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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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Stages of Change

That Nike commercial that tells us “Just Do It!”, irks the hell out of me.  While intended as an inspirational message of empowerment, it misses the mark on how to create and sustain lasting change.  As I’ve come to realize (both professionally and personally) change is a process that takes time.  When I reflect on my own steady progression of growth thru life, two resources seem to describe this journey well.  The first is the transtheoretical stages of change model which addresses feelings of ambivalence toward change:

“People who successfully make changes in their lives progress along a continuum of predictable stages: 1) precontemplation – not aware of, or minimizing the problem; 2) contemplation – acknowledging the problem and considering possible changes; 3) preparation – making plans; 4) action – following through with plans and 5) maintenance – keeping the new actions as a part of daily activity” (Frasier, et al, 2001).

The second resource which inspires this post is a book by Carl Rogers (2012) titled “On Becoming A Person”.  While the stages of change model provides a witnesses acount of the change process, Roger’s description is a first-hand perspective.  In one interesting segment of this book, he describes a continuum of openness to change.  In an attempt to describe this continuum he makes the following observation:

“[this] Process involves a loosening of feelings. At lower end remote and unowned…At the upper end process of experiencing a continually changing flow of feelings becomes characteristic of the individual.” (Rogers, 2012, p. 157)

It is worth noting that while Rogers, (2012) description of change is similar in many respects to the Prochaska’s Transtheoretical model, it is comprised of 7 stages. Additionally, Rogers theory describes an abstract growth process as we move from ridgidity toward openness to change.  What I like about Rogers theory is it describes this process of change as a gradual transformation in how we relate to our feelings.

In this post I intend to discuss the process of change from two unique standpoints. One perspective will provide a theoretical overview of the stages of change from those in the helping professions. Another perspective will be a first-hand accounting of my experiences in a past relationship.  In this emotionally abusive situation, I underwent the very stages of change described here.   With the benefit of 20-20 hindsight, I am grateful for where I am today.  That experience is a stark contrast to my current marriage to a wonderful and loving man, almost 17 years.  I’ve honestly had to step back and debate whether or not I wish to share this experience in such an open forum. My decision is that openness & honesty will be 2 essential guiding standards in the creation of this blog.  After all, hiding experiences like these implies shame – which is unwarranted.  It just also happens to be the “badass” alternative, 🙂 🙂 🙂 …

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Pre-Contemplation

22033“Precontemplation is the stage in which there is no intention to change behavior in the foreseeable future” (Norcross, et al, 2011, p. 144).

Second Hand Observation

According to Prochaska’s Transtheoretical model of change, individuals here are unaware of their problem and are reluctant to discuss matters in detail.  Rogers, (2012), notes an “unwillingness to communicate [about] oneself…communication is [instead] about externals…feelings are neither recognized or owned.  Personal constructs…are extremely rigid” (p. 133).  Feelings are managed with a goal of repression, in order to maintain a sense of security thru avoidance.  Unwilling to seek help independently, clients often enter counseling at the insistence of someone else.

First Hand Experience: “The ‘IT’ years…”

First Year of College…

“There is no need to talk about it: it won’t change a thing,” (Fraser, et al, 2001, 214).  This was my attitude in the first year of our relationship.  I felt a sense of complete hopelessness and lived in denial of the problem.  It was my first serious relationship and introduction to the dating world.  I was in my second year of college when we met, although not your “typical young adult”.   He was my first serious relationship:  prior to him I hadn’t even so much as even kissed a boy before.   I had just left high school that previous year, with a huge chip on my shoulder.  I was a bullied child with a well of unresolved hurt.  Since my best friend, Ruby Stricker moved in sixth grade, I hadn’t experienced a feeling of acceptance or belonging amongst peers.  I was the girl with the cooties that got picked last in P.E., and sat alone at the lunch table.  By the time I reached high school, I would go weeks without speaking more than a few words to people.  These exchanges included “pass the salt” (at home), or “can I use the bathroom” (at school).  This left me with six full years of stagnation in the area of social development.  While I was eighteen chronologically, an insecure sixth grader still lurked within.  As a result, I had huge expectations for my freshman year.  I hoped to make friends & wanted nothing more than to be accepted.  As you might expect, reality didn’t live up to expectations.

While I did experience some companionship with fellow dorm residents, a cavernous divide separated us.  They were your typical college freshmen, and I was  “different”.   Conversations with fellow dorm mates provide a unique window into this divide and my “burgeoning issues”.  Concerned for my level of naivety, the developmental divide between us made it difficult for me to be regarded as an equal.  I recall being very frustrated by this: their parental concern angered me.  Today, I realize I had misperceived it as a demeaning insult.  I wanted nothing more than to be like them, but had no idea of how to make up for “lost time”.  I finished that first year with very few friends and still had yet to go on my first date.

As I entered my sophomore year, I was still completely ignorant of my “issues”.  The consequences of my own chosen methods of adaptation to bullying continued to play out.  The self-imposed isolation throughout teens, now made it difficult to relate to those my own age.   Desperate to solve the problem, I was eager to to take the first “zero-to-sixty” route to maturity I could find.  Little did I know, I was to meet a guy who would deliver just that “and more”.

Meeting “IT”

(((FYI – in conversations with my family about this time of my life, my mother has requested we not mention “that name” .   In time we’ve adopted the nickname “IT” to refer to him.  I use this in reference to this individual throughout the post))) 

…From the moment we met, we were like moths to a flame, drawn to each other for all the wrong reasons.  We were the other’s “quick fix” solution to unresolved hurt.  His involved a complicated relationship with a “domineering” mother.  Mine involved a chip-on-your-shoulder mentality in the aftermath of prolonged bullying and emotional neglect.    We never did have that “honeymoon period” common in most “unhealthy relationships” (Burman, 2003; Fraser, et al, 2001).  Instead, I would describe our relationship from the start as a “boot camp” in which IT made the development of a traumatic bond, his priority.  I lost my virginity very early.   It happened so fast, I remember it in retrospect as an unreal “out-of-body” experience.  It was only when he crawled on top, that it dawned on me what was happening .  My head spun: it was over almost as suddenly as it began.

He immediately set a plan in motion, to turn my insecurities into a certain self-perceived fact that I was totally worthless and helpless without him.  Reading me like an open book, he berated me for my inability to fit in.  I was ugly and stupid.  He told me there was no way any other guy would want me.  I believed him, (based on past experience, it appeared a logical conclusion at the time).  This resulted in the gradual reinforcement of learned helplessness (Burman, 2003; Fraser et al, 2001).  He would push the boundaries of what I would put up with, by using my naivety to his advantage.  He dangled “girlfriend” status in front of me like a carrot on a stick.  Achieving this status meant doing what he said, no matter how crazy, willingly and without complaint.  If not, I was to receive anger and rejection.  This was an unthinkable horror I intended to avoid at all cost.  I “NEEDED” him.  Before long, I was his personal slave –  the sole reason for my existence was to do his bidding.

Now under his “complete control”, the next phase of his plan was set into motion.  He started to isolate me from others, insisting I move to another dorm and take a single room.  Away from my friends, I was alone again, just like high school.  Old insecurities re-emerged and with it, crippling depression.   I only wanted love and acceptance. He utilized these urgent needs to his favor.  He was very possessive and insisted I never leave his sight without his say.  However, he cheated on me constantly – openly and without apology.  In fact, he would share intimate details of his “trysts”.  He insisted I listen attentively without complaint so he could drive home the idea that I was lucky to have him.  Fearful of rejection, I complied as instructed.  At first, it was difficult to conceal my feelings.  I would sob uncontrollably while he laughed and called me pathetic.  In time I learned to separate myself from my experiences, as if I were floating outside my body and witnessing the events like an observer.  He could do as he pleased – I felt nothing.

