Anthr 1 Third Assignment Due Friday 11222019.docx

Anthr 1: Third Assignment Due:
Friday 11/22/2019 by 11:00 p.m.
This assignment is worth 30 points No late
papers will be accepted.
Assignment Overview
The topic for this research paper is deceptively simple: When
and how did we become “human?
This assignment is a Position Paper in which you are to take a
position on the topic (based on your personal understanding of
the material presented in this class) and support your position
by reviewing, discussing and citing reputable research sources.
A. Your first paragraph must explain your definition of what it
means to be “human”, ending with a thesis statement that
encapsulates your plan to support your position.
B. IMPORTANT: This assignment covers only from the past
2.5 million years ago to today.
a. DO NOT include discussion of species prior to 2.5 million
years ago.
b. DO NOT include discussion of the development of
bipedalism for this assignment.
C. Present and analyze the current scientific research regarding
this topic.
D. Your paper must end with a clear and concise conclusion that
recaps your argument and restates your thesis.
So … how do I do this?

1. Introduce and define the scope and focus of your paper in a
concise thesis statement that appears at the end of your first
paragraph. A thesis statement tells the reader what the paper is
about.
2. Support your position as stated in your thesis. Ways to
support your position include discussing physical aspects of
hominin evolution over the past 2 million years (what changed,
what species, what impact?), genetic aspects of hominin
evolution over the past 2 million years (what derived, what
species, what impact?) and/or cultural aspects of hominin
development (what changed, what species, what impact:
changes in stone tools, social group behaviors or interactions,
symbolic representations, etc.). What is your supporting
evidence for your position on when did hominins become
“human” in the last 2 million years?
3. Read and refer to at least three different sources (more
sources are recommended). DO NOT use Wikipedia or similar
crowd-contributed websites as sources of information for this
paper. Talk with the college reference librarian for help in
finding appropriate research for your paper. You may use links
in the class power points to research further sources for your
paper (NOT the power points themselves).
4. Recap and conclude. Your conclusion must include a
restatement of your thesis and clearly reference your analysis
and position on this topic.
5. Submit your completed assignment by clicking on the Turn-
It-In link at the bottom of the Assignment page on the course
website.
IMPORTANT:
Submit your paper as a Word doc or .docx or as .rtf or .pdf file.
Canvas does not accept work submitted in .pages or as Google

Docs, Google Drive shared documents or as ZIP files. I cannot
grade your paper if I cannot open it!
Requirements for this Assignment
A. Type your name, the topic (Third Assignment) and the due
date in the top left corner of your paper. DO NOT put anything
else at the top of the page. DO NOT use a cover page, DO NOT
include an abstract for this paper.
B. Minimum at least four full pages of text. 4 to 5 pages is an
appropriate length for this assignment. Double-spaced, one-
inch margins (check your left and right margins), typed in
English, 12-point font.
C. Include a full source page at the end of your report (three
sources minimum, more is better). List complete source
citations in APA format. Include as much of the following
information as possible: author(s) family name followed by
first initial, year of publication, title of article or book, name of
journal, magazine or book including volume/issue and page
numbers of publication, website where the article was
published, date of website information retrieval.
Website APA citation format examples:
The Writing Center. (2019). Plagiarism. University of North
Carolina at Chapel Hill. Retrieved January 4, 2019, from
https://writingcenter.unc.edu/tips-and-tools/plagiarism/
D. Use in-text citations to identify the source(s) of quoted
and/or technical and/or highly specialized information included
in your paper. In-text citations look like this: (family name of
author, first initials of author, year of publication). For
example: (Smithson, J. 2019). DO NOT use footnotes. DO
NOT include the entire source citation as an in-text citation.
E. IMPORTANT: Do not plagiarize information presented in
your paper. Do not copy from any source, including the

article(s) you use as references. Do not copy and paste or
change a few words in someone else’s sentence structure and
call if your own. This is still plagiarism! Plagiarized papers
will receive a score of “0”.
Grading Rubric
This assignment is worth 30 points: 25 points for content and 5
points for correctly written source page. I am looking for a
clear position statement (your personal definition of when we
first became “Human”), a well written, concise and original
discussion of current information on this topic AND a properly
constructed reference page that contains all sources of
information used to support your position.
· Excellent work (score 27-30): Demonstrates thorough
understanding of the topic through specific, detailed discussion.
Analysis addresses all aspects of the assignment prompt.
Conclusion is comprehensive and concise.
· Good work (score 24-26): Demonstrates moderate
understanding of the topic through discussion, but lacks
sufficient detail. Analysis addresses aspects of the assignment
prompt, but is skewed towards the student’s point of view (did
not analyze the topics, just answered the questions).
Conclusion is adequate but not thorough.
· Adequate work (score 21-23): Demonstrates some
understanding of the topic but lacks sufficient discussion and
details. Analysis lacks details and/or insufficient understanding
of research information. Able to draw generic conclusion or
missing conclusion.
· Inadequate work (score 18-20): Demonstrates some
understanding of the topic, but little effort was made to
complete this assignment. Opinion outweighs analysis, little
demonstration of having learned anything about the topic.
· Not acceptable work (score 17 or below): Did not understand
the assignment.
· Plagiarized work or no assignment submitted: score of “0”

ORIGINAL RESEARCH
Influence of lifestyle, health behavior, and health indices
on the health status of underserved adults
Theresa A. Kessler, PhD, RN, ACNS-BC, CNE (Professor) &
Elise M. Alverson, DNP, RN, FNP-BC, CNE
(Associate Professor)
Valparaiso University, Valparaiso, Indiana
Keywords
Adults; health; lifestyle; underserved;
outcomes.
Correspondence
Theresa A. Kessler, PhD, RN, ACNS-BC,
Valparaiso University, Valparaiso, IN 46383.
Tel: 219-464-5289; Fax: 219-464-5425;
E-mail: [email protected]
Received: July 2011;
accepted: January 2012
doi: 10.1002/2327-6924.12027
Abstract

Purpose: To examine how lifestyle, health behavior, and health
indices best
predict health status in underserved adults.
Data sources: Eighty-four underserved adults from a nurse-
managed center
completed an investigator-developed instrument to measure
lifestyle, health
behavior, and health indices. The SF-12 Health Survey
measured general
(SF-1), physical (PCS), and mental (MCS) health status.
Conclusions: The majority of the sample was female (64%).
Sixty-three
percent were at or below 200% of the federal poverty level. For
nonsmok-
ers, five independent variables accounted for 47.1% of the
variance in SF1
(p < .000), 33.5% in PCS-12 scores (p < .001), and 23.2% in
MCS-12 scores
(p = .017). For smokers, six variables accounted for 48.7% of
the variance in
SF1 (p = .024), 41.7% in PCS-12 scores (p = .067), and 25.4%
in MCS-12
scores (p = .378).
Implications for practice: Findings provide partial support for
the impact of
lifestyle and health behaviors on health status outcomes.
Focusing concurrent
interventions on improving multiple behaviors may have the
greatest impact
on health status outcomes.
The quality of a person’s day-to-day life is an important
indicator of health status (U.S. Department of Health and
Human Services [HHS], 2010). Over the past 20 years,
considerable effort has been devoted to the measure-
ment of health status as an outcome of public health

and clinical indicators. Health status is a result of a per-
son’s lifestyle, which includes health behaviors (Bruhn,
1988) and is equated with health-related quality of life
(HRQL). HRQL refers to a person’s perception of phys-
ical and mental health status over time (Centers for
Disease Control and Prevention [CDC], 2009). Know-
ing an individual’s health status or HRQL offers health-
care providers important information about the impact of
lifestyle, health behaviors, and health care on increasing
quality and years of life.
Tracking health status in diverse populations can help
identify groups who have poorer physical or mental
health. One group of adults who tend to report poorer
physical and mental health status is those with a low in-
come. Unfortunately, adults with low income also tend
to be underserved. The underserved include those who
are uninsured, underinsured, or uninsurable and have
difficulty finding access to health care (Beauchamp &
Childress, 2009). Having a limited access to health care
results in the underserved having poorer health out-
comes and increased mortality rates compared to persons
who are insured (Institute of Medicine [IOM], 2004).
How a person manages day-to-day life can be reflected
in overall health status. Identifying those persons with
poor physical or mental health status can guide poli-
cies and interventions to improve health (CDC, 2009).
To achieve this goal, the aim of this secondary analy-
sis was to identify the predictors of health status for un-
derserved adults seeking care at a nurse-managed health
center. This information may be used to provide better
health promotion guidance and to design interventions
that have the greatest impact on improving overall health
for the underserved.

