical, cost-effective tool that can help them to meaningfully involve consumers in a collaborative effort to promote commonality of expectations.

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Each phase of the training was based upon both theoretical and empirical research that documented the importance of the content to achieving consensus. For example, expectations about VR counseling relationships, processes, and goals are largely influenced by personal values and beliefs, initial impressions of the counselor and consumer, and differing worldviews. Accordingly, the decision to include a values exploration component to the training curriculum appeared a logical first-step to building a foundation for the discussion of expectations and their alignment. The use of values clarification/exploration exercises to improve selfunderstanding and enhance relationships has received wide support in the field of counseling and psychology, particularly in the areas of counselor education [24,25] and family/marital therapy [4,16,23]. The need for counselors to explore and question their own value systems in order to improve counseling relationships and outcomes has also been recognized in the professional literature. For example, Corey et al. [10] raise the question: “If counselors never reexamine their own values, can they expect to provide a climate in which consumers can reexamine theirs?” Thus by asking questions such as, “What is my position on this issue?”, “Where did I develop my views?”, “Are my values open to modification?”, and “Have I challenged my views and am I open to being challenged by others?”, counselors will not only gain insight into their own beliefs and values that may impact the counseling relationship, but they will be better prepared to encourage consumers to do the same. The importance of counselors assessing their values related to culturally diverse consumers has also been addressed in the multicultural counseling literature. Sue and Sue [36] for example, claim that counselors have a responsibility to 1) become aware of biases, stereotypes and assumptions based on culture, 2) become aware of consumer values and worldviews, and 3) develop culturally appropriate intervention techniques. The PEAP is based on a basic Conflict Resolution Approach. Discrepant values, interests, and perceptions are present in any relationship. When discrepancies are present, conflict will undoubtedly arise. Conflict occurs as a result of the perceived incompatibility of one’s actions or goals with those of another [12]. Only a small portion of conflicts result from truly incompatible actions or goals. The greater problem, in most cases, arises from misperceptions of the other person’s actions or goals as unjust, unfair, or inequitable. Conflicts may arise when the consumer, the counselor, or both partners perceive discrepancies in Expectan-

cies about each other’s roles and responsibilities, the manner in which services are delivered, the type and amount of services provided, and the like. Conflicts may surround issues of Consumer eligibility, timeliness of services, case closure, agency or Counselor error, and agency policies [17]. Directly addressing discrepancies at the level of the consumer-counselor relationship is highly desirable because it demonstrates that the consumer is valued as a member of the Working Alliance, will be treated fairly, and will receive high quality services [17]. Clarifying the nature of differences before they escalate into formal disagreements serves to enhance communication between the consumer and counselor. Generally speaking, the same basic conflict resolution interventions that guide parties at international and industrial levels can be used to resolve discrepancies at the level of the VR partnership. Once discrepancies are identified, in this case using a profile generated by counselor and consumer responses to the EARC, the counselor and consumer can work together to select and implement specific, practical solutions for moving toward a single set of shared Expectancies. The PEAP incorporates many of the basic principles of conflict resolution. For example, the process is designed to accurately identify and define the nature of the discrepancy from the perspectives of both partners. Open communication about differences is required if partners are to begin working toward resolution. The aim of communication should be to develop an understanding and mutual acceptance of each other’s interests, values, perceptions, and notions of fairness even if these may differ. Understanding and mutual acceptance occur when each partner has the opportunity to identify interests and goals. Before responding, the other partner must accurately restate those interests and goals. Reversing roles and communicating from the other person’s point of view also facilitates understanding and mutual acceptance [12]. Partners who communicate in this fashion often find that their viewpoints are not as discrepant as they originally believed. Relationships may become entangled with problems that arise from discrepancies. The tendency to think in adversarial terms and to treat people and problems as one and the same is sometimes present. If this occurs, discrepancies must be re-framed as differences in interests and goals rather than as a “contest of wills” [13]. Re-framing discrepancies as problems which the “team” must confront together encourages the consumer’s active participation and mutual responsibility in resolving the conflict. It also promotes a “we”