In time, he was my “sole source” of acceptance and love.  Desperate to have somebody in my corner, “losing him” was now a source of fear and panic.  I was “lucky” to have him and fell for his plan; hook, line and sinker…

Contemplation

image“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.” (Norcross, et al, 2011, p144).

Second Hand Observation

In the contemplation stage, a growing ambivalence begins to emerge as individuals begin to struggle with their own self-evaluations of dysfunctional behavior, (Norcross, et al, 2010).  Aware that a problem exists, individuals often describe feeling “stuck”.  Concerned about the energy and risk involved in change, resistance prevents further action.  Stages two and three in Roger’s description of growth/change provide additional insight on the nature of this resistance.  In stage two, problems are acknowledged but externalized (Rogers, 2012).  Feelings start to ‘bubble up’ and are unacknowledged.  Emotions are used to assess what is of value to us.  In phase three, an emerging understanding develops of how emotions exist in reaction to events while also defining their nature.  With this realization, we begin to re-examination our perceptions and beliefs of the situation. “Is all as we perceived it to be?” Questions such as these produce a growing awareness of our problems.

First Hand Experience

The move to New York…

The burgeoning depression I felt as a result of his imposed isolation was now intermingled with a constant state anxiety and feelings of hoplessness.  My body was a jumble of nerves, I couldn’t keep food in me, my heart was pounding out of my chest.   This state of “near panic” was due to the unthinkable:  losing what I perceived was my only real chance at love and belonging.    The very idea of this terrified me.  While I didn’t have the courage to “hurt myself”,  the emotions were overwhelming enough, that this option was starting to become quite attractive.

As the semester came to a close, he began planning our next move.  By this time, I had managed to alienate myself from all the friends I made first year.  We were spending every minute together.  He refused to let me out of his sight.  During finals week he made an executive decision that we were to hop the next Greyhound to New York City – his hometown.  Plopping down two duffle bags in my room one day, he told me to fill them up and “leave the rest of your shit here”.  I did as I was told, and only informed my parents of our move after arriving in Staten Island, where his mother dropped us off at an apartment she found.  With only $1000.00 in our pocket, it was my job to figure out how to support both of us.  I got a job at a restaurant, and begged my parents to help and they relented.  However, I received an angry letter from my father shortly thereafter, demanding “how could I do this”.  He told me I made my mom cry in attempt to induce guilt.  In short: I was “disappointing them”.  My sister, then only 12, was incredulous at how stupid I was.  “I would never hurt mom and dad like that”, she exclaimed, and set forth a path toward “being perfect”, that involves always following the rules as the “good girl”.  I was angry, for their failure to be there when I needed.  Couldn’t they see how this was an end result of years of many years of bullying and torment?

It was when we arrived in New York, that a new phase of our relationship began –  10x worse than what I had experienced previously.  Every second of my day was lived in a “pins and needles” like environment.  Trying desperately to “hold my head above water” emotionally, my only concern was to please him.   This meant stressing over every little thing.  The food was too “salty”.  I forgot to “lay out his clothes”.  Every little misstep was intermingled with negative commentary about my ineptness.  He called me “pea-brain” because I was so stupid.

The control was also amped up by this point, since we lived together.  There wasn’t a single move throughout the day that I could make without his say so.  He controlled the money, so I couldn’t do anything without his permission.  I was only allowed to eat small amounts of food, including oatmeal and ramen noodles 1-2 times daily.  My weight plummeted to around 90, (at 5’8″).  I was anorexic looking.  Meanwhile he ate like a king and started gaining lots of weight.  I remember watching him consume food longingly while crying inside because the hunger was beyond bearable.  He did this intentionally because it drove me crazy.

The demeaning and controlling behaviors steadily increased as his demands became more and more insane.  I was to sleep on the floor next to his bed like a dog because this enforced my status in the relationship.  I only entered it when he wanted “to get him some”.  I spoke only when spoken to.  I was to refer to him as “Sir”.  I had to ask permission to take a “piss”.  I was allowed to bathe only once every week or two for minutes at a time or he would pour a bucket of ice water on me.   After months of this, I was dirty and smelly since I rarely bathed.  My hair was greasy and tangled since I rarely had an opportunity to groom.   My clothing was usually disheveled since I only had minutes to dress.  I now looked like a starving, homeless, crazy drug-addict.   People walking down the street would stare at me visibly in horror.

The return home…

After a year of this, he decided a move was in order.  He felt moving to my hometown was a good idea since it was more affordable.  He also discovered he could manipulate my parents into giving me money, due to their concern for my well being.  By this time, I felt stuck and totally helpless.  I was certainly sick and tired of his treatment, but felt there was no other option.   I did recognize by this time that our relationship was a repeat of my childhood.  I knew it wasn’t a coincidence, that old traumas and fears from then were  re-emerging.  He was my “band-aid”: used to conceal issues I hoped to avoid. Like an addict in need of a “fix”, he had me where he wanted.  There was nowhere I could go.   By admitting this to myself, I was able to examine how the past explained the present.   However, I was still not strong enough to process those old memories.   I preferred, instead, to box them up in the attic of my mind with all the other baggage.

Preparation

22039“Preparation is the stage in which individuals are intending to take action in the next month and are reporting some small behavioral changes” (Norcross, et al, 2011, p144)

Second Hand Observation

In the preparation stage, clients begin making “baby steps” towards lasting change (Norcross, et al, 2011, p. 144).  With a full awareness of one’s problems, clients in this stage are ready to begin taking action in the upcoming months.  In this stage our goal is to begin understanding our situation more fully as we prepare to institute some big life changes.  Emotions are expressed with greater intensity regarding current experiences and past events.  The client begins to understand the importance of accepting and claiming ownership of all emotional experiences (both good and bad).  However, especially hurtful and traumatic experiences are still met with resistance.  Underlying a desire for change “is a realization of concern about contradictions and incongruences between experience and self….Example: I’m not living up to what I am” (Roger, 2012, p. 138). 

First Hand Experience

Fast-forwarding a few years, we now live in my home town and are working on completing a bachelor’s degree.   The relationship – as described above –  is otherwise unchanged.  I learn to acclimatize through a state of (almost perpetual) dissociation and numbing.  I am much like a marathon runner, emotionally conditioned to the situation.  Gradually, I gain awareness of the patterns in our relationship.  I come to understand that the unresolved insecurities from childhood bullying are a core component.  A sense of incongruency develops when I recognize this emerging clarity isn’t reflected in my dysfunctional life choices.   I desperately desire to leave, but feel incapable and stuck.  There is no pond to jump to where acceptance and love lie.  The only other option is aloneness – which frightens me.  A series critical incidences occur during this time which force me to examine our relationship further…

The first incident occurs just before Christmas break….