Framework
According to Bruhn (1988), multiple influences includ-
ing cultural, environmental, social, and personal factors
impact the development of lifestyle. Lifestyle is a broad
674 Journal of the American Association of Nurse Practitioners
25 (2013) 674–681 C©2013 The Author(s)
C©2013 American Association of Nurse Practitioners
T. A. Kessler et al. Influence of lifestyle, health behavior, and
health indices on the health status
term that equates with a person’s behaviors, attitudes,
and outlook or philosophy of life. Lifestyle is acquired and
changes over time. Health behaviors, as part of lifestyle,
include actions and/or inactions that directly or indirectly
affect health status. Because a healthy lifestyle or health
behaviors are not always systematically taught, learned
unhealthy behaviors take considerable effort to modify.
Positive factors such as a consistent healthcare provider
can facilitate and promote healthy behaviors. Because
little or no encouragement from the provider can de-
ter change, healthcare providers must consistently en-
courage the adoption of a healthy lifestyle and health
behaviors.
Lifestyle, health behavior, and health status
Health status is multidimensional and includes phys-
ical, mental, and social well-being and not merely the
absence of disease or illness in an individual. It is depen-
dent on a person’s perception of health and health be-

haviors. When examining the health status of the under-
served, these adults typically report poorer health status
as compared to the general adult population (Alverson
& Kessler, 2012; Bharmel & Thomas, 2005; Salsberry
et al., 1999; Schrop et al., 2006). Adults with the lowest
income or education reported more unhealthy days than
did those with higher income or education (CDC, 2009).
Having a poorer health status impacts day-to-day life and
may interfere with the ability to work and carry on daily
activities.
Common unhealthy lifestyle behaviors of cigarette
smoking, physical inactivity, higher alcohol consump-
tion, and poor dietary practices often lead to increased
mortality and morbidity (Kvaavik, Batty, Ursin, Huxley,
& Gale, 2010; van Dam, Li, Spiegelman, Franco, & Hu,
2008). In addition, use of tobacco, eating a high-fat
diet, and being physically inactive contribute the most to
chronic disease and mortality in the United States (CDC,
2010). Often times, studies report the effect of a single
lifestyle behavior rather than the combined effect of mul-
tiple behaviors on increased risk of cardiovascular disease,
cancer, and mortality (Kvaavik et al., 2010). Hence, it is
more difficult to identify how a combination of day-to-
day actions affects a person’s health status.
In a European prospective study of nearly 8 years, four
factors were examined for their effect on chronic diseases
(Ford et al., 2009). The four factors of never smoking,
engaging in physical activity, having a body mass index
(BMI) less than 30, and eating a healthy diet led to a
lower risk of developing various chronic diseases such as
diabetes, cancer, and heart disease. In a U.S. study, an
increased number of behaviors related to smoking, eat-
ing a poor nutritional diet, being inactive, and consum-

ing greater amounts of alcohol led to increased mortality
(Kvaavik et al., 2010).
While some studies have found that unhealthy lifestyle
behaviors were related to health status outcomes in var-
ious populations, no studies consistently report the effect
of lifestyle or health behaviors on the health status of the
underserved. What is known is that persons who are un-
derserved often engage in unhealthy behaviors; however,
how these behaviors impact health status is not known.
The underserved tend to report an increased rate of
smoking (CDC, 2008b; Schrop et al., 2006), an increased
consumption of alcohol (CDC, 2008b), and a failure to
engage in leisure time physical activity (CDC, 2008b).
For health behaviors such as participating in screening
behaviors or taking prescribed medications, data support
the fact that the underserved tend to engage in screening
behaviors less frequently than the general population
(Alverson & Kessler, 2012; CDC, 2008a). For prescribed
medication usage, the underserved tend to use fewer
prescription medications when needed than the general
population (U.S. Census Bureau, 2006). These lower
rates of screening practices and use of prescription medi-
cations may be directly related to a lack of access to health
care. Few researchers have examined the effects of these
health behavior actions or inactions on health status. In
one study, taking prescribed medications was inversely
related to measures of health status, while engaging in
recommended screening behaviors was not related to
health status outcomes (Alverson & Kessler, 2012).
Factors found to provide a greater link with health
status include those related to illness such as hav-
ing an increased BMI (Alverson & Kessler, 2012; Ford
et al., 2009), being diagnosed with acute and/or chronic
medical conditions, and experiencing daily symptoms

(Alverson & Kessler, 2012). According to the litera-
ture, those with lower income levels are less likely to
be at a healthy weight compared to the general popu-
lation (CDC, 2008b; Larson, Schlundt, Patel, Beard, &
Hargreaves, 2008). In one study, 72% of underserved
adults reported at least one persistent or chronic medical
condition, and 89% reported at least one current symp-
tom related to illness (Alverson & Kessler, 2012). Over-
all, these health indices impact both physical and mental
components of health status on a daily basis.
Based on previous research, multiple lifestyles, health
behaviors, and health indices are believed to influence
health status (Alverson & Kessler, 2012). Thus, the spe-
cific research question for this secondary analysis was:
what are the lifestyles, health behaviors, and health
indices that best predict health status in underserved
adults?
675
Influence of lifestyle, health behavior, and health indices on the
health status T. A. Kessler et al.
Method
Design
For this predictive study, a secondary analysis was
completed on data regarding lifestyle and health behav-
iors among underserved adult clients seen at a nurse-
managed center in a single county in the Midwest. The
nurse-managed health center was established to provide
holistic care to underserved adults who previously did not

have access to primary health care. The original study
used a cross-sectional, correlational design. Approval to
conduct the study was obtained from the Institutional Re-
view Board (IRB). A nonprobability, convenience sample
of 84 underserved adults was recruited. Clients were in-
vited to participate in the study if they were (a) adults
seen at the health center, (b) age 18 and older, and
(c) able to read and speak English.
Procedures
Data from the original study were collected using two
instruments. The Short Form-12 (SF-12), a self-report
measure of health status, is a shortened version of the
Medical Outcomes Study SF-36 questionnaire (Ware,
Kosinski, & Keller, 1996). The SF-12 contains a single
item measuring general health status (SF1) and 11 items
with forced choice response options measuring physi-
cal (PCS-12) and mental component summary (MCS-
12) health status. The single-item SF1 asks: “In general,
would you say your health is: excellent, very good, good,
fair or poor”? PCS-12 measures attributes of health re-
lated to physical functioning, role limitations as a result of
physical health problems, bodily pain, energy and fatigue,
and MCS-12 measures attributes of social and role limi-
tations related to emotional problems and mental health
distress (Ware et al., 1996). Higher scores represent bet-
ter mental and physical health status. The SF-12 has been
used in a variety of studies and has support for reliabil-
ity and validity (Adams et al., 2006; Bharmal & Thomas,
2005; Cockerill et al., 2004; Mainous, Griffith, & Love,
1999; Resnick, 2002; Salsberry et al., 1999; Schrop et al.,
2006; Ware et al., 1996). The Cronbach’s alpha in this
sample was 0.88.
The Hilltop General Health Survey (HGHS) is a self-

report instrument developed by the research team to as-
sess demographic information, lifestyle, and health be-
haviors (Alverson & Kessler, 2012). The instrument in-
cludes both open- and closed-ended items. Fitting with
Bruhn’s (1988) framework, questions focus on behav-
iors that make up a person’s lifestyle and include actions
or inactions that may affect health status. Items include
questions related to tobacco usage, substance abuse, ex-
ercise patterns, health screening behaviors, current symp-
toms, and the diagnosis of acute or chronic medical con-
ditions. Two advanced practice nurses (APNs) who have
experience working with the underserved evaluated the
instrument for face validity during its initial use.
On randomly selected days over a period of 4 months,
research assistants approached potential subjects while
they were waiting for their appointments at the nurse-
managed center. Subjects agreeing to participate com-
pleted the questionnaires in approximately 15 min. The
overall response rate was 97%.
Data analysis
Data were entered into SPSS-Version 18 and checked
for accuracy. Normality of data was examined before per-
forming statistical analysis. Based on the initial analysis of
the data, a total of six predictors: lifestyle (hours of sleep
and smoking/packs per day), health behavior (number
of prescription medications), and health indices (number
of medical conditions, BMI, and number of symptoms)
were targeted and entered into the regression equation
(Kessler & Alverson, 2012). Previous studies also found
these same factors were related to health status (Kroenke,
Kubzanski, Adler, & Kawachi, 2008; Larson et al., 2008;
Zanjani, Warner, & Willis, 2006).