attitude or interdependence among partners who, together, are striving toward the shared goal of maximizing the effectiveness of the Working Alliance. In defining the discrepancy, it is important that the consumer be provided with the program or agency’s point of view [17]. Guidelines and boundaries within which the consumer and counselor must work should be clearly communicated [11]. After discrepancies have been accurately defined and understood by both partners, the next step is to clarify misperceptions, particularly when these (rather than true discrepancies) are the real problem. Careless communication is the source of many misperceptions [13]. The counselor, for example, may make a statement that is interpreted by the consumer as a commitment when the counselor does not, in fact, intend to commit. Striving to constantly clarify not only what is said, but also how the other person interprets one’s statements can prevent miscommunications. Trust is another key factor and has been described as “the single most important element of a good working relationship” [12, p. 107]. Keeping promises, following through with commitments, and behaving reliably are all conducive to establishing a trusting relationship. Not only one’s actual behavior but also how the behavior is interpreted can serve to either promote or impede a trusting relationship. Although a counselor’s behavior (such as arriving late for appointments) may be perceived by the busy practitioner as excusable, it may be perceived by the consumer as a lack of reliability. Discrepancies may be minimized by sharing ideas regarding how a single set of shared Expectancies can be achieved. Brainstorming, without criticism, helps to produce a comprehensive list of potential strategies for resolving discrepancies. Then, potential strategies can be evaluated by both partners who can then reach consensus on precisely which strategies are selected for implementation. Reconciling interests, as opposed to compromising between positions, should be the function of any options chosen [13]. The final steps in resolving discrepancies involve the actual implementation and evaluation of resolutions. Both partners should, at this point, be able to agree on what each other’s roles and responsibilities will be. While some residual degree of discrepancy is likely to remain, this can be explicitly acknowledged, accepted and respectfully considered in the selection of both rehabilitation goals and methods. It is neither practical nor necessary to have a discrepancy-free relationship before proceeding with rehabilitation planning. The Counseling Relationship Agreement (CRA) is a means for enhancing relationships and was developed

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and included as an integral part of the intervention because the benefits and guidelines of using CounselorConsumer contracts in individual counseling and psychotherapy are well-documented in the literature [27, 32,34]. The value of using contracts with couples in marriage counseling to address conflictual relationships has also been reported [40]. The use of contracts in VR, however, has not been widely addressed. Although VR Counselors are familiar with the use of IPEs to ensure mutual agreement and understanding about the vocational goals and services to be provided, this type of agreement does not specifically address the CounselorConsumer relationship. Issues such as agreement regarding the roles and responsibilities of the Counselor and consumer, the need for open communication of information and feelings, and how dissatisfaction or conflicts will be handled, are often assumed by the Counselor and Consumer rather than openly and explicitly addressed. As previously reported, Koch [21] found that VR consumers enter into the rehabilitation process with clear preferences but ambiguous anticipations regarding services. She notes that these results reflect the findings of a previous study conducted by Galassi et al. [14]. Given the evidence that Consumers often do not know what to anticipate or expect from VR services, it appears that a method of informing them about the VR process would be advantageous. Specifically, using an orientation and socialization approach to educate consumers about what to realistically expect from the VR process may enable them to clarify their own expectations. Consumers could then determine if their expectations “fit” with the information provided. Thus, clarifying expectations at the onset of the VR process may serve as “divergence prevention” by eliminating false assumptions and unrealistic anticipations. The use of orientation and socialization methods to enhance the counseling process has been supported in the professional literature. In a study of students who accessed a university counseling center, Tryon [38] found that teaching the Consumer about the counseling process, and longer intake interviews, were positively associated with Consumer engagement. Similarly, the advantages of preparing Consumers for counseling has been recognized by professionals working with new or “non-Consumers” [35], by those working in the areas of brief or time-limited counseling [5], and those working with social-work groups [15]. Thus, it appears educating or orienting consumers new to the VR system may be an equally beneficial process. Specifically, informing consumers regarding issues such as the purpose

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and policies of VR agencies, the Counselor-consumer relationship, and the roles and responsibilities of the VR consumer and counselor may serve to engage the consumer, dispel any false expectations, and reinforce the understanding that he or she is considered a valued partner in the VR process. Additionally, the use of Professional Disclosure Statements has been promoted as a valuable means of helping the consumer to understand the parameters of the counseling relationship, the services to be provided, and essential information that may be important to the consumer’s decision-making throughout the VR process [33].

