G.A.D – “The stress is killing me!!!”

Click here for a “Quick-&-Dirty” overview of Generalized Anxiety Disorder….

During a discussion with my therapist recently I learned that some of my symptoms are reflective of Generalized Anxiety Disorder.  Until she mentioned this, it hadn’t occured to me.  However, I must admint, she does have a point.  I’ve always been a worry wart, and find my anxiety the most difficult to manage on a daily basis.   Anxiety urges us to action perceived in that moment as a solution to our concerns and fears.  When overcome with anxiety, I try my best to “keep it in check”.  However, sometimes it does get the better than me, and I react in an irrational and/or poorly-thought-out manner.  What follows is a quick review of research that provides interesting causal explanation for G.A.D….

Beliefs & G.A.D.

Koerner, et al, (2015) note that certain beliefs about worry correlate with Generalized Anxiety Disorder, including “negative beliefs about uncertainty, and schemas reflecting unrelenting standards…the need to self-sacrifice…and less positive views of other people and their intentions” (p. 441).  Additionally, how we view worry effects the way we handle and mange this emotion.  “When individuals encounter a threatening situation, positive beliefs about the usefulness of worry are activated, which in turn initiate worrying as a coping strategy” (Koerner, et al, 2015).

Stressful Life Events & G.A.D.

Life events play a role as precipitating factors in the onset of generalized anxiety disorders and panic disorders….The objective of this study was to investigate the frequency, specificity and typology of stressful life events occurring in patients with generalized anxiety disorder and panic disorder…A significant proportion of patients in both groups reported stressful life events occurring in the year before the onset (87.5% in the group with generalized anxiety disorder and 76.3% in the group with panic disorder). More patients in the panic disorder group have reported events of the “loss” type and at least one event considered to be severe and very important compared to the generalized anxiety disorder patients. A significant proportion of patients in both groups have reported conflict and events involving threats. (Romosan, et al, 2004, p. 36).

Theoretical Interpretations of G.A.D.

A Psychoanalytic Perspective…

“According to psychoanalytic theorists, individuals with anxiety experienced difficult early relationships with unavailable and unresponsive caretakers In psychodynamic models, psychopathology is understood to occur as a result of excessive defenses against anxiety and guilt-producing, mixed feelings toward loved ones.” (Greenberg & Watson, 2017, p. 20-21)
  1. Click here to read about Sigmund Freud’s Psychoanalysis

  2. Click here to read about Psychodynamic Therapy

  3. Click here to read about Carl Jung’s Analytic Psychology

  4. Click here to read about Alderian Psychotherapy

  5. Click Here to read about Karen Horney’s Psychoanalysis

A Learning Theory Perspective

From a learning theory point of view, people are anxious and fearful of feelings that are associated with negative outcomes. Learning theory approaches to GAD have suggested that uncontrollable and unpredictable aversive events may play an important role in the devel- opment of GAD (Greenberg & Watson, p. 21)
  1. Click here to read more about Classical Conditioning

  2. Click Here to read more about Operant Conditioning

C.B.T. & G.A.D.

“Cognitive behavioral worry is a result of problems with affect regulation, including (a) heightened intensity of emotions, (b) limited understanding of emotions, (c) negative responses to current emotions, and (d) unhelpful management of emotions. According to this view, GAD results from deficits in affect regulation with an over reliance on worry to manage diffiult emotional experiences” (Greenberg & Watson, 2017, p. 23)

Click here to read more about Aaron Beck’s CBT

Carl Rogers & G.A.D.

“Rogers suggested that anxiety occurs when the needs of the organism are in conflict with introjected conditions of worth from signi cant others. Fully functioning people do not need to distort experience…with introjected conditions of worth” (Greenberg & Watson, 2017, p. 24)

Click here to read about Carl Roger’s Nondirective Approach

Existential theorists

Existential theorists see anxiety as a core part of the human condition and as an unavoidable component of life. In their view, anxiety results from individuals having to face choices without clear guidelines and without knowing what the outcomes will be, and from being aware that they are ultimately responsible for the consequences of their actions…existential view sees anxiety as stemming from the inability to cope with the challenge of living and to choose to live in a healthy and productive way.” (Greenberg, & Watson, 2017, p. 24)

Click Here to read about Existential Psychotherapy

E.F.T. & G.A.D.

Repeated exposure to threatening, painful, and negative life events…without adequate protection, soothing, and nurturing compromises people’s emotional processing and affect regulation capacity, as well as their identity formation…If needs for connection and protection go unmet, individuals become distressed and their feelings of fear, sadness, and shame remain inadequately symbolized and soothed….These children feel solely responsible for their well-being. The lived experience plus the harmful situation are coded in emotion schematic memory. Thus, from an EFT perspective, an important contributor to GAD is the inability of people to process their emotions and soothe, comfort, and protect themselves when experiencing distress so as to return to a state of peace and calm.” (Greenberg & Watson, 2017, p. 25).

Click Here to Read My Posts on Emotions…

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References

Greenberg, L.S. & Watson, J.C (2017). Emotion-Focused Therapy for Generalized Anxiety. American Psychological Association.
Koerner, N., Tallon, K., & Kusec, A. (2015). Maladaptive core beliefs and their relation to generalized anxiety disorder. Cognitive behaviour therapy, 44(6), 441-455.
Shrestha, R. (2015). Stressful life events and coping strategies among patients with generalized anxiety disorders. Journal of Institute of Medicine, 37(3).
Arul, A. S. S. J. (2016). Study of Life Events and Personality Dimensions in Generalized Anxiety Disorder. Journal of clinical and diagnostic research: JCDR, 10(4), VC05.
Romosan, F., Lenci, M., Stoica, I., & Dehelean, L. (2004). Stressful life events and anxiety disorders. Timisoara Med J, 54(1), 36-38.

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Stages of Change & Domestic Abuse Survivors

In this post, I’m reviewing literature that discusses the stages of change as it applies to providing care to victims of intimate partner violence. As an intern working at a homeless shelter for women, I find the work highly relevant to what I see from day to day.  This post includes segments of old assignments…

“Why does’t she just leave him?!?!?!?”

“Queries like, “Why does she put up with that?” and “Why does she stay?” continue to haunt battered women…The implication is that the battered women’s behavior is problematic…This ego-deflating and incriminating element can serve to keep a woman trapped in a situation she may view as incapable of ending herself” (Burman, 2003, p. 83).

During my internship class last quarter, a fellow classmate began discussing a client she was seeing who was just left an abusive relationship.  At one point my professor made an interesting statement that made me stop and think:

“The key is to understand the unresolved issues they have yet to work through”

This statement made me stop and think a bit about my own history, and the “it years”.  Mind you, the abusive behavior was psychological and emotional.  However, there is certainly a parallel.   Throughout the relationship, I can’t tell you how many times I heard someone say: “Why don’t you just leave him?”  I recall thinking silently, “it’s just so complicated, you don’t understand.”  My response was, often to remain silent, and simply ignore the question.  There was no point in explaining to those who ask, what they are blind to and unable to conceive…

It is for this reason, that my professor’s comments really struck me.  In response to questions such as these I might say iterate what my own professor said, “what unresolved issues lay in their life history that I hadn’t worked out yet as an explanation for why they would be in a relationship like this?”

To put it another way, let’s look at this issue from a behavioral perspective.  Mind you, this theory isn’t necessarily my favorite since I feel we are much more than pavlovian dogs.  However, what’s clear about human behavior is that we do what works.  Even, if at first, behaviors appear self-destructive, we must ask ourselves what they “payoff” is.  In my own case, there was an emotional “hot potato” was the unresolved trauma of bullying and ostracism in my childhood.    I was so incredibly desperate to avoid the rejection and loneliness of my childhood, this relationship was the “lesser of two evils” as an alternative to re-experiencing the traumas of my childhood.

Admittedly, this personal perspective in my own life history, might not apply to many other cases of domestic violence.  However, the point is, rather than asking “why don’t they leave?”  We must ask ourselves, how this relationship reflects the the summative emotional impact of life experiences?  I love John Malkovich’s assertion that to a create character successfully we must see them without judgment.  Maybe this is also true with clients:  to see their life experiences without judgment.

“Attempting to understand the nature of the battering and how women cope, we can glean some insights into…the strengths that are utilized to make the decision to leave, act upon and sustain this goal” (Burman, 2003, p. 84).

Two articles are useful in providing information in understanding a domestic violence situation as a guide throughout the counseling process.  These articles describe a woman’s adaptations to spousal abuse in terms of the following stages: pre-contemplation, contemplation, preparation, action, maintenance, and termination (Burman, 2003; Fraser, et al, 2001).  According to this theory, change is not a singular event but a process that occurs in an observable sequence of stages.   For example, during pre-contemplation, a woman tends to minimize and deny the issues and their consequences. Traumatic bonds are quite pronounced at this point and a sense of isolation and dependence grows along with a growing feeling of responsibility and self-blame (Burman, 2003, p85). The contemplation phase marks a period of ambivalence during which an increasing level of cognitive dissonance develops and a woman vacillates on whether to leave (Burman, 2003, p85). Determination and Action involve the process of preparing to leave and enacting one’s plan. Finally, brief descriptions are provided of the maintenance and termination stages.  What follows is an overview of the stages of change as it applies to victims of intimate partner violence.

