Transcript Tricks of the Trade

Tricks of the Trade:
Specific Techniques to Use with
Difficult Clients
Region VIII Employment Conference
October 17-19
Spearfish, SD
Presented by:
Robert H. Arnio, Ph.D.
Psychological Associates of the Black Hills
1818 West Fulton St. # 201
Rapid City, SD
[email protected]
Agenda
• Major Processes in Counseling
• Methods or procedures best suited in the
vocational rehabilitation setting
• Discussion and demonstration of specific
techniques
Role of Counseling in Rehabilitation
Parker and Szymanski Rehabilitation Counseling, 1998
• Without adequate counseling, the core ingredient
of rehabilitation counseling, many rehabilitation
clients would be unable to achieve the goals of the
rehabilitation process. The ultimate goal of
rehabilitation – the independent, effective, and full
functioning of clients – is predicated upon and
intimately linked to, intensive counseling by a
skilled, professional rehabilitation counselor . . .
Consequently, the primary task of rehabilitation
counseling is the removal of such barriers,
whether inflicted by oneself, or by society.
Role of Counseling in Rehabilitation
Parker and Szymanski Rehabilitation Counseling, 1998
• In search for a personal vantage point in
counseling with the rehabilitation client, the
student and the practitioner have the option of
selecting from more than a dozen major
approaches. For purposes of presentation, these
approaches are categorized as psychoanalytic,
humanistic, rational, behavioral, cognitive, and
eclectic (or integrative. p 224) (Gives 8 guidelines
for deciding on a theory)
Therapeutic Components Shared by All
250 Psychotherapies
J. Frank, 1980
Psychotherapy
(Professional Counseling)
A planned, emotionally charged, confiding interaction
between a socially sanctioned healer and a sufferer(s),
in which the healer seeks to reduce or eliminate the
sufferer’s distress or disability through symbolic
communications (usually words, but sometimes
exercises). The healer may or may not involve the
sufferer’s relatives or significant others. This process
may also include helping the sufferer accept the
distress as an inevitable aspect of life and an
opportunity for personal growth.
What type of counseling to use?
• Counselor characteristics
– 1/3 of change is based on Counselor
– Same counselor, different techniques
• Client characteristics
– Demographics
– Psychological Characteristics
– Diagnosis (Diagnostic Related Groups)
Problem Centered Approach
W. Pinsof, Northwestern University
• Psychotherapy is human problem solving.
Patients’ view of their problems constitute the
presenting problem. Every problem has its own,
unique “maintenance system.” The problem
maintenance system exerts constraints on the
clients so that solutions to the problem are not
successfully developed and implemented. What
started the problem and what keeps it from being
solved may no longer be the same thing. Different
counseling approaches need to be used with
different problem maintenance structures.
• (e.g. workaholic injured)
Example
Example
Solution Focused Therapy
John Littrell
• Gregory Bateson and Milton Erickson
• Mental Research Institute (MRI)
• Steve de Shazer; Bill O’Hanlon; Insoo Kim
Berg
• The person is so saturated in thinking about
the problem, they cannot see the solution
that is available to them.
Research
Client Codes:
Change
Non change (everything
not in change)
Therapist Codes
E: Elicit Change
A: Amplify Change
I: Initiate Change (future)
N: Non-change (all other)
Constructing Change: A Research
View of interviewing; Gingerich,
de Shazer, Weiner-Davis 1989
Solution Focused Model
• Concerned with building solutions, not
problem solving.
• Task is to build solutions = tx concerned
with the nature of the solutions, not the
nature of the problems.
Different assumptions:
• Client = has the beginning of the solutions
• Find out about exceptions to the problem
• These provide the cues or keys to what the
client needs to do to build solutions
Solution Focused Assumptions
• People can change rapidly
• People have many resources, both internal and
external they are not aware of
• People are doing their best at any given time.
