Tricks of the Trade: Specific Techniques to Use with Difficult Clients Region VIII Employment Conference October Spearfish, SD Presented by: Robert H. Arnio, Ph.D. Psychological Associates of the Black Hills 1818 West Fulton St. # 201 Rapid City, SD 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. 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) Role of Counseling in Rehabilitation Parker and Szymanski Rehabilitation Counseling, 1998 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 sufferers distress or disability through symbolic communications (usually words, but sometimes exercises). The healer may or may not involve the sufferers 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 Solution Focused Therapy John Littrell Gregory Bateson and Milton Erickson Mental Research Institute (MRI) Steve de Shazer; Bill OHanlon; 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 persons 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: Whats 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 thats 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? Whats 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 ComplexitySimplicity Many Kinds of ProblemsMany Kinds of & Many Kinds of Problems & A SolutionsHandful 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 therapists 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 therapists 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 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 clients 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 clients 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 clients resolve and self-efficacy Assist client in making transition to working on long other term goals After Example Thats 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