Overview of The Stages of Change

Pre-Contemplation

The pre-contemplation stage is characterized by either denial and minimization of the problem.  For example, during this stage a client may resist any attempts to discuss and acknowledge that abuse is occurring. This might can present as a defensiveness towards anyone who suggests and/or suspects that there is a problem (Burman, 2003).  Alternatively, the client might also present with a desire to accommodate “herself to the situation, constantly hoping that by pleasing her partner he will change his ways” (Burman, 2003, p. 84).  Sometimes expressions of hopelessness regarding the possibility of change can also be seen (Frasier, et al, 2001).  Alternatively, the client may describe the hopelessness of the situation while blaming herself and/or others:

“There is no need to talk about it; it won’t change a thing,”

“If the supper had been ready on time…”

“But, he is a good provider…”

“If the children weren’t so noisy…”

During this early stage, the traumatic bond begins to develop.  I prefer to call it a “boot camp” period, where you’re slowly broken in like a pair of new boots.  Momentary expressions of love and/or positive reinforcement are intermingled with various forms of abusive behavior.  You’re slowly isolated from others and dependency upon your partner grows slowly over time.  An extremely low self-esteem exists that one cannot see beyond, as an all-encompassing perspective of oneself.  This is the hardest to explain, for those who don’t understand.  However, I would simply like to note that people can’t see what they haven’t experienced, like explaining the color purple to a blind man.

Contemplation

This stage is characterized by feelings of ambivalence as the client vacillates between “concern and..unconcern, motivation to change and to continue unchanged” (Burman, 2003, p. 85).  The therapist’s primary goal is to addrress feelings of ambivalence.  As the situation continues in an unremitting manner, the client’s coping mechanisms wear down. Consequently, denial is no longer possible and they begin to recognize that a problem exists.  The client struggles to make sense of their partner’s behavior and process their feelings of ambivalence by weighing various options as “what if’s”.

“I wish that I could figure out what to do differently so he won’t get so angry with me,.”

“What would happen if I did leave, can I ‘go it alone’?”

Preparation

“Patients in this stage are consciously aware of their problems. They are `committed’ to taking action usually within the next month” (Frasier, et al, 2001, p. 214).  During this stage the primary goal is to “determine the best course of action and prepare to carry it out” (Burman, 2003, p. 86).  Planning is underway as the client seeks counseling, legal assistance, saving money, and a safe place to stay.  Both resources for this post mention that change is sometimes a fluctuating process and clients can occasionally be seen moving back and forth between preparation and contemplation (Burman, 2003; Fraser, et al, 2001).

Action

During this stage, the client begins putting her plans into action and makes efforts to change.  “The prospect of leaving, is often dangerous and scary, provoking feelings of fear and anxiety (Burman, 20030.  Therefore, great energy is now directed toward ensuring your personal safety and rebuilding your life.   Victims of abuse may seek counseling, participate in a local support group for victims of domestic violence, and/or request that their partner seek treatment as part of a court-ordered protective or restraining order. Some victims may also train for or seek work outside the home in order to establish economic independence.” (Fraser, et al, 2001 p. 214).

Maintenance

During the maintenance stage, clients are struggling to avoid problematic behaviors.  The goal during this stage is to prevent relapses into old destructive habits.  Burman, (2003) states that 5-7 attempts are commonly made to leave an abusive relationship before success is achieved. “Various reasons have been given for this action, including ‘fear, continuing emotional involvement, desire to keep the family together, and lack of viable alternatives'” (Burman, 2003, p.86).   “Maintenance depends not only on the thoroughness of the action plan but also on a continuing support system” (Fraser, 2001, p. 2014).

Assessment Client Needs

Nature of Abuse

It is also important to obtain more detail on the nature and severity of the past abuse history in order to begin working through the effects of these experiences (Burman, 2003).   This should also entail an assessment for symptoms of PTSD and dissociation.

Self-Esteem & Coping Style

Issues for women recovering from a history of spousal abuse include a diminished self esteem, as well as dysfunctional cognitive and affective adaptations (Holiman & Schlilit, 1991). This diminished self-esteem can be thought of as a sense of powerlessness and low self-worth. It causes individual’s develop maladaptive belief systems about themselves in relation to others (Holiman & Schlilit, 1991). Emotionally, long-term spousal abuse also causes a paradoxical attachment, in which victims come to rely on a hope for something they never receive (Holiman & Schlilit, 1991).

Readiness for Change

Interventions should be geared towards a client’s level of readiness for change and aimed addressing resistance. For example, for women who have not yet left relationships, you would note they are either one of two things. They may be in the pre-contemplative change and unwilling to acknowledge the problem. Or they may be in the contemplative change and considering leaving, but unsure of how they may do so.

Depression & self-care (Kakurt, 2014)

Participants in this article described feeling depressive symptoms and difficulty engaging in adequate self-care (Karkurt, et al, 2014). Additionally they felt a mixture of emotions including being overwhelmed and stressed about the big life decision they just made. These overwhelmed feelings would arise when they began discussing the tasks before them as they attempted to rebuild their lives. Others were angry for themselves for not having left sooner.

Shame & Self-Blame (Karakurt, 2014)

A subgroup of participants in this research suffered with several more severe co-morbid diagnoses that required additional interventions. Issues common in this group include bipolar disorder, depression, suicide, dissociative PTSD, borderline personality disorder (Karakurt, et al, 2014). Finally, individuals who had suffered longer-term severe abuse, were most likely to deal with feelings of excessive guilt and self-blame (Karakurt, et al, 2014).   These feelings of guilt and self-blame made their decision to leave particularly difficult to cope with. For example, this article describes one participant stating they felt they had betrayed the trust of their partner (Karakurt, et al, 2014). This insight points at the importance of understanding an abusive situation from the perspective of someone who has lived it.   From an outsider’s point of view, these feelings make little sense. On the other hand, from the perspective of someone living the experience, the feelings are altogether different. It is our job to work at appreciating things in this vantage point, and helping from within this perspective.

Emotional Response to Violence

Holiman, (1991) “describes a paradox for women in violent situations: the woman is trapped because she feels even more afraid when she contemplates separation than when she imagines being intimate in a battering relationship…the fear of being without a partner was overriding, more important than whether or not the violence stopped” (p. 346).

When I read the above quote, I was again reminded of that relationship in college.  I would like to reiterate it wasn’t physically violent,  however emotionally, psychologically and sexually abusive.  I can recall a similar feeling of fear upon separation.  I recall breaking up with him during a family vacation to London.  My mother had arranged it with his parents.  He was going to visit them for a week, while I went to London.  It was my first time away from him.  I recall breaking up with him from this safe distance, and feeling a nagging fear & anxiety throughout the remainder of the trip.  This paradoxical feeling is admittedly difficult to explain however quite overwhelming.  Holiman (1991) suggests this is due to a process of traumatic bonding takes place between the woman and her partner, similar to the relationship between hostage and captor.” (p. 346).

Interventions

“Effective Interventions Matched with Stages of Change” for victims of abuse. (Fraser, et al, 2001, p. 215).

“Roberts’ Seven-Stage Crisis Intervention Model & Battering Severity Continuum” (Holiman, 2003, p. 88).

Burman, (2003) includes a description of a Crisis Intervention Model based on research that focuses on domestic violence.  This Crisis Intervention Model is based on the idea that abuse can be observed to occur along a continuum of severity.  “Divided into seven stages, the model details hierarchical assessment and intervention activities that aim to subdue a crisis so that strength-oriented empowering cognitive, and independent function can be achieved” (Burman, 2003, p. 88).

Crisis Defined:

“An acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail and there exists evidence of distress and functional impairment. The subjective reaction to a stressful life experience that compromises the individual’s stability and ability to cope or function. The main cause of a crisis is an intensely stressful, traumatic, or hazardous event, but two other conditions are also necessary: (1) the individual’s perception of the event as the cause of considerable upset and/or disruption; and (2) the individual’s inability to resolve the disruption by previously used coping mechanisms. Crisis also refers to “an upset in the steady state.” It often has five components: a hazardous or traumatic event, a vulnerable or unbalanced state, a precipitating factor, an active crisis state based on the person’s perception, and the resolution of the crisis.” (Roberts, 2005, p. 778)

Seven Stages of Intervention (Roberts, 2005).

Continuum of Abuse (Burman, 2003).

A treatment plan

The following is a hypothetical treatment plan I created for my practicum course some time ago.  I utilized the resources below to create it…

References

Burman, S. (2003). Battered women: Stages of change and other treatment models that instigate and sustain leaving. Brief Treatment and Crisis Intervention, 3(1), 83.
Fraser, P. Y., Slatt, L, Kowlowitz, V., & Glowa, P. T. (2001). Using the stages of change model to counsel victims of intimate partner violence. Patient Education and Counseling. 44, 211-217.
Holiman, M. & Schlilit R. (1991). Aftercare for battered women: How to encourage maintenance of change. Psychotherapy. 28(2), 345-353.
Karakurt, G., Smith, D., & Whiting, J. (2014). Impact of Intimate Partner Violence on Women’s Mental Health. Journal of family violence29(7), 693-702.
Roberts, A. R., & Ottens, A. J. (2005). The seven-stage crisis intervention model: A road map to goal attainment, problem solving, and crisis resolution. Brief Treatment and Crisis Intervention, 5(4), 329-339

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Stages of Change: Treatment Needs & Strategies….

