NCE – Strategic Family Therapy

Based on the work of Milton Erickson & Jay Haley, this pragmatic model is more focused on problem solving than insight (Metcalf, 2011). According to this theory, problems develop due to an unbalanced hierarchical structure and dysfunctional communication patterns. The therapist’s role is to observe these patterns in the family, and develop a strategy to address them. It is a directive therapy that isn’t as concerned with how one defines the problem as much as it is with the fact that you’re taking some sort of action to resolve things.  Metcalf, (2011) states that family therapists should focus on “the purpose of the problem” (p. 272).  Action is the key to change, not insight.

Definition of the Problem

According to “SFT” communication in families always comprises a “command message” (Metcalf, 2011, p. 276), defined as unspoken and implied rules of conduct and interaction.  These family rules can be observed in patterns of interaction and behavior by a therapist.  The purpose of this rules is to main an interactional homeostasis.  The term “feedback loops” (Metcalf, 2011, p. 276), refers to stimuli and response interactions that are frequently observed.  As you might expect positive feedback loops create a problem and negative ones solve it.  In therapy, the key to solving problems is to first address the aforementioned rules that define the family’s interactions.  By focusing and defining on the problem and the factors related to it, the family can become motivated to change.  “Strategic family therapists believe that to change family organizational patterns and therefore alleviate the identified problem, the routine in which the clients communicate with one another must be altered.” (Metcalf, 2011, p. 277).

Theoretical Assumptions

SFT aims to solve the problems in the family and alter the underlying structure that produces it.  Many concepts from systems theory can be found in SFT.  For example, homeostasis describes the tendency of a family to maintain the status quo.  The butterfly effect describes the tendency of small changes to produces tremendous ones.   SFT also uses the concept of triangulation in which the tension between two family members is the byproduct of a third one.

How Change Happens

There are two types of change in SFT.  “First-order changes occur when family members attempt to solve a problem repeatedly with the same solution only by increasing the level of intensity” (Metcalf, 2011, p. 280).  Second order change occurs when the family system can shift into a new homeostasis by altering the rules in the family (Metcalf, 2011).

One Concept: Directives

​As a directive and pragmatic therapy model, SFT utilizes directives that are helpful in redefining the rules, structure and boundaries in a family (Metcalf, 2011). The goal of these directives is to motivate clients to modify the interactional patterns which underlie ongoing problems. Two types of directives are described in our textbook: (1) straightforward directives and (2) indirect directives (Metcalf, 2011). Straightforward directives are utilized when the therapist lays out his instructions for helping the family modify their existing interaction patterns (Metcalf, 2011). In contrast, indirect directives utilize metaphor and paradox to provide motivation for change (Metcalf, 2011). For example, paradox directives involve instructing clients to engage in more of the very behaviors that cause problems. This creates a double-bind situation in which change becomes more attractive than inaction (Metcalf, 2011). Ordeal interventions, a slight variant paradox directives, are also utilized by SFT. They involve imposing significant changes that are much more extreme than the desired transformations. This is thought to make those needed transformations much more attractive to the client.

Strengths & Weaknesses

​Benefits of SFT are its pragmatic nature, and tendency to provide a positive spin on problems, not based psychopathology. Despite these benefits, there are several concerns I have about this theory. In fact, I was not surprised to learn that SFT is not a popular model of therapy (Metcalf, 2011). Criticisms of this approach include the manipulative nature of its interventions, and a failure encourage the careful examine underlying issues (Metcalf, 2011). Paradox directives provide just one of many manipulative interventions utilized by SFT.
I also had concerns about how SFT conceptualizes the nature of helplessness (Metcalf, 2011, p262). In keeping with this pragmatic approach, SFT is not concerned with how the therapist conceptualizes evidence of helplessness (Metcalf, 2011). The only thing that appears to matter, is how the therapist’s conceptualization of problems, guides their manipulative strategies (Metcalf, 2011). Finally, I feel the textbook’s discussion of helplessness on page 262, reflects an attitude of blame (Metcalf, 2011, p262). In my opinion, it is wrong to blame a client for a symptoms of learned helplessness.

Working Template

  1. Building rapport – greet family, point out successes/strengths.
  2. Understanding the Presenting Issue – Work towards an agreed-upon understanding of the problem
  3. Assess Family Dynamics – Focus on problem now not their origins.
  4. Developing Goals – Negotiation of goals with family members
  5. Amplify Change – don’t take credit for change, and remain neutral in how chance occurs since this promotes lasting change.

References

Metcalf, L, (2011). Marriage and family therapy: A practice oriented approach. New York: Springer Publishing Company

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MCC 670 – Clinical Hypotheses

“The ‘H’ in the acronym SOHP stands for hypothsis section – a shorter heading than formulation discussion that incorporates clinical hypotheses.  As explained in Chapter 1, all theories are bundles of hypotheses.  You have several choices for creating your formulation: (1) use a formulation that is based on a single theoretical approach; (2) use a ready-made integrative formulation; (3) use an empirically supported treatment model; (4) create your own integrative formiulation” (Ingram, 2013, p. 87).

What is Hypothesis?

“A Hypothesis is a single explanatory idea that helps to structure data about a way that leads to better understanding, decision making and treatment choice.” (Ingram 2012 p. 111).  Ingram, (2012), suggests utilzing a three page worksheet to organize your thoughts with: (1) data in the first column; (2) hypotheses in the second column; and (3) ideas for a plan in your final column, (p. 86).

Common Errors…

This system is useful in preventing you frm developing hypothess that have no basis in data you have gathered.  There are three common errors therapists make according to Ingram, (2012).

  1. ERROR #1:  The formulation/hypothesis lacks supporting data.
  2. ERROR #2: The formulation is not supported by data.
  3. ERROR #3:  The formulation omits a strong hypothesis.

Common Mistakes…

  1. “The hypotheses section does not introduce new data” (Ingram, 2012, p. 90).
  2. “The hypothesis section focuses on the specific problem of the specific client” (Ingram, 2012, p. 91).
  3. “Hypotheses all lead to treament plans” (Ingram, 2012, p. 92).
  4. “Hypotheses are discussed with professional-level thinking and writing skills” (Ingram, 2012, p. 94).

 Book contains 30 hypotheses in 7 Categories…

Thes hypothes are based on theories of psychotherapy, new approaches, and empirically suported treatment (Ingram, 2012).   Each category begins with an overview of the theory and/or empirically supported treatment it is based on.  For example, the Behavior and Learning Models are based on behavioral analysis and therapy.  Key concepts from this theoretical perspective are discussed at the beginning of the chapter for review before the hypotheses falling under this category are reviewed.    Each hypothesis the begins with a summary that includes a title, definition, explanation, and examples of cases for which this hypothesis is applicable.  Next under each hypothesis is a discussion of key ideas, treatment planning ideas, and tips to determine its usefulness and applicability in specified cases, along with suggested readings.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Treatment Plan

​The Purpose of a Treatment Plan…

The purpose of a treatment plan is to address the “HOW of therapy” (Ingram 2012 p. 95).  It acts as a guide for the counselor throughout the therapy process.  When developing your treatment plan, it is useful to look at the information gathered from your IDI and ask how this strategy can help the client achieve their goals?  Or in other words, what problems is it designed to address?

BOOK EXAMPLE:  “In order to help the couple effectively manage conflict…(Outcome Goal), I will use Hendrix’s imago therapy (Strategy)…Family therapy is the treatment of choice (Strategy) to reduce Johnny’s Oppositional Behavior (Outcome Goal).

