In chapter 12 we saw that the interview serves as the primary assessment tool in decision-making counseling, and that there is fairly close agreement among the various schools of counseling as to how the early stages of the interview ought to proceed. Paying attention to any cognitive, affective, motor, and somatic behavior the client displays is important not only for the gathering of accurate assessment data but also for establishing the counselor as a "personified" secondary reinforcer. Counselors who develop this "reinforcing relationship," as it is sometimes labeled, are more likely to have an impact on their clients' behavior. Verbal reinforcement or modeling interventions, for example, become more powerful.
We should realize that acknowledging these facets of the laws of reinforcement does not detract one iota from the sincerity of our counseling motives. The fact that we may pay close attention to our clients out of deep concern for them does not alter the parallel fact that such attention may improve the efficacy of our counseling interventions.
In this chapter we shall explore a wide variety of cognitive-behavioral interventions that are available for the conduct of decision-making counseling. The choice of which techniques to use depends first of all upon the particular skill deficits the counselor assesses. For any given skill deficit, however, several interventions may be applicable. Unfortunately, there are relatively few comparative studies in the counseling literature that clearly demonstrate the superiority of one technique over another. A good guideline would be to select the counseling intervention with the firmest research basis whenever possible.
The summary model and assessment questions depicted in table 12.1 provide a convenient outline for our discussion of interventions in decision-making counseling. Although I have attempted to illustrate most pertinent interventions, undoubtedly many others could also be applied. Still others await discovery.
In the first place, behavioral counselors do not suggest listening as a cure for all client ills. Rather, they see it as a specific intervention, the efficacy of which on certain kind of client problem, namely high affective arousal, is open to empirical scrutiny. Moreover, the potential effects of listening when applied to such client problems are readily interpretable in the language of behaviorism: Listening permits an extinction process to occur. Let us take, for example, the case of a client who begins talking about a situation that presently produces high levels of guilt or maladaptive anxiety. In talking about this situation, the client is in fact exposing himself or herself to the problematic conditional stimulus (CS) or source of discomfort. If the "listening" counselor presents a nonjudgmental, positively-rein forcing demeanor (that is, if the counselor does not introduce or reintroduce a noxious unconditional stimulus WSJ the client's teamed guilt or anxiety can be expected to extinguish. This is why many clients report feeling better after a confession or a catharsis. "Nothing terrible happened after all!" It is also why the technique of systematic desensitization seems superfluous with some clients once the fear hierarchy has been constructed.
If listening alone does not reduce debilitating affective arousal to manageable levels, other intervention procedures may be employed. Relaxation training or any of the varieties of systematic desensitization, for example, are techniques for lowering anxiety and guilt. Cognitive restructuring is also apropos, particularly when the client seems immersed in self-defeating anger. Cognitive restructuring involves identification of the irrational self-statements that give rise to the negative emotion and counselor modeling of a more adaptive thought pattern.
Paraphrasing is perhaps the principal intervention strategy to be used at this point. Paraphrasing is simply an extention of the assessment dictum to pay attention to all cognitive, affective, motor, and somatic behavior displayed by the client. My definition of paraphrasing is broader than Ivey's (1971); it includes reflection of feeling as well as content, Paraphrasing means to repeat what was said in the way it was said but more concisely.
Paraphrasing, of course, demands that the counselor understand what the client is saying, which brings me to a brief digression. Because clients will rarely aid the counselor by using clear, unambiguous language, the counselor must reflexively probe for specific examples of terms used by the client. Probing means to cue and reinforce the client for using operational definitions. For instance, the counselor might respond to a client's cloudy terminology as follows: " 'Inconsiderate.' Would you give me a few examples of how your (husband/fwife) is inconsiderate of you?" (Client responds.) "That's helpful to me; I see what you mean." Or perhaps, "When do you feel 'really down'? Can you tell me what it's like, what's going on in your head?" (Client responds.) "Uh, huh. That's a pretty good description. I think I understand what's happening with you, but can you tell me a little bit more about the 'hassling' you've been getting from your parents?" Counselors should only attempt paraphrasing when they have a fairly firm grasp on what the client is saying.