• A small change in one person’s behavior can lead
to far reaching changes in others
• When you focus on the solution, there is much you
do not need to know
Nature of Solutions
• Solutions come from the clients and therefore are
natural and fitting. Solutions are generated by the
client so they fit their natural way of doing things,
ie. Natural way of finding solutions so therefore it
happens quickly but is long lasting.
• Ask these questions within the context of the
therapeutic relationship and therefore the client
finds their own solutions.
Four Step Process
in the Solution Focused Approach
• Describe the problem specifically
• Examine attempted solutions and
exceptions to the problem
• Define a Goal
• Give compliments and assign a task
5 Useful Questions
1. Questions Highlighting Pre-session
change
2. Exception-finding Questions: Enhancing
Existing and Past Successes
3. Miracle Questions
4. Scaling Questions
5. Coping Questions
All interviews are composed of questions
and answers:
• Exception finding questions
• Miracle Question: Client hypothetical solution
What life would be like after they have a solution
= how they want their life to be different
• Scaling questions are client generated. Not what
is normal or abnormal. Is way the client measures
change.
• Externalization of the symptom (problem)
Goal Negotiation - occurs right after
the social stage of the interview
• What do you think needs to happen as the result of
your coming here?
• What needs to happen for you to say that his was a
good idea that we did this (coming to the session)?
• Aside from that, what would you like to see
different in you life circumstances?
Deliver the Message
– Compliments – acknowledge and validate clients points
of view about their life and their problems.
– Bridging statement: Some sort of rationale about why
they should do the task that the tx is going to suggest
– Homework or task the tx suggests:designed to
implement the solutions implemented by the clients in
their own setting. Great deal of attention to the clients
life in the real world, not in the therapy room.
Miracle Question
After we talk today, go home and go to bed
tonight and when the house is quiet, the
miracle happens. The problem that brought
you here today is gone. It has disappeared.
So when you wake up in the AM what
would be the first small clue that something
has happened, the problem is gone. What
would you first notice?
Miracle Question
• What will you notice different in (other
family member) so you know that the
miracle has happened for them. If that were
to happen, what would you do that you are
not doing now? What would happened after
that.
Miracle Question
•
•
•
What would you notice different about X
and Y now that the miracle has happened.
Now suppose you do this, what would you
do. What would you do different.
What would you notice different about X
to let you know that a miracle has
happened and the problem is solved.
Second Sessions:
• Second session:
– What’s been better since the last session?
– What kind of solution has the client
generated?
– Clients come up with ways that are good for
them.
• Tasks of the second session:
•
Elicit anything that is better What have
you noticed that is different about X; an what have
you noticed that’s different about Y.
•
Amplify the difference – then look at
the ripple effect (circular impact)
•
Reinforcing – much of which is indirect,
e.g. “Wow, how did you do that.”
Reiterate the above procedure. Use scaling questions as to
where things are at right now
• What else would be different if the miracle has
happened
•
• I guess any one who \developed a vocational
problem would . – Normalization negative
feelings and anxieties
•
• When was the last time even little pieces of this
miracle has happened.?
•
When you see that little bit of a miracle
happen, what seems to happened different? The
make it circular.
Scaling questions;
Day after the Miracle;
• 10 need not come back (close the case)
• 1 where they were when you called.
• Where to you think things are at
right now?
• What’s helped – during the session
• What needs to happen so that you
can be 10 percent better or closer to your
goals?
Problems
Solutions
Trend Toward
Complexity
Trend Toward
Simplicity
Many Kinds of Problems
& Many Kinds of
Solutions
Many Kinds of
Problems & A
Handful of
Solutions
Example
Responding to Visitors,
Complainants and Customers
Insoo Kim Berg, Family Therapy Networker, Jan-Feb, 1989
• Visitors – have no complaint, except maybe
that someone has made them come see you.
• Complainants – have a complaint but do not
see themselves as part of the solution.
• Customers – have a complaint, and indicate
they are ready and willing to do something
about it with the therapist’s help.