Standards for Creating a Treatment Plan…

  1. STANDARD #21: The plan is focused on resolving the identified problem and achieving outcome goals” (Ingrams, 2012, p. 95).
    1. Does strategy stray from plan?
    2. Write strategy and problem in one sentence (see above).
  2. STANDARD #22:  The plan follows logically from the hypothesis and does not introduce new data.
    1. Does your plan have no “foundation in the hypothesis section? (Ingram, 2012, p. 98).
    2. Do you have a hypothesis with no plan to address it? (Ingram, 2012).
    3.  If you see new data in plan, need to add to database, or eliminate it from the plan.
  3. STANDARD #23;  The plan is informed by knowledge of research literature.” (Ingram, 2012, p. 99).
    1. Check remaining posts from MCC 670.  They provide examples of how relevant research and theory can guide your treatment plan.
    2. Evidence Based Practices are required by third-party payers…
  4. STANDARD 24:  There is clarity regarding strategy, sub-goals and process goals; procedures and techniques; priorities and sequencing and the desired client-therapist relationship” (Ingram, 2012, p. 100).  What follows are a few relevant considerations…
    1. New therapists might include more information to guide their efforts.
    2. The number of sessions allowed by insurance and affect how much detail is required.
    3. Some clinical hypotheses requre more detailed and specified plans.
    4. “The plan should describe what kind of relationship is desired and what should be avoided” (Ingram, 2012, p. 101).
    5. Specify the sequence of interventions in your plan (Early/Middle/End).
  5. STANDARD #25: “The plan is taylored to the specific client; Such factors as gender, ethnicity, sexual orientation, and spiritual are considered” (Ingram, 2012, p. 103).
    1. Cultural Competency is important in the development of rapport (I.e. language, relationships, metaphors, relationships, boundaries, body language) and to create strategies relevant to the client.  (Ingram, 2012).
    2. Other considerations:  Stages of change; amount of structure; and levels of authority displayed by the therapist (Ingram, 2012).
  6. STANDARD #26:  The plan is appropriate for the treatment setting, contractual agreements, and financial constraints” (Ingram, 2012, p. 107).
    1. What is insurance willing to prove?
    2. WHat sort of therapy modality is utilized at your facility?
    3. What are the clients motivations, expectations, and resources?
  7. STANDARD #27: The plan incorporates community resources and referrals” (Ingram, 2012 p. 108).  Be aware of community resources available….
  8. STANDARD #28:  The plan addresses legal, ethical and mandated reporting issues.” (Ingram, 2012, p. 109).  Be knowledgeable of legal and ethical standards…

A Sample Treatment Plan…

Client Last Name, First Name, MI: Jones, Illana, T.

Address: 1234 Something Street

City, State, Zip: Everywhere, NE 12345

Telephone (s): (402)-123-4567

Parent/Guardian (if client is a dependent): N/A

Informant (if other than the client): N/A

Client SSN: 111-11-1111

Place of Birth: Indianapolis, Indiana

Date of Birth: ​09/21/1986​​​

Age: 28

Gender: ​Female​​​​

Race: Hispanic/Latino

Chief Complaint/Presenting Problem:

Client is a 28-year-old mother married mother of two young children, who currently lives in base housing. She has been referred by the base doctor after complaining of depressive symptoms and failing to contract for safety. She appears significantly underweight, cries easily and complains of a debilitating depression.

Diagnostic Impression:

• 296.32 (F33.1) – Major Depressive Disorder, Severe, Recurrent Episode
• 307.1 (F50.02) – Anorexia Nervosa, Binge-eating/Purging type, Moderate.
• 995.53 (T74.22XA) Child Sexual Abuse, Initial Encounter
• V15.59 (Z91.49) Personal History of Self-Harm
• Rule Out – Suicidal Behavior Disorder

Case Formulation (biopsychosocial history and MSE) Summary:

Biopsychosocial History
  1. Emotional/Psychiatric History – The client’s psychiatric background includes a diagnosis of major depression, anorexia nervosa, and self-harming behaviors. History of self-harm includes cutting behavior and a distant hospitalization in eighth grade for a suicide attempt. Cutting behavior onset in eight grade, includes small cuts and eraser marks on skin to relieve stress. Significant history of anorexia, binge-purge type, starting in eighth grade. Latest psychiatric hospitalization to stabilize anorexia after her daughter’s birth when she gained 40 pounds. Previously prescribed antidepressants, but stopped taking them. Is not currently being followed by a mental health provider. Her current symptoms include feelings of worthlessness, social isolation, fatigue, and suicidality with no plan in place. Patient is also notably tearful and significantly underweight.
  2. Social History – Ilana is a 28-year old stay-at-home mother of two young children ages 3 and 5. She has been married to her husband, David, for seven years. She recently moved into base housing three months ago, after a series of job-related transfers due to her husband’s line of work. Describes the frequency of these transfers as difficult for her, and complains of isolation after their latest move.
  3. Family of Origin: The client was born to Umberto and Guadalupe, restaurant owners in a small Midwest town. She reports her early childhood as mostly “idyllic” and states her large extended family played a significant role in her daily life. Her older sister, Reyana is just two years her senior. Ilana describes an unhealthy competitive relationship with her sister and feeling like the “ugly duckling”. Mother’s concern for her weight at this time further exacerbated these insecurities. Ilana’s eating disorder history has an onset at about this time as well.
  4. Academic & Intellectual History – Ilana’s academic history is unremarkable. She reports she was a always a good student. Holds a bachelor’s degree in psychology.
  5. Employment History – The client is a stay-at-home mother with no recent employment history and no plans to return to work with two young children at home.
  6. Cultural and Religious Background – Ilana describes herself as “not very religious” although states she was raised in a large Catholic family. While Ilana grew up in a small predominantly white community, she was raised by a large Hispanic family with rich cultural traditions. She expresses great appreciation for this culturally diverse background.
  7. Medical History – Ilana’s developmental history is largely unremarkable. Ilana mentions a growth spurt in junior high resulting in a significant weight gain, at which point her mother started her on Weight Watchers. Pregnancies described as difficult due to weight gain and exacerbation of eating disorder symptoms. Hospitalization required after oldest child to stabilize eating disorder symptoms. Youngest child born two months early, resulting in exacerbation of depressive symptoms.
  8. Legal History – N/A
  9. Offender Issues – N/A
  10. Victim Issue – Ilana reports an incidence of sexual abuse involving fondling by a great uncle when she was five. While she remembers little about the incident, she states her family was quite emotional and entered counseling as a family to address this issue.
  11. Substance Abuse History – Ilana does not drink, smoke, or use illicit drugs.
Mental Status Exam
  1. Appearance – The client is a well-groomed 28-year-old female who appears her stated age. Is extremely underweight with cuts marks along inner thighs and arms.
  2. Behavior – Crying and tearful throughout the interview.
  3. Cooperation – Client is cooperative throughout the interview although mentions her reluctance to be here.
  4. Speech & Language – Client’s speech is articulate and coherent. Nonetheless, she is minimally responsive to the therapist’s questions.
  5. Thought Form & Content – Thought processes are goal-directed and coherent. Transient thoughts of self-harm with no plan in place.
  6. Mood & Affect – Mood and affect appear congruent. Client complaints of debilitating depression and is tearful throughout interview.
  7. Perception – Unremarkable.
  8. Level of Consciousness – Client is alert and oriented.
  9. Insight & Judgment – Partial insight noted in light of limited capacity to understand underlying issues. Judgment poor in light of inability to make reasonable decisions pertaining to adequate self-care.
  10. Cognitive Functioning – Unremarkable.
Problems (specific concrete behaviors):
  1. Unmanaged Depression
    1. As evidenced by Psychological Evaluation
    2. As evidenced by depressive mood and affect.
    3. As evidenced by suicidal ideation.
    4. As evidenced by feelings of worthlessness and isolation.
  2. Inability to maintain healthy weight
    1. As evidenced by BMI of 16 during doctor’s exam.
    2. As evidenced by report of binging and purging behaviors.
    3. As evidenced by inadequate food intake.
  3. Difficulty coping as manifested in cutting behavior.
    1. As evidenced by visible cuts on arms and thighs.
    2. As evidenced by client’s report of cutting behavior to “feel better”.

Hypotheses (etiology):

  1. Exacerbation of depression due to poor understanding of underlying symptomatology and discontinuation of medication.
  2. Increase in suicidal ideation and cutting behavior due to deficient coping skills and ongoing rumination with poor metacognitive insight into thought processes.
  3. Re-emergence of eating disorder behavior due to poor self-care, low self-worth, and a feeling out of control with binging and purging habits. Onset associated with competitive relationship with sister, and criticism from mother for weight gain in junior high.