As an intervention strategy paraphrasing has the immediate effect of reinforcing the client's continued talking about a given problem area. In other words it supplies the counselor with further assessment data that will then indicate whether the client's concern is a problem of choice. At the counselor's discretion paraphrasing may be supplemented with other interventions, such as Socratic dialoguing, in an attempt to clarify the problem. However, the assessment of the client's problem as one of choice and the intervention that defines it as such is a final paraphrase that tentatively sifts through and fits the data at hand into a choice framework that the client in turn will accept, reject, or modify.
Cognitive restructuring procedures are apropos when clients seem to have a fatalistic or other self-defeating outlook on their ability to have a positive impact on their lives. For example, Ellis (1962) addresses one facet of this topic with his observations on the irrationality of needing to find someone on whom to depend. Not infrequently, clients will continue this dependency-seeking behavior in counseling by asking the counselor what course of action to follow. Counselors should scrupulouslv avoid donning this decision-making yoke, as it reinforces the client's avoidance of responsibility and sets the counselor up as an inevitable scapegoat when the choice proves less than ideal.
Other clients may recognize their concern as a problem of choke but fail to realize that "not to decide is to decide." In other words, procrastination or avoiding deliberate decision making is in fact tantamount to selecting an alternative that may prove relatively disadvantageous. "Maybe I'll decide to quit smoking after the first of the year" or "If that lump in my breast doesn't go away by next month, I'll have to do something about it" illustrates the dangers of this approach. Interventions such as emotional role playing that sensitize the client to the long-range consequences of indecisiveness may be useful in such cases. Kravetz and Thomas (1974) offer a number of behaviorally based suggestions for working with indecisive clients.
Cognitive modeling is probably the most pertinent strategy for helping clients develop an adaptive perspective on the process of decision making. A cognitive model "thinks out loud" in an attempt to foster a similar thought pattern in the observer, By serving as a live cognitive model, the counselor can efficiently inculcate the decision- paradigm in the client. Key components of the counselor's script (that is, verbalized thought pattern) are that there are ways of generating alternatives and procedures for discovering which alternative is likely to be best. The script should also pay homage to the fact that the responsibility for selecting an alternative rests with the client, but if need be the counselor can provide help with its implementation. Any of the client's verbal behavior that suggests the development of an adaptive decision-making perspective should, of course, be met with liberal reinforcement from the counselor.
Although the foregoing techniques are intended to prevent rash behavior, the client will frequently have already responded impulsively before talking to the counselor. In such cases cognitive restructuring in conjunction with other skill-building interventions such as behavioral rehearsal or covert modeling may prove useful.
To illustrate these interventions, let us consider the case of a client who is unfairly passed over for a promotion. He or she obviously has a career decision to make. Ruminations on the supervisor's ancestry or repeated urges to quit on the spot can be interrupted by thought stopping. The act of resigning impulsively may also be averted if the client covertly experiences some of the perhaps unconsidered outcomes of that response (for example, negotiation for a new job from a position of need rather than security). In the event the client has already impulsively resigned, the counselor may consider interventions designed to "undo" the response. For instance, cognitive restructuring (along the lines of "your personal adequacy does not depend upon this supervisor's appraisal") combined with behavioral rehearsal (directed toward asking that the resignation request be ignored) can restore the possibility of an adaptive choice
In this example and in any other, the impulsive response might well prove to be the best alternative. The point is not to prevent the response from being made but to prevent it from being made impulsively. It may certainly be in the client's best interest to change jobs (that is, the SEUs for leaving may be higher than for staying); but to respond without deliberation would be maladaptive,
The problem-solving literature has supplied the counselor with a diverse array of interventions for helping the client generate alternatives. In the first place the counselor can foster a creative instructional set by suggesting to the client that he or she has the ability to find potential Solutions. In this optimistic atmosphere the counselor may also wish to invoke originality training, brainstorming, or some form of metaphorical thinking in an attempt to help the client develop a larger response repertoire.
Despite these interventions, however, the client in many instances will simply not discover viable alternatives known to the counselor. Thus the counselor may wish to model these alternatives. It is important that the counselor preface any such modeling procedures with the disclaimer that the alternatives to be modeled need not be implemented unless the client freely chooses to do so later. In other words the counselor should make it clear that he or she is suggesting what might be done rather than what ought to be done.
Counselor-generated alternatives may or may not be better than those already in the client's response repertoire; the client will ultimately have to evaluate their worth. At the moment of introduction they are simply other options to consider. However, at the very least they may stimulate the client to generate still more alternatives.