A commonly related lifestyle behavior of exercise was
not entered into this analysis because of concerns with
validity of the findings from the original study (Alverson
& Kessler, 2012). In the initial study, 45% of the under-
served subjects reported engaging in some type of exer-
cise, most frequently walking. However, the researchers
found that the subjects had a broad interpretation of ex-
ercise; subjects reported minimal daily walking at home
or work as exercise. When the data related to exercise
frequency were analyzed, there were weak negative cor-
relations between exercise frequency and health status
outcomes. In addition, the relationship between exercise
and BMI was positive, which added to the concerns about
the measurement validity of exercise.
Simultaneous multiple regression was used to exam-
ine these predictors of health status because both lifestyle
and health behaviors are of comparable importance to
daily health status (Polit & Beck, 2008). Pearson’s cor-
relations amongst the predictors were calculated to assess
for multicollinearity (Field, 2009). In addition, tolerance
and variance inflation factor (VIF) statistics were calcu-
lated to assess for multicollinearity (Field, 2009). The
level of significance was set at p < .05 and two-tailed tests
were used. A power analysis was calculated to assess the
risk of a Type II error. This analysis is useful in describ-
ing “after-the-fact” sample results (Polit & Beck, 2008).
Based on the number of subjects in the original study, this
secondary analysis had a power level greater than 0.70.
676

Table 1 Sample characteristics
All participants, N = 84
Variable % Mean (SD) Range
Gender
Male 33.3
Female 64.3
Missing 2.4
Age (years) 38.9 (12.23) 19–64
Ethnicity
African American 0
Asian 1.2
Hispanic 3.6
Other 1.2
White 91.6
Missing 2.4
Income
<1999 17.9

2–3999 8.2
4–5999 6.0
6–7999 7.1
8–9999 17.9
10–25,000 36.9
Missing 6.0
Education level 12.46 (1.76) 8–17
Smoking packs/day 0.86 (0.32) 1/2–2
Hours of sleep/day 7.16 (1.87) 3–13
Number of prescription
medications
1.89 (2.33) 1–12
BMI 29.29 (7.87) 18–54.8
Number of medical
conditions
1.72 (1.75) 0–8
SF1 2.9 (0.94) 1–5
PCS-12 42.26 (10.91) 20.70–62.38

MCS-12 41.50 (13.25) 10.96–64.15
Note. BMI, body mass index; SF1, Short Form 1; PCS, physical
component
summary; MCS, mental component summary.
According to Polit and Beck (2008), most researchers
have a power level well below 0.80 because of sample
size limitations.
Results
The demographic characteristics of the sample are dis-
played in Table 1. The demographic data were consis-
tent with the total population seeking care at this nurse-
managed health center. The majority of subjects (63%)
who reported their income indicated that they were
at or below 200% of the federal poverty level (HHS,
2011). The primary language of this sample was English
(98%). The remaining 2% spoke Spanish as their pri-
mary language. For lifestyle behaviors, 44% of the sub-
jects smoked and had an average of 7 h of sleep per night
(see Table 1). For health behaviors, 61% used at least
one prescription medication. Overall, the subjects were
overweight with an average BMI of 29.29. Eighty-seven
percent of the subjects identified at least one symptom,
such as depression, nervousness, joint pain, or bowel
changes. Seventy-two percent reported at least one cur-
rent acute or chronic diagnosed medical condition for
which they were seen at the nurse-managed center.
The top five reported medical conditions included men-
tal health issues (37%), hypertension (25%), “stomach
problems” such as gastroenteritis and gastroesophageal
reflux disease (22%), menstrual changes (20%), and di-

abetes mellitus (17%). For health status outcomes, the
mean SF1 score was 2.9 (SD = 0.94), PCS-12 was 42.26
(SD = 10.91), and MCS-12 was 41.50 (SD = 13.25).
Predictors of health status outcomes
Two regression models were tested for lifestyle, health
behavior, and health indices depending on whether the
subject smoked. The intercorrelations of these indepen-
dent variables ranged from 0.003 to 0.741 suggesting lack
of multicollinearity (see Table 2). Tolerances were > 0.1
and VIFs were all below 10 further indicating lack of
multicollinearity (Field, 2009; Hair, Anderson, Tathan,
& Black, 2006). For the nonsmokers, the independent
variables accounted for 47.1% of the variance in SF1, a
measure of general health status (F = 9.625, df = 5, 51,
p < .000), 33.5% of the variance in PCS-12 (F = 5.140,
df = 5, 51, p < .001), and 23.2% of the variance in MCS-
12 (F = 3.085, df = 5, 51, p = .017) (see Table 3). For the
subjects who smoked (n = 27), the independent variables
accounted for 48.7% of the variance in SF1 (F = 3.166,
df = 6, 20, p = .024), 41.7% of the variance in PCS-12
(F = 2.383, df = 6, 20, p = .067), and 25.4% of the vari-
ance in MCS-12 (F = 1.136, df = 6, 20, p < .378). For the
nonsmokers, number of medical conditions was a single
significant predictor of SF1 and PCS-12, and number of
symptoms was a single significant predictor of MCS-12.
For those who smoked, smoking was not a single signifi-
cant predictor of health status outcomes (see Table 3).
Discussion
In this sample of underserved adults, the selected
lifestyle behaviors, health behaviors, and health indices
were determinants of variations in health status out-
comes. For the nonsmokers, the combination of hours

of sleep, number of prescription medications, along with
medical conditions, BMI, and number of symptoms sig-
nificantly contributed to the model’s ability to predict
general, physical, and mental health status. Previous
studies have similar findings. Health status or HRQL
was found to be negatively affected by poor lifestyle
677
Table 2 Pearson’s correlation matrix (N = 60)
Variable 1 2 3 4 5 6 7 8 9
1. Hours of sleep –
2. Packs smoked (n = 27) 0.003 −
3. Prescription meds −0.232 −0.182 −
4. BMI −0.277 −0.082 0.246 −
5. Total symptoms −0.149 −0.066 0.674** 0.407** −
6. Medical conditions −0.019 −0.161 0.731** 0.450** 0.741**
−
7. SF1 0.175 0.035 −0.583** −0.369** −0.588** −0.642** −
8. PCS 0.143 0.178 −0.436** −0.396** −0.413** −0.545**
0.547** −
9. MCS 0.147 0.045 −0.364** −0.231 −0.442** −0.306*
0.426** 0.155 −
component summary; MCS, mental component summary.
*p < .05, **p < .01.

Table 3 Multiple regression of predictors for health status
SF1 PCS MCS
Predictor β p β p β p
Nonsmoker (n = 57)
Sleep 0.125 0.219 0.135 0.253 0.073 0.561
Medications 0.010 0.956 0.166 0.595 −0.299 0.206
Medical conditions −0.416 0.050* −0.580 0.024* −0.310 0.253
BMI −0.145 0.220 −0.156 0.250 −0.072 0.617
Symptoms −0.210 0.172 0.026 0.882 −0.431 0.028*
Smoker (n = 37)
Sleep 0.256 0.162 −0.045 0.812 0.227 0.300
Medications −0.216 0.459 0.065 0.837 −0.362 0.307
Medical conditions −0.415 0.170 −0.427 0.184 −0.323 0.269
BMI −0.050 0.800 −0.405 0.067 −0.113 0.637
Symptoms −0.005 0.988 0.074 0.819 −0.206 0.575
Packs −0.068 0.684 0.164 0.364 0.008 0.967
component summary; MCS, mental component summary.
*p ≤ .05.
and health behaviors (Borzecki, Lee, Kalman, & Kazis,
2005; Katz, McHorney, & Atkinson, 2000). The difference
in explained variance between PCS (33.5%) and MCS
(23.2%) scores was not surprising, because most of the
independent variables entered into the regression model
are linked more strongly with physical aspects of health
such as pain, fatigue, and role limitations (Ware et al.,
1996).