We had just finished our first semester back at school after a move from New York City.   We were living in the dorms at that time and planned to move in my parent’s apartment house once a vacancy opened up.  As Christmas neared, my mother insisted I come home to spend time with the family.  Her parents had just moved into the house after immigrating from the Philippines and she wanted me to spend time with them.  I was happy to see my grandfather, and desired to see him more.  Our last visit was when I was nine and he spent the summer at our house.  I remember growing close to him and being sad when he left.  When my mom stopped by the dorms to pick me up, IT forbade me to go.  A shouting match occurred between them and before long they are each holding me by an arm, pulling me in opposite directions.  After what seemed like an eternity, my level-headed father tells us to get in the car so we could discuss this.  Once we climbed in the car I noticed IT was crying(!).  I was shocked in that moment to discover IT’s “iron clad” armor was actually just show.  In reality, he was a scared and insecure child inside.   The only compromise we could come to, was for IT to accompany me to their house during the day and sleep at his place at night.  Mind you, the dorms were closed and he had nowhere to stay.  The only spot he could find was a van with and extended cab, in the driveway of a university maintenance worker’s house.  It was cold, dirty, and smelled of gasoline.   I hated him for ruining my Christmas and returning all the presents so he could spend the money.  I hated him for the time he took away from my family.  I hated him for making me sleep in that disgusting van.  Still, I felt completely helpless….

The second series of incidents involves encounters between IT and my former classmates.

On one such occasion, he informs me of two new friends he’s made: former bullies of mine.  IT talks about the time they enjoyed hanging out and describes their conversation.  He makes sure to tell me they thought I was a loser and I should be dumped.  On another occasion, I discover he was cheating on me with the most popular girl in school.  Again his storytelling involved a detailed accounting of their times together.  After years of this same treatment, I began questioning these stories as part of his plan to brainwash me.  However, when this girl started following me around in her car whenever I went out, I thought maybe there was a grain of truth to his story.

With every incident like this, the chinks in his armor start to appear.

I come to realize in time that he is completely full of hot air.  Underlying a thin veneer of confidence and good showmanship, is a well of insecurity and ineptness.   Underlying his assertion that I’m a helpless idiot is the reality that I’m pulling all the weight.  I work hard to support the two of us, (he is unemployed and only receives tuition money from his parents).  I work hard to help him get good grades (while holding down a full schedule myself).  I wait on him hand and foot, (he does nothing).  My hopes for love and belonging are now shattered.  I am now completely numb to any and all emotions – like a robot.  He is an asshole and I despise him but feel stuck.

Inside my mind, an emotional equation functions much like a “scale of justice”.   On one side, are the emotional burdens associated with being in this relationship.  On the other side are insecurities, feelings of worthlessness, and traumas I hope to avoid.   As each day passes, a few pieces fall from one side of the equation to the other.  The options of staying and leaving play out in this manner as I weigh this decision.  It is only a matter of time before the scale finally falls in the opposite direction….

Action

 image“Action is the stage in which individuals modify their behavior to overcome their problems” (Norcross, et al, 2011, p144).

Second Hand Observation

The action stage is observed through changes in a client’s behavior with the commitment of time and resources to sustain such a change (Norcross, et al, 2011, p. 144).  Rogers, (2012), provides commentary regarding Stage Five of his own theoretical model in the following statement: “There is an increasing quality of acceptance of self-responsibility for the problems being faced, and a concern as to how he has contributed” (p. 142).  Client’s in this stage display a heightened emotional awareness expressed as a desire to gain clarity.  As a result, feelings are experienced in the present.  This is accompanied with a “desire to be the ‘real me’” (Rogers, 2012, p. 142).  This need for change is goaded by a desire for honesty and self-responsibility (Rogers, 2012).

First Hand Experience

My Grandfather’s Passing….

In my junior year, my grandparents decide to move in with my aunt who lives in Texas.  As Filipinos accustomed to a tropical climate, they disliked the South Dakota winters.  Sad to see them leave, I promised to myself that “someday” I wouldmake time for them.  However, later that summer, my grandfather is hit by a drunk driver while out enjoying a bike ride.  I packed quickly and traveled to Texas with my family for the funeral.  I was numb and quiet throughout the visit.  I got my first taste of “freedom” in four years at this time. I could eat whatever I wanted, I didn’t have to ask permission to piss, and took leisurely showers every morning.  After relaxing into these experiences, nagging thoughts began to enter my brain.  My grandfather would never get to see me “well”.  His last memories of me woud be in this state of “fuckedupness”.  Of all my grandparents, I felt closest to him.  Our only time meeting was during the summer before I turned nine.  I began reminiscing about that time and was saddened by the fact that I lost our final opportunity to spend time together.  The real “kick in the gut”:  I chose instead to focus on appeasing “that bastard” waiting at home.  I knew there was something I had to do.

The London Trip.

On the way home from our trip to Texas, my mother expressed her concern.  I was quieter than usual, and she didn’t understand “what was wrong”.  An overwhelming sense of dread washed over me as I admitted to her that I wasn’t looking forward to getting home.  I didn’t elaborate but she knew implicitly what I had meant.  “Serendipitously”, just weeks after that exchange, my mother arranged a two week family vacation to England.  She then called IT’s family back home in New York and encouraged them to fly him home, since IT would be alone during this period.  They do, and somehow, (despite “his” protestations), I have a two week vacation to look forward to.  While over there, I’m treated to another two weeks of complete freedom.   On our third night there, I confess to my mother I needed to leave and felt now was my only real “safe chance”.  She gave me a hug and promised to be there for “moral support” during this call.   Our conversation was very brief and I’m not sure what I said.  I only know my heart was exploding out of my chest and my hands shook uncontrollably.  After a quick “I can’t do this any more”, he says “okay whatever” and drops the phone.  IT’s father then gets on the line and says he has to retrieve his son, who is outside in the snow without shoes or a shirt on.  I’m bawling at this time, but grateful for the courage I’ve mustered.  My mother gets on the phone and exchanges pleasantries with his dad.   I’m shocked – it’s over as quickly as it started.

The rest of the vacation is a blur.  My mind is muddled and my emotions are up and down like a roller coaster.  No longer numbed and in a state of robotic dissociation, my thoughts and emotions run wild.  While grateful to be out of the relationship, years of emotional brainwashing still remain.  I am still that addict in need of her “drug of choice”.  The emotional withdrawal of going cold turkey is unbearable.  “White-knuckling” it inside, I do my best to give “good face”.  I am strangely fearful and anxious without him nearby, (knowing we will probably never see each other again).  While I was able to contextualize these fears as based on his “emotional conditiong”, they remained unabated.  Unable to enjoy the vacation, I tried my best for my mother’s sake.  From an observer’s perspective, this decision might seem courageous.  From my own, this decision amounted to me “yelling uncle”.   Emotionally, I just had the living crap beat out of me.  I left the relationship that day, an empty shell with nothing left to give, a shadow of my former self…

((In the video below, Gabriela Andersen-Schiess crosses the finish line completely exhausted, after running a marathon during the 1984 Olympics.  It visually depicts my emotional state during this time:))

Maintenance

24816“Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action” (Norcross, et al, 2011, p144).

Second Hand Observation

The maintenance stage can be observed as the sustained maintenance of behaviors incompatible with one’s problems for a sustained period of time (Norcross, et al, 2011).  Rogers, (2012), describes stage six of his model of change by stating: “Once an experience is fully in awareness, fully accepted, then it can be coped with effectively” (p. 145).  Where there was once stuckness there is now allowing.  Where there was once resistance there is now acceptance.  As a result, the client is able to handle the problem effectively.  Problems are not externalized as “somebody else’s fault” so we can play victim.  They are not taken inward with a sense of shame while we “beat ourselves up”.  Instead, “he is simply living some portion of it knowingly & acceptingly [one step at a time]” (Rogers, 2012, p.150).