To illustrate the use of some of these procedures, let us consider the case of a rather shy, twenty -two-year-old epileptic bookkeeper who lost her job when flood waters destroyed her place of employment. Although her disease has been in remission for two years, she believes her inability to find work is due to medical prejudice on the part of potential employers. At the outset of counseling she viewed her only alternatives as withholding or not withholding the fact of her illness on future job applications. Brainstorming procedures generated additional alternatives: become self-employed, go back to school, remain unemployed and apply for welfare, move to another city where employers might be less prejudicial, and deny the history of epilepsy until after being hired. During the course of their interaction the counselor suspected from her reticent demeanor that her job interviewing skills might be deficient. So the counselor then modeled how she might present herself and her medical history to a potential employment interviewer as another alternative for further consideration.
Therefore adaptive decision making may call for input on possible alternatives from beyond the counselor-client dyad. For example, in doing group counseling I am frequently pleased to observe the high quantity and quality of alternatives generated by the group for an individual's decision; these alternatives are often more promising than those the client and I would have generated in a dyad. Groups of clients, however, are not readily available when an individual client presents a decision-making concern. Nor are some clients open to the prospect of discussing their lives in the context of a group. Therefore verbal cuing and reinforcement along with modeling procedures are possible interventions for helping the individually seen client search for additional alternatives outside the context of counseling.
The extensive research on these techniques has been covered in chapter 9, so two brief examples should suffice here. The unemployed epileptic client might be cued and praised for planning to ask an epilepsy foundation (or a personal friend with a similar problem) about additional options. Another client with no vocational plans might view a model tape depicting a similar individual visiting a career resource center to get some idea about job opportunities.
There is no set cutoff point for determining when a sufficient number of external sources have been tapped. Procedurally, one might ask the most likely sources for alternatives and then ask these same sources about other potential sources. Within a fairly short time growth of the expanding list of alternatives will plateau and the search can be curtailed.
Procedurally, the counselor begins by asking the client what are the pros and cons and the likelihood of occurrence for each alternative. Many of the same problem-solving interventions used for the generation of alternatives can be continued at this point. For instance, brainstorming can now focus on the identification of potential consequences. Outcome psychodrama is designed to produce a similar effect, This technique essentially involves cuing the client to think about and vividly imagine what might happen following, for example, a divorce or the selection of a particular career.
The counselor's own experience will often suggest positive or aversive consequences the client may not know in spite of the foregoing interventions, For example, a youth indicating an interest in one of the construction trades may report that the comparatively large wage and the chance to work outdoors offer high utility and strong probability; yet the youth may be unaware that the seasonal nature of the work may lead to frequent periods of unemployment.
The counselor may find modeling an effective way of exposing potential consequences and probabilities the client does not already know. Management of this technique, however, can be tricky. It is imperative that the counselor guard against the easily given impression of advocating or speaking against a particular alternative; such a mistaken impression would seriously jeopardize the counselor's credibility with the client. More important, though, if such an impression were true, it would signal unconscionable meddling. The counselor's principal task at this point is to supplement the client's limited perspective with as much information as possible on the likely outcomes of each course of action. Even though the counselor may occasionally have biases as to which alternative might be better (from the standpoint of the counselor's idiosyncratic utilities and probability estimates), the counselor is ethically obliged to give all credible alternatives a fair and thorough hearing. Therefore the counselor should preface his or her script with comments to the effect that the information presented is not intended to steer the client in any direction but rather to identify consequences that may not have been considered.
Such reference sources abound in the field of occupational choice. For example, exhaustive information on various lines of work is attractively packaged and readily available in most career resource centers. This information can be supplemented by vocational interest and aptitude tests that identify in general terms the likelihood of a client's success in a given career.
Although verbal cuing and reinforcement are the principal intervention strategies for encouraging information seeking, audio or video modeling procedures are also promising if the frequency of a particular kind of decision is sufficiently high to make their development cost effective. For example, a film depicting a youth talking with individuals already employed in a prospective profession could be used extensively in a high school or college counseling setting. For less typical concerns, on the other hand, counselors may use themselves as live models illustrating how more information might be obtained. A client considering elective surgery, for example, could be shown what to ask the recommending and consulting physicians.