In a previous post, I provide an overview of the Stages of Change from a personalized perspective.  “In the transtheoretical model, behavior change is conceptualized as a process that unfolds over time and involves progression through a series of five stages: precontemplation, contemplation, preparation, action, and maintenance” Norcross, Krebs & Prochaska, 2011, p. 143).  The point of this post was to illustrate that change is a process and not a singular event.  In other words, “Just Do It” doesn’t cut it as useful advice for those attempting to institute changes in their lives.

The purpose of this post is to review the stages of change from a pragmatic perspective.  I discuss each stage and review treatment needs and potential strategies.

STAGE #1: Precontemplation

“Precontemplation is the stage in which there is no intention to change behavior in the foreseeable future. Most patients in this stage are unaware or under-aware of their problems. Families, friends, neighbors or employees, however, are often well aware that the pre-contemplators suffer from the problems” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

“During the pre contemplation stage, individuals are not even considering changing and may not even see advice provided to them as applicable to their lives” (Zimmerman, et al, 2000, 1409).  The goal for a therapist with a client in the pre contemplation stage is to increase their concerns for problematic behaviors and/or situations and provide hope that change is possible (Sullivan & Flemming, 1997).   In order to achieve this goal, the primary task is expanding the client’s awareness of their life situation.  At times, this might entail simply providing the client information, such reviewing symptoms of a diagnosis, or the side-effects of a medication.  However, it is also essential that explore the client’s perspective of things.  How do they perceive their situation & what meaning do they live to current life events?  Have they attempted to change before?  These questions can assess what the barriers to change are.  People are rarely liable to change if there is no benefit to doing so.  Therefore, it is critical that we understand the factors the client is struggling with as they weigh their options (i.e. change vs. no change).

Strategies

  1. Establish Rapport & Build Trust
  2. Assess the client rationale for current life-style choices…
  3. Begin to assess barriers to change.
  4. Elicit the client’s current perception of the problem.
  5. Expand the client’s current perspective by providing factual information
  6. Build up the client’s confidence in the idea that change is realistic & possible.
  7. Examine discrepancies between the client’s perception and how others view things.
  8. Provide personal feedback on assessment findings.
  9. Discuss relevant diagnoses, symptoms, and possible treatment.

Interview Approach

The primary goal is to develop rapport and establish trust.  Take time to discuss the client’s understanding of the problem.  Non-judgmentally provide factual information regarding the client’s problematic and/or self-destructive behaviors and express your concern (Sullivan & Flemming, 1997).   Begin establishing an “agree to disagree” standard in order to begin discussing divergent perspectives of the client’s life-situation (Sullivan & Flemming, 1997).  Periodically assess the client’s readiness to change.

STAGE #2: Contemplation

“Contemplation is the stage in which patients are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Contemplators struggle with their positive evaluations of their dysfunctional behavior and the amount of effort, energy, and loss it will cost to overcome it” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

“During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain” (Zimmerman, et al, 2000, p1409).  In other words, they are now able to acknowledge that change needs to happen, however remain ambivalent.  The idea of change, is either overwhelming, or highly undesirable.  The therapeutic goal, therefore, is address the client’s feelings of ambivalence.  In other words, what factors weigh in heavily for and/or against the idea of change?  How can this decisional balance tipped in favor of change?  Increasing the client’s understanding of their options can help them make more informed decisions.

Strategies

  1. Acknowledge feelings of ambivalence & normalize this experience as a part of the change process.
  2. Develop a list of factors for & against change.
  3. Provide clear & nonjudgmental messages regarding the client’s need to change.
  4. Examine the client’s personal values in relation to change.
  5. Address intrinsic & extrinsic factors related to the client’s motivation to change.
  6. Assess the client’s feelings of efficacy & expectations regarding process of change.
  7. Ask the client to begin considering small changes and assess their outcome.

Interview Approach

Continue building the therapeutic relationship.  Validate & acknowledge the client’s feelings of ambivalence regarding the idea of change.  Explore the factors underlying feelings of ambivalence.   Discuss positive an negative factors associated with change (Sullivan & Flemming, 1997).  Create a discrepancy between the client’s values and actions (Sullivan & Flemming, 1997).  Consider making small changes in order to address feelings of ambivalence (Sullivan & Flemming, 1997).

STAGE #3: Preparation

“Preparation is the stage in which individuals are intending to take action in the next month and are reporting some small behavioral changes (‘‘baby steps’’). Although they have made some reductions in their problem behaviors, patients in the preparation stage have not yet reached a criterion for effective action” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

During the preparation stage, patients prepare to institute small changes. Sullivan & Flemming, (1997), note that while pre-contemplation and contemplation work well with motivational interviewing techniques, CBT and/or 12-step approaches are useful for the remaining stages.  During this stage, clients work on strengthening their commitment to change.  Therapists should help client’s work though various strategies to institute planned changes.

Strategies

  1. Assist the client in refining their goals & plans for change.
  2. Help the client review the options available & determine a best course of action.
  3. Review previous attempts to institute changes in order to understand what didn’t work.
  4. Elicit the assistant from the clients social support system.
  5. Encourage the client to take action daily to institute change.

Interview Approach

Acknowledge the significance of the client’s decision to institute changes, and reaffirm their ability to successfully achieve their goals.  Help the client develop a plan of action and examine how the road ahead looks.  Reassure the client that progress sometimes involves relapse.

STAGE #4: Action

“Action is the stage in which individuals modify their behavior, experiences, and/or environment to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Individuals are classified in the action stage if they have successfully altered the dysfunctional behavior for a period from 1 day to 6 months” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

Helping professionals are really eager to see their clients reach the action stage.  Helping the client implement strategies for change and develop a plan to prevent relapses into old habits.  Therapeutic goals during this stage can center around problem solving, developing a sense of self-efficacy and strengthening your support system.

Strategies

  1. Review the client’s plan for change and revise as necessary.
  2. Develop a relapse plan & prepare the client for this possibility.
  3. Help the client process the difficulties encountered in creating change.

Interview Approach

Be a source of support and encouragement and acknowledge feelings of withdrawal and/or discomfort that tend to accompany efforts to let go of unhealthy habits.  Reinforce the client’s resolve and the importance of remaining in recovery.

STAGE #5: Maintenance

“Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. This stage extends from 6 months to an indeterminate period past the initial action. Remaining free of the problem and/or consistently engaging in a new incompatible behavior for more than 6 months are the criteria for the maintenance stage” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

Treatment needs during this stage involve maintaining changes & preventing old habits to crop up again. For example, I’ve tried to lose weight before, but have yet to realistically sustain it over a significant length of time. Life gets in the way, and I end up slipping and gaining a bit.  Recycling through the stages above is common & it is vital to normalize this experience with clients.  This can help clients examine what hasn’t worked out well in order to learn from past mistakes.

Strategies

  1. Help the client develop a support system that can help the client maintain life changes.
  2. Help the client develop new coping strategies in order to let go of old habits.
  3. Help the client examine behavioral & situational issues that can cause relapse.
  4. Help the client work through the beliefs & expectations that guide their progress.

Interview Approach

Help the client anticipate difficulties in creating lasting change and provide opportunities toward through this struggle.  Should relapses occur, help the client work through underlying factors that may have contributed to it.  Help client develop a sense of self-efficacy so that lasting change an be seen as realistic and achievable.

References

All of the information from this post has been adapted and summarized from the following resources below…

  1. Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of clinical psychology, 67 (2), 143-154.
  2. Sullivan, E., & Fleming, M. (1997). A guide to substance abuse services for primary care clinicians: Treatment Improvement Protocol (TIP) Series 24. Center for Substance Abuse Treatment, Rockville (MD): DHHS Publication, (1997).
  3. Zimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). A ‘stages of change’ approach to helping patients change behavior. American family physician, 61(5), 1409-1416.

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“Git Er Done!!!” – Motivation & Change

Motivation is Essential for Change….

“clients’ level of motivation for change is often a good predictor of outcome.  Motivation can be influenced by many naturally occurring interpersonal and interpersonal factors and by specific interventions…three are at least three critical components of motivation: readiness, willingness and ability” (Miller & Rollnick, p. 9).  

Willingness to Change

Change happens if an individual feels it is important for them.  Miller & Rollnick, (1991) describe a psychological self-monitoring function that acts like a thermostate.  Any aspects of our reality that are not in sync of our personal values produce a desire for change.  This discrepancy between our current reality and desired goals produces a willingness to change.  It’s polar opposite is resistance.

The Righting Reflex:  “When people perceive a discrepancy between how things are and how they ought to be, they tend to be motivated to reduce that discrepancy if it seems possible to do so.” (Miller & Rollnick, 1991, p. 20)

Ability to Change

Ability to change can be thought of a belief in our level of capability to achieve a specific goal..  When individuals believe they don’t have the ability to change, they are resistant to trying.  Individuals that face a discrepancy between actions and values (as desired above) who are do not feel capable of change can resort to using defense mechanisms.  Defense mechanisms provide an alternative to change via the adjustment of perceptions, beliefs, and thoughts.