First Hand Experience

The aftermath…

With IT out of my life, I was able to move forward.   I began to relax into the simplicity of daily life.  I redecorated my apartment, and removed anything that reminded me of him.  I enjoyed  the pleasures of complete freedom.  My grades and overall health improved and I got my emotional “sea-legs” back.  After graduation, I moved to be closer to my sister and found a job.  Still not “over” the effects of all these experiences, I tried my best to manage them.   In those early years, I began to focus upon healing and addressed the most raw wounds of that period.  The support groups I attended were a vital lifeline.

20-20 hindsight…

It is now over 20 years since I broke up with this guy.   I don’t know where to begin discussing this last stage of change.  It just might need to be the subject of another post, since this one is already much longer than I had intended.   I can, however, reassure you that in time even the deepest wounds heal.  It’s taken a long time to work through the effects of this experience and put it into perspective.  In fact the last reminants of baggage from that relationship have finally been put to rest in the last few years as I’ve worked in repairing the relationships in my family.  In case you are wondering, I’m happily married now to a loving man and enjoy a relationship that once seemed impossible.  Today, memories of this experience rarely come up. I can honestly say I hold no ill-will towards IT. Healing began as I examined those reasons for entering and staying in such a relation.  I took a DBT therapy skills group and started procrssing old traumas.

In time, I discovered that in order to move forward, I would need to forgive and begin healing.  Doing so has been essential to make room for the “good stuff” that has since followed.  In fact, this experience provided me a chance to grow.  Strangely, the relationship I enjoy now, stands on the shoulders of lessons learned during this time…

Over the years I’ve learned that guys like this follow their own fucked-up rule book.  Click here for insights on how to spot a guy like this…

References

Burman, S. (2003). Battered Women: Stages of Change and Other Treatment Models That Instigate and Sustain Leaving. Brief Treatment & Crisis Intervention. 3(1).
Brown, B. (2015). Rising Strong. Random House: New York
Frasier, 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, 43(2), 211-217.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of Clinical Psychology, 67(2), 143-154. doi:10.1002/jclp.20758
Rogers, C. (2012). On becoming a person: A therapist’s view of psychotherapy. Houghton Mifflin Harcourt.

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“IT’s Unspoken Rules”

In a previous post I shared my story of an bad relationship, titled “Stages of Change”.  It has been over twenty years since I managed to leave.  I often refer to this period as “the IT years” after my mother jokingly one day to “please stop saying that name!!”  It was the most trying time of my life.  In the 20+ years since leaving, I’ve grown by leaps and bounds.  I’m grateful for the lessons learned and the loving marriage I enjoy today.  In this post I share some of my 20/20 hindsight.  What follows is an overview of his “modus operandi”.  If you’re dating a guy who thinks like this – RUN!!!

STEP 1: spotting your victim

imagePsychologically abusive men are masters at spotting the perfect victim.  On reflection, “IT” and I were a perfect match at the outset.  There’s definitely a grain of truth to the notion that “like attracts like”.  I was an insecure and naive girl who desperate for love and acceptance – even if all I found were empty promises.  “IT” had insecurities as well, but a bloated and narcissistic ego that fucked up  his perspective of things.  He could do no wrong and everybody else was the problem.  Others’ thoughts and feelings were only important insofar as this information could be used to get what he wanted through a process of covert manipulation (think wolf in sheep’s clothing). The perfect victim for this type of guy is a naive, trusting, & inexperienced girl who doesn’t know any better. Other key ingredients include: insecurity and desperation.   So what can you do to avoid a relationship like this?

  1. NUMBER ONE: Know your true worth and never attribute it to externalities such as others’ opinions or the quality of your meat-suit.
  2. NUMBER TWO: Take your time to let him show his true colors. People can only pull the wool over your eyes for so long…and please remember when he shows you his true colors – believe him the FIRST time
  3. NUMBER THREE: Have your priorities straight. Make sure you know what love is.  Ask yourself this: “If I let him love me, would it measure up?”  This should be a bottom line.  You  get what you ask for.

STEP 2: the honeymoon

CarrotonaStickThis phase is critical in establishing the “rules of engagement” for an abusive relationship. It provides victims a small taste of what they desperately desire.  Many describe this as a honeymoon phase. I don’t like this term since connotes something loving or sweet is underway.  The reality is, a “relationship addiction” is being established:  (i.e. a strong and harmful need that, despite your best intentions, you can neither control nor explain). Keep in mind, becoming addicted requires the following: (1) an urgent uncontrollable need, (2) an addictive agent and (3) the addict.  Bringing these three ingredients together takes time and carefully choreographed efforts.  In this phase the goal is simply to establish the first ingredient: an urgent need (think carrot on stick).

So did how “IT” do this?

Everything that happened in this stage, was designed to reinforce my insecurities.   “IT” held promises of love & commitment just out of reach while simultaneously making it clear he didn’t need me.  I wanted to be his “girlfriend”, but had to prove myself worthy.  His goal was to reinforce my low self-esteem through a continual barrage of criticism.  He kept testing the limits of what I would put up with in order to establish control.  In time, I put up with his constant cheating and my sole purpose became to do his bidding.  Before I knew it, I was under his complete control and there wasn’t anything I could do without his approval.  Keep in mind, these changes took place over time, like a slippery slope.

What is 20-20 hindsight telling me now???

  1. FIRSTLY: If I had known what love was I would have realized it wasn’t supposed to hurt like that.  I would have seen him for what he was when we met. His limited capacity for love was visible in his actions and words – if I had just paid closer attention.
  2. SECONDLY: If I been secure in my own self-worth, I would have claimed ownership of it as a fact.  I would have realized nobody can have power over me as he did – UNLESS I ALLOWED THEM TO. 
  3. THIRDLY:  This experience in retrospect is like the Wizard of Oz story.  If you recall, Dorothy has everything she needs to get home, (i.e. the ruby slippers on her feet).  The journey through Oz is about learning to believe in herself.  

STEP 3: psychological manipulation

Carrying the addiction metaphor further in this discussion, the two other critical ingredients of an addictive relationship include: the presence of a drug of choice (“IT”) and the addict (“ME”). Creating these two things requires psychological manipulation: influencing someone’s emotional state, cognitions, and perceptions for your own benefit.

“IT” followed a few “rules of thumb” in his ongoing efforts to manipulate my mental state for his benefit:

  1. NEVER SHOW HER LOVE:  This implies need, want and caring.   This is a sign of weakness and something a person can use against you.  Only when she has completely submitted to your complete control, do you even allow her to see that you give shit.   REMEMBER: ALWAYS IN CONTROL
  2. MAKE HER JEALOUS:  The goal is that she lives in constant fear of losing you.  Only when her existence is filled with constant agony and heartache, can you be sure you’re in control.  In this state, she is willing to do whatever it takes to “KEEP YOU”.  Enjoy this, but never let your guard down: SHE MUST ALWAYS LIVE IN FEAR.
  3. VIOLATE HER RULES  – CREATE YOUR OWN:  Learn what her limits are and violate them.  Remember, the goal of emotional manipulation, is to create a state of complete control, whereby the only rules that exist are your own.  She is at your mercy, living and existing to do your bidding.  USE HER DESIRE FOR YOU AGAINST HER.  
  4. ALWAYS KEEP A FEW “SPARE WOMEN” ON THE SIDE:  Make sure she knows, you are not the kind of guy who is able to remain monogamous.  Let her know, that you expect her to remain faithful, and that it isn’t realistic that you be held to the same standard.   This leaves her always uncertain and never able to be comfortable in the relationship.  
  5. YOU ARE EVERYTHING:  Maintain an air of irrational self-confidence that exists without regard to any evidence (or lack thereof).  It doesn’t matter what others think.  The point is, you are “The best thing since sliced bread”. 
  6. SHE IS NOTHING:  Use her insecurities against her at every available opportunity.  The goal is to make sure she comes to accept her insecurities are fact.  In time, against your irrational self-confidence she will feel completely helpless and lost without you.  Only at this point, can you be sure you have complete control.  