The lifestyle behavior of smoking, measured by packs
per day, added limited explanatory power to the second
regression model. Even though the model significantly
predicted general health status, smoking only explained
an additional 1.6% of variance in SF1 scores. Further-
more, smoking did not add significant explanatory power
to PCS or MCS scores even though this lifestyle behav-
ior added 8.2% of the variance in PCS scores and 2.2%
of the variance in MCS scores. This finding was simi-
lar to Kroenke and colleagues (2008), who found quit-
ting smoking was not related to improvements in HRQL.
However, for this sample, smoking did add a larger per-
cent of explained variance in PCS scores. Borzecki et al.
(2005) found smoking status made a significant contri-
bution to HRQL in a sample of male veterans. How-
ever, never smokers had significantly higher PCS scores.
The lack of consistent findings related to the lifestyle
impact of smoking on health status warrants further
examination.
The lifestyle behavior of sleep was associated with
health status outcomes in the initial study (Alverson &
Kessler, 2012). On average, the underserved adults in this
sample were getting 7 h of sleep each night; those subjects
who were getting less sleep had lower SF1 scores. Seven
to 8 h of sleep is considered an essential component of a
healthy lifestyle. However, no studies were found linking
sleep with health status in the general population or the
underserved.
When looking at the three health indices of diagnosed
medical conditions, BMI, and current symptoms, the
678

number of diagnosed medical conditions had the greatest
explanatory power for the measure of general health sta-
tus, especially for the nonsmoker. The underserved in this
study reported a variety of acute and chronic diagnosed
medical conditions. Identifying the number of diagnosed
medical conditions is less subjective than self-reported
lifestyle or health behaviors, which are more prone to
measurement error and may better reflect current factors
affecting daily health. By managing medical conditions
over time, health status outcomes may improve regard-
less of reported lifestyle behaviors.
The number of diagnosed medical conditions and pre-
scription medications used were significantly correlated
in this sample. Sixty-one percent of subjects reported tak-
ing at least one prescription medication during the previ-
ous year. In 2005, 44% of adults with a family income of
at least 100% of the poverty level took prescription med-
ications at least once (U.S. Census Bureau, 2006). Often
times being diagnosed with medical conditions results in
the use of prescription medications, thus, managing or
decreasing the number of acute or chronic medical condi-
tions may also lead to less prescription usage. Other stud-
ies have failed to report the impact of prescription usage,
medical conditions, and symptoms on health status in the
general population or the underserved.
In this sample, nearly 50% of the underserved adults
had an increased BMI. Previous research has demon-
strated that a high BMI and low levels of physical activ-

ity are associated with poorer health status, while those
who have moderate or vigorous physical activity tended
to be less overweight (Jia & Lubetkin, 2005) and perceive
a better HRQL (Fontaine, Cheskin, & Barofsky, 1996; Jia
& Lubetkin, 2005; Katz et al., 2000; Wendel-Vos, Schuit,
Tijhuis, Kromhout, 2004).
Improvements in physical and mental domains of
health status are important predictors of mortality
(Kroenke et al., 2008) and health status (Borzecki et al.,
2005). The findings from this study provide partial theo-
retical support for the impact lifestyle and health behav-
iors may have on health status outcomes. The lifestyle
behaviors of adequate sleep and smoking, the health be-
havior of taking prescription medications, and the health
indices of number of diagnosed medical conditions, BMI,
and number of current symptoms as a group significantly
contributed to the ability to predict general health status,
PCS, and MCS scores in underserved adults. One inde-
pendent variable in the model, number of medical condi-
tions, significantly contributed to the variance in health
outcomes. This finding fails to support the impact of indi-
vidual lifestyle and health behaviors as key predictors of
health status. However, this finding suggests that a vari-
able related to health indices, such as number of medi-
cal conditions, may be a stronger predictor of health sta-
tus. Another explanation is to consider that the impact of
lifestyle and health behaviors on health status is not uni-
directional. Maybe having a poorer health status results
in individuals getting less sleep, not following a healthy
diet, and taking an increased numbers of prescription
medications. In addition, the regression models demon-
strated that other variables not entered into the analy-
sis contributed more to health status outcomes. There-
fore, it is important to do further research on the impact

of lifestyle and health behaviors on health status but to
consider other variables that impact health status in the
underserved.
When comparing the amount of explained variance in
all health status outcomes (SF1, PCS, and MCS) for smok-
ers and nonsmokers, a similar pattern of explained vari-
ance was obtained. Interestingly, the independent vari-
ables were most predictive of the single-item measure of
health status (SF1). This finding further supports the po-
tential use of a single item as a clinically useful measure
of general health status with the underserved.
An important limitation of this study concerns the gen-
eralizability of the results. There were a small number
of subjects in the total sample and even fewer numbers
of subjects who identified themselves as current smokers
impacting the ability to detect the strength of relation-
ships. The subjects were mostly female, white, and mid-
dle aged. However, the sample was representative of the
clients seen at this nurse-managed center. Having a re-
sponse rate of 97% helped decrease some of the bias from
responders and nonresponders. The underserved adults
seen at this nurse-managed center may not be reflective
of other underserved adults or the general population. On
the other hand, people with a low socioeconomic status
tend to have lower HRQL, which was similar to the re-
ported health status of those in this study. The self-report
nature of the variables may affect the validity of the find-
ings. However, health status is a self-report measure, and
there is no other feasible way to collect most lifestyle and
health behavior data.
Implications for practice
Healthcare providers must continuously assess lifestyle,

health behaviors, and health indices in the underserved
because of their potential impact on health status and
mortality. Because the underserved tend to seek care for
more episodic health concerns than for health promotion,
providing interventions that manage immediate medical
conditions may have the greatest impact on health status
outcomes. Once improvement occurs, providers should
begin to focus on multiple lifestyle behaviors such as
679
encouraging weight loss, getting adequate sleep, and
smoking cessation. Focusing on multiple behaviors at the
same time appears to have a greater impact on health
status outcomes as compared to focusing on a single
behavior.
The use of a single measure of health status, such as the
SF1, may provide a clinically valid method of assessing
health status. Because the underserved often have lim-
ited access to health care and delay seeking medical care,
using a single-item measure may be ideal for providers
working with the underserved. Being able to capitalize
on a measure of health that is simple, quick to use, and
provides valid data may be a powerful tool to use when
there is limited time and contact with clients.
Because nurse practitioners (NPs) care for a higher
proportion of individuals who are underserved (Brown,
2007; Grumbach, Hart, Mertz, Coffman, & Palazzo, 2003)
or have no health insurance (Deshefy-Longhi, Swartz, &

Grey, 2008; Goolsby, 2005), they are in an ideal posi-
tion to impact health status outcomes by providing care
with a focus on illness and life management (Joanna
Briggs Institute, 2006). In a study of low-income women,
the subjects believed their primary care NPs were im-
portant sources of social support to help them main-
tain healthy behaviors (Lopez Bushnell, Cook, Wells, &
Johnson, 2000). Nurses are on the “front lines” and have
close working relationships with individuals where they
live (CDC, 2009). As primary care providers, NPs have
the ability to impact health status outcomes.
Conclusions
Overall, the underserved adults in this study re-
ported lower health status scores and practiced unhealthy
lifestyle and health behaviors. A combination of lifestyle,
health behaviors, and health indices impacted physical
and mental health status outcomes. The number of di-
agnosed medical conditions was the single best predictor
of health outcomes. Surprisingly, cigarette smoking was
not a significant predictor of health status in this sam-
ple of underserved adults. However, evidence supports
the use of health promotion interventions, such as de-
creasing smoking behaviors and engaging in exercise, to
impact health indices (HHS, 2008; Kroenke et al., 2008;
Resnick, 2002).
Managing acute and chronic medical conditions is criti-
cal to improving the health of the underserved. Improve-
ments in the other health indices, such as prescription
medication usage and/or symptom complaints, should
also lead to improved health status outcomes. NPs are in
a unique position to assess and design interventions that
influence the health status of individuals in underserved
populations.

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Counseling and Values ■ October 2012 ■ Volume 57 147
© 2012 by the American Counseling Association. All rights
reserved.