Readiness to Change

“One can be willing and able to change, but not ready to do so…this third dimension, readiness, has to do with relative priorities: ‘I want to, but not now'” (Miller &Rollnick, 1991 p. 11).  Motivational Interviewing suggests we do not see low readiness in a pathological manner but as a normal part of the change process.

When Client’s are Not Motivated….

According to Motivational interviewing, human beings are seen as having a “built-in desire to set things right” (Miller & Rollnick, 1991, p. 20).  As stated earlier, change is a byproduct of motivation.  Motivation is a byproduct of any perceived discrepancies between what how things are and how they ought to be. So what happens when we encounter a client who is resistant to change despite clear evidence that it is needed?  Here are just a few examples from Miller & Rollnick (1991).

“You would think that having a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more and take his medication.” (Miller & Rollnick, 1991, p. 3).

“You would think that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking.” (Miller & Rollnick, 1991, p 3).

In the examples, it is often natural to react with frustration and sadness.  We see behavior that appears self-destructive, yet are unable to help the client see this.  Motivational interviewing, suggests not conceiving the client’s resistance in a self-destructive or maladaptive in nature, but instead a part of the process of change.  Consider the following:

What happens when someone with a righting reflex (R) [i.e. motivated]  meets a person who is ambivalent (A) [resistant]?  As A speaks to R about the dilemma of ambivalence, R develops an opinion as to what the right course of action would be for A to take. R then proceeds to advise, teach, persuade, counsel, or argue for this particular resolution to A’s ambivalence….By virtue of ambivalence, A is apt to argue the opposite, or at leastpoint out problems and shortcomings of the proposed solution. It is natural for A to do so, because A feels at least two ways about this or almost any prescribed solution. It is the very nature of ambivalence.” (Miller & Rollnick, 1991, p. 20-21)

In this above example, we see what happens when the client and the counselor are not on the same page.  So what is the missing piece of the puzzle that the counselor is missing? The client lacks motivation to change.  They are not ready, willing or able…

“Our perspective is that exploring and enhancing motivation for change is itself a proper task, at times even the most important and necessary task, within helping relationships such as counseling, health care, and education.” (Miller & Rollnick, 1991, p. 21)

OUR GOAL:  Developing Discrepancy

Miller & Rollnick, (1991) state that our goal should be to have the client voicing arguments in favor of change.  “When you find yourself in the role of arguing for change while your client (patient, student, child) is voicing arguments against it, you’re in precisely the wrong role” (Miller & Rollnick, 1991, p .22).

So how can we get our clients to begin arguing in favor of change?  In motivational interviewing, arguments in favor of change are called “Change talk”.  The client engages in “change talk when they are motivated.  “The larger the discrepancy, the greater the importance of change” (Miller & Rollnick, 1991, p. 22).  In other words, clients become motivated as feelings of ambivalence are resolved and they gain awareness of discrepancies between their reality and desires.   Change talk falls into one of four categories…

  1. “Disadvantages of the status quo. These statements acknowledge that there is reason for concern or discontent with how things are. This may or may not involve an admission of a ‘problem.’ The language generally reflects a recognition of undesirable aspects of one’s present state or behavior.” (Miller & Rollnick, 1991, p. 24).  
  1. Advantages of change. A second form of change talk implies recognition of the potential advantages of a change. Whereas the first type of change talk focuses on the not-so-good things about one’s current status, this second type emphasizes the good things to be gained through change. Both kinds, of course, are reasons for change.” Miller & Rollnick, 1991, p. 24).  
  1. “Optimism for change. A third kind of talk that favors change is that which expresses confidence and hope about one’s ability to change. It may be stated in hypothetical (I could) or declarative form (I can do it). The common underlying theme is that change is possible” (Miller & Rollnick, 1991, p. 24).  
  1. Intention to change. As the balance tips, people begin to express an intention, desire, willingness, or commitment to change. The level of intention can vary from rather weak to very strong commitment language. Sometimes the intention is expressed indirectly by envisioning how things might be if change did happen” (Miller & Rollnick, 1991, p. 24).  

Images: 1

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press

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Motivational Interviewing & Ambivalence

Misinterpreting Ambivalence

“It is easy to misinterpret ambivalent conflict as pathological — to conclude that there is something wrong with the person’s motivation, judgment, knowledge base, or mental state. A sensible conclusion from this line of reasoning is that the person needs to be educated about and persuaded to take the proper course of action” (Miller & Rollnick, 1991 p. 14)

Ambivalence is a frustrating dilemma that involves feeling two ways about something.   For example, I have been feeling lonely for a while and looking to establish new friendships.  I’m finding the task somewhat daunting with so little free time.  As adults, we establish friendships based on convenience, with those we have an opportunity to interact with regularly. Individuals at my stage in life tend to have quite a bit on their plate.  Between work and home life, where does one find time to establish new friendships?  My ambivalence reflects a conflict between two opposing desires. On the one hand, I feel lonely and desire to establish friendships. On the other hand, I have insecurities stemming from earlier childhood experiences, and am fearful of opening up to others.

When others misinterpret my ambivalence.

There is a coworker I chat with often via text at work.  We are both employed by healthcare float pools and often work at the same facilities, (although rarely on the same floor).  She is a social butterfly who is always urging me to just be more friendly and strike up conversations every so often.  From her perspective I would surmise she is frustrated by my lack of “motivation, judgment, and knowledge base” (Miller & Rollnick, 1991).  In other words, she could easily interpret my ambivalence as an unwillingness to take the initiative and establish friendships.  Alternatively, she might interpret my as a matter of social anxiety or ineptness on my part.  (Mind you, this is just an example, of the sort of consructive criticism I’ve heard before.  Coworkers, friends, and even my sister express advice of this sort from time to time regarding my “shyness & reclusive nature”)

What others miss about my ambivalence…

So what is my perspective? As I stated earlier, I have two conflicting emotional reactions to the idea of establishing friendships.  On the one hand, I feel lonely and wish to cultivate a few meaningful female friends.  Every once in a while, I might have something on that I want to share with somebody…Or mabye I might just simply want to sort things out: (I’m a verbal processor :))  From time to time, I can unknowingly bombard my poor hubby with assorted idle chatter.  As somebody who likes “thinking out loud” to verbally process my thoughts and come to a conclusion, it’s a habit I’ve have had difficulty breaking.   My hubby always tries his best to listen.  However, every once in a while he’ll comment jokingly: “You need to get a few female friends to go out with so you can talk about this at greater length.”  When he says this, I’m aware that he’s done all the listening he can take, and I need to find somebody else to talk to…

At moments such as these, when I need somebody to talk to, I become sad.  As feelings of loneliness arise, so do feelings of fear and anxiety.  I am fearful of opening up to others, primarily because I don’t want to re-experience the rejection and ostracism I dealt with in high school.  I can then berate myself for a lack of experience due to years of self-imposed isolation.  The alternative thought arrises at some point:  Wouldn’t it be much easier to stay home and lounge on the sofa while binge-watching something on Netflix?

…And then there are the pragmatic aspects of developing friendship that produce more frustration… First off, Idespise technology and/or social media as required forms of interaction in today’s social world. However, these things are here to stay and I’ve learned tried to adapt. For example, I might exchange texts occasionally with a coworker or fellow intern.  Every once in a while I might also call to ask a question, discuss a concern, and/or brain-pick.   I stress occasionally about how my text might be interpreted. I also worry about how my own texts are interpreted.   If she doesn’t call, I worry what that might mean.  If I call I worry about being a bother.

So here’s a breakdown of my example of misinterpreted ambivalence.

  1. 1st HAND P.O.V – My social ambivalence reflects unresolved insecurity and hurt stemming from early childhood bullying and ostracism.  In large part, I am anxious and fearful, because I don’t want to get hurt again.
  2. 2nd HAND P.O.V. – Other’s might misinterpret my social ambialence as reflecting the fact that I’m a shy or introverted.  Alternatively, someone could interpret this ambivalence as reflective of social ineptness or simply a lack of motivation to put a little effort into the establishment of friendships.  
  3. THE MAIN POINT – Ambialence is a normal part of the process of change,  it reflects a psychological conflict that needs to be resolved for change to happen.

A Different Perspective on Ambivalence…

“Ambivalence is a common human experience and a stage in the normal process of change. Getting stuck in ambivalence is also common, and approach-avoidance conflicts can be particularly difficult to resolve on one’s own. Resolving ambivalence can be a key to change, and indeed once ambivalence has been resolved, little may be required for change occur. However attempts to force resolution in a particular direction..can lead to a paradoxical response, evening strengthening the very behavior they were trying to diminish” (Miller & Rollnick, 1991, p. 19).

In order to resolve ambivalence, it is vital to understand that stuckness is a normal part of the process of change.  In fact, at the heart of the matter, is resolving one’s own conflicting feelings on an issue. Miller & Rollnick, (1991), suggest conceptualizing one’s dilemma’s as a decisional balance.  “Transactional analysis often regards the experience of ‘ feeling stuck’ as the manifestation of an impasse or an intrapsychic conflict or interpersonal roadblock…Impasses occur each time we encounter a situation in which our current adaptations cannot make sense of or handle meaningfully…(Petriglieri, 2007, pp. 185-187).”  Addressing the issue, from this perspective can be seen as a matter of weight costs and benefits for each course of action.   So how might this explanation apply to my social ambivalence?  