[3]

[4]

[5]

[6]

[7]

[8]

4. Summary and conclusions The early identification of discrepancies in Consumer-Counselor Expectancies appears to be a promising preliminary step for establishing effective Working Alliances. Within the VR arena, counselors and consumers can work together to select and implement practical solutions for moving toward a single set of shared Expectancies. This process involves a conflict resolution model, accompanied by specific actions intended to facilitate and extend the process. Application of the skills learned by participants in the training intervention may lead to a better alignment of Expectancies, which consequently may serve to strengthen the Working Alliance, reflecting a strong Counselor-Consumer partnership in the true spirit of the principle of comanagement and mutual participation.

[9]

[10]

[11]

[12] [13] [14]

[15]

Acknowledgment Preparation of this paper was supported in part by a field-initiated project (Enhancing Consumer-Counselor Work Relationships in Rehabilitation), which was funded by Grant #H133G980135-00 from the National Institute on Disability and Rehabilitation Research to Virginia Commonwealth University.

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Appendix A A Sample Computer-Based EARC Scale Report for a Counselor-Consumer Dyad Counselor Name: John Kounselor Consumer Name: Jane Konsumer Expectation Discrepancy Profile Our research has indicated that congruence in counselor-consumer expectations about the consumer’s rehabilitation counseling program and outcomes will improve counselor-consumer working alliance, consumer satisfaction, and rehabilitation outcomes. The computer has calculated your scores on the Expectations About Rehabilitation Counseling Scale-Counselor Form and the scores of your consumer on the Consumer form. The results can be used to identify and resolve discrepancies in expectancies, the resolution of which will, in turn, improve the consumer-counselor working relationship. The EARCS assesses four domains of counseling expectancies: (a) counselor behavior, (b) consumer behavior, (c) clinical rehabilitation service needs, and (d) vocational service needs. The following table provides raw scores information for both the counselor and the consumer on the four expectancy domains: Counselor (Raw Score): 111 Consumer (Raw Score): 120 Min=24, Max=120 Counselor (Raw Score): 27 Consumer (Raw Score): 39 Min=8, Max=40 Counselor (Raw Score): 15 Consumer (Raw Score): 16 Min=6, Max=30 Counselor (Raw Score): 17 Consumer (Raw Score): 12 Min=6, Max=30 Based upon these scores, a discrepancy score has been calculated for each domain based on a norm group of 78 counselor-consumer pairs. If the discrepancy score in any of the expectancy domains is greater than the cut-off score, you may want to discuss with your consumer why both of you have substantial differences in expectations in that specific expectancy domain. Discrepancy Score: 9 Cut score=19 and above


Discrepancy Score: 12 * Cut score=10 and above Discrepancy Score: 3 Cut score=9 and above Discrepancy Score: 7 Cut score=8 and above ITEM ANALYSIS Counselor Behavior Subscale 23. responsive to consumer’s needs. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 11. encourage consumer to make sound decisions. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 25. fair to consumer. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 2. professional, supportive, and competent. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 39. keep promises to consumer. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 18. efficient in coordinating rehab services for Consumer. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 15. counselor and consumer respect each other. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 24. both behave in a responsible and trustworthy manner. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 16. sensitive to disability, minority, and cultural issues. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 40. creative and resourceful in solving problems. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 26. agency treats Consumer with dignity and fairness. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 44. consumer and counselor accept each other’s limitation. Counselor’s Rating: 1 2 3 [4] 5 Consumer’s Rating: 1 2 3 4