Conditions That Create Therapeutic
Connection: A Phenomenological Study
Colette T. Dollarhide, Marjorie C. Shavers, Caroline A. Baker,
David R. Dagg, and Demetra T. Taylor
In this phenomenological study, counselor and client
participants (N = 14)
described the conditions that fostered meaningful therapeutic
connec-
tions. Among all participants, consistent descriptors appeared
that were
rigorously synthesized into a detailed depiction of therapeutic
contact.
Keywords: counseling, therapeutic connection, healing,
phenomenological
A
lthough many counseling and psychological theories propose
hu-
manistic and phenomenological therapeutic techniques, words to
describe the therapeutic connection between counselor and
client
remain vague. The counselor ’s act of acceptance of the client’s
emotional
pain and internal experience is an anecdotally understood
curative factor
(Rogers, 1995), but in the age of managed care, the debate
continues over
whether it is both necessary and sufficient. Factors within the
therapeutic
relationship such as unconditional positive regard (Glauser &
Bozarth, 2001;
Rogers, 1995) and counselor qualities such as empathy (Kottler,

Montgomery,
& Marbley, 1998) have been described in an attempt to connect
the quality of
the relationship to client growth. Terms such as therapeutic
alliance, therapeutic
bond, and working alliance have been applied to describe the
quality of the
relationship between counselor and client (Peterson &
Nisenholz, 1999) but
are not clearly operationalized.
In the desire to operationalize curative behaviors and attitudes,
various
terms have been used in various counseling textbooks, but no
definitive
study was located that outlined what the counselor did or did
not do that
enhanced healing for the client. The purpose of this study was
to fill that
void in the counseling literature.
Theoretically Grounded Terms for Healing
The exact relationship factors that hypothetically provide for
client growth
have been described with various terms, usually situated in a
theoretical ori-
entation. For example, Rogers (1995) highlighted the
importance of empathy,
Colette T. Dollarhide, Marjorie C. Shavers, Caroline A. Baker,
David R. Dagg, and Demetra T. Taylor,
Counselor Education and School Psychology, Ohio State
University. Marjorie C. Shavers is now at
Department of Graduate Studies in Education, Morehead State
University. Caroline A. Baker is now

at Department of Counselor Education, University of
Wisconsin, River Falls. David R. Dagg is now
in private practice in Worthington, Ohio. Correspondence
concerning this article should be addressed
to Colette T. Dollarhide, Counselor Education and School
Psychology, Ohio State University, 305 W.
17th Avenue, PAES Building, Room 446, Columbus, OH 43210-
1124 (e-mail: [email protected]).
148 Counseling and Values ■ October 2012 ■ Volume 57
unconditional positive regard, congruence, and matching
affective expression
as the core conditions of a therapeutic relationship in client-
centered therapy.
Similarly, Geller (2002) explored therapeutic presence, not as a
technique but
as the way the therapist extends self as one human being to
another, and
Ahern (2000) documented how therapists attempted to establish
presence
with clients. In terms of training, these therapeutic strategies
are visible in
microskills training (Ivey, D’Andrea, Ivey, & Simek-Morgan,
2007; Ivey, Ivey,
& Zalaquett, 2007), in which skills are taught sequentially that
culminate in
transtheoretical helping behaviors.
From the gestalt tradition, contact (Perls, Hefferline, &
Goodman, 1951)
and supporting contact (Polster & Polster, 1974) require the
therapist to be
attentive and set the pace and quality of contact congruent with

the client’s
needs. In the psychoanalytic tradition, the holding function of
the therapist
(the therapist’s ability to focus on the distress of the client
during therapy)
is crucial (Richard-Jodoin, 1989), resting on the stability of the
therapeutic
environment and on the acceptance of the therapist.
From Eastern traditions have come several concepts that have
been used to
describe meaningful therapeutic relationship qualities. Thomson
(2000) pro-
posed that counselors practice Zazen, from the Soto School of
Zen Buddhism,
as a set of qualities in which the counselor becomes fully
present (focused)
in the client’s immediate concern. Mindfulness and willingness
have been
suggested by several authors (May, 1982; Murgatroyd, 2001;
Nichol, 2006) as
essential counselor qualities in therapeutic interaction.
Specifically, Linehan
(1993) described mindfulness as the core skill of dialectical
behavior therapy,
in which the “wise mind” (p. 214), the intuitive sense of
rightness, is used
to still the self in order to make better contact with the client.
Other descriptions of the curative factors in the counseling
contact can be
conceptualized on the basis of how emotions are addressed.
Active engage-
ment with client affect is proposed within the humanistic
approach, and new
therapies have been proposed that connect emotions with body

sense. For
example, Welwood (2001) described therapeutic unfolding as
“the process of
making implicit felt meaning explicit” (p. 335) through clinical
presence and
resonance with the client’s emotions and felt sense as a
metaphor for contact
within humanistic counseling. According to Hendricks (2007),
validating
the emotional felt sense of a client’s painful experience as well
as moving
deeper into the felt sense is curative, because processing
emotions is crucial
for focusing-oriented experiential psychotherapy.
Another phenomenon that exists in the literature about
counseling and
healing is witnessing. Higgins (1994) described adults who had
experienced
horrific childhood abuse and believed that “overcoming [abuse]
hinged
on fully recognizing how bad the past was and bearing extensive
witness
to their abuse in the attentive company of trusted loved ones
and/or a re-
spected therapist” (p. 293). Papadopoulos (1999) described his
experiences
with Bosnian refugees and the solace that therapeutic
witnessing can bring.
Likewise, Fosha (2004) suggested that “tracking and processing
emotions
to completion—in an emotionally-engaged patient–therapist
dyad where

the individual feels safe and known—constitutes a powerful
mechanism of
therapeutic transformation” (p. 30). This is performed by a
counselor who is
empathetic, affirming, affect facilitating, affect coregulating,
and emotionally
engaged. Greenberg (2004) maintained that acceptance of an
emotional experi-
ence is key to therapeutic transformation, and the first step in
this process is
awareness of emotions. In medical literature, the role of
emotions has been
extensively explored; for example, Cepeda et al. (2008)
proposed that the
emotional disclosure of patients with cancer through narrative
may reduce
physical pain and enhance well-being, and social psychology
researchers
(Harber, Einev-Cohen, & Lang, 2007) found that participants’
disclosure of
painful thoughts and feelings related to a recalled betrayal
counteracted the
effects of emotional exhaustion.
Although various terms exist to describe the therapeutic
connection, a clear
description of how counselors and clients perceive the process
of receiving
validation and personal connection during disclosure of
emotional pain is
lacking (see Perls et al., 1951; Snygg, 1941). Research-based
descriptions of the
experience of healing interaction in the counseling milieu, from
the perspective

of both the counselor and the client, are nonexistent. The
behaviors, attitudes,
and/or statements that both counselors and clients identify as
curative have not
been described phenomenologically in a process perspective
that can be prac-
ticed directly in clinical work and taught to counseling students.
We designed
the present study to address that deficit by asking nonmatched
counselors
and clients to describe the affective, cognitive, and behavioral
aspects of their
experience of therapeutic connection during sessions of
emotional disclosure.
Method
Design Overview
This study was conducted as a full phenomenological study as
described
by Moustakas (1994). First, each of us in the research team
engaged in the
epoche process, in which current assumptions, perceptions, and
ideas were
journaled and discussed in our research group to address
researcher bias and
to examine how our perceptions as researchers may taint the
analysis process
(Moustakas, 1994). We conducted a literature review to provide
context for
the study into meaningful therapeutic experience, involving
exploration of
counseling, psychology, medicine, and nursing research. In the
literature
review, we examined all possible structural implications