As our relationship drew to a close, I came to recognize “IT’s” emotional manipulation for what it was…

Near the end of my relationship with “IT” (just before the london trip),  he complained about how bad I was in bed.  He cheated on me constantly (and without apology) throughout our relationship.  He began describing in detail what he was doing with these “other women”.  I remember listening to his story and recognized a familiar thread of emotional manipulation.  It dawned on me that he was hoping to make me jealous.  I began to think silently of other things that happened throughout the course of the relationship.  His own “hot air” ideas of self-importance were coupled with the assertion that I was completely worthless.  Were these things also manipulative endeavors on his part?

I came to realize his goal was to compensate for his insecurities by treating me this way.  In his mind, if I was desperate to win his affections, then he could feel secure.  I wondered, what sort of insecurities fueled this idea.  Needless to say, since I was in a perpetual state of dissociation and numbness, this tactic wasn’t working.  Sensing this, he switched gears and started getting angry.  This didn’t yield the desired response either, since I was beyond the point of giving a shit.  Instead, I reminded him that he is the only guy I’ve every been with and haven’t had as “much practice”.  I described the consistent message he had driven home over the years that I was ugly and unlovable.  I asked him how I was supposed to feel when he told me this?  I wondered silently why he wanted me if I was so ugly and unlovable?  After a moment of silence he responded with a devilish smile and said “pretty KJ”…

In that moment, a poorly disguised veil of bullshit had been lifted.  Remembering his favorite nickname for me was “ugly KJ”, this response grabbed my attention.  It occurred to me then that he was manipulating me.  He simply wanted to get his way, and didn’t care how as long as I did what he wished. The devilish smile, reflected a “I don’t give a fuck” attitude, in support of this conclusion.  I realized then that he didn’t love me, and if he did he was unable to show it.  This was one of the last times we spoke, before I left for London with my family and broke up with him (from a safe distance)….

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Studying for the NCE – The Initial Session

Abstract

This paper address issues surrounding the initial family therapy session.   It will begin by discussing common anxieties and expectations of family members in therapy.  There will then be an overview of my own anxieties as a beginning therapist.  The paper concludes with a plan that can help me prepare for my first session with a therapist to address these issues.

As a student therapist, imagining my first one-on-one session with a client is a daunting notion.  Family therapy is significantly more overwhelming, in light of the relationship issues and inherent circular causality.  These anxieties are often coupled with a family members who have divergent expectations, anxieties and concerns.  What follows is an overview of common issues concerning clients when beginning therapy for the first time. 

Client Anxieties & Expectations

Desire For Resolution

Prior to the first session, while family members are waiting to be seen, an array of anxieties are likely to loom in everyone’s mind.  Oftentimes, when families enter therapy it is because problems have become unmanageable and they cannot handle things independently.   The initial anxieties clients’ experiences prior to a session are often related to ongoing turmoil at home.  A desire for resolution is a key expectation that fuels efforts to seek outside help.  Clients’ enter the first session with a lot of hope that a remedy to the turmoil can be uncovered (Patterson, et al, 2010).  Each family member probably has a different take on the underlying issues, which further complicates matters.  Ironing these divergent perspectives in the first session can start as everyone takes time to discuss their take on key issues bring the family to therapy.   During this first session the therapist will need to discuss these issues in order to define therapeutic goals (Patterson, et al, 2010).

Motivation and Resistance

Another observation related to clients’ anxieties pertains to the varied levels of motivation present.  This divergence in motivation amongst family member can be observed at the onset of start therapy regarding a noticeable desire to work through issues.  Some family members will be more resistant to the entire therapy process, which is likely to complicate matters further.   It will be important for the therapist to assess motivation and what stages of change each family member is at (Patterson, et al, 2010, p36).  Motivational interviewing techniques can help with resistance and ambivalence as key barriers to therapy.

Perceptions of Therapy

Past experiences in therapy are likely to further color clients’ expectations prior to the first session.  In fact, as a student therapist, when I share with others my career goals, I have occasionally come across people who claim “they don’t believe in therapy”.  While this can at times be related to negative experiences in therapy, it can also be simply an individual’s desire not to “rehash old issues”.   In reality there are many paths to the same point of resolution that are reflective in temperament-based differences.   Some individuals may be more responsive to therapy than others.  Addressing a client’s believes about therapy will require establishing a connection and attending with administrative issues while discussing any past experiences.

Professional Anxieties & Expectations

Performance anxiety is a huge issue for me as a student therapist.  Family counseling is more anxiety inducing than traditional therapy for me, since I’m now in front of a group of people.   Part of this anxiety is related to the fact that I will bring all my life experiences, biases, perceptions, feelings, and temperament to the table while with clients.  Self-awareness will be key to understand how these factors influence my work as a therapist in individual and family counseling.  My tendency has been address such anxieties by being over-prepared with thorough research.  This can involve taking time to review thorough clients’ medical and psychosocial histories as well as cultural backgrounds can be helpful.  Telephone interviews will be helpful in gaining clarity on the nature of the problem and its underlying complexities.

Finally, I feel its also important to mention that anxiety is part of the learning process with beginning therapists.   The stages of development for beginning therapists are all a part of this process (Patterson, et al, 2010).  This development process includes leaning essential skills, developing a theoretical framework, and self-examination.  As I have experienced them, thus far, they have occurred concurrently.

Putting Clients at Ease

Before Initial Contact

Addressing my own performance anxiety will be an essential preparatory step before I can attend to the client’s expectations and concerns.  This will entail self-awareness, adequate self-care, and an acceptance of anxiety as part of the learning process.   Pre-session telephone interviews, discussed in Patterson, et al, (2010), are also an essential step to addressing client’s expectations and anxieties.   Talking with family members in these pre-session phone calls, can allow the therapist an opportunity to assess these expectations and concerns.  In addition to developing a better understanding of the presenting problems, client expectations can also be discussed.  Based on this information, the therapist engages in some preliminary hypothesizing (Patterson, et al, 2010, p22), on the possible nature of the presenting problems.  This process can help the therapist in developing questions for the first interview that can further clarify matters.

Developing Connections

Patterson, et al, (2010) describe joining as a means to make “clients feel a sense of connectedness, which usually arises when they feel you understand, respect, and care about them” (p25).   Joining begins when you shake a clients’ hands and greet them in the waiting room.  It continues when you engage in some preliminary small talk before “getting down to business”.  The main goal of this social talk is to create a safe and secure environment that makes the clients feel at ease (Patterson, et al, 2010).  As the first session progresses, attentive listening skills and direct eye contact will also facilitate the joining process (Patterson, et al, 2010).

Administrative Issues

Confidentiality Issues, Fee Structures, and Release of Information Forms are just a few administrative tasks that should also be addressed during the first session (Patterson, et al, 2010).  These administrative issues, can address several of the client’s concerns about entering into therapy.  Common concerns for most clients entering therapy involve cost and how confidential information will be handled.  Discussing your fee structure and the client’s insurance policy can address cost-related issues (Patterson, et al, 2010).   Limits of confidentiality and how you handle confidential information amongst family members can also ease clients’ anxieties.  The main goal of this discussion is to dispel any anxieties, by making the client aware of what they can expect in therapy.