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7. positive and hopeful regarding Consumer’s progress. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 20. communicate clearly and directly with consumer. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 1. skillful and experience in working with Consumer’s disability group. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 6. consumer and counselor cooperate with each other. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 32. agency has the right inter-agency linkage to help Consumer. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 8. consumer and counselor communicate openly and completely. Counselor’s Rating: 1 2 3 [4] 5 Consumer’s Rating: 1 2 3 4 36. actively listen to consumer’s concerns and issues. Counselor’s Rating: 1 2 3 4 [5] Consumer’s Rating: 1 2 3 4 10. provide consumer with honest feedback regarding rehab potential. Counselor’s Rating: 1 2 3 [4] 5 Consumer’s Rating: 1 2 3 4 28. put Consumer’s best interest above all else. Counselor’s Rating: 1 2 3 [4] 5 Consumer’s Rating: 1 2 3 4 29. consumer and counselor share openly each other’s frustration. Counselor’s Rating: 1 2 [3] 4 5 Consumer’s Rating: 1 2 3 4 3. consumer and counselor share responsibility for goal setting/ attainment. Counselor’s Rating: 1 2 [3] 4 5 Consumer’s Rating: 1 2 3 4 13. actively seek Consumer’s input during all stages of rehabilitation. Counselor’s Rating: 1 2 3 [4] 5 Consumer’s Rating: 1 2 3 4 Clinical Rehabilitation Service Needs Subscale 4. consumer needs Counselor’s Rating: Consumer’s Rating: 22. consumer needs Counselor’s Rating: Consumer’s Rating: 12. consumer needs Counselor’s Rating: Consumer’s Rating: 17. consumer needs Counselor’s Rating:

independent living services. 1 [2] 3 4 5 1 3 4 5 supported employment services. 1 2 [3] 4 5 1 3 4 5 supported living arrangements. [1] 2 3 4 5 2 3 4 5 family counseling. 1 2 3 [4] 5


Consumer’s Rating: 1 2 3 4 43. consumer needs psychological counseling. Counselor’s Rating: 1 [2] 3 4 5 Consumer’s Rating: 1 2 4 5 38. consumer needs benefits counseling (e.g., SSI, SSDI, and Medicaid) Counselor’s Rating: 1 2 [3] 4 5 Consumer’s Rating: 1 2 4 5

Consumer Behavior Subscale 41. consumer completes his or her rehab program successfully. Counselor’s Rating: 1 2 [3] 4 5 Consumer’s Rating: 1 2 3 4 9. consumer follows through with his or her assignments and rehab activities. Counselor’s Rating: 1 2 [3] 4 5 Consumer’s Rating: 1 2 3 4 35. consumer opens to suggestions and feedback. Counselor’s Rating: 1 2 [3] 4 5 Consumer’s Rating: 1 2 3 4 30. consumer is open and honest with counselor. Counselor’s Rating: 1 2 3 [4] 5 Consumer’s Rating: 1 2 3 4 37. consumer shows up on time for appointments. Counselor’s Rating: 1 2 3 [4] 5 Consumer’s Rating: 1 2 3 4 19. consumer participates in rehab plan development with counselor. Counselor’s Rating: 1 2 3 [4] 5 Consumer’s Rating: 1 2 3 4 5. consumer finds job upon completion of rehab program. Counselor’s Rating: 1 2 [3] 4 5 Consumer’s Rating: 1 2 3 4 42. consumer realistic about his or her strengths and limitations. Counselor’s Rating: 1 2 [3] 4 5 Consumer’s Rating: 1 2 3 5

Vocational Service Needs Subscale 14. consumer needs Counselor’s Rating: Consumer’s Rating: 34. consumer needs Counselor’s Rating: Consumer’s Rating: 21. consumer needs Counselor’s Rating: Consumer’s Rating: 33. consumer needs Counselor’s Rating: Consumer’s Rating:

vocational testing. 1 [2] 3 4 5 2 3 4 5 vocational counseling. 1 2 3 [4] 5 1 2 3 4 job placement services. 1 2 [3] 4 5 2 3 4 5 job seeking skills training. 1 2 [3] 4 5 2 3 4 5