Treatment Goals (mutual):

  1. PROBLEM – Unmanaged Depression
    1. GOAL ONE – Symptoms of depression will be significantly reduced until they no longer impede with daily functioning.
      1. OBJECTIVE ONE: Ilana will take all medication as prescribed and attend all scheduled meetings this month.
      2. OBJECTIVE TWO: Ilana will develop increased understanding of maladaptive thought processes underling depressive feelings as a result of participation in DBT Skills Group.
        1. INTERVENTION: Therapist provides referral to DBT Skills Group and forwards case information to provider, Jane Doe LMHP.
          o Responsible Party – Kathleen Johnson, Future LMHP
        2. INTERVENTION: Jane Doe, LMHP monitor’s Ilana’s progress and provides her therapist with relevant updates
          o Responsible Party – Jane Doe, LMHP
      3. OBJECTIVE THREE Ilana will develop a safety-plan with her husband and report no suicidal thoughts for one month.
    2. GOAL TWO – Overcome resistance to therapy, and develop solid therapeutic relationship as evidenced by commitment to therapy and open communication.
      1. OBJECTIVE ONE: Ilana will discuss with therapist the nature of her resistance to therapy in this month’s sessions.
      2. OBJECTIVE TWO: Ilana will discuss what she hopes to achieve in therapy and commit to active participate
      3. OBJECTIVE THREE: Ilana will discuss her concerns and any areas of disagreement with the therapist should they come up at any point in time.
  2. PROBLEM – Inability to Maintain Healthy Weight
    1. GOAL ONE – Restore healthy body weight.
      1. OBJECTIVE ONE: Ilana will visit her physician weekly for regular weigh-in’s.
        1. INTERVENTION: Physician will monitor Ilana medically and forward information as necessary to her therapist.
          o Responsible Party – Base Doctor.
      2. OBJECTIVE TWO: Ilana will record her daily dietary intake with her husband’s assistance and monitoring.
      3. OBJECTIVE THREE: Adherence to dietary recommendations of primary care physician as indicated by food log.
    2. GOAL TWO – Reduce binging and purging behavior.
      1. OBJECTIVE ONE: Client will closely monitor self care, listen closely to her bodily cues.
      2. OBJECTIVE TWO: Ilana will avoid people and places that tend to trigger any urges to engage in binging and purging behavior.
        1. INTERVENTION: Therapist will assist Ilana this month in developing a list of triggers for her binging and purging behavior.
          o Responsible Party: Kathleen Johnson, Future LMHP.
        2. INTERVENTION: Therapist will assist Ilana in developing strategies to avoid these triggers.
          o Responsible Party: Kathleen Johnson, Future LMHP.
    3. GOAL THREE – The client will build a healthy self-esteem.
      1. OBJECTIVE ONE: Eating disorders will no longer be the focus of her interactions with sister and mother.
      2. OBJECTIVE TWO: Ilana will develop positive self-talk and healthy coping strategies.
  3. PROBLEM – difficulty coping as manifested in cutting behavior
    1. GOAL ONE – Gain insight into the reasons for cutting behavior.
      1. OBJECTIVE ONE: Ilana will develop greater emotional awareness and learn alternative methods for regulating emotions.
        1. INTERVENTION: Ilana will learn emotional regulation skills in a weekly DBT Skills Group.
          o Responsible Party: Jane Doe, LMHP
        2. INTERVENTION: Therapist will discuss with Ilana, her DBT Skills Group homework in individual sessions.
          o Responsible Party: Kathleen Johnson, Future LMHP
      2. OBJECTIVE TWO: Ilana will identify a list of self-harm triggers with her therapist next session.
    2. GOAL TWO – Find alternative methods of coping as a healthy replacement for cutting behavior.
      1. OBJECTIVE ONE: Ilana will utilize DBT skills in order to regulate emotions in a healthy manner.
      2. OBJECTIVE TWO: Ilana will develop a list of soothing techniques, to calm persistent negative feelings with her therapist during the next session.
      3. OBJECTIVE THREE: Ilana will work develop a list of activities that can allow her to release or expressing painful emotions during the next session.

Supports:

The client’s extended family is very supportive. She has a loving husband and is motivated by her desire to be a good mother to her children.

Obstacles

Ilana’s reluctance to seek therapy is concerning. Additionally she displays low self-esteem as evidenced by her assertion that “I’m a terrible wife and mother”. These statements are also indicative of low insight into the affect of depression on her thought processes.

Additional Information Needed

Treatment team includes Ilana’s base doctor who will monitor her weight regularly. In-house Psychiatrist will follow for pharmaceutical treatment of depression. Jane Doe will also be conducting a weekly skills group, which Ilana expected to participate in.

Assessment Measures to Track Progress

Ilana will visit her base doctor weekly for weight monitoring. Psychiatrist will assess client monthly to monitor her response to medications. Therapist will assess client’s depressive symptoms and suicidal ideation monthly in order to determine her baseline.

Treatment (model, location, therapist style, focus, frequency)

Individualized therapy to occur weekly in conjunction with weekly DBT group meetings.

Pharmaceutical Treatment

Client is referred to in-house psychiatrist for evaluation this week. Pharmaceutical Treatments to be determined at this time.

Adjunct Treatment(s), (e.g. support groups)

Client referred to Dialectical Behavioral Therapy Skills Group as an adjunct treatment to individualized therapy. Information on eating disorder support groups has also been provided.

Prognosis

Prognosis guarded due to the client’s reluctance to participating in therapy and inadequate following through with treatment recommendations. The multifactorial nature of Ilana’s issues significantly increases the need for close management and ongoing support.

_____________________________​______________
Signature, Title​​​​​/Date

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – objective vs subjective

​Ingram, (2012) provides a clear differentiation between subjective and objective data in the following statement: “What the client tells you goes in [Subjective Data}…how the client tells it goes in [Objective Data]” (p. 83). In other words, the subjective section contains information pertaining to the client’s own story (Ingram, 2012, p7). In contrast objective data refers to observations noted in how a client tells their story. For example, in the subjective data section, it is critical to exclude a therapist’s observations and theoretical formulations. Additionally, in the objective data section, information pertaining to a client’s own personal interpretations and verbal reports should be excluded.

The Importance of This Distinction

​Ingram (2012) states that it is essential to provide a separate section for objective and subjective data in order to clearly differentiate the information’s source. The purpose of the subjective data is to provide a place where the client’s own story can be told (Ingram, 2012). For this reason, it contains information from the client and the client’s family. It excludes clinical observations and hypothetical case formulations. In contrast, objective data includes information pertain to clinical observations, including tests, medical records or “therapist’s observations” (Ingram, 2012, p6). It excludes case formulations and information pertaining to the either the client or family members’ verbal reports (Ingram, 2012).

Examples of Objective vs. Subjective.

​The best examples I provided for this assignment come from the Practicum Course for this program. Those of you, who have completed it, are aware that we are to complete a series of 10 recordings of simulated therapy sessions. Since my recording partner backed out, I had to find somebody at the last minute. My recording partner was a fellow student from the Group Therapy course. For these recordings, she created a hypothetical client by the name of “Jessica”. The storyline that unfolded as a result of this process is also purely “hypothetical”. What follows are excerpts from these assignments.

SUBJECTIVE

Jessica states that her husband is very displeased with all recent changes that have occurred since she entered therapy and has become increasingly abusive. Apparently, she got into an altercation with her husband after an argument. She expresses great frustration with the entire therapeutic process and is disinterested in continuing. She openly acknowledges at this point that her only reason for being here is because her employer requires it as a condition of her employment. Currently she attributes her husband’s abusive behavior to a “bunch of crazy hopes”, and blames the therapist and support group for the recent events that have inspired. She feels very hopelessness regarding her situation and openly discusses suicidal thoughts. Although she has no plan at this time she will not enter a contract for safety but is willing to call me nightly.

OBJECTIVE

Jessica presents today in a state of extreme state of distress, crying uncontrollably at the beginning of our session today. She appears with sunglasses that cover two black eyes and her appearance is very disheveled. Jessica openly expresses suicidal thoughts throughout the session although no plan currently is in place. Speech is reflective of a very emotionally labile state. She is very hopelessness regarding her current life situation. Affect appears consistent with overall mood. Insight and judgment are very limited during this session. They are reflective of heightened emotions and a feeling of extreme hopelessness. Ability to control impulses is very poor in light of Jessica’s events.”

Conclusion

I’d like to add that the above examples are my own recent “best attempt” at differentiating between objective and subjective data and I’m very open to criticism (?). As you can see, my recording partner threw a couple of “curve balls” at me, and presented me with a very extreme hypothetical scenario. It was indeed challenging and very educational from an ethical standpoint.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Setting Outcome Goals

In the last post, I discuss the problem definition process that occurs during the 1st session of therapy…

“The development of a list of problem titles involves two separate processes…'(Ingram, 2012, p41).  Ingram, (2012), defines a problem as “difficulties, dysfunctions, complaints, and impairments that are identified by the client’ (p. 41)….Additionally, they should be defined as a ‘solvable target (Ingram, 2012, p. 45).  In other words.  what is the desire outcome for this specific problem?  

This post focuses on the process of defining outcome goals when we begin developing our treatment plan.