Defining Goals

Clarifying everyone’s expectations and goals for therapy will involve continuing the discussion that began in earlier phone interviews.   The preliminary hypothesizing that occurs after the initial phone interviews can provide guidance on the questions the therapist must ask.  Taking time to allow each family member to discuss his or her concerns is critical.   There are liable to be multiple problem areas with divergent perspectives on each issue.  Expectations may be unrealistic, the issues unclear, and occasionally some family members may have unstated agendas (Patterson, et al, 2010).  Several key concerns guide this discussion.  Firstly, are the client’s presenting problems within the scope of our care and ability (Patterson, et al, 2010)?  Secondly, do you have a clear understanding of the client’s expectations and can everyone come to a consensus about the goals for therapy (Patterson, et al, 2010)?

Building Motivation

In the pre-session phone interview, it will be possible to assess levels of resistance in family members and determine how willing they will be to participate.  These initial insights can be further explored during therapy through motivational interviewing techniques.  Clients’ should be assessed in terms of their level of resistance against the stages of change (Patterson, et al, 2010).  Motivational interviewing techniques can be helpful in addressing any ambivalence to the possibility of change (Patterson, et al, 2010).

References

Patterson, J., Williams, L, Edwards, T., Chamow, L. & Grauf-Grounds, C. (2009). Essential Skills in Family Therapy: From the First Interview to Termination. New York: Guilford Press.

 

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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 – 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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NCE – Essential Family Skills…


 

PAPER #1 (prior to first session)

Abstract

This assignment focuses on a fictional family, the Banyons. What follows is a consideration of information needed prior to the initial session. Issues involving seating arrangements, the initial greeting, and session goals are also discussed.

Introduction

A family’s decision to enter therapy often comes after much turmoil as they come to terms with the idea they may be unable to resolve issues on their own. Previous experiences and attitudes about therapy amongst family members are likely to vary and influence initial contact.   Patterson, et al, (2009) suggests that the period of time leading up to an initial therapy session is a critical time. Not only can it determine if the family will be willing to commit to therapy, the outcome of the first session can be greatly influenced by a therapist’s preparatory work.

This paper is the first in a series of assignments, which follows along with a fictional family, the Banyons. Mary Banyon is the first to make contact with the therapist’s office after her husband suggests that his mom move in due to declining health.   Concerned about the effects that this might have with the entire family, she desires they enter therapy in order to work through this issue.   She has three kids living at home, including two college age students.

In order to prepare for the first session, it would be the suggestion of this author that a therapist start by mailing out an intake form for Mary Banyon to fill out and return.  Information gathered from this intake form can include: (1) demographic data, (2) a description of the problem, (3) list of family members, (3) history of past counseling, and (4) substance use, medical history as well as (5) criminal background (Patterson, et al, 2009). After receiving this information from Mary, a brief phone interview would be warranted. This could allow the therapist to further assess information such as the family’s sociocultural background, expectations for therapy, and the exact nature of the problem.

Information Needed

Certain information is essential in order to prepare effectively for the first session with the Banyon family. What follows is a list of information needed prior to the first family session. With this information, a therapist can develop key questions that can provide guidance in planning for the initial session.

Defining the Problem

            Qualls & Williams (2013) define Caregiver Family Therapy as a therapeutic framework that address issues related to long-term care needs of elderly members. Based on what information we currently have, it appears that the family is in pre-caregiving stage. During this period, family patterns are unchanged, but accommodations are being considered due to declining health in an elderly family member (Qualls & Williams, 2013). In addition to discussing the concerns of all family members regarding this decision, several other issues can be expected.   Family roles will change in response to gradual increases in the level of care required (Qualls & Williams, 2013). Long-term plans will need to be discussed, in light of grandma’s declining health. Finally, the immediate issue of the providing physical accommodations is likely to involve a big adjustment for the entire family, in addition to causing financial strain.

Prior to the first meeting, it will be important to determine if there is crisis situation at hand and if scope-of-practice issues warrant a referral. How bad is Grandma’s health and is medical intervention necessary? Additionally, while Mary appears to be the spokesperson for the family, it is important to talk with other family members as well prior to the first session. This will make all family members feel more welcome and provide some clarity regarding their concerns.

Who Should Come?           

            In Mary’s initial phone call to the receptionist, she states that it is her hope the entire family attends. While everyone living at the home is impacted by the problem, without further information, it is difficult to determine if this is a good idea. A telephone interview may be warranted first to determine if Mary and her husband are in agreement with this decision. How do they plan to accommodate this change financially?   Who will be providing the bulk of grandma’s caregiver needs as her health declines? What is the current state of their relationship? Issues such as these can determine whether or not to include the children in the first meeting.   If issues such as these are unresolved it may be warranted to exclude the children initially. Finally, I would suggest including grandma only once the family has come to some agreement on the matter. This can allow her to address her concerns and assess her adjustment to these changes.

Expectations & Anxiety

            It is important to note that often families only seek therapy when they find they are unable to handle issues on their own (Patterson, et al, 2009). With this in mind, areas of disagreement are inevitable amongst family members. Prior to the first session, it is important to assess everyone’s expectations about therapy. Has anyone had previous experiences in therapy? Finally, while Mary’s motivations are clear, how do the other family members feel about therapy? With this information, it is possible to develop a clearer idea of any disagreements that exist. The stages of change model, can help address prevalent attitudes toward therapy, and varied levels of resistance amongst family members (Patterson, et al, 2009).

It must also be noted that any unforeseen legal issues or medical problems may warrant referral, since these are out of a therapist’s scope of practice.

Cultural Background

            Ariel, (2000) states that “There are good grounds for believing that the coping mechanisms employed by families are at least partially dictated by the specific cultures to which they belong” (p25). For this reason, cultural competence is a vital component of family therapy. The culturally defined features in a family’s belief system, roles structure and modes of affective expression are likely to define how to best proceed during the first session.   Since the intake form includes basic demographic data, it is possible to address this during a telephone interview. This can be addressed in questions that require Mary to elaborate on information provided, such as religious background. Information such as this can provide guidance for the therapist on issues such as seating arrangements, etc.

First Session Goals

            Initial goals for the first session include allowing each family member to an opportunity to discuss their concerns and goals for therapy.   In order to establish a positive therapeutic relationship with everyone attending the first session, it may be warranted to conduct a telephone interview with each individual beforehand. Naturally, the therapy goals are limited by the levels of resistance amongst family members to participating in therapy.   What follows is a list of goals for the first session.

  1. Administrative issues: Issues of confidentiality, fee structure, and Release of Information should be addressed during the first session.
  2. Establishing a Connection: Patterson, et al, (2009) describe joining as a key goal at the onset of family therapy (p25). This involves developing a connection that can set the foundation for a positive therapeutic relationship with all family members.
  3. Clarifying Goals: It is important to give all participants an opportunity to discuss their concerns regarding grandma’s long-term care needs and goals for therapy. Areas of conflict and previously unstated agendas can delineate areas of disagreement that need to be addressed in future sessions (Patterson, et al, 2009).
  4. Motivational Interviewing: It is likely that some family members are less motivated to participate in therapy. Motivational interviewing techniques can be utilized to address resistance while taking time to listen to concerns with a goal of eliciting participation.
  5. Scope of Care & Competence Issues: If it is determined, that grandma’s health is worse than previously stated referrals may be warranted. Additionally, areas outside one’s skill set may require a referral to someone more adept at handling the Banyon case.