  1. Unresolved insecurities stemming from childhood experiences pollute my thinking today.
  2. My interpretations of others’ opinions becomes a foundational element of how I see myself.  
  3. When I think with my feelings in a knee-jerk manner, my unresolved insecurites turn into self-fuffilling prophecies, by withdrawing and isolating myself.  
  4. Examining how my knee-jerk coping styles perpetuate my insecurity and loneliness can provide the clarity necessary to overcome this ambivalence.
  5. Tipping the decisional balance chart, involves carefully breaking down decisional alternatives in this manner. Which route is the preferable alternative???

In these posts, I share how I’ve worked through ambivalence & feelings of stuckness in my life:

“Getting Unstuck & Why I Started this Blog” 

“An Underdog’s Credo: Choking vs. Panic”

Types of Psychological Conflict…

Miller & Rollnick (1991) describe three types of ambivalent conflict. “In the approach–approach conflict, the person must choose between two similarly attractive alternatives An avoidance–avoidance conflict, in contrast, involves having to choose between two evils—two (or more) possibilities Still more vexing is the approach–avoidance type. This kind of conflict seems to have special potential for keeping people stuck and creating considerable stress. Still more vexing is the approach–avoidance type. This kind of conflict seems to have special potential for keeping people stuck and creating considerable stress” (p. 15).
  1. Here is an example avoidance-avoidance conflict, in which I keep a crappy job because it pays well to support my family.  My choices here: a shitty job or being broke.  

  2. Here is an example of approach-avoidance, described my Miller & Rollnick (1991) as a “fatal attraction..kind of love affair”

Ambivalent Paradoxical Responses…

“The theory of psychological reactance predicts an increase in the rate and attractiveness of a ‘problem’ behavior if a person perceives that his or her personal freedom is being infringed or challenged. Secondary effects of a change within the person’s social environment may also account for detrimental shifts” (Miller & Rollnick, 1991, p. 18)

Miller & Rollnick, (1991) note that  common response to the utilization of deterrents to curb negative behavior is an increase of that behavior.  I like to think of this as a passive-agressive rebelliousness.  As a married mother of two boys, I’m the only source of estrogen.  The males in my family tend to utilize this response to any repetitive requests for them to do/not do something, (i.e. nagging) 🙂 ….  For example, my son hates being late for school, if I keep nagging him to get up earlier he can rebel by dragging his feet in the morning.  The consequence is he gets to school even later and complains about it more.  My youngest complains about being tired at school, yet responds similarly when I tell him to get to bed earlier.  When I  discussed this with my husband, he noted this knee-jerk, response is probably a result of the boy’s picking up on his bad habits 🙂 … These behaviors could be interpreted as an innate desire to challenge the restrictions placed on personal freedom.

A Solution to Ambivalence

So how do you resolve ambivalence?  I’ve spent too many years on a hamster wheel in my own life. Overcoming my own stuckness has been at the heart of my efforts to create forward-motion.  As I mentioned earlier, Miller & Rollnick (1991) discuss a decisional balance chart as a useful tool to overcome ambivalent. When I reflect on my own decision making processes at different points in life, I see flaws in my thinking.  At the heart of the matter, underlying my stuckness, were unresolved hurts and traumas that caused flaws in my thinking.  Addressing these issues head on and allowing healing to occur has been critical for forward progress.

Understanding & Handling Resistance

“My Mental Merry Go Round”

In conclusion Miller & Rollnick, (1991) also suggest the following as a solution to ambivalence:

“Instead of focusing, then, on why a person doesn’t want to make a particular change, it is sensible to explore what the person does want. This is not to ignore the topic of change. Rather, it provides a context for change. Sometimes a behavioral course adjustment does not occur until people perceive that change is relevant to achieving or preserving something that is truly important or dear to them” (Miller& Rollnick, 1991, p. 18).

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Petriglieri, G. (2007). Stuck in a moment: A developmental perspective on impasses. Transactional Analysis Journal. 37(3), 185-194.

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Motivational Interviewing & Resistance

It seems apparent that what a person is doing either isn’t working or is self-destructive; you can see a better way, yet the person persists in the same behavior. In a way, it is captured in the words, “You would think . . . ”

“You would think that having a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more and take his medication.” (Miller & Rollnick, 1991, p. 3).

“You would think that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking.” (Miller & Rollnick, 1991, p 3).

Change vs. Resistance: Two Sides of The Same Coin (Miller & Rollnick, 1991).

In a previous post, we discussed the nature of motivation: Here we consider it’s opposite: Resistance.

The Therapeutic Relationship: Consonance vs. Dissonance

“When things are going well in a motivational interview, there is a sense of moving together smoothly…the feeling is quite different when instead of moving together, the counselor and client seem to be struggling against one another” (Miller & Rollnick, 1991, p. 43).  In fact, conversations between therapist and
client occur along continuum, falling somewhere between understanding and misunderstanding.  Miller & Rollnick, (1991) utilize the terms consonance and dissonance to describe these extremes.  With consonance we have compatibility of perspectives between client and therapist: everybody is on the same page.  In contrast, dissonance involves an inconsistency and contradiction of perspectives: complete misunderstanding.

Miller & Rollnick, (1991) caution against defining dissonant conversations with clients as byproduct of resistance.  Resistance is a term that tends to implicitly apply blame to the therapist.  In reality, dissonant conversations with clients reflects more on the quality of the therapeutic relationship.  “Dissonance in a counseling relationship is not the product…of only one person’s behavior.” (Miller & Rollnick, 1991, p. 43). So what is the solution?  Miller and Rollnick, (1991) state it is the therapist’s job to recognize dissonance, interpret it accurately, and adjust accordingly in order to restore a feeling of consonance between therapist and client.

Client Behavior: Change Talk vs. Resistance

Miller & Rollnick, (1991) also assert that the insights on consonance and dissonance can apply to the understanding of client behavior.  “Resistance is a signal of dissonance in the client relationship…a meaningful signal” (Miller & Rollnick, 1991, p. 46).  The opposite of resistance is change talk, (discussed in a previous post).  Change talk reflects an increase in internal motivation and the resolution of ambivalence.  Resistance, in contrast reflects a high ambivalence, and low internal motivation.  Miller & Rollnick describe four categories of resistant behavior:

  1. ARGUING: The client contests the accuracy, expertise, or integrity of the counselor.”  (Miller & Rollnick, 1991, p. 48).
  2. INTERRUPTING: The client breaks in and interrupts the counselor in a defensive manner.”m(Miller & Rollnick, 1991, p. 48).
  3. NEGATING: The client speaks while the counselor is still talking, without waiting for an appropriate pause or silence.” (Miller & Rollnick, 1991, p. 48).
  4. IGNORING: The client shows evidence of not following the counselor.”  (Miller & Rollnick, 1991, p. 48).

How Should Counselor’s Respond???

“With patients in precontemplation, often the role is like that of a nurturing parent, who joins with a resistant and defensive youngster who is both drawn to and repelled by the prospects of becoming more independent. With clients in contemplation, the role is akin to a Socratic teacher, who encourages clients to achieve their own insights into their condition. With clients who are in the preparation stage, the stance is more like that of an experienced coach, who has been through many crucial matches and can provide a fine game plan or can review the participant’s own plan. With clients who are progressing into action and maintenance, the psychotherapist becomes more of a consultant, who is available to provide expert advice and support when action is not progressing smoothly” (Norcross & Krebs & Prochaska, 2011, p. 145)

Miller & Rollnick (1991) suggest that clients are “understood within the context of the counseling relationship” (p. 51).  Recognizing the fluctuation between dissonance and consonance in the therapeutic relationship is essential, so the therapist can adjust accordingly.  What follows are examples of what not to do:  

  1. “ARGUING FOR CHANGE: The counselor directly takes up the pro-change side of ambivalence on a particular issue and seeks to persuade the client to make change.” (Miller & Rollnick, 1991, p. 50).
  2. ASSUMING THE EXPERT ROLL:  The client structures the conversation in a way that communicates that the counselor ‘has the answers’.” (Miller & Rollnick, 1991, p. 50).
  3. “CRITICIZING, SHAMING, BLAMING, OR LABELING.”  (Miller & Rollnick, 1991, p. 50).
  4. “BEING IN A HURRY: Sometimes the perceived shortness of time causes the counselor to believe that clear, forceful tactics are called for in order to get through…if you act like you only have a few minutes, it can take all day to accomplish a change.”  (Miller & Rollnick, 1991, p. 50)

Misc Techniques…

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of clinical psychology, 67(2), 143-154.

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What is Motivational Interviewing

Everybody knows someone who is making perplexingly unhealthy choices detrimental to their well-being.   It’s quite tough to watch helplessly as a loved one acts self-destructively.  We see their lives heading down a path leading to nowhere.  We are brutally where the end of the road can take them but are helpless to stop them.   All we can do is stand by and watch in horror.  I experience this all-too-often as a student therapist and healthcare worker.

What is motivational interviewing?

Motivational interviewing is a unique client-centered approach that helps the client’s achieve lasting changes in their lives.  It does this by helping the client resolve an feelings of ambivalence to change while clarifying internal motivations to change.  Motivational interviewing is defined by the following characteristics (Miller & Rollnick, 1991).