(underlying dynam-
ics of the phenomenon under study; Moustakas, 1994), in which
the focus
was on related terms such as contact, rapport, connection,
healing, empathy, and
presence. The interview questions were derived to allow the
respondents to
fully explore the experience of therapeutic connection and
healing, without
leading the respondent to predesigned conclusions. With each
interview, the
data were then collected through open-ended inquiry to collect
behavior,
cognitions, and affect before, during, and after the experience
under study
(Moustakas, 1994). Each element of the design is more clearly
described in
the following sections.
Researcher Bias
The first author is a counselor educator with 20 years of clinical
and counselor
education experience, with research experience focused
primarily in qualita-
tive research. At the time of this study, the coauthors were all
experienced
counselors and doctoral students in counselor education in the
first author ’s
program. Culturally, three members of the research team are
Caucasian and
two members are African American. Three members are from

the local com-
munity and two are from various parts of the United States.
In terms of gender, our research team consists of four women
and one
man. As members of the research team, we were excited to
conduct a rigor-
ous phenomenological study as described by Moustakas (1994),
and we all
had courses in qualitative methodology. Biases held included
the belief that
counseling is a meaningful, profoundly transformative and
healing experi-
ence and that this healing experience has common elements that
were not
adequately described in the literature. Additionally, we each
had significant
clinical experience and first-hand understanding of the
conditions under
which healing took place. These experiences were described and
bracketed
as much as possible to allow for true contact with the data
generated through
the interviews.
Participants
Two populations were involved in this study: counselors and
clients (not
matched). Counselors were defined as practicing professionals
with master ’s
degrees or doctoral degrees in counseling and licensed to
practice in the
state. These participants were recruited from diverse community
agencies.
Representatives of the client population were recruited from our

research
program; we invited 1st-year counselor education students who
had ex-
perienced counseling as a client. We hypothesized that, because
of their
professional interest in counseling, counselor education students
would be
less likely to experience counseling as something negative or
stigmatized
and thus would be willing to talk about their experiences.
Furthermore, this
population’s familiarity with the terminology of the profession
could help
them respond to the research questions and would not pose
negative biases
that could alter the results of the study.
A total of 14 participants were interviewed; six participants
identified
themselves as counselors and eight participants identified
themselves as
clients having received counseling at some point in their lives.
The counselor
respondent pool comprised five female counselors and one male
counselor,
all between the ages of 37 and 60 years. Three of these
respondents identi-
fied as Caucasian, one identified as African American, one
identified as
multiracial/African American, and one identified as Japanese.
The average
years of counseling experience was 12.8 years; theoretical
preferences included
eclectic, client centered, cognitive behavior therapy, and
interpersonal; two
counselors claimed no theory preference or were atheoretical.

All of the client participants were women between the ages of
23 to 52
years old. Five participants identified as Caucasian, two
identified as Afri-
can American, and one identified as blended race
Hispanic/Caucasian. The
maximum time spent in counseling was 4 years.
Data Collection
After institutional review board approval was granted, potential
participants
were invited through flyers, e-mail announcements, and word of
mouth.
Volunteers contacted the first author, who assigned the
interviews in con-
sultation with the volunteer, so that participants were not
interviewed by
anyone on the research team with whom there were existing or
potential
educational or professional relationships. Each member of the
research team
was assigned three to four participants to interview once it was
confirmed
that there were no dual relationships or conflicts of interest.
Informed
consent was obtained from each participant for taping and
future member
checking. The interviews lasted from 60 to 120 minutes each.
To further
protect participants, we coded tapes and transcripts for

anonymity; once
transcribed, the tapes were destroyed. Each verbatim transcript
was sent to
the participant for review and approval, then to the entire team
for analy-
sis. The recruitment and interview processes continued until the
data were
sufficiently saturated and redundant to ensure that the full
spectrum of the
clinical phenomenon under study had been captured for
analysis. After
data analysis and synthesis, the results were sent to all
participants for their
feedback and suggestions; all participants (100%) approved the
results as
representative of their experience with only one minor edit.
Interview Questions
The interview protocol appears in the Appendix. The interview
questions we
developed were derived from a process of discussion, reflection,
and revi-
sion to probe for the experience under study. The questions
were carefully
worded to avoid having the participant talk about painful
experiences for
which she or he sought or provided counseling; the focus was
on experiences
of healing after emotional disclosure. Additional feedback was
sought from
three expert readers who read the questions and indicated that
the questions
were appropriate for both populations under study.
Data Analysis

Once in the data pool, the data were examined in
phenomenological reduc-
tion, in which each story is examined for each horizon; that is,
each singular
statement is viewed as a separate event in the phenomenon to
arrive at a
process view of the entire experience (Moustakas, 1994). We
eliminated
redundancy and minor details to reduce the experience to its
essential ele-
ments. Next, we examined each lived story for the textural
dimensions and
exemplars of the story, which were clustered into themes
(Moustakas, 1994).
These analytic processes were conducted by each member of the
research
team independently; we then met as a team to discuss the
horizons and
details deemed to be minor to arrive at consensus at this stage.
After engaged dialogue, we then synthesized the themes into a
textural
description—the “what” of the experience under study. In the
next step of
imaginative variation (Moustakas, 1994), all possible meanings
for the themes
were sought and phrased in meaningful ways relative to the
context of the
study. In this stage, we attempted to explore all possible
alternative inter-

pretations of the data to check for research bias or distortion.
Consistent and
inconsistent themes of the story were juxtaposed to find the
invariant themes
that account for the phenomenon (Moustakas, 1994). Finally,
the textual and
structural descriptions were then merged into a unified diagram
and sent to
the participants for member checking and were unanimously
approved as
accurately depicting the phenomenon of healing contact in
counseling. These
results were juxtaposed with current literature to make sense of
discoveries.
Indicators of Rigor in Qualitative Research
Threats to validity in qualitative research involve four
conditions: cred-
ibility, transferability, dependability, and confirmability
(Lincoln & Guba,
as cited in Marshall & Rossman, 2006). According to Kline
(2008), cred-
ibility is facilitated through rigorous description of
methodology; the goal
of the present study is to provide in-depth description.
Transferability is
established through extensive triangulation. In our study, we
triangulated
the inquiry and the findings using literature, member checking,
outside
reader(s), and research team consensus. Dependability and
confirmability
(Kline, 2008; Marshall & Rossman, 2006) mean that the study
could be
confidently replicated with reasonably similar findings found

through
thick description of methodology and results. The subjective
nature of
qualitative research makes this a challenge; however, in this
study, the
epoche process we engaged in allowed us to explore each of our
personal
experiences and biases, which were then monitored during the
design, data
collection, and analysis phases. Additional strategies to enhance
rigor in
this study included cross-checking, peer debriefing, looking for
exceptions
to themes, using literature to look for possible alternative
explanations,
and recording of descriptive note taking.
Results
The results of this study revealed consistent events in the
experiences of
both clients and counselors. Findings are not reported in the
order of the
interview questions; the process of phenomenological analysis
yields a
holistic overview of the entire phenomenon. First, we present
the results of
the client participants, followed by those of the counselor
participants, and
finally a synthesis of both.
Client Participants’ Descriptions

As depicted in Figure 1, what is helpful must be bracketed by
what is not
helpful. “Not helpful” experiences can be described by three
types of dis-
respect: disrespect of client (being “cut off,” “laughed at,” and
“yelled at”),
disrespect of culture (being “labeled” and “pathologized”), and
disrespect of
process (the counselor asked no questions, provided no insight,
demonstrated
no interest, and gave advice). As a result, clients reported
feeling “stupid,”
“hopeless,” “more alone,” “violated,” “misunderstood,” and
“unsafe.” As
one participant stated, “You didn’t feel the caring or support at
all. . . . You
felt insignificant and stupid and more alone . . . even worse than
you did
before.” Another participant recalled her counselor ’s reaction
to a relapse:
“It was a verbal slap in the face. . . . She seemed angry and I
was confused
about what just happened. I remember being so grateful that our
time was
up, ’cause I just wanted to get out of there.”
In contrast, when clients described their most meaningful
counseling
experiences, they consistently described what the counselor did
and how
the counselor was. They described the actions of the counselor
as “present,”
“quiet listening,” and “drawing out and accepting feelings”;
they said that
the counselor “saw my world,” “accepted me,” and “showed it