Simulation is another promising intervention for identifying additional discriminative stimuli. Essentially, this strategy allows the client to try out a given alternative without risk or commitment. job simulation kits, discussed in chapter 9, have been used in the counseling field for the past decade. This same principle can be extended to nonvocational. choices as well. For example, a childless couple ambivalent about the prospect of having children might acquire invaluable discriminative stimuli from weekend babysitting experiences or the temporary placement of a foster child in their home. Prior to divorce, a couple might likewise profit from experiencing the different life-style on a trial basis.
As with the generation of alternatives, there is no set cutoff point for determining when a sufficient number of discriminative stimuli have been identified. Eventually, however, a point of diminishing returns will set in and the costs (negative utility) for continuing the search will outweigh the perceived benefits of supplemental information. In establishing the market value of a common antique, for example, an exhaustive search of all sales records is not likely to add much information beyond what can be obtained from a representative sample of auction catalogs and dealer price lists.
Maladaptive utilities are often accompanied by maladaptive probability estimates. Clients, for example, might report that if they change majors or temporarily drop out of school, their parents will disown them. A more adaptive perspective would be that in the long run, unpleasant as the prospect of being disowned may be, it really doesn't matter; moreover, the probability of actually being disowned is far less than a certainty. Although maladaptive utilities and probability estimates often occur together, in some instances the utilities may be adaptive but the probability estimates are out of kilter. Such might be the case with clients who over or underestimate their chances of being accepted at a particular university.
Cognitive restructuring is a very relevant intervention strategy should either of these client problems prevail. Essentially, this technique involves isolating and examining the irrationality of the utility or the probability estimate in question, followed by the counselor's modeling of a more adaptive point of view.
Emotional role playing and outcome psychodrama may be particularly helpful in exploring the logical consequences of a maladaptive utility. A young woman choosing marriage in order to experience the utility of "being taken care of" might be encouraged to think about what might happen if the marriage were to end in twenty years through death or divorce. Other more specific forms of cognitive restructuring that are also apropos for confronting maladaptive utilities include the induced-cognitive-dissonance and awareness-of-rationalization techniques described in chapter 5, both of which involve bringing competing adaptive utilities to the fore. It might be pointed out, for example, that a proclivity for academic perfectionism such as setting the curve in all course work, despite its real and rationalized benefits, may be detracting from the experience of utilities derived from other competencies. Or the social strokes gained from cigarette smoking may pale in comparison to the reinforcement that might be expected from a normal life span.
Although cognitive restructuring is perhaps the most applicable technique for confronting maladaptive probability estimates, other interventions may also be employed. Thoresen and Mehrens (1967), for example, suggest that peer models who verbally explore the discrepancies between their own previous subjective probability estimates and new data might reduce similar discrepancies in the client.
Finally, it should be clear to counselors that if clients report utilities and probability estimates that differ from their own, this does not constitute grounds for judging them maladaptive. Utilities are possibly maladaptive when there is general professional consensus that such is the case. If a client is planning to select a car, house, or university on the basis of prestige, for example, counselors have no right to impose their own utility for economy. Probability estimates are possibly maladaptive when they do not correspond to convincing new data. For example, a client may legitimately reject an expectancy table showing that high school math grades caution against selection of an engineering curriculum in college on the grounds of standard error of measurement, being an academic late bloomer, or a newfound interest in solving the problems encountered in that field. The evidence is against another client, however, who estimates recovery from the lung cancer caused by cigarette smoking to be higher than 10 percent. The major point here is that counselors need to be extremely judicious in their designation of a utility or probability estimate as being maladaptive.
Janis and Mann's (1977) balance sheet and Carkhuff's (1973b) decisionmaking grid (figures 5.2 and 7.1) are variations on Franklin's wisdom of the ages. All three response-selection paradigms condense and graphically depict the utilities assumed to be inherent in each alternative, allowing the decision maker to see clearly the alternative with the greatest utility. No experimental comparisons of these fairly similar paradigms have been attempted; however, Janis and Mann do present evidence that their own balance sheet results in reduction of postdecisional regret and increased adherence to the decision (Hoyt & Janis, 1975; Mann, 1972).