A Client-Centered Approach

Motivational interviewing has an indebtedness to the work of Carl Rogers in its client-centered approach.   It focuses on developing a concern and understanding of the client’s perspective.  Miller & Rollnick (1991), note that by utilizing a client-centered approach to encourage change, Motivational Interviewing has the following unique characteristics.

  1. It is collaborative in nature and avoids the authoritarian approach (Miller & Rollnick, 1991, p. 22).
  2. This approach focuses in drawing out client insight and develop intrinsic motivation (Miller & Rollnick, 1991).
  3. This method respects individual by asserting that responsibility for change rests upon the client.  (Miller & Rollnick, 1991).

A Consciously Directive Approach

Motivational interviewing, however, diverges from the Rogerian approach, as a consciously directive alternative to instituting change.  This approach is intentionally directed toward resolving any feelings of ambivalence to change.  Getting unstuck, involves working through ambivalence by creating discrepancies between behavior, goals, values, and beliefs.

It is a Method of Communication

“Third, we emphasize that motivational interviewing is a method of communication rather than a set of techniques It is not a bag of tricks for getting people to do what they don’t want to do. It is not something that one does to people; rather, it is fundamentally a way of being with and for people—a facilitative approach to communication that evokes natural change” (Miller & Rollnick, 1991, p. 18).

It Elicits Intrinsic Motivation to Change

“The focus of motivational interviewing is on eliciting the person’s intrinsic motivation for change. It differs from motivational strategies intended to impose change through extrinsic means: by legal sanctions, punishment, social pressure, financial gain and such. Behavioral approaches often seek to rearrange the person’s social environment so that one kind of behavior is reinforced and another discouraged” (Miller & Rollnick, 1991, p. 19).

It Focuses on Resolving Ambivalence

This method focuses on exploring and resolving ambivalence within the client and is based on the idea that change cannot happen unless the client is willing to do so.  Change cannot be imposed upon a client if it conflicts with their beliefs, values, and goals (Miller & Rollnick, 1991).  By addressing the cause of a client’s own “stuck-ness” they develop an internal motivation for change.

Lessons to Learn about Motivational Interviewing…

An article I found titled “Eight Stages in Learning Motivational Learning” provides an overview of skills practitioners must develop in order to utilize Motivational Interviewing successfully (Miller & Moyers, 2006, p. 3).

“practitioners acquire expertise in this method through a sequence of eight stages: (1) openness to collaboration with clients’ own expertise, (2) proficiency in client-centered counseling, including accurate empathy, (3) recognition of key aspects of client speech that guide the practice of MI, (4) eliciting and strengthening client change talk, (5) rolling with resistance, (6) negotiating change plans, (7) consolidating client commitment, and (8) switching flexibly between MI and other intervention styles” (Miller & Moyers, 2006, p. 3).

STAGE #1: THE SPIRIT OF MOTIVATIONAL INTERVIEWING

The first lesson a new therapist must encounter in utilizing motivational interviewing adeptly is to appreciate how it is unique.  What follows are three key descriptive characteristics of motivational interviewing:

  1. COLLABORATION – “Certainly one key component of the spirit of motivational interviewing is its collaborative nature. The counselor avoids an authoritarian one-up stance, instead communicating a partner-like relationship. The method of motivational interviewing involves exploration more than exhortation, and support rather than persuasion or argument” (Miller & Rollnick, 1991, p. 33).
  2. EVOCATIVE – “Consistent with a collaborative role, the interviewer’s tone is not one of imparting things (such as wisdom, insight, reality) but rather of eliciting, of finding these things within and drawing them out from the person…It is not an instilling or installing but, rather, an eliciting, a drawing out of motivation from the person. It requires finding intrinsic motivation for change within the person and evoking it, calling it forth” (Miller & Rollnick, 1991, p. 33).
  3. AUTONOMY – “In motivational interviewing, responsibility for change is left with the client—which, by the way, is where we believe it must lie, no matter how much professionals may debate what people can be ‘made’ or ‘allowed’ or ‘permitted’ to do and choose. Another way to say this is that there is respect for the individual’s autonomy” (Miller & Rollnick, 1991, p. 33).

STAGE #2:  (OARS) CLIENT-CENTERED COUNSELING SKILLS

“The second stage of skill development is not unique to MI. It involves acquiring proficiency in the use of classic client-centered counseling skills…Along with reflective listening, three other counseling micro-skills are particularly emphasized in MI, using the mnemonic acronym OARS: asking open questions (O), affirming (A), reflecting (R), and summarizing” (Miller & Rollnick, 1991, p. 8).

Basic Attending Skills

Active Listening Skills

Questions & Listening Responses

Confrontation, Reflecting, Focusing & Influencing

STAGE #3: RECOGNIZING CHANGE TALK

“MI departs from client-centered counseling in being consciously and strategically goal-directed. Originally developed to help people change addictive behaviors…[it] is directed toward particular behavior change goals. A key process is to help clients resolve ambivalence by evoking their own intrinsic motivations for change. When MI is done well, therefore, it is the client rather than the counselor who voices the arguments for change. Particular attention is given to client “change talk,” verbalizations that signal desire, ability, reasons, need, or commitment to change…If unable to recognize change talk when it occurs, the counselor cannot reinforce and shape it toward commitment” (Miller & Moyers, 2006 p. 7). Another resource for this article notes paradoxically, that it is the reflective, supportive, and client-centered approach that increases a client’s openness to change (Miller & Rollnick, 1991).  In contrast, traditionally confrontational and directional techniques increase resistance (Miller & Rollnick, 1991)

STAGE #4: REINFORCING CHANGE TALK

Once the client recognizes the client’s openness  & desire to change, therapists utilizing MI, must learn to further reinforce it.  This intentional reinforcing can happen through a series of strategies such as the following: “(e.g., ‘In what ways might this change be a good thing?’), and is cautious with questions the answer to which is resistance (e.g., ‘Why haven’t you changed?’)” Miller & Rollnick 1991, p. 8)

STAGE #5: ROLLING WITH RESISTANCE

“The client rather than the counselor should present the arguments for change. Change is motivated by a perceived discrepancy between present behavior and important personal goals or values.” (Miller & Rollnick, 1991, p. 26).  Using this method effectively requires therapists to understand that arguing directly with a client’s resistance to change, only reinforces it.  Rolling with resistance means inviting arguments against change and seeing resistance as a need to change the way you are communicating with the client.  Change can be enabled through a process of active problem solving the includes an acknowledgment the client’s concerns.

STAGE #6: DEVELOPING A CHANGE PLAN

“Miller and Rollnick described therapeutic skillfulness in timing, in knowing when to move on to the development of a change plan. The usual procedure is to offer a transitional summary of change talk (desire, ability, reasons, need) that the client has offered for making a change, and then to ask a key open question, the essence of which is “What next?”… Part of the skill here, then, is knowing when to attempt the transition from Phase 1 to Phase 2…is proficiency in developing a specific change plan (not necessarily treatment plan) without evoking resistance” (Miller & Moyers, 2006, p.10)

STAGE #7: CONSOLIDATING CLIENT COMMITMENT

Once the client has been to acknowledge a need for change, helping them follow through with their plans is the next critical task.  Commitment talk implies that a decision has been made, the client is committing to it and attempting to develop a plan.

STAGE #8: SWITCHING BETWEEN MI AND OTHER COUNSELING METHODS

“MI was never meant to be the only tool in a clinician’s repertoire. It was developed primarily to help clients through motivational obstacles to change. Within the language of the transtheoretical stages of change (Prochaska & DiClemente, 1984), MI was originally conceptualized for helping people move from precontemplation and contemplation, through preparation and on to action” (Miller & Moyers, 2006, p. 21).  Therefore, therapists must learn to utilize it alongside other methods.

What it is & What it Isn’t

Core Strategies

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Miller, W. R., & Moyers, T. B. (2006). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions, 5(1), 3-17.

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Confrontation, reflecting, focusing & influencing

The final basic counseling skills post, focuses on the more advanced skills: (confrontation, influencing, focusing, & reflection of meaning). Included below is a “quick & dirty” overview of these skills….

“Confrontation is not a direct, harsh challenge.  Think of it, rather, as a more gentle skill that involves listening to the client carefully and respectfully; and, then, seeking to help the client examine self or situation more fully. Confrontation is not “going against” the client; it is “going with” the client, seeking clarification and the possibility of a creative New, which enables resolution of difficulties. (Ivey, et al, 2010, p. 241)


Of all the basic counseling skills, I am notoriously fearful of confrontation.  My supervisor utilizes motivational interviewing to engage in a form as way to elicit change.  However, I’ve noticed that confrontation doesn’t have the same connotation as it does in daily life.  In my own family, confrontation is a dirty word that we avoided at all costs.  Consequently, when there confrontation did occur, the air was filled with an awkwardness that you could cut with a knife.  In the end, cause we were never good at airing our differences, the end result was always misunderstanding….

So with this as my own personal background, the idea of confronting clients is especially terrifying.  To be honest, I’m afraid of a creating misunderstand and realize  at times its necessary to bite the proverbial bullet.  Confronting clients is a risk-taking venture that challenges the therapeutic relationship that you work hard to build.  However, the potential payoff is that we can provide the client an opportunity to challenge their own beliefs and perceptions.  My course textbook describes confrontation as involving three steps:

“First: Listen and identify conflict in clients’ mixed messages, discrepancies, and incongruity” (Ivey, et al, 2010, p. 243).