without
saying a word.” One participant said, “We had the same set of
glasses on.”
Another said, “[The counselor was] pulling something from my
brain that I
Figure 1
Client Participation Themes
NOT CONNECTED CLIENT FELT
Disrespect of client: cut off, shut off, laughed at, yelled at
Stupid, hopeless, more alone,
Disrespect of culture: labeled, pathologized violated, worse
off,
Disrespect of process: no questions, no insight, no progress,
misunderstood, unsafe
no interest, no caring (advice giving)
- - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - - -
CONNECTION PROCESS
WHAT COUNSELOR DOES: HOW COUNSELOR IS:
Be present, be quiet, listen, draw out/accept feelings Calm,
patient, even, genuine, empathic,
See client’s world, accept, show it without words humor,
sincere, warm, positive
Physical: eye contact, full attention, hug
“Beacon in the lighthouse”
CONNECTION: MEANINGFUL, MOST HELPFUL
HOW CLIENT EXPERIENCES THE CONNECTION: How it
made her or him feel
Affirmed, validated, understood, heard, cared about, reassured,

freedom
Empowered, encouraged, calm, hopeful, change in energy
AFTER CONNECTED SESSION:
Relief: free, full-body exhale, warm bath, warm fuzzy, cry,
weight off, head up
Grateful
AFTER AFFECT, THEN COGNITIVE WORK IS POSSIBLE
Question, challenge, honesty, respect, reality check, objective,
clarify, reframe
was thinking but didn’t know how to say.” Physically, the
counselor “made
eye contact,” “gave me their full attention,” and served as the
“beacon in the
lighthouse” as a source of hope. The counselor was uniformly
described as
“calm,” “patient,” “genuine,” “empathic,” “sincere,” “warm,”
and “positive,”
with “a good sense of humor.” One participant described her
counselor this
way: “She’s so sincere in every word that comes out of her
mouth [you tell]
that she really means it.”
Client participants described their affective experience of that
meaningful
connection as “affirmed,” “validated,” “understood,” “heard,”
“cared about,”

“empowered,” “encouraged,” and “hopeful.” As stated by one
respondent,
“Relief that you are not the only person in the world that thinks
or feels this
way. . . . Thank you. Grateful. Grateful.” After the session in
which clients
experienced connection with the counselor, they felt “relieved,”
“free,”
“warm bath/warm fuzzy,” “crying with relief,” “weight off,”
“head up,”
and “profoundly grateful.” One respondent stated, “It was the
full-body
all-over, just kind of like the tension was eased, like muscles
that were
tense that I didn’t realize are now relaxed” and “You leave your
session
and you’re almost like bouncing out of the office because that
just feels so
good.” Another respondent echoed her words with “Then when .
. . you
know that someone understands you it’s kind of like this full-
body exhale
and like tension just eases and oh, the load off your shoulders is
so nice, it’s
like warm-bath relaxation.” It was after this point that client
respondents
indicated that they could then engage in the cognitive work of
counsel-
ing, in which the counselor “questioned,” “challenged,” and
gave “honest
feedback,” a “reality check,” “objectivity,” and “reframe.” As
stated by one
respondent, “I actually felt better after the fact [intense
emotion] and the
more times that I cried about the situation the better off I was. .
. . Then she

challenged some of my thoughts and even some of my feelings.”
Counselor Participants’ Descriptions
As can be seen in Figure 2, the counselor participants’
experiences were
similar to those of the client participants. When describing
sessions in
which connection did not occur, counselors described
experiences that
were similar to those described by client participants. They told
of ses-
sions in which they engaged in “telling,” “teaching,” “problem
solving,”
and “advice giving.” One respondent said, “What was not
helpful? The
advice or problem-solving stuff, not helpful.” Two counselors
touched on
the role of culture and said that connection was difficult if they
shared
too much about their experiences and if they could not identify
with the
client’s culture. Connection was enhanced if they could identify
with the
client’s issues by sharing, for example, “I too have struggled.”
The role
of cognition was mentioned by three of the six counselors, who
indicated
that focusing too much on “book learning” or theory by
intellectualizing
the client’s issue blocked their ability to establish a meaningful
therapeutic

connection. One counselor said that in preparing for a session,
“I try to go
‘in’ as far as possible. I need to be rid of all theory. I let my
spirit use my
head, instead of my head using my spirit.”
The counselor participants described the connection process in
consistent
terms. In this process, the client’s pain was manifested in affect
(“shame,”
“guilt,” “detachment,” “self-neglect,” and “fear”) and in body
(“could see
it in their body language,” “no eye contact,” “as if she was
carrying a heavy
burden”). According to one counselor, “They just needed to be
connected
. . . both of them were so detached from anyone.” Another said,
“Crying. . . .
Shame because they have a difficult time making eye contact.
Guilt because
they struggle to make eye contact and then their voices become
lower as if
they’re telling a secret.” In response to the pain they perceived
in the cli-
ent, the counselor participants felt a “call to action”; “call to
helping”; or
a pull in the “gut,” “core,” “stomach,” “back,” “chest,” and
“heart.” One
counselor stated,
I give my heart to the other person’s heart. . . . So the moment I
noticed the connection is
that my heart meets their heart then there is some merger or
connection there. . . . At first
I have to feel that their heart is opened up. . . . I felt that I could

hear the clicking that they
opened the door. And then after that how much of my heart will
they take?
Figure 2
Counselor Participation Themes
NOT CONNECTED
If counselor tells, teaches, problem solves, gives advice
If counselor leads with cognition, theory, intellect
If counselor does not share client’s culture or shares too much
about self (know-it-all)
- - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - - -
CONNECTION PROCESS
Counselor sees client pain
Client affect: guilt, detached, self-neglect, fear
Client physical presentation: burden, no eye contact, see in
body
Counselor feels discomfort (must suspend cognition, theory)
Feels call to action, call to helping, gut, core, heart (give my
heart to client), chest, stomach,
back, neck, face
WHAT COUNSELOR DOES: WHO COUNSELOR IS:
Pain: attend to pain, emotional knowing, open self up, let
clients feel Spiritual: inner healing
Still: listen, witness, sit and hold pain, grounded self, silence
Connection to all persons
Pace: walk with, not in front; silent waiting for client Faith,
hope, authentic, natural

CONNECTION: MEANINGFUL, MOST HELPFUL
HOW COUNSELOR EXPERIENCES THE CONNECTION:
HOW CLIENT FEELS:
Learn about connection Relief, burden lifted, eye contact,
verbal feedback
More confident with connection with next client Takes
ownership, tells more hard things
Change in energy Gratitude
AFTER AFFECT, THEN COGNITIVE WORK IS POSSIBLE
What was described next was consistent among the counselors:
Their
response to the perceived pain included attending to the pain,
“emotional
knowing,” “open[ing] myself up,” saying “I feel you.” They
became “still”
to better “listen,” “witness,” “ground myself,” and “offer
silence.” One
counselor said, “Simply listening nonjudgmentally to what the
client is tell-
ing me, and sitting and holding the pain for them.” Another
described her
experience of the connection as follows:
For me, that means that I can see myself in that other person
and I try to open up myself
to that other person so that they can see themselves in me. Once
you are able to look at
another person and see yourself, see your own experiences and
see you own life, that is

what a connection means to me. When you can actually see that
person’s pain.
The counselors paced the session by “walking with, not in front
of the cli-
ent” and engaged in “silent waiting for the client.” This merged
with what
they knew of themselves that enabled them to help others. They
spoke of
their own spirituality and “inner healing”; feeling “connection
to all”; and
having “faith,” “hope,” “authenticity,” and being a “natural
helper.” One
counselor spoke about how the connection in counseling
brought connec-
tion to the client’s life:
I have a lot of clients that end up . . . feeling connected even to
strangers, to people they
don’t know, to animals, to things that our culture doesn’t really
embrace as something to
be connected to. . . . When a client says to me not only am I
connected with myself, but
I’m connected to things outside of me because I see those things
as a powerful part of me,
those are the best counseling sessions.
After the connection experience, the counselor participants felt
“more
energy,” “affirmed,” “more present,” and more comfortable that
what they
were doing was helpful. They reported that clients expressed
relief through
statements such as “a burden has been lifted” and “it’s off my
back.” One
counselor said, “I can sometimes feel a palpable sense of relief

in the room
emanating off them [the client].” Clients were reported to make
eye con-
tact, take ownership over their issues, and share more “hard
things.” As
one counselor stated, “They keep coming back and they tell me
other hard
things. . . . I think it’s when they start taking some of the
ownership that is
the best feeling for me, because to me that’s them making
progress.” Often,
gratitude was directly expressed. At this point, cognitive work
(if a part of
the counselor ’s orientation) was engaged. One counselor said,
“I give some
feedback like that, and sometimes I can get them to see things
differently, but
without giving advice, but try to help them brainstorm different
possibilities.”
Synthesis
As we identified consistent essential elements of the
phenomenon of
therapeutic connection as described in the two previous sections
for
client and counselor participants, the invariant textural and
structural
dimensions became evident (Moustakas, 1994). Lack of
empathy, lack
of respect, intellectualizing, and lack of interpersonal skills