All the foregoing response-selection paradigms assume the probabilities for each identified utility are certain (that is, equal to "I"). There is no provision for dealing with the concept of differential expected utility (for example, two alternatives with the same possible utility but one offering a higher likelihood of the utility actually being realized). The decision-making grid designed by Katz (1966) and depicted in figure 8.2, on the other hand, does include this concept.
Katz's grid is apropos for vocational decision making but without modification it might be a bit imposing and unwieldy for nonvocational concerns. Any of the paradigms proposed by Franklin, Carkhuff, or Janis and Mann could be improved by simply including probability estimates to correct the utility data. Then, using the SEU model, one's choice would be dictated by the maximization of expected utility rule, that is, selection of the alternative with the highest utility-probability product.
Modeling variations are the primary counseling interventions for inculcating a response-selection paradigm. Typically, the counselor will serve as a live model, illustrating how the paradigm works. Elements of cognitive modeling, that is, teaching a client how to think through the system, would certainly be apparent. Other forms of modeling, ranging, for example, from programmed instructional booklets to videotapes illustrating individuals employing a response-selection paradigm in resolving a decision- concern, might also be employed.
Comprehensive behavioral programming is the appropriate intervention option for clients with seriously deficient skill levels. Chapter 3 illustrated comprehensive programs that may be helpful to individuals who have decided to lose weight or to stop smoking. The rationale behind a comprehensive treatment program is that although any individual technique might produce a statistically significant difference in promoting a given behavior, a practical difference is more likely to occur if the counseling concern is addressed on several fronts by a variety of interventions. The decision -in making counseling model described in this chapter is actually a comprehensive counseling program wherein different interventions are brought to bear on various skill deficiencies.
With the implementation of a comprehensive program for helping a client implement a response the conduct of decision making becomes indistinguishable from other kinds of counseling. For example, the counselor no longer needs to be concerned about pushing a particular alternative; the client has already made the choice and the counselor is now free to dispense liberal social reinforcement for client progress in that direction. The focus of counseling shifts from deciding to doing what has been decided.
Many clients do not need comprehensive behavioral programming because their skill levels are sufficiently high to implement a selected response. If there is some question, however, as to the adequacy of these skills, either stress- or emotional- inoculation training, which prepare the client for potential difficulties arising during implementation, may be helpful. Such preparation includes education about what might happen, training in a variety of pertinent coping skills, and possibly practice in applying the coping skills to simulated stressful situations.
To help clients conceptualize the problem, counselors must focus on three skills. First, simple listening, relaxation training, systematic desensitization, or cognitive restructuring can reduce debilitating affective arousal. Second, paraphrasing, probing (cuing and reinforcing specificity), and Socratic dialoguing can help define the problem correctly. Third, cognitive restructuring, emotional role playing, and cognitive modeling along with verbal reinforcement are possible ways to inculcate the decision-making paradigm.
To help clients enlarge their response repertoires, counselors must intervene in three other skill areas. First, thought stopping, thought substitution, covert sensitization, outcome psychodrama, or emotional role playing may prevent clients from making an impulsive response- If a client has already responded impulsively, cognitive restructuring along with behavioral rehearsal or covert modeling may be employed. Second, a creative instructional set in conjunction with originality training, brainstorming, or metaphorical thinking can facilitate the generation of alternatives. Should the client not discover viable alternatives known to the counselor, modeling procedures may be apropos. Third, verbal reinforcement and modeling can be used to promote the generation of additional alternatives outside the counselor-client dyad.
To help clients identify discriminative stimuli, counselors must concentrate on two pertinent skill areas. First, many of the interventions used for alternative generation, along with outcome psychodrama or the judicious use of counselor modeling, may expose the client to previously unknown utilities and probabilities. Second, verbal reinforcement for consulting with other reference sources is a pertinent procedure for promoting a search for additional discriminative stimuli; modeling and simulation strategies may also be relevant.
To help clients select a response, counselors must direct their efforts on three final skill areas. First, cognitive restructuring, emotional role playing, outcome psychodrama, or peer modeling can be used to develop adaptive utilities and probability estimates. Second, modeling variations are the primary interventions for teaching clients how to employ a response-selection paradigm. Third, comprehensive behavioral programming with stress inoculation or emotional inoculation can facilitate response implementation.
Having discussed the assessment of decision-making skills and illustrated a variety of pertinent cognitive-behavioral counseling interventions, I focus in the next chapter on the topic of evaluation in decision-making counseling.