Initial Greeting & Seating Arrangements

In addition to observing each individual’s role within the family system, it will be important to provide some structure during the first session. The initial greeting is critical in establishing a connection with the family as a whole. Arranging seating thoughtfully, can allow each member to feel like an equal contributor to the conversation.   Patterson, et al, (2009), state that the manner in which a family interacts during therapy holds clues to the nature of family interactions in the home (p6). Careful observations coupled with the mindful rearrangement of seating, such as described in the textbook’s Cinderella story, can address these issues (Patterson, et al, 2009).  Actions such as this are based on initial hypothesizing coupled with careful observation (Patterson, et al, 2009). Paying “close attention to what is known” (Patterson, et al, 2009) can help the therapist structure and guide the discussion during the first session. Based on the information received throughout this session, interpretations can be made that can clarify the issue at hand, and everyone’s expectations for therapy (Patterson, et al, 2009).

References

Ariel, S. (2000). Culturally competent family therapy: A general model. Westport, Conn: Greenwood Press.

Patterson, J., Williams, L, Edwards, T., Chamow, L. & Grauf-Grounds, C. (2009). Essential Skills in Family Therapy: From the First Interview to Termination. New York: Guilford Press.

Qualls, S. H., & Williams, A. A. (2013). Caregiver family therapy: Empowering families to meet  the challenges of aging. Washington, DC: American Psychological Association.  doi:10.1037/13943-000

PAPER #2 (the first session)

Abstract

This assignment focuses on a fictional family, the Banyans. What follows is a list of prioritized treatment goals developed after the initial session.  Also discussed are strategies utilized to address them potential issues that will arise in the near future.

Introduction

This paper lists prioritized treatment strategies for the Banyan family after the first session.   Patterson, et al, (2009), state that treatment plans are utilized to define clearly the problems needing to be addressed in therapy and the interventions developed to address them (pp 77-78). Treatment plans provide a way of formally defining the goals of therapy with clients in writing (Patterson, et al, 2009). The initial steps to completing a treatment plan include: developing a problem list, understanding the client’s desire for change, and case conceptualization (Patterson, et al, 2009). With this information in hand, it is possible to then develop a list of long-term goals and treatment interventions (Patterson, et al, 2009).   An overview of these initial treatment plan steps is included below.

Step One: Listing Problems

A brief description of the client’s presenting problems is available for purposes of this assignment. Writing down a list of problems with clients can initiate the treatment planning process and provides a way of ensuring everybody is “on the same page”. What follows is a brief problem list for the Banyan family.

  1. Couple/Family: Ben is concerned about his mother who has Alzheimer’s and wants her to move into their home.   While Ben and Glenda are very close, Mary feels she has been a controlling and divisive force within the family.   The entire family is affected greatly by this decision. With limited space and financial resources, everyone may need to sacrifice in order to accommodate Glenda.
  2. Mary Banyan: Mary is a housewife who has never been employed outside the home. Since she is home during the day, it is expected she will take on the lion’s share of caretaking duties for Ben’s mother, Glenda, should she move in. Since she was the one to first seek therapy, this appears to concern her greatly.
  3. Ben Banyan: Ben has a mother who was recently diagnosed with Alzheimer’s. Since his siblings are unable to provide her assistance, he is her only resource. While he owns a construction company, it appears he has had to seek financial assistance from his wife’s parents at times. This indicates his ability to financially assist Glenda is limited. Finally, since Ben is very close to his mother, this diagnosis is probably devastating news.
  4. Thomas, Julia & Jacob Banyan: While Thomas is having difficulty in school and has no direction, Julia is excelling academically. Not much is known about Jacob, as a quiet shy child, outside of an array of medical issues.
  5. Glenda Banyan: With declining health and a new diagnosis of Alzheimer’s, Glenda needs to make plans for her future long-term-care needs. Her resources are reportedly limited, and the only family she can rely on is her son Ben.

Step Two & Three: Client Expectations & Case Conceptualization

            The family enters therapy in the hopes that everyone can come to an agreement on how to handle Glenda’s declining health. While Ben wants Glenda to move in, Mary is resistant to the idea.   The family comes to therapy in the hopes of coming to an agreement on how to address Glenda’s long-term care needs. Addressing this disagreement will first require that the family clearly understands the nature of Glenda’s issues. With this knowledge, the family can determine how they can realistically address them (Qualls & Williams, 2013). As they contemplate this decision further, everyone must also come to terms with the role restructuring that will occur and sacrificed that are required (Qualls & Williams, 2013).   In this respect, Mary is right that everyone needs to sit down and discuss there thoughts on this matter.

Treatment Goals & Priorities

  1. Goal One – Increase the family’s understanding of Glenda’s condition and caregiver needs: Based on the information provided from the initial interview, nobody in the family appears to have ever worked in the healthcare field. It is logical to assume, therefore, that the family is unaware of what involved with providing care to an Alzheimer’s patient.   In addition to a failing memory, Alzheimer’s also produces extreme behavioral and mood changes.   Additionally, as the disease progresses, patients often require ever-increasing levels of assistance with activities of daily living (Qualls & Williams, 2013). Before the family can begin to iron any disagreements, they need to educate themselves on the nature of Glenda’s condition.   It is for this reason that I would suggest Ben and Mary meet with Glenda’s doctor to discuss in detail, her current health and long-term prognosis. Referrals to long-term care specialists can help them develop a clearer idea of what the future holds for Glenda. This can allow the family to begin plan accordingly.
  2. Goal Two: Identify a list of alternatives and resources to begin addressing Glenda’s need for caregiver assistance. It appears that Mary and Ben disagree on how to handle Glenda’s declining health. While Ben is against long-term-care, Mary is wary of moving Glenda in, without considering the implications carefully.   Before ironing out this disagreement, they should carefully consider all alternatives first.   I would suggest that Mary and Ben begin listing the ramifications of all options and identify resources that can provide assistance.   This investigation process should involve visits to home health care agencies and long-term facilities.
  3. Goal Three: Discuss implications of these expected changes for the family. With all this information in hand, it will be possible to begin discussing all options.   As Mary stated, this should, at some point, involve the input of all family members affected by this decision. This should eventually mean considering the concerns of Mary and Ben’s children. Initially, though, I would start with private couples sessions between Mary and Ben. This could allow them to process this information privately.
  4. Goal Four: Address any potential conflict between Mary and Ben as it pertains to Glenda. As stated earlier, it is clear that Mary and Ben have different ideas of how to handle Glenda’s declining health. Underlying this disagreement is a long-standing issue regarding Ben’s relationship with his mother. Mary feels Glenda is very controlling and has never gotten along with her. Ben, who is close to his mother, is struggling to cope with this devastating news. It will be essential for Ben and Mary to iron out this longstanding misunderstanding. I suggest that before they do so, they focus initially on gathering all the information they require to make an informed decision.
  5. Goal Five: Discuss ramifications of Glenda’s care needs with Mary and Ben’s children. Help them adjust effectively to these changes. It is fairly clear that Ben and Mary are interested in obtaining the input of their kids as they make this difficult decision. Nonetheless, I believe Mary and Ben have some issues to iron out first. After they have done so, it will then be possible to consider any concerns their offspring may have. Helping the oldest kids adjust to these changes will be essential. Family resources will be stretched to their limit in order assist Glenda. Chances are, they may be on their own financially, sooner than expected. Based on current assessment information, Julia is expected to adjust better than Thomas, who may require greater assistance in this transition. Finally, more information is required of Jacob, who we know little about.