“Every problem title is paired with an outcome goal, a description of the desired state at the end of therapy – how you will know the problem is solved” (Ingram, 2012, p. 61).   Achievement of outcome goals is the definition of effectiveness.  Therapists gather evidence and progress with outcome goals in mind.  If no progress is made, it may be necessary to reconsider your original case formulation.

Tips for Creating Good Outcome Goals…

Ingram (2012), suggests that outcome goals be specific and measurable in order to guide treatment planning.   Cognitive flexibility and critical thinking are important to help a therapist move from varied levels of abstraction.  Concrete goals can and measurable so success can be recognized.  However, this can limit one’s options at times if goals are too rigid and highly specified.   Other considerations listed in my Ingram (2012), are listed below:

  1. “Be aware of cultural biases and avoid becoming an agent of social conformity” (Ingram, 2012, p. 62).
  2. “Be sure to examine the values related to a stated goal” (Ingram, 2012, p. 62).
  3. “Question whether the client is accepting others’ definitions of happiness” (Ingram, 2012, p. 62)
  4. “How & when are not part of outcome goals….This is in the plan”  (Ingram, 2012, p. 62).

Benefits of Clearly Defined Future Goals…

  1. It can halve a positive effect on the client’s motivation.
  2. Creating a plan with the client can help instill.
  3. Clearly defined goals can help the client progress along the stages of change.
  4. Can help the client clearly define what they want (i.e. choice therapy).

Helping Clients Define Their Goals.

“Client’s usually put forth their problems without difficulty but they often need prodding and a good amount of creativity to put things in terms of a desired future” (Ingram, 2012, p. 63).  What follows are more tips from my textbook:

  1. SMART – Specific, Measurable, Attainable/Achievable, Realistic/Relevant & Time Specific
  2. PUERE – Standards for creating good goals…
    1. Use Positive Terms.  State what you do wan’t not what you don’t want.
    2. Outcome Goals must be Under your Own Control.
    3. Goals must be Evidence-Based, measurable, and operationalized.
    4. Goals must be Realistic and achievable.
    5. They must be ecological and holistic in nature.

Standards for Outcome Goals…

  1. “STANDARD ONE (LOGICAL CONNECTION) – Outcome goals are directly related to the problem title and endorsed by the client” (Ingram, 2012, p. 67)
    1. Should be evaluated for progress regularly
    2. Should ensure align with client’s goals
  2. “STANDARD TWO (THEORETICALLY NEUTRAL) – Do not contain the therapist’s connection” (Ingram, 2o12, p. 69)
  3. “STANDARD THREE: Outcome goals are realistic, attainable, and testable with evidence of real-world functioning.” (Ingram, 2012, p, 70).
    1. Not based on assumption of normal life difficulties.
    2. Not based on client’s agenda to change somebody else
    3. Not based on Utopian Beliefs or Perfectionist Standards.
  4. “STANDARD FOUR: Outcome goals do not contain the how of the treatment plan. People stifle ambitions based on perception of achievability of goals they set” (Ingram, 2012, p. 70).

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC – 670 Defining The Problem

“​The development of a list of problem titles involves two separate processes…”(Ingram, 2012, p41).  Ingram, (2012), defines a problem as “difficulties, dysfunctions, complaints, and impairments that are identified by the client” (p. 41).

FIRST, by gathering data and developing a preliminary list of problems. NEXT, by conceptualizing and giving titles to the problems we can better understand our treatment targets.  If they are defined by the client we refer to them as complaints.  Problems defined by significant others are relationship problems. Problems defined the professionals who counseling are called diagnoses.  Helping the client understand and gain some awareness regarding the nature of this problem is essential.

Step #1: Understanding the Goal

“When the goal is to arrive at a diagnosis, we check the list of criteria to see if there are enough to warrant the diagnosis, as if the criteria are a means to an end. When we think in terms of problem lists, the criteria are the end – they give us names of problems” (Ingram, 2012, p. 42)

The Presenting Problem

The presenting problem consists of the client’s stated reasons for seeking therapy in his/her own words.  It is not uncommon for the client’s presenting complaint to undergo a transformation as they develop a greater understanding of their problems.  For this reason, it is useful to record how it changes over time.

“SHOULD I JUST ACCEPT THE CLIENT’S STATED PROBLEMS OR AM I SUPPOSED TO GO FURTHER AND FIND OTHER PROBLEMS?”

In response to this question, Ingram (2012), describes three different attitudinal perspectives. However, at the end of this discussion, Ingram, (2012), stay

Narrow Position

According to this position, the therapist should simply accept the client’s complaints without attempting to create awareness of needs the client hasn’t mentioned.

Intermediate Position

Here, the therapist focused on the client’s request but if other problems become obvious, they will invite client to consider them.

A Comprehensive List

According to this perspective, the therapist should be concerned about the whole person, and examine all aspects of function in terms of a holistic assessment of the individual.  Just because the client is able to identify some problems, that doesn’t mean they are accepted as critical for treatment. The approach this book upholds is to utilize a comprehensive problem list. It is better to be too inclusive than to miss something important.  Finally, it is important to note that “the therapist’ values inevitably enter the problem-identification process” (Ingram, 2012).

Step #2: Developing A Comprehensive Problem List.

With the attitude of someone who is brainstorming, write down every problem (Ingram, 2012, p43). Complete the following assessments.

THE BASIC SID

  1. BEHAVIOR – What is the person doing, and not doing; what can others observe; the quality of skills?
  2. AFFECT: Internal emotional experience and overt verbal and nonverbal expression of feeling.
  3. SENSATION: Awareness of the body; use of senses; what is seen and heard with minimal filtering through cognition.
  4. IMAGERY: Mental imagery about past, present, or future; fantasies and dreams
  5. COGNITIVE: Constructed meaning; self-talk, beliefs, and schemas; cognitive skills; mental abilities
  6. INTERPERSONAL, SOCIAL, & CULTURAL: Relationships with others; family context; membership in social groups; cultural issues; and issues of social injustice.
  7. DRUG AND BIOLOGICAL: Physiology; biology; genetics; medical issues; use of illegal drugs, including alcohol.

DOMAINS OF FUNCTIONING (WHODAS)

Ingram, (2012) lists several domains of function that can be found in the DSM-IV manual.  “Therapists need to balance a psychiatrists emphasis on pathology with a counselor’s concern for growth and development” (Ingram, 2012, p. 44).
These domains are listed below, (Ingram,2012, p. 44-45).

a. Health and safety
b. Home Management
c. Financial status
d. Life planning
e. Academic
f. Employment
g. Legal status
h. Leisure and Recreation
i. Communication
j. Friendship
k. Family
l. Emotional Intimacy
m. Sexuality
n. Parenting
o. Religion & Spiritual
p. Cultural

Also contained in the DSM-IV is the Global Assessment of Functioning. While it is currently an out-of-date assessment, I’m including a link of it here for the sake of thoroughness. It is important also to note that the new DSM-5 manual focuses instead on the WHODAS-2. I’m also including a link for this instrument, since it is utilized at my current place of employment.

Step #3 Creating The Preliminary Problem List

“The quantity of problems on the preliminary list might make you feel hopeless. Remember you can combine and condense the list until it is manageable”. (Ingram, 2012, p46).

Overall goal

When defining problems it is useful to think about they can describe the target of your future therapeutic efforts. Ingram, (2012) suggests that “the problem title is a brief specific phrase…[and] stay focused on the client’s reason for being in therapy, not yet moving to your conceptualization of the problem” (p 45). Additionally, “avoid using language that reveals our explanations that attribute a cause for their problem” (Ingram, 2012, p 45).  Finally, check to make sure you Problem List is comprehensive.  While it is vital that we address the client’s pain, we must not automatically accept the client’s understanding of the problem without critical examination.

Standards for Problem Definition

  1. Problems should be defined as a “solvable target” (Ingram, 2012, p.45) for therapy. In other words, what is the desired outcome.
  2. Problems must reflect the client’s current level of functioning and capture their real-life problems.
  3. Problems are specific and designed with an individual client in mind based on data gathered.  This will aid in the development of your treatment plan.
  4. Do not include technical jargon, or theoretical concepts.  These things reflect a clinical hypothesis.  Your goal is to summarize findings from your data gathering.  This can allow for a therapist to utilize whatever theory might best apply at a later point.  Ask yourself if what you’re writing down is s hypothesis or a problem definition.
  5. Be cautious of how your values and biases might color your understanding of the client’s problems.  “Does the problem title reflect the client’s values?” (Ingram, 2012,)</h6<
  6. “How do you handle a list of 20 or more problems? The solution is lumping and splitting.  Lumping involves combining separate problems into a single problem” (Ingram, 2011, p. 55).  This is useful if signs and symptoms overlap and stem from common cause.  Occasionally, this might involve the utilization of an umbrella title.  With outcome goals for each sub-Problem.  Splitting involves “dividing one problem into separate problems…” (Ingram, 2912, pp. 56) Instances in which splitting might be useful include those cases in which separate treatments are needed or if this aids in clarity,
  7. Finally, be sure your problem list is complete and comprehensive.  “The omission of problems is a much more serious error than inclusion of too many problems” (Ingram, 2012, p. 60).