Discrepancies can be a divergence between one’s actions and beliefs, or simply feelings of ambivalence. For example, my therapist once directly confronted me after I told her for the fifty-millionth time that I need to start exercising and losing weight. She responded, you’ve been wanting to do this for five years but have never gotten around to it, what has been stopping you?

“Second: Clarify and clearly point out issues to clients and help them work through conflict to resolution.” (Ivey, et al, 2010, p. 243).

Relationships difficulties can be an excellent source of ambivalence. I like to start out by asking questions that can clarify the issues my client is struggling with.  Having all the facts and viewpoints in a particular situation is the next logical step to helping the client find a resolution…

“Relationship is critical here as we make the conflict clearer to the client”  (Ivey, et al, 2010, p. 243).

The scariest step for me is where you make the nature of the conflict clear to the client.  This can involve paraphrasing, or summarizing what the client has said.  This can often provide the client an opportunity to reflect on what they have said.

Finally: Listen, observe, and evaluate the effectiveness of your intervention on client change and growth” (Ivey, et al, 2010, p. 243).

Evaluating the client’s response is useful in ascertaining where the client is along the stages of change. My textbook concludes by noting that “confrontation itself is a not a distinct skill; it is a set of skills that may be used in different ways. The most common confrontation uses the paraphrase, reflection of feeling, and summarization of discrepancies observed in the client or between the client and her or his situation. (Ivey, et al, 2010, p. 256)

“Focusing is a skill that enables multiple tellings of the story and will help you and clients think of creative new possibilities for restorying Use selective attention and focus the interview on the client, problem/concern, significant others (partner/spouse, family, friends), a mutual “we” focus, the interviewer, or the cultural/environmental/contextual issues. You may also focus on what is going on in the here and now of the interview” (Ivey, et al, 2010, p. 241).

I am a student therapist who is also in therapy  I find the biweekly sessions simultaneously therapeutic and educational.  Every time I see my therapist I leave with several insights about my life that had previously not occurred to me.  I think it helps that I have started to see a new therapist.  I marvel at how naturally he utilizes these counseling skills without a single thought.

However, I must admit, there are times when the technique of focusing aren’t especially useful.  For example, previous therapists I have had, haven’t utilized this skill very adeptly.  Consequently, I found attempts to focus our conversation on certain issues to be frustrating.  When based on limited understanding I find myself struggling to find the opportunity to discuss the issues I struggle with most. I believe firmly focusing is not useful as a skill without a simultaneous attempt to ensure you and your client are on the same page.

“The goal of reflection of meaning is to facilitate clients in finding deeper meanings and values that provide a guiding sense of vision and direction for their lives. e goal of interpretation/reframing is to provide a new way of restorying and understanding thoughts, feelings, and behaviors, which often results in new ways of making meaning. Clients usually generate their own meanings, whereas interpretations/reframes meanings that are close to core experiencing. A reflection of meaning looks very much like a paraphrase but focuses on going beyond what the client says. Often the words ‘meaning,’ ‘values,’ ‘vision,’ and ‘goals’ appear in the discussion” (Ivey, et al, 2010, p. 293-294).

The final advanced skill discussed in my textbook are various influencing techniques.  These skills provide a more direct approach to client change and are useful in helping the client see things from a different perspective.  Five influencing skills were discussed: (Ivey, et al, 2010).

  1. SELF-DISCLOSURE – I have learned to be cautious about self-disclosure & am mindful to do so in if it provides something beneficial to the client. Self-disclosure provides the client e a unique perspective on a similar experience as food for thought.
  2. FEEDBACK – Feedback in encouraging the client to acknowledge strengths or recognizing how far they have come.
  3. INFORMATION/PSYCHO-EDUCATION – When I utilize psycho-education, it is usually to help the client  understand symptoms and/or diagnoses in order to manage their overall well-being more effectively.
  4. LOGICAL CONSEQUENCES – For example, I might discuss the client’s potential options in a particular situation, in order to determine the best alternative.  By writing them out and seeing it in front of them, this can be a useful and influential tool to see things more clearly.
  5. DIRECTIVES – the textbook (Ivey, et al, 2010), discusses direction as another influential tool, although this is something I don’t use very often – if at all.

References

Ivey, A.E; Bradford Ivey, M; & Zalaquett, C.P. (2010). Intentional Interviewing and Counseling.  Belmont, CA:  Brooks/Cole.

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Questions & Listening Responses


Reflective Listening…

For my new position as a PLMHP, I’m asked to review a Clinical Training Manual in which we’re provided an overview of basic counseling skills.  In this clinical training manual it describes essential skills for the beginning therapist.  This manual defines reflective listening as follows:

“listening is not a passive skill eflective listening can be broken down into four components: listen, understand, clarify, and energy” (Capstone, n.d.).  

“Listening involves the nonverbal communications that occur while someone is talking and includes active listening sills discussed here.   Understanding involves paraphrasing what the client has said and helps to establish trust and rapport with the client, since they feel that you understand what they are saying” (Capstone, n.d.).  Finally, reflective listening involves clarifying, when necessary, in order to make sure you understand what the client is saying.  Additionally, when utilized properly, reflective listening “injects energy into the conversation” (Capstone, n.d.)

Asking questions

Next, in this series is information pertaining to those basic communication skills that are most relevant to my experiences as a new therapist.  Establishing effective communication requires an ability to ask questions and provide listening responses that encourage elaboration.  One of my course textbooks provides the following advice on asking effective questions:

“Effective questions open the door to knowledge and understanding. e art of questioning lies in knowing which questions to ask when. Address your first question to yourself: if you could press a magic button and get every piece of information you want, what would you want to know? Thee answer will immediately help you compose the right questions.” (Ivey, et al, 2010, p. 93)

As a new therapist, the questions I ask are useful in getting a conversation started.  Open questions are useful in eliciting elaboration from the client on their life story.  An example of closed questions can be when we paraphrase what the client says for clarification &/or reflection. Finally, the manner in which questions are asked determines the responses I receive.  What follows is a “quick and dirty” definition of open questions and closed questions…

Open Questions

“Open questions are those that can’t be answered in a few words. ey encourage others to talk and provide you with maximum information. Typically, open questions begin with what, how, why, or could: For example, “Could you tell me what brings you here today?” You will find these helpful as they can facilitate deeper exploration of client issues” (Ivey, et al, 2010, p. 94).

Closed Questions

“Closed questions can be answered in a few words or sentences. ey have the advantage of focusing the interview and obtaining information, but the burden of guiding the talk remains on the interviewer. Closed questions often begin with is, are, or do: For example, “Are you living with your family?” Used judiciously, they enable you to obtain important specifics” (Ivey, et al, 2010, p. 94).

Listening responses

“Listening is the attending, receiving, interpreting, and responding to messages presented aurally” (Prout & Watkins, 2014, p. 132).  In this respect, it requires more than hearing and understanding what our client is saying.  Effective communication of what we hear, is essential to ensure we are interpreting our client accurately.    “Verbal person centeredness (VPC) focuses on …highly person-centered communication, which is characterized by explicit recognition of the other person’s feelings and encouragement to elaborate and contextualize those feelings according to the perspective of the other.” (Ivey, et al, 2010, p. 44).   What follows is a description of different types of listening responses that are useful in guiding the course of the conversation with a client…

Encouragers

Encouragers are minimal responses such as head nods, hand-gestures or the infamous “Uh-huh”.  They are utilized to indicate you are listening and “help clients feel comfortable and keep talking in the interview” (Ivey, et al, 2010, p. 151).  Now, I personally would caution against utilizing these encourages too much.  When I start receiving the frequent “uh-huh” responses in rapid succession, I realize I’ve neared the end of our conversation.  Doing this to my therapist could be quite distracting…

Seeking Clarification

At times the client may be making contradictory statements.  On occasion, the therapist isn’t entirely certain about how to interpret the meaning in what the client is saying.  Seeking clarification simply requires restating what you heard the client said,  it lets the client know you are listening & provides reassurance you are both on the same page.

Paraphrasing

Paraphrasing simply involves restating & summarizing what the client is saying.  It can be useful in helping the client to reflect on what they just said.  However can be annoying when used too frequently. My textbook describes the paraphrase as consisting of four elements (Ivey, et al, 2010):

  1. A SENTENCE STEM: “it sounds like…”
  2. KEY DESCRIPTORS USED BY THE CLIENT: “….you’re struggling to make sense of his response to your questions about the relationship…”
  3. STATE IN SUMMARY WHAT YOU HEARD THE CLIENT SAID: The above response, can be my question after hearing the client describe recent changes in the relationship as she describes how frustrated and confused she is feeling….
  4. FINALLY,  THE GOAL OF A PARAPHRASE IS TO ASK FOR ACCURACY.  

Reflections

Reflections of content can provide the client an opportunity to reflect thoughtfully on what they are saying.  For example, if a client expresses confusion regarding a comment somebody made, I might ask, “what confuses you.”  However, reflections can also be more complex and privide the therapist to test their hypothesis.  For example I might say, “it sounds like you’re frustrated by the lack of communication.”