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27. consumer needs vocational training. Counselor’s Rating: 1 2 [3] 4 Consumer’s Rating: 1 2 4 31. consumer needs psychological testing. Counselor’s Rating: 1 [2] 3 4 Consumer’s Rating: 2 3 4

5 5 5 5

Appendix B Vocational Rehabilitation Expectancies Modification Questionnaire – VREM-Q NAME:

DATE:

INSTRUCTIONS Please read each statement carefully. Rate each item by selecting “T” for True or “F” for False, according your beliefs about the statement. If you are unsure how to respond, select the response that is closest to your own opinion. True or False Consumer behavior 1. Consumers should make their own decisions about their own lives, independent of their families 2. There is no valid reason for a Consumer to consistently not follow through with agreed-upon plans 3. Regarding Consumers, there is a fine line between being an effective “self-advocate” and a “pain in the neck” 4. If a Consumer constantly questions my ideas and recommendations, it is a sign that he or she has a problem with authority, and will likely have difficulty accepting supervision in the workplace Consumer / disability characteristics 5. Consumers who are uncertain about whether or not they want to return to work should never become Consumers of the VR agency 6. Individuals with certain disabilities are less likely to succeed in VR than others 7. Intelligent Consumers are the most employable VR Policy / Job Issues 8. A Counselor should never break an agency rule on behalf of a Consumer 9. It is no use asking for better resources from the agency to do my job, since no matter what I do, nothing will change 10. It is difficult to justify spending thousands of dollars to serve one Consumer with severe physical disability, when the same funds could be used to serve several Consumers with mild to moderate disabilities 11. A Counselor cannot justify opening a case on a new Consumer, if that Consumer cannot articulate a reasonable, specific vocational goal during the initial interview Counselor responsibility 12. A Counselor who arrives late for an appointment is being disrespectful to the Consumer 13. I treat each Consumer the same, regardless of his/her race, gender or lifestyle 14. When Counselors and Consumers disagree, the Counselor is usually right

T

F

T

F

T

F

T

F

T

F

T T

F F

T T

F F

T

F

T

F

T T T

F F F


15. When Consumers evidence difficulty with identifying goals and making decisions, the Counselor needs to take a more active role and help guide him or her in a reasonable direction 16. In certain situations, it is acceptable for Counselors to assist Consumers with non-vocational activities; i.e. emergency errands, provide transportation, etc. . . VR Expectations 17. If a Counselor and Consumer cannot agree on vocational goals, there is no way they can work together effectively 18. Consumers have a right to expect their Counselors to respond to their needs quickly 19. Many Consumers are basically looking for a “free ride” from VR 20. I can predict early in the relationship whether or not my Consumer will be successful in VR 21. A Consumer’s past behavior virtually always predicts his or her future behavior 22. I believe all Consumers have vocational potential

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T

F

T

F

T

F

T T T T T

F F F F F

Appendix C The Counseling Relationship Agreement (Template) Purpose The Counseling Relationship Agreement is used by the VR Customer and Counselor to assist them to work cooperatively throughout the vocational rehabilitation process. Open, honest communication is important in all relationships, including the one between the VR Customer and Counselor. If the VR Customer and Counselor can build a strong working relationship based on trust and open communication, and if each of them has clearly defined responsibilities, it is more likely the customer will have success in achieving his or her goals. This form serves as a written agreement, stating that the customer and Counselor will discuss any concerns about their relationship and/or the vocational rehabilitation process while they are working together. Terms of Agreement enter into this Counseling Relationship

With an understanding of the purpose outlined above, I (Customer Name) on (Counselor Name) For the length of this Agreement, I

.