Reference

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – BASIC-SID

​Ingram (2012) describes the problem identification process as involving two key tasks: defining “the presenting problem…[and developing a] comprehensive problem list” (p43). The BASIC SID comprehensive problem framework involves assessing the following areas: “behavior, affect, sensation, imagery, cognitive, spiritual, interpersonal, [and medical]” (p43). Developed by Arnold Lazarus in the 1980’s, this assessment method allows a holistic assessment of clients, without the influence of theoretical conceptualization in the process (Ingram, 2012).

I begin by providing a brief description of the components of a “BASIC SID” Framework

  1. BEHAVIOR – what the person is doing / not doing / what others observe / quality of skills presented
  2. AFFECT – internal emotional experience and overt verbal/nonverbal expression of feelings.
  3. SENSATION – awareness of body, use of senses with degree of cognitive filtering of information.
  4. IMAGERY – nature of r/t past/present/future/ dream vs. reality
  5. COGNITION – meaning, self-talk, belief, schemas, etc….
  6. SPIRITUAL – religion/non-religion
  7. INTERPERSONAL/SOCIAL/CULTURAL = relationships with others, family context, social/cultural groups, acculturation levels.
  8. DRUG / ALCOHOL / MEDICAL HISTORY

Next, I provide a brief list of issues present in Illana’s case study (as assigned) then conclude with my impressions of this tool.

Ilana’s Preliminary Problems

Behavior

Little is provided in the case history that describes Ilana’s specific behaviors during the therapy session. At the same time, it is important that she is described as “significantly underweight” (Author, 2015), and appears depressed. Additionally, it should be noted that she is resistant to therapy and only sought counseling after “the doctor threatened to call child protective services” (Author, 2015).
Affect – Ilana is described as depressed and describes a history of suicidal behavior and cutting behavior (Author, 2015). She describes feelings of worthlessness and states “I’m a terrible wife and mother” (Author, 2015). Additionally, Ilana, describes herself as lonely and “unhappy all the time” (Author, 2015).

Sensation

Ilana describes a history of cutting behaviors and presents with cuts on her thighs and arms (Author, 2015). She states her cutting helps her cope because it makes her feel better afterwards (Author, 2015). Additionally, she also describes a complex history of eating disorders and states she “always felt better when…hungry” (Author, 2015).

Imagery

The “mental imagery” (Author, 2015), in Ilana’s case is rich in information on her life history. It provides a useful context with which to understand many underlying issues. Ilana describes her early childhood as idyllic (Author, 2015). She describes memories of her extended family and summer vacations at her grandparents’ lake house (Author, 2015). She describes details of an incident when she was five, of being fondled by an uncle, although states her memory of this incident is vague (Author, 2015). Regarding her eating disorder history, she reports the positive comments from family that encouraged her to maintain these weight loss efforts (Author, 2015). Finally, the early years of her marriage are filled with memories of loneliness and isolation (Author, 2015). She describes a difficulty pregnancy, while her husband is away at basic training, and then an extended assignment in Spain during this time (Author, 2015).

Cognitive

Ilana describes  an extended history of depression, self-harm, and anorexia. Her self-talk reflects feelings of self-doubt as she describes her inadequacies as a mother, wife. Distant memories of her childhood with older sister Reyana also reflect this pattern, particularly when she describes herself as “the ugly duckling” (Author, 2015). Ilana’s cognitive skills do not currently reflect a great deal of self-awareness. Instead, Illana is highly resistant to therapy, and has only sought counseling upon her doctor’s assistance. Additionally, she doesn’t display a high degree awareness or self-responsibility regarding her eating disorder, cutting behavior, and suicidal thoughts. Her current mindset is overwhelmed by feelings of depression, loneliness, and inadequacy.

Spiritual

Not much is mentioned about Ilana’s spiritual and religious background. While her early childhood is described as idyllic and involving an extended family with “rich cultural traditions” (Author, 2015), nothing is known about religious aspects of her background.

Interpersonal, Social & Cultural

Ilana is a 28-year-old married mother of two young children ages five and three. (Author, 2015) She is of Hispanic descent and grew up in the Midwest with an older sister in a multigenerational setting. (Author, 2015) She graduated with a Bachelor’s degree in psychology and met her husband, David, in College (Author, 2015). According to the case study she was raised in a large family that is “rich with cultural traditions” (Author, 2015).

Drug & Biological

Ilana describes a history of cutting and is grossly underweight (Author, 2015). Additionally, it appears she has an extensive eating disorder and self-harming history (Author, 2015). In addition to being prescribed antidepressants, she has been hospitalized several times for suicidal behavior (Author, 2015). Finally it is important to note she was unwilling to contract for safety while visiting with her base doctor recently (Author, 2015)

Is This List Comprehensive?

The final part of this discussion board assignment requires us to comment on how comprehensive the BASIS SID assessment is. Firstly, regarding the case study above, the BASIS SID assessment provides a good preliminary overview of presenting issues. Further assessments are naturally critical to define the specific nature of her issues. I would like to assess her eating disorder and depression more closely. Finally, her history of self-harm is also quite concerning and requires closer examination. However, when utilized to develop a “comprehensive problem list”, this assessment method is quite useful. The one caveat I might include, is that the level of experience of its user determines the effectiveness of this tool.

Reference

Author, (2015) Case Study – Illana. Retrieved from:
https://cyberactive.bellevue.edu/bbcswebdav/pid-7724673-dt-content-rid-10879782_2/courses/MCC670-T301_2163_1/Case%20Study%20-%20Ilana.pdf
Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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Mcc670 – Metamodal Questions

Based on NLP which says that people create faulty mental maps of reality and fail to test these cognitive/linguistic maps against experiences from senses.  According to founders of Neuro-Linguistic Programing (NLP) individuals frequently have faulty conceptualizations of reality . In order to address this issue, metamodal questions are used in therapy to understand how a client constructs their personal representation of reality. Through the utilization of metamodal questions cognitive errors such as overgeneralization, or all-or-nothing thinking can be uncovered (Ingram, 2012). The goal of these questions is to understand how the client processes information and develop clear idea of what is going on (Ingram, 2012).

Understanding the problem according to NLP

metaperspective defined

This concept is defined as the act of understanding our representation of reality is not the same as the true nature of things.  I discussed this concept briefly in another post after a conversation with my sister.  When we fail to acknowledge that our meta perspective doesn’t always adequately reflect the true nature of things we run into a proble.

The Gap Problem…

NLP defines this issue as a “gap problem”.  The inevitable gap between our cognitive map of things and real world experience, the bigger a problem is.   So in light of this we must begin asking ourselves what information we’re deleting and what we’ve distorted.

Understanding the NLP Solution via metamodal questioning…

The Goal…

The goal of NLP is to gather information that can help us determine where our informational gaps lie and if metamodal violations exist that can cause insufficient cognitive maps of reality exist.  As therapists our primary goal consists of helping the client develop a clearer understanding of what is happening and develop better informational processing skills.

The Metamodal Questioning Process.

STEP ONE –

Begin by ask for real data of experience to be fully described.  In the context of an intake interview you might begin by simply giving the client some time to tell the story of what lead them to seek counseling.

STEP TWO – 

Next you might ask questions that can help clarify the information upon which the client is basing his view of reality on. For example, if the client states “everyone hates me” you might respond by asking for specific sensory data, interactions and/of events that lead you to this conclusion.

STEP THREE  –

Finally, take time to explore further, any  information that may or may not support and not supporting the client’s perspective.  Here are a few Practicing Metamodal Questions (Examples) from Ingram (2012).