Responding to Visitors,
Complainants and Customers
• Visitors – have no complaint, except maybe that
someone has made them come see you.
– Sympathize with their plight of being forced to see you
– Avoid trying to get them to admit they can do
something to help the problem
– Compliment them for whatever they are doing that is
good for them, or whatever they do that they do well.
– Allow the possibility they may eventually come up with
a complaint that they will talk about with you.
Responding to Visitors,
Complainants and Customers
• Complainants – have a complaint but do not see
themselves as part of the solution.
– Compliment them for the helpful information they have
provided about the situation, for anything they are
doing that is good for them, and for whatever they do
they are good at.
– Consider giving them a task to think about or observe
something that may provide a better understanding of
the complaint. Do Not give a task that involves
behavior change.
– Be patient, knowing that in time they may move to
recognizing that they can be part of the solution.
Responding to Visitors,
Complainants and Customers
• Customers – have a complaint, and indicate they
are ready and willing to do something about it
with the therapist’s help.
– Compliment them on the positive things they are doing
for themselves and for anything they are doing that
might be a step toward resolving the complaint.
– Give tasks to think about, observe or take action
regarding the complaint in accordance with their style
of cooperating.
Stages of Change
•
•
•
•
•
Precontemplation
Contemplation
Preparation
Action
Maintenance
Stages of Change
• Precontemplation
– The person does not consider the behavior of
focus to be a problem and/or is not currently
considering changing the behavior. For a person
at this stage, the benefits of the behavior are
greater than the costs.
Stages of Change
• Precontemplation
– Help the person engage in the counseling
process and begin considering patterns and
potential effects of not solving the issues that
brought them to your office.
• Decontaminate the referral process
• Explore the meaning of the events that brought them
to your office.
Stages of Change
• Contemplation
– The person is considering that there may be a
problem and is seriously contemplating
changing behavior, but is struggling with mixed
feelings about changing.
Stages of Change
• Contemplation
– Help the person see the big picture. Discover
discrepancies between their current behavior
and their goals for the future, and consider
making some changes.
•
•
•
•
Normalize ambivalence
Weigh pros and cons of changing
Imagine the future
Elicit change and self motivation statement and
amplify those for the client
Stages of Change
• Preparation –
– Help the person resolve the ambivalence about
changing, develop a sense of ability to change
(if it has already happened, it is probably
possible), and make the initial plans for going
about changing.
• Clarify the client’s own goals and strategies
• Help develop plan for change
• Assist client in decreasing barriers to change
Stages of Change
• Action
– Help client initiate change, cope with
difficulties in the change process, and
gain social support for new ways of
being.
• Support small steps toward change
• Only offer expertise or advice with client’s
permission
• Emphasize that setbacks and lapses are unintended
failures of the planning process and help to improve
long-term plans. (adjusting courses in flight)
Stages of Change
• Maintenance
– Help client cope with difficult situations,
maintain commitment and energy, initiate new
facets of living to help client integrate them,
and process discouragement when it happens.
• Affirm client’s resolve and self-efficacy
• Assist client in making transition to working on long
other term goals
After Example
That’s all folks
Symptoms of Brain Injury and Alcohol
Abuse
• Difficulty initiating meaningful activity
– Brain Injury
• Fatigue
– Both
• Impulsivity
– Both
• Motor problems (gait and balance)
• Brain Damage
• Diminished Judgment
• Both
• Slowed thinking
• Both
Symptoms of Brain Injury and Alcohol
Abuse
• Depression
– Both
• Personality changes
– Both
• Trouble tracking conversations
– Brain Damage
• Limited insight
– Brain Damage
Symptoms of Brain Injury and Alcohol
Abuse
• Word finding difficulties
– Brain Injury
• Short-term memory loss–
– Both
• Sequencing difficulties
– Brain Injury
• Concrete thinking – abstract metaphors
– Brain Injury
• Emotional dysregulation
– Both