Agreement with

(Date) agree to meet the following responsibilities in my role as (Customer Name)

Customer: 1). 2). 3). 4). 5). Likewise, for the length of this Agreement, I agree to meet the following responsibilities in my role as Counselor: (Counselor Name)

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1). 2). 3). 4). 5). If either I

, or I have a concern that one or both of us is not fulfilling our agreed (Customer Name) (Counselor Name) upon responsibilities, that we have differences in opinion that are limiting our progress, or that some other issue is affecting our relationship, we will discuss the concern(s) with each other immediately. In order to occasionally check how satisfied we are with our working relationship, we agree to discuss our relationship during meetings to month(s). be held every month(s), and will be effective This Counseling Relationship Agreement will last for a period of . On this date, this Agreement may be revised, renewed, or terminated. If either of us become until (Date) dissatisfied with our Agreement prior to this date, we may request to revise or terminate it at any time.

(Signature of VR Customer)

(Date)

(Signature of VR Customer)

(Date)

Appendix D Sample Professional Disclosure Statement Katherine Alexander, M.S., CRC Division of Vocational Rehabilitation 300 La Grange St, Middletown, WI Phone: 608-262-2881 e-mail: [email protected] Hello. My name is Katherine Alexander and we will be working together here at the Division of Vocational Rehabilitation. My job, as your Counselor, is to help you to figure out what your work goals are, and then together, to figure out what we will need to do to help you reach those goals. Since we will be working closely together, I thought I would give you a little bit of information about me, so that we can start getting to know each other. About Me: I am 38 years old and am married, with two children who are 5 and 9. I’m from a very small town in South Carolina, but have lived in Wisconsin for the past 25 years. I’ve been working with people with disabilities for about 10 years and I really love my work. I have been lucky enough to work with all kinds of people, so I’ve had a lot of experience with a lot of kinds of disabilities. Five years ago I learned sign language and started working with people who were deaf, so I’ve learned a lot about deafness, as well as the other disabilities. When I’m not working, I like to read and I also collect antique doll furniture. Mostly, I like to spend time with my children and my family.


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My Values: In my work as a VR Counselor, I try to be guided by the belief that most of us want to do the best that we can for ourselves and our families. I think people want to work hard and want to succeed, but that sometimes things get in our way and make it difficult. We all make mistakes, but we all have the ability to learn from our mistakes. I believe that everybody can work, if we are just committed enough and creative enough to find ways around the problems that keep us from doing what we know we can do. I also believe that people have the right to make decisions about their own lives. My job is to help you do this, not to do it for you. I may not agree with every decision that my Consumers make, but I do respect them and always try to do my best to understand their situation and why they feel that a particular decision is the right one for them. I believe in honesty. I’ll try to be honest with you about what I’m thinking and feeling as we work together and I hope you will be honest with me too. Roles and Responsibilities: My role is to assist you in becoming employed and to help you make a plan for reaching your job goals. I want to know about any problems that might make that difficult and to understand your needs and preferences. Together, we’ll make a plan and I’ll try to assist you however you might need assistance as we carry that plan out. Your role is to be as honest and open as you can be about any issues related to your disability or to your plans for employment. You will be actively involved and will be asked to carry out some activities like getting your medical records, going to appointments, or following up on job leads. Your Rights: You have many rights in your relationship with Vocational Rehabilitation and with me. You have the right to make your own decisions and to withdraw from involvement with us at any time. You have the right to ask questions if there is anything you do not understand. You have the right to be actively involved in everything we do together. If you are not happy with me or with the agency, you have the right to file a complaint. These rights are yours and I want you to feel free to use them. My Education and Qualifications: As mentioned above, I went to school for many years and I have completed a lot of extra training. I have passed tests and gotten some additional qualifications. I am sharing these with you because I want you to feel confident that I have the background to be able to assist you. Here is a brief summary of my qualifications to work with you as your VR Counselor Education: Masters: Rehabilitation Counseling U of Wisconsin – Madison 1991 Bachelors: Psychology U of Wisconsin – Madison 1989 Credentials: I have been a Certified Rehabilitation Counselor since 1992. I also have advanced training in sign language and I am a certified Red Cross Instructor. If you have any questions, please ask me. I look forward to working with you!