  1. Is the client missing some important details? (where, when, what, whom)
  2. Does the client use ague pronouns leading to generalizations (i.e. Everyone)? Ask for clarification and specifics
  3. Does the client tell his/her story with vaguely with few observable actions & behaviors ?  Again ask for them to clarify.
  4. All-Or-Nothing Thinking.  Is the client jumping to conclusions?
  5. Is the client making assumptions about others’ feelings?
  6. Cause/Effect Error.  Is the client assuming that “a” caused “b”? Attempt to and disconfirm the link between a & b.
  7. Is the client imposing values upon others? inquire on source of belief…

What follows are three examples of metamodal questions that could be utilized in the Case study of Clara assigned in my MCC 670 course.

Example One

In the Clara’s case study, she is said to making the following statement: “But my brother is an idiot and he’s just sticking around to get what money my father has left – I’m not going to let him win this one” (Author, 2015). Ingram, (2012) suggests a statement like this can reflect a cognitive error best described as “mind reading” (p34). A great multimodal response to this comment might be: “What is it specifically about your brother’s actions that has lead you to this conclusion?” When worded in this way, this asks the Clara to provide detail to support this assessment, while not making her feel you’re either negating or challenging this assertion.

Example Two

Clara also makes the following statement in an intake interview with the therapist: “Everybody has always shoved me around, telling me what to do. I’ve got a brain.” Our Ingram (2012) textbook would classify this statement as a potential overgeneralization (p33). A useful multimodal response, would require her to provide more detail in support of this generalized assumption (Ingram, 2012). For example, the therapist might state: “What is it that people do to make you feel this way? Can you provide examples?”

Example Three

Clara makes the following brief statement about her mother: “Mother believed in using the switch if everything wasn’t done just the way she wanted it.” This statement provides an opportunity to gather more information about a possible abuse history. In this example, my response would focus on gathering the missing details so I could develop a clearer idea of the specific incidents related to this comment. In this instance, I might say: “How does your mother like things done? Is it difficult to maintain your mother’s standards as her primary caretaker?

References

Author, (2015) Case Study – Clara.  Retrieved from: https://cyberactive.bellevue.edu/bbcswebdav/pid-7724670-dt-content-rid-​10879816_2/courses/MCC670-T301_2163_1/Case%20Study%20_Clara.pdf
Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Data Gathering

Ingram (2012) describes the intake interview as an assessment phase that typically occurs in 1-3 sessions. Oftentimes employers set specific requirements including a timeline for completion along with a predetermined format. However, Ingram (2012) states that the degree of structure and limitations on flexibility affect the client’s ability to engage in a storytelling process. Ingram (2012) defines problem solving as ideally involving minimal influence in order to gather information and identify the goals and problems. Testing a potential hypothesis exists as the initial stage of solution formulation in this process.

​According to Ingram (2012) the Intake Interview occurs in three phases. During the phase one, the client is allowed to tell their story as the counselor remains attentive and expresses understanding. In the second phase of the intake interview process, the counselor directs the clients toward key topic areas in an effort to complete this initial assessment (Ingram, 2012). Two key goals during this stage include determining of a crisis intervention is needed, and testing clinical hypotheses (Ingram, 2012). During the final phase, taking time to summarize progress thus far is important alongside a discussion and overview of the counseling process.This can help the client understand what to expect from therapy.

Ingram (2012) begins by describing the counseling as a problem-solving process that occurs in stages as follows:

  1. STEP ONE – Gather data —>

  2. STEP TWO – Identifying problem–>

  3. STEP THREE – Decide on goals—>

  4. STEP FOUR – Test hypothesis—>

  5. STEP FIVE – Move toward solution—>

Ingram (2012) encourages us to minimizing our influence over the problem solving process in the early data-gathering stage.

Ingram (2012) cautions that predefined approaches shape and restrict the client’s storytelling process and content that is provided – be flexible.  My biggest problem – thus far has been learning to balance a need for note taking with the development of a rapport.  Additionally it is important to be aware of how the process of social exchange can further influence the outcome of the data gathering process.  Ingram (2012) provides the following examples of how our level of influence can vary during the intake interview:

  1. Minimal influence – “allow silence, follow-up questions, encouragers, paraphrasing, reflection of feeling.” (Ingram, 2012).

  2. Mild influence- selective summary, probing topic chosen by the therapist, offer a bunch, reassurance

  3. Moderate influence – challenging questions, give suggestions, confrontation if inconsistence

  4. Maximal influence- interpret, teach, set limits, direct.

Ingram (2012) describes the intake interview as a process that occurs in three stages.

Phase One

Invite clients to tell stories in their own way unobstructed while you track this story and express understanding.  The primary goals are as follows:

  1.  During first session goals
  2. Gather cultural data
  3. Create good rapport & establish credibility
  4. Be sensitive and ask questions rather than rely on assumptions

Phase Two

This is the exploration phase (Ingram, 2012). It involves directing client toward topics of your choosing so you can complete the intake process.  The goals during this phase include   (1) testing the emergency hypothesis, to rule out need for crisis intervention, and (2) testing clinical hypotheses with questions, in order to assess your understanding of the problem.  What follows is a list of tips to minimize your influence during the data gathering portion of the intake interview (Ingram, 2012).

  1. Leading client to areas that you think are important, by blending listening with questioning.
  2. Do not bombard with questions.  Create bridge between client discuss and u r ?’s
  3. No agenda setting at this point.  The focus is on data gathering…
  4. Be aware that some exploratory questions carry advice
  5. Keep in mind, some questions encourage the client to think differently

Phase Three

Closing involves keeping track of time without being distracting and summarizes session. Psychoeducation important along with helping client understanding what to expect, (i.e. informed consent, & intake paperwork).

Data Gathering & The Therapeutic Relationship

Finally, Ingram, (2012), provides a few important suggestions for attending to the establishment of a therapeutic relationship during this phase.

  1. Empathetic listening and nonjudgmental acceptance are critical during this phase since this can impact what the client shares…
  2. Self-Awareness is vital and should be part of your training.  In addition to understanding. how other people perceive and respond to you, be mindful of the impact values, emotional reactions, cognitive filters and defensive tendencies, or cultural biases might have.
  3. Cultural Competence – Counseling doesn’t occur in a vacuum in the sense that we bring to the tables our sociocultural perspective as the filter through which we view life. An understanding of diverse cultures other than your own is especially critical.

Finally, Ingram, (2012) provides a quick overview of a few essential data gathering tools frequently utilizing during the intake process.

  1. ADDRESSING (Age, development, disability, religion, ethnicity, socioeconomic status, sexual orientation, indigenous status, national origin, gender.)
  2. GENOGRAM(Family Tree Diagram) – Includes  three generations using symbols to represent nature of relationships, gender, marriages, Etc
  3. FOUR (problem, outcome, obstacles, and resources)
    1. PROBLEM – what is wrong? Since when? How:
      1. Describe problem
      2. Discuss onset and developmental course.
      3. Progressive deterioration and history….
      4. Past attempts to solve
    2. OUTCOME – What do you want to happen?
      1. Your vision of the future?
      2. Where do you want to be?
    3. OBSTACLESBarriers to what you want?
      1. Internal barrier?
      2. Environmental obstacles
      3. Cultural / Social Issues
    4. RESOURCE & SUPPORT –what would help you get what you want?
      1. Environmental changes
      2. Applying new habits and skills. Etc…
    5. BASIC SID(Behavior, affect, sensation, imagery, cognition)
    6. Check out this description of Multimodal questions…
  4. OTHERS
    1. Evidence-based self-Reporting Instruments – Beck Depression Inventory, etc….
    2. Behavioral Observation Rating – Child-Symptom-Inventory 4
    3. Self-Monitoring Charts – antecendents/consequence/Trauma….

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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NCE – Group Therapy Overview

What is a Group?

Various Modes of Counseling discussed in the counseling theories section are all useful in the Group Therapy Setting.  (Groups have a definable membership.  There is unity and members interact with a shared sense of purpose.  Before the 1960’s and 1970’s most help was given in a dyadic relationship.” (Rosenthal, 2005)

Historical Considerations

Founder of Social Work. Jane Addams, is credited with holding early “moralistic group discussions”, the early version of group therapy.  Henry Pratt, began running groups in the early 1900’s for TB patients, for purposes of support and mutual encouragement.  The term “group therapy” was coined in 1931 by Jacob Mureno, the father of psychodrama.  In 1941, he created the American Society for Group Psychotherapy and Psychodrama.  A year later S. R. Slavson founded the American Group Psychotherapy Association.  Practitioners of individual psychology are quick to point out that Alfred Adler’s group guidance in the 1920’s and 1930’s with families also help to spark the group movement.