prevented
the therapeutic connection from occurring. All of the
respondents spoke
of the speed with which the lack of connection was apparent to
them,
indicating that the potential for connection was assessed from
the first
moments of counseling.
As the therapeutic relationship developed, counselor actions and
attributes
created the environment in which clients could self-disclose.
When client
pain was expressed either verbally or nonverbally, counselors
disclosed that
they felt some calling to respond, reporting some discomfort as
the cue to
attend to the client’s affect. The counselor ’s skills and personal
attributes
served to deepen the potential for connection and engender
trust, instill
hope, and share appropriate background information.
Professional skills that prompted connection included the use of
silence,
emotional attending, remaining grounded, witnessing, empathy,
and pacing.
The counselor attributes of faith, hope, authenticity, warmth,
and patience
served to affirm, empower, and encourage the client. Growth
was experi-
enced by both the counselors and the clients, in that counselors
experienced
a renewal of energy and purpose, and the clients experienced
concurrent
expansion of a more holistic sense of self and contraction of

pain through
gaining perspective and affective relief.
Finally, to move forward, the counselor and the client continued
to process
and contextualize the client’s pain. When the connection was
effective, the
client was willing to take ownership and share more “hard
stuff” with the
counselor. Counselor activities shifted to cognitive
interventions as needed
to facilitate continual client growth as congruent with the
counselor ’s theo-
retical orientation.
Discussion
This study shows significant potential for understanding
therapeutic con-
nections with clients. However, findings must be contextualized
with several
limitations that constitute threats to the integrity of the results.
First, this
study, although achieving data saturation, consists of the
phenomenological
experiences of 14 people. Because of the nature of qualitative
inquiry, vari-
able interpretations of the data will exist. Furthermore, the
study reflects a
predominantly female respondent pool. To balance these
concerns, we took
care to recruit diverse participants with variable theoretical
orientations, to
bracket preconceptions, to fully engage the diverse members of
our research
team in active discussion and debate, and to suspend

conclusions until all
participants could comment on the accuracy of the figures.
Although coun-
selor participants of this study came from various theoretical
orientations,
it would still be of value to conduct replication studies with
practitioners of
discrete theoretical schools to capture and describe experiences
of meaning-
ful connections within various therapeutic traditions.
Viewing these findings in the context of the literature does
provide sup-
port for the viability of the results. Although the focus of this
study was
on “the most meaningful counseling experience” of clients and
counselors,
there is support for the importance of counselor qualities such
as hope,
warmth, authenticity, and acceptance as found in the client-
centered and
humanist traditions (Friedman, 2001; Kottler & Hazler, 2001;
Rogers, 1995).
The description of faith, hope, and spirituality mentioned by the
client par-
ticipants is also consistent with humanism (Elkins, 2001). Other
counselor
qualities such as presence (Ahern, 2000; Geller, 2002),
supporting contact
(Polster & Polster, 1974), mindfulness (Murgatroyd, 2001;
Nichol, 2006), the
holding environment (Richard-Jodoin, 1989), and willingness

(May, 1982) are
interpretable from the findings in which contact with client pain
is engaged
with courage. Specifically, the counselor activity of witnessing
client pain
without fear supports the findings of Higgins (1994),
Papadopoulos (1999),
and Cepeda et al. (2008) and the positions of Fosha (2004) and
Greenberg
(2004), who posited that processing emotional pain is vital for
client growth.
Implications for Practice
From the present study, it is evident how important it is for
counselors to
foster therapeutic connections. Although rapport building,
presence, and
mindfulness are all highly desirable and needed components of
the therapeutic
experience, the intentional creation of deep therapeutic
connection allows
greater processing and healing to take place. The client feels
connected to the
counselor, and together they can move forward to active
interventions not
possible prior to the connection. As the clients and counselors
both reported,
the working relationship significantly changed for the better the
moment
this connection took place. Counselors need to recognize the
potential in this
and gain greater self-awareness regarding the client’s presenting
concerns as
well as feelings about the client. Understanding self and
situation is crucial

to allow a deep connection and relationship.
Furthermore, the deep connection created a safe place for
processing pain,
which cleared the emotional blockage to make way for cognitive
work. This
would have important implications for cognitive-oriented
counselors, who
may view these findings as germane only to affect-oriented
practitioners.
It may be incumbent on all counselors to reflect on the dynamic
interplay
between affect and cognition (Goleman, 1995) in order to foster
deep thera-
peutic connection as needed to diffuse client distress before
attempting
cognitive interventions.
Conclusion
Is the therapeutic relationship both necessary and sufficient, as
Rogers (1995)
claimed? On the basis of the respondents’ experiences, the
relationship is
necessary and sufficient for the emotional catharsis that
preceded cognitive
processing. Contrary to those therapeutic traditions that claim
that a work-
ing relationship is all that is needed (e.g., rational emotive
behavior therapy
[Ellis, 1973] and solution-focused behavior therapy [Sklare,

1997]), it seems
that counselors would be more likely to provide meaningful and
helpful
counseling services if they first facilitated the client’s
emotional expression
as appropriate. For counselors who prefer a more affect-oriented
therapeutic
approach, the insights from this study could reaffirm that
therapeutic efficacy
is not always measured in weeks toward a goal but rather in the
quality of
the connection between the counselor and the client.
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APPendix
interview Questions
Counselor Questions

1. Demographics
a. Age, gender, time as a professional counselor, ethnicity
b. Theoretical orientation (humanist, behaviorist, etc.)
2. We are studying what counselors do when a client talks
about a very painful emotional event.
a. What is your internal reaction when a client tells you about a
painful or sad event?
b. To what extent do you show the client what you are feeling
or thinking when a client
shares something painful?
3. Describe a time during a counseling session in which you
felt as if you were seeing the
client’s painful experience firsthand, when you felt a deep or
profound understanding of the
client during a counseling session.
a. What do you call that sense of deep understanding?
b. How did that deep sense of understanding feel to you?
Describe where in your body you
experienced it.
c. Without using any counseling jargon, describe what you say
and do when a client is
expressing painful memories or painful thoughts.
d. What did you do that was powerful or profound to you in the
moment?
e. How did you know if it is helpful to the client? What does
the client do or say that helps
you know that what you have done is meaningful for the client?
4. Describe the best counseling session you have ever had with
a client. What made it the best?

5. Describe an experience when you noticed the client sensing
your support and presence.
Describe an experience when you offered yourself to the client
and the client didn’t sense
your support and presence.
6. Recall a time in your personal life that you told someone
about a source of pain in your life.
a. What did the listener say or do?
b. What was helpful to you in that moment? What was not
helpful in that moment?
c. What do you wish the listener had said or done differently to
be more helpful to you at
that time?
7. What about you as a person enables you to support/validate
clients? How do you know this?
Client Questions
1. Demographics
a. Age, gender, ethnicity
b. How long have you been or how long were you in
counseling?
c. Would you say that, overall, counseling has been helpful to
you?
2. Describe the most meaningful moment in your counseling
experience.
3. If you have felt an intense sense of sadness and pain during
a counseling session:
a. What was it like for you?
b. How did your counselor handle it?
c. What was most helpful in that session?
4. What would be most helpful to you during a counseling
session when you are feeling an

intense sadness during counseling?
5. Tell me about a time when you felt that you were really
understood during a counseling
session, that the counselor really “got it.”
a. What would you call it?
b. What did it look like? How do you know if someone really
gets what you’re saying or
what you’re feeling?
c. How did it feel? Describe what happens inside of you when
you feel true understand-
ing and support from your counselor. Describe where in your
body you experience that
sensation of understanding and support.
d. Tell me about a time when your counselor tried to “get it”
but didn’t.
Copyright of Counseling & Values is the property of Wiley-
Blackwell and its content may not be copied or
emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission.
However, users may print, download, or email articles for
individual use.

Anthr 1 Third Assignment Due Friday 11222019.docx

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