Summarizing

“Summarizing what the client has said is different from paraphrasing the mes- sage. When you are ready to summarize you have arrived at a succinct and clear understanding of the client’s perspective. You are encapsulating not only what the client said but also adding and integrating the material that was generated by your responses to the client” (Ivey, et al, 2010, p. 148).

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References

Capstone, (n.d.) Clinical Skills & Clinical Skill Enhancement. Capstone Behavioral Health.
Ivey, A.E; Bradford Ivey, M; & Zalaquett, C.P. (2010). Intentional Interviewing and Counseling.  Belmont, CA:  Brooks/Cole.
Prout, T.A. & Wadkins, M.J. (2014).  Essential interviewing and counseling skills.  New York, NY: Springer Publishing Company.

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Active Listening Skills

DEFINITION : “Listening is the attending, receiving, interpreting, and responding to messages presented aurally” (Prout & Watkins, 2014, p. 132).

In the counseling field, listening requires much more than simple comprehension of the verbal messages receive from our clients.  As therapists, we must capture the meaning of the messages communicated the client, utilize this to develop an understanding of our clients and form a plan for therapy.  In other words, our ability to listen requires the skills of effective communication, empathetic understanding & attending skills (Drab, n.d.)   One interesting comment from my textbook, includes the need to act as an “authentic chameleon” (Prout & Watkins, 2014, p. 133), by adjusting our interactive style to the needs of the client.  Also of interest is a review of three key types of listening in everyday life discussed in research:

  1. MARGINAL LISTENING:  “individuals are hearing but not paying attention to the other person.  The listener may be distracted or involved in formulating the next response, and this inattention is likely to lead to a less than ideal interaction.”  (Prout & Watkins, 2014, p. 133)
  2. EVALUATIVE LISTENING: “involves concentrating intently on what is being said, but this type of listener focuses only on the literal meaning of the words and does not acknowledge subtle verbal cues or nonverbal communication.”  (Prout & Watkins, 2014, p. 133)
  3. ACTIVE LISTENING: “entails receiving verbal and nonverbal messages from others, processing them and responding in a way that encourages further discussion.”  (Prout & Watkins, 2014, p. 133)

Therapeutic Listening: Skills Required…

The above-listed types of listening (marginal / evaluative / active) come from research on forms of listening in everyday relationships.  What are some unique considerations for listening as a counselor? Prout & Watkins (2014), note that “people who are new to counseling are frequently preoccupied with learning what to do to help clients, instead of focusing on how to be – the facilitative condition for being able to enact those specific counseling strategies.” (p. 138). What follows are random insights from my textbooks that provide “food for thought” as I consider “how am I being” while I see my clients???

Empathy, Genuineness & Unconditional Positive Regard…

“Genuineness, unconditional positive regard and empathy are the key components of Rogers’s…facilitative conditions of therapy…[they] create an environment that allows clients to grow and change” (Prout & Watkins, 2014, p. 134).  These qualities are essential to truly understand the meaning in what the client express and appreciate their lived experiences more fully (Prout & Watkins, 2014).  This is easier said than done when in the midst of a counseling session.  Thus far, I’ve noticed that counseling practice, requires us to think on our feet as we follow our gut, education, and lived experience while “making things up as we go along”.  People are complicated and there are no exact recipes for success.

For example, there are times, when I’ve entered a counseling relationship and find struggling with a nagging uncertainty as I realize that there I don’t have many common experiences to draw upon.  In this case, personal education and supervisory consultation are critical.   There are other situations in which I find myself relating to the client’s situation very well.  At such times, I become concerned that my understanding of their situation reflects more my own past experience, than their current reality.  In this case, I’m aware of the potential risk of transference issues. So what is the solution here?  Empathy, is a two-fold process that involves accuracy of perception and effectiveness of communication.  Therefore, “active empathetic listening” (Prout & Watkins, 2014, p. 134) involves a conscious effortful attending by the counselor that communicated effectively to the client.  

My course textbook breaks down the process of active empathetic listening into three stages:

  1. FIRSTLY, we must be able to pick up on all the verbal and nonverbal communication.
  2. SECONDLY, we must be able to understand the meaning & content of what is expressed.
  3. FINALLY, We must process this information, my textbook describes two types of processing that occur while we listen “top-down” & “bottom-up”  Since, I didn’t like the definitions provided in my textbook, I found this video to help clarify things:

Affect Tolerance & Mindfulness….

Listening within counseling is unique since the therapeutic relationship is inherently imbalanced.  What makes the relationship between therapist and client so unique is its one-sided nature.  In fact, the ACA (2014) code of ethics prohibits dual relationships where a counselor provides services to a friends, family members or significant others.  What follows is a description of the counseling relationship from the ACA Code of Ethics Manual

“Counselors facilitate client growth and development in ways that foster the interest and welfare of clients and promote formation of healthy relationships. Trust is the cornerstone of the counseling relationship, and counselors have the responsibility to respect and safeguard the client’s right to privacy and con dentiality. Counselors actively attempt to understand the diverse cultural backgrounds of the clients they serve. Counselors also explore their own cultural identities and how these affect their values and beliefs about the counseling process” (American Counseling Association, 2014, p. 4).

In other words, while healthy relationships are two-sided in nature, the therapeutic relationship is one sided: focused specifically on “client growth and development” (American Counseling Association, 2014, p. 4).  In order to facilitate the development of a relationship like this good attentive listening skills are required.  “Counselors must be able to hear, and perhaps tolerate vicariously experiencing distressing emotions that may occur during counseling” (Prout & Watkins, 2014, p. 138). My course textbook provides two suggestions:

  1. AFFECT TOLERANCE:  Counselors must “Develop affect tolerance to respond empathetically to client’s experiences of distress without overly identifying with it or avoiding it.  Affect tolerance has been described as being willing and open to experiencing feelings” (Prout & Watkins, 2014, p. 136).
  2. MINDFULNESS:  “suggested as a practice that can help counselors train their minds to attend fully to their clients…defined as…paying attention in particular way: on purpose, in the present moment and nonjudgmental” (Prout & Watkins, 2014, p. 136).

Observational Skills…

“In working with [clients[, if you miss those nuances…if you don’t notice when their emotions, gestures, or tone of voice doesn’t fit what they are saying, if you don’t catch the fleeting sadness or anger that lingers on their face for only a few milliseconds as they mention someone or something…you will lose your [clients]” (Ivey, et al, 2010, p. 123).

Observational skills are a critical tool in determining how the client interprets the world.”  (Ivey, et al, 2010, p. 141).  In discussing observational skills, there are two points I’d like to touch on:

#1: What are we supposed to observe?

    1. CONFLICT:  Much of the time spent in therapy centers around working through the conflict, stressful situations, ambivalence, and incongruence (Ivey, et al, 2010).  Are there discrepancies between a client’s actions and words?  Does the client hesitate or resist talking about certain subjects?  Are there discrepancies between the client’s inner world and external situation:?  What conflicts exist in the client’s relationships?
    2. NONVERBAL BEHAVIOR:  What sort of nonverbal communication does the client display?  What do you notice about their facial expressions and eye contact?  How about the client’s body language and mannerisms?
    3. VERBAL BEHAVIOR:  “Noting patterns of verbal tracking for both you and the client is particularly important.  At what point does the topic change and who initiates the change?  Where is the client on the abstraction ladder?…Is the client making I or other statements?” (Ivey, et al, 2010, p. 141).

#2:  How can we improve our observational skills?

  1. TIP ONE – AWARENESS:  “Looking at your way of being an be equally important as, or more important than observing your client.  Start by taking brief inventory of your own nonverbal style” (Ivey, et al, 2010, 134).
  2. TIP TWO – MULTICULTURAL SENSITIVITY: “Note individual and cultural differences in verbal and nonverbal behavior…Use caution in your interpretation of nonverbal behavior (Ivey, et al, 2010, p. 141).

Reflective Listening

Once the skills of paying attention, empathy, and observation are in place, it is possible to begin developing advanced listening skills defined in my course textbook as reflective interviewing (Prout & Watkins, 2014)

types of reflective statements:

  1. SIMPLE REFLECTIONS: “made by repeating or rephrasing the client’s statements” (Prout & Wadkins, 2014, p. 139).
  2. COMPLEX REFLECTIONS: “When making a complex reflection, a mental health professional is making an interpretation of ta client’s statement by substituting a word or making a guess at unspoken meaning.” (Prout & Wadkins, 2014, p. 139).

Tips for reflective listening…

Mirroring the client’s affect is a useful way of showing empath.   Using the client’s vocabulary is Often more useful than the uh-huh’s and academic language I use frequently.   At times, directing the subject matter to ensure the client stays on topic can allow for a more in-depth discussion of matters.  Finally, listening requires us to uncover the underlying themes and/or bigger picture as we utilize these insights to determine our best course of action..

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References

American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.
Drab, K. (n.d.) The top ten counseling skills. Retrieved from: http://www.people.vcu.edu/~krhall/resources/cnslskills.pdf
Ivey, A.E; Bradford Ivey, M; & Zalaquett, C.P. (2010). Intentional Interviewing and Counseling.  Belmont, CA:  Brooks/Cole.
Prout, T.A. & Wadkins, M.J. (2014).  Essential interviewing and counseling skills.  New York, NY: Springer Publishing Company.

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