Primary, Secondary, & Tertiary Groups…

These are classifications of groups.  Primary groups are preventative and attempt to ward off problems.  Nearly all guidance and psycho-educational groups fall into this category.  The group would be trying to prevent drug addiction or a medical problem.  Secondary groups are both preventative and remediative.  Some form of emotional or physical disturbance is already present.  Goal with secondary groups is to shorten the length of a disorder and prevent it from getting worse.  One example of a secondary group might be one for rape victims or individuals in recovery.  Tertiary groups are intended as psychotherapy for those with long-term emotional problems.  Teritiary groups focus more on each individual’s mental health than you would find in a primary mental health group.

The Good & The Bad…

Benefits of Group Therapy….

Human behavior can really be studied in a social context.  The group setting provides an opportunity to try out new behaviors in a safe setting.  It also allows individuals to receive feedback from other members in addition to the therapist.  They helpful in the improvement of social skills.

Therapeutic Factors According to Yalom

  1. Instillation of hope -faith that the treatment mode can and will be effective.
  2. Universality – Means that as human beings we are not the only person in the world with a given problem or difficulty.  This key benefit of group participation helps members feel that others have similar problems.  Sometimes referred to as Mutuality.
  3. Imparting of information – didactic instruction about mental health, mental illness, psychodynamics or whatever else might be the focal problem of the group. (Ex. OCOA, Alanon; learning about the disease process itself).
  4. Altruism – opportunity to rise out of oneself and help somebody else; the feeling of usefulness.
  5. Corrective recapitulation of the primary family group – experiencing transference relationships growing out of primary family experiences providing the opportunity to relearn and clarify distortions.
  6. Development of socializing techniques – social learning or development of interpersonal skills.
  7. Imitative behavior – taking on the manner of group members who function more adequately.
  8. Interpersonal learning – receiving feedback from others and experimenting with new ways of relating.
  9. Group cohesiveness – the most critical factor to consider when pre-screening individuals
  10. Catharsis – opportunity for expression of strong affect.
  11. Existential factor – recognition of the basic features of existence through sharing with others (e.g. ultimate aloneness, ultimate death, ultimate responsibility for our own actions).

Rosenthal on Benefits of Group Therapy…

  1. Groups allow counselors to see more clients in the same amount of time.
  2. Groups generally are more cost effective.
  3. Groups gives a sense of belonging support and is a microcosm of society.
  4. Groups provide opportunities for vicarious learning (spectator therapy)

Disadvantages of Group Therapy

  1. Less time is focused on the client than with individual therapy
  2. The client has less intensity with the leader versus what he /she would have in an individual counseling session with a helper.
  3. Groups can be intimidating and stifle client disclosure
  4. Group sessions are often longer than individual sessions and take more of the client’s time.
  5. Lack of assurance of confidentiality is a major issue.
  6. Misapplication of interventions when family or individual therapy would be more appropriate.
  7. Organizing the group is difficult and groups are complex to run.
  8. The Risky Shift Phenomenon “The risky shift phenomenon postulates that group decisions are generally riskier than decisions that would be made by individual members.” (Rosenthal, 2005)
  9. Group Polarization “Here the individual members exaggerate their original position on a topic so the group as a whole will have a more mainstream position.” (Rosenthal, 2005).

Types of Groups

Counseling & Therapy…

Within individual therapy these terms mean the same thing.  However, in group therapy a distinction is usually implied.

  1. Counseling groups usually focus on growth, prevention, and enhancement of self-awareness.
  2. Therapy groups focus more on remediation, and personality reconstruction.  Therapy groups usually have a longer duration and are much more likely to dwell on unconscious material and family of origin issues.

Why this distinction?  Group therapy emerged in a big way during and after WW2 due to a shortage of trained therapists.  Groups allowed professions to work with more patients when there was a shortage of helpers. Some counseling historians  believe that Carl Rogers helped popularize this idea.  Another individual who was helpful in promoting the group therapy movement after WW2 was Dr. Kurt Lewin who developed Field Theory and formed NTL or National Training Labs to study group dynamics in 1947.

Structured Groups

Group leaders often speak of Structured Groups.  These are groups with a central theme like anger control.   Themed groups are becoming very popular and they are often conducted as self-help groups or support groups.  Self-help support groups include meetings like AA, Al-Anon or Weight Watchers.  They are composed of people with a common interest.  Although they may use professional consultants, they are not led by professional helpers.

EXAM HINT – 20 or so years ago counselor’s rarely referred clients to support groups.  Today the practice is extremely common.

T-Groups

“T” stands for training. Sensitive group stresses skills desirable in a business or organizational setting.  The thrust is on the group process and not on personal growth.  Hence, the T Group deals with issues of leadership and decision making and how employees can conduct themselves in a more productive fashion.

Personal Growth Group

Purpose is to aid healthy individuals in their desire to deal better with daily life or major transitions (i.e. divorce, etc)…

Ideal Characteristics of a Group

Group Size

What exactly is effective?  Some books list 5-8 is a good size for adults.  Others recommend as much as 5-12.  However, Rosenthal (2005) states that 8 is the most-often recommended ideal size for adult therapy groups.  With children you might want 3-4 kids to a group.

Length of Sessions

Most experts would recommend two hours as more than enough time for adult groups.  However, with children you might want to shorten the time to 30-40 minutes and meet biweekly instead.  1.5 hours seems to be the average for most adult therapy groups.

Membership Screening

The American Counseling Association and the Association for Specialists in Group Work both recommend screening group members beforehand.  Pre-Group / Individual Interviews need to be seen beforehand to determine if their needs can be met through participation.  Moreover, you want to make sure person is appropriate and won’t hinder the groups functioning.  Suicidal individuals, sociopathic personalities, paranoid individuals and psychotics would generally be excluded from most counseling groups.   Another poor candidate would be the highly self-centered or hostile belligerent individual.

Click Here to Read the ASGW’s 2007 Ethical Guidelines.
Click here to read AGPA’s Ethical Guidelines

Most leaders prefer private screening session in order to increase the potential for a two-way exchange with clients.  However, Rosenthal (2005) states that group screenings are also important in order to assess how the client will interact with other potential members.  Yalom, states that cohesiveness is the primary consideration to keep in mind when you are selecting participants.  In terms of the person, their ability to trust is generally the most important trait for a group member.

Opened vs. Closed Groups

In Open Groups you can replace members when one leaves.  New members are admitted throughout the life of the group.  This keeps the number of clients attending the open group stable.   However, new members are unaware of prior interactions within a group.  Additionally, adding new members can be detrimental to group cohesiveness.

In the Closed Group, no new members can be added once it begins.  This is great for group cohesiveness, however if everybody quits, the group can really shrink over time.

Two Final Words of Caution

Remember that the client’s previous experience in group is one of the least important factors. Another caution, is that leaders may be prone to pick member are high in conformity.  Although this has benefits, research has shown that conformists are likely to be authoritarians.   This can produce its own dilemmas.

Group Dynamics

Concepts like leadership style and norms technically fall under the category of group dynamics.  Group dynamics is defined as the study or body of knowledge pertaining to how groups operate.  Group dynamics postulate that groups are dynamic and ever changing.  People are interacting and reacting constantly. People with an interest in group dynamics, want to know what forces internal and external are shaping the behavior of the group and its members.

Body Language…

My advice for groups is that you will find it nearly possible to face members squarely all the time, if they are sitting in a group.  Turn toward the person whom you are speaking.  Literature pertaining to proxemics indicate that during the initial sessions, the leaning forward behavior on behalf of the counselor could actually be perceived as negative, if the client’s are of a different race.

Clients and counselors tend to sit closer together when they are closer in social status, age, race, ethnicity, and mode of dress.  The feeling of psychological closeness can be observed in individual and group settings where the seating arrangements are flexible and individuals can choose any seat he/she wishes.

Types of Leaders…

  1. Process leaders are outcome oriented and focus more on behavioral goals.  They tend to be slanted towards behavioral approaches of therapy.  The emphasis is on the outcome.
  2. Process leaders are focused on the interactions between members.  A statement by a process leader.  “Bill always responds out of his critical parent whenever talking to Ann.”

styles of leadership

There are three basic styles of leadership:  Authoritarian, Democratic and Lassiez-Faire.  Each is described below:

  1. Authoritarian Style – leader determines policies and gives orders to of the group.  Members often dislike this style.
  2. Lassiez-Faire Style – Leader adopts a hands off policy and participates very and the group runs itself.
  3. Democratic Style – The policy is set by the group, aided by the leader, who urges group interaction.

A well-known study suggests that the democratic style is the most desirable and most cases but definitely every case.  For example, if you had to make a decision very rapidly in a crisis the authoritarian mode might be best.  Some literature does go beyond these three basic types:

  1. Charismatic Leader – use their personal power and attractiveness to run a group.  Clients can adore this type of leader and become irrational because of it.
  2. Confrontive Leadership Style – the leader reveals the impact of their own behavior on themselves as well as the impact on other group members.  The focus here is usually the present moment.
  3. Speculative Leadership Style – Focuses on the here and now and zeroes in on the meaning of the leaders own behavior and that of the group members.  Emphasize very heavily what is transpiring right now in the group.  Research indicates these leaders are often seen as somewhat charismatic and less peer-oriented than confrontive leaders.

Co-Leadership…

Advantages…

All leaders, regardless of style display empathy and caring.  Some groups rely on more than one leader.  This is known as co-leadership or co-facilitation.  The good news is with co-leadership you don’t need eyes in the back of your head to now everything that is going on.  Is also beneficial when one leader has to miss a session.  Shared leadership reduces burnout.  Allows leaders to process feelings between sessions.  If one leader is dealing with countertransference issues, the other leader can step in.  They frequently sit across from each other in order to minimize the us versus them notion.

Disadvantages…

Co-Leaders may view this setting that they are competing with one another.  This may cause co-leadership conflict.  If co-leaders don’t meet between sessions, they may be working against one another at times.  If leaders don’t trust one another, the group will not run smoothly.  When co-leaders are intimate, they may inappropriately use this time to work on their issues too much.

Norms, Groundrules & Group Norms

Every group has norms, parameters of acceptable behavior. T hey may be written or unwritten.  It is easier to experience them than consciously define them. The specific guidelines that the leader sets, are know the ground rules. When the ground rules become the norms of behavior, they are called group norms.

Presence of Shared Goals…

It is best if the group comes to a mutual concenseus in terms of goal setting.  That although goal setting, most researchers have found that goal setting is a weakness in many groups.

Structure of Groups…

In highly structured groups, the leader has specific activities or tasks for group members. Less structured groups do not have this.   The term “unstructured” has come under fire as it pertains to less structured groups, since technically all groups must have some form of structure.  A group cannot “not” have structure.  Some research does indicate that structured exercise with feedback can result in better communication and feeling.  However, structure alone is insufficient.

Cohesiveness

The strength of the bonding process between group members.  Some people use the word “unity” when discussing this concept.  Cohesiveness is really a double-edged sword  in the sense that although it is desirable it can stunt creativity and conformity at times.

Group Roles.

  1. The Joker – acts silly and jokes around all the time.
  2. Energizer – provides the group with enthusiasm
  3. Follower – non-assertively goes along with everything group wants.
  4. Scapegoat – person everybody expresses hostility toward and accuses them when something goes wrong.  They get dumped on
  5. Peeping Tom – This member insists on interrogating members a series of inappropriate questions
  6. Gatekeeper – believes it is his/her job to make certain everybody participates.  Secretly wishes they were running the group.  He/She may never get around to working on own problems.
  7. Storyteller – contributes irrelevant tales of woe whenever possible.
  8. The Social Isolate – present but nobody even knows that this person is there.  When they try to reach out, their contributions are unnoticed.
  9. Harmonizer – member who tries to placate or make things friendly. Smooth things over between members.

Finally, from a global standpoint, members may assume basic types of roles.  There are task roles and there are maintenance roles and self-serving roles.  Task and maintenance roles are considered positive. Self-serving roles hinder the groups roles.

  1. Task roles – facilitate the group’s ability to define goals and implement problem solving strategies.
    1. Information providers
    2. Clarifiers
    3. Summarizers
    4. Opinion Givers
    5. Elaborators
    6. Initiators.
  2. Maintence Roles -also seen as healthy and serve to alter, maintain, or strengthen the group overall.  Maintenance roles serve to enable compromise, supportive contribution and development of group standards.
    1. observer
    2. compromiser
    3. conciliator
    4. Follower
    5. Standard Setter
    6. Encourager
  3. Self-Serving Roles – These roles are seen as negative and hold the group back and work against it.  Clients who silent, resist, intellectualize, manipulate, withdraw, attack are said to be playing a negative group role.
    1. People who don’t participate
    2. Blockers
    3. Monopolists
    4. Critics
    5. Dominators

In a health group members are flexible and can move in and out of roles and change roles when necessary.  Both task and maintenance roles are necessary.  If only one is done, no progress occurs.

EXAM HINT:  Group therapists rely on the term role conflict to describe a situation in which there is a discrepancy between the way a member is expected to act versus the way he/she naturally behaves

Group Development

Exam Hint:  Since it is impossible to remember all the models of group development I want to suggest that most of them are similar enough that a basic grasp of group stages will get you by.

Group development is usually expressed in terms of stages.   These stages of development occurs as follows:

  1. STAGE ONE – Most models whether they call the first stage forming, orientation, pre-affiliation, or exploratory, deal with approach / avoidance behavior.  Clients may wish to participate but have a fear they won’t be accepted.  They may be uneasy and suspicious.  They may try to identify with members of a similar social status.  In fact you see similar people trying to sit together in this stage.
  2. STAGE TWO – Storming/Transition, or Power/Control.  Marks the time of the greatest conflict. Opposing subgroups may pop up and people may try to mentally rank order themselves with others.  A hierarchy or group pecking order may be evident.  People will fight each other for dominance, and members may even rebel against the leader.
  3. STAGE THREE – The stage becomes cohesive like a family.  Members are more intimate.  This is an action-oriented time and problem solving phase.  Since a lot of work happens here it is generally called the working stage.
  4. FINAL STAGE – termination stage, adjourning, separation, breaking away.

Sociogram

As a leader  you may wish to construct to a picture of sub-groups and coalitions an assess their overall impact on the group.  The sociogram was introduced by Marin Owen Jennings in 1950 and it graphically displays the relationships of group members. It is a picture of what is going on in the group.  A sociogram depicts attraction and repulsion by use of lines and arrows, etc.  The study of person to person relationships in a group setting is known as socioemetry.

Developing Competency…

  1. Training – A therapist can have a room full of degrees and licenses, and no training in group work.  Such a person should not be running groups according ot most groups.  ASGW recommends counselors who have compelted a groups course supplemented with at least ten hours of supervised experience, (twenty is recommended however).
  2. Counseling for Counselors – Some counselors just don’t have the personality to do so effectively.  Gerald Corey, believes that group leaders should first become the member of a group themselves before running one.  Individual therapy is also recommended before becoming a therapist.
  3. Group leaders should also provide members with informed consent information.  Information such as where the group will meet, when it meet, the counselor’s credentials, the methods used, the cost of meeting times and the fact that there are limitations to confidentiality.  You need to discuss the fact that you cannot guarantee confidentiality in the group since members may breach it and this is beyond your control.
  4. Groups leaders must keep in mind that group participants have rights.  One right is knowing what psychological risks will be evident by attending the group.  The ethical group leader discusses these risks during the first session and works throughout meetings to reduce these risks.  According to ASGW guidelines, if things get too bad, they may withdrawal.  Group participation is voluntary in nature, you should never force someone to stay in the group.  Two major risks are scapegoating (members gang up on a member) and breach of confidentiality.
  5. Group leaders can use all the skills utilized by individual counselors, (paraphrasing, attending, clarifying, empathizing, etc)…but, leaders can also utilize summarizing, blocking, and linking quite a bit.
    1. Summarizing – ask each member to recapitulate what learned in the group, or the leader may wish to do so.
    2. Blocking – used to stop/block inappropriate behaviors.
    3. Linking – Used to relate what one is saying/doing to another person’s predicament.  The leader illuminates points of mutual concern.
  6. Group Leaders can vary their approach by focusing either the group as a whole, or focus on one at a time.  This is a choice and can really be made regardless of what modality you are utilizing.
    1. Group as a whole strategies – are called “horizontal interventions”
    2. Focusing on an individual – called a “vertical interventions”
Final Exam Hint:  Some group counselors do a so-called ecological assessment to decide if a group is appropriate, and if so what methodology will work best.  This assessment provides information about psychological, social, cultural, and economic needs of group members. Community surveys, focus groups, and thorough demographic analysis can help you.  Adept leaders often secure information from textbooks, the internet to plan group on session-by-session basis.

References

Rosenthal, H. (2005). Vital information and review questions for the NCE and state counseling exams. Routledge
Yalom, I. & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books. pp.1 – 2.

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