Expected Upcoming Issues

Patterson, et al, (2009), describe problems of family counseling often arise very much like an onion, in layers. Based on the current information known about the family what follows are additional layers that may unfold at some point.

  1. Glenda’s health will continue to decline and she may become more difficult to manage. In addition to requiring greater levels of assistance with activities of daily living, her behavior, mood and temperament are likely to transform over time.
  2. The difficult relationship between Mary and Glenda can’t fully be fully resolved in light of Glenda’s diagnosis. Regardless the family’s decision, Mary will need to come to terms with this fact and resolve this issue independently through a process of forgiveness. This can allow her to help Ben grieve while the family adjusts.
  3. Since Ben is close to his mother, I expect he may struggle to come to terms with Glenda’s slow decline. Helping Ben grieve this loss will be a critical component of therapy.
  4. Thomas is expected to struggle the most in his transition into financial independence. His lack of motivation and direction are likely to hamper the family’s efforts to assist Glenda. A significant amount of energy must also be devoted to help him work through this transition.
  5. Little is known about Ben and Mary’s youngest son Jacob. As a quiet and shy individual, it is concerning that his parents have little to say about him. It is expected that Jacobs developmental needs may receive less attention than needed as this family struggles with this dilemma. It will be important to assess Jacob’s reactions to the upcoming changes.

Overall Strategy

Rather than seeing the family as a group from the outset, I have a different plan. I believe that Ben and Mary have some issues to work out as a couple first, before the children are brought in therapy sessions. In addition to ironing some long-standing disagreements regarding Glenda, it will be important for them to research all options. The financial constraints and feasibility of alternatives will need to be ironed out before the input of their offspring is considered. Finally, Ben also needs time to begin coming to terms with this new information. Only after Ben and Mary have made some headway, would I consider including their children.

References

Patterson, J., Williams, L, Edwards, T., Chamow, L. & Grauf-Grounds, C. (2009). Essential Skills in Family Therapy: From the First Interview to Termination. New York: Guilford Press.

Qualls, S. H., & Williams, A. A. (2013). Caregiver family therapy: Empowering families to meet the challenges of aging. Washington, DC: American Psychological Association. doi:10.1037/13943-000

Paper #3 (assessment)

Abstract

This paper looks at how to assess family functioning. It will begin with an overview of essential components of an assessment from our course textbook. The paper will conclude with the presentation of option for assessing family strengths and weaknesses from research.

Introduction

​The purpose of this assignment is to provide a review of how to assess the strengths and weaknesses in a family. Our course textbook provides a nice overview of the general assessment process based on pathological diagnosis (Patterson, et al, 2009). In contrast, a research article I found for this assignment utilizes a strength-based perspective and provides a framework for assessing family resilience (Walsh, 2003). Together, these two perspectives provide an overview of the strengths and weaknesses in a family.

A Diagnostic Perspective

Patterson, et al, (2009) provide an overview of a Generalized Assessment Plan, which includes the following information: (1) the presenting problem, (2) issues of harm (3) substance use, (4) medical issues and (4) a psychosocial background (Patterson, et al, 2009). I discuss each briefly below:

Exploring the Presenting Problem

​Initially, time should be taken to discuss the family’s reason for seeking therapy. In addition to developing a clearer understanding of their concerns, this provides the therapist an opportunity to establish a rapport with the family. Taking time to listen to each family member’s description of the presenting problem is critical to assess variances in how it is conceptualized. Understanding the family’s methods of coping and attempts to resolve matters is also important (Patterson, et al, 2009).

Issues of Harm

​Patterson, et al, (2009) states therapists must remain vigilant of any issues of potential harm such as suicide, sexual abuse, or domestic violence. For example, suicidal ideation involves asking about a history of any suicidal ideation and the details of a plan. Considerations must be made when addressing in front of family members, and the influence this information can have on the overall family dynamic. It is also important to look for signs of violence since it occurs in approximately 15% of families nationwide (Patterson, et al, 2009). Since families are often reluctant to openly discuss sexual abuse and neglect, it will be important to look for any evidence. As a mandatory reporter, clinical judgment is required to investigate intuitive nudges and concerns for a client’s well being. (Patterson, et al, 2009).

Substance Abuse

​Despite the fact that substance abuse is a major health care problem, many new therapists overlook this issue (Patterson, et al, 2009). In addition to being masked by an array of comorbidities, clients and family members are often unaware of the issue (Patterson, et al, 2009). It will be important for therapists to be familiar with assessment tools such as the “MAST”, “AUDIT”, and “CAGE” tests (Patterson, et al, 2009).

Medical Issues

​Frequently, underlying mental health issues are organic and neurological causes that are easy to overlook for those lacking a medical background. A review of the client’s medical history can uncover a history of chronic diseases that might explain some symptoms. Diagnostic tools such as the mental status exam and neuropsychological examinations, can also provide clues of a possible medical issue. Finally, an awareness of organic brain symptoms including disorientation and recent memory impairment can indicate a need for a referral.

Psychosocial Assessment

​Patterson, et al, (2009) mentions affect, behavior, and cognition, as three key areas of psychopathology to assess for purposes of DSM-5 diagnosis. This diagnostic framework is useful in contextualizing the client’s presenting problems. Assessments of meaning provide additional insight into the nature of a family’s understanding of underlying issues. Assessing the family and couple as a system requires an examination of issues such as the familial life, role structures, communication styles, and conflict resolution skills (Patterson, et al, 2009). Finally, Patterson, et al, (2009) briefly mention holistic and spiritual assessments as additional components of a psychosocial assessment frequently overlooked by therapists.

A Resiliency Framework.

In contrast to the diagnostic perspective reviewed above, an article I found for this paper utilizes a family resiliency framework (Walsh, 2003). According to Walsh, (2003), resiliency refers to the “ability to withstand and rebound from disruptive life challenges” (p1). Examining the relational context of resilience in a family system is useful in uncovering untapped strengths. While the deficit-based perspective clarifies the nature of presenting problems, a resiliency framework provides solution-based guidance (Patterson, et al, 2009; Walsh, 2003). From this perspective, crises can be seen as a potential source of growth and relational transformation. Families often respond to crises in a manner that reflects ripples in a pond that span generations. Understanding the nature of this response to crisis, requires a biopsychosocial and ecological perspective. Walsh, (2003) suggests that an assessment of family resilience should look at three key areas (1) family belief systems, (2) organizational patterns, and (3) problem solving processes.

Family Belief Systems
​Family belief systems influence

how family defines and response to crisis. According to Walsh, (2003) adaptive belief systems have three key elements. Firstly, belief systems that make meaning out of adversity provide as resiliency that allows families to face crisis (Walsh, 2003). Secondly, adaptive belief systems reflect a positive outlook that exists in polar opposition to learned helplessness (Walsh, 2003). This positivity provides families with a well of hope that they will persevere. Finally, a deep transcendent spiritual faith that allows families to see a purpose in life beyond one’s immediate existence (Walsh, 2003).

Organizational Patterns

​A second key component of family resilience, is its organizational pattern (Walsh, 2003). The flexibility of a family’s organizational structure determines its ability to bounce back after crisis and adapt to a “new normal” (Walsh, 2003). The connectedness present with a family’s role structure solidifies its commitment to collaboration through crisis. Based on these insights, a review of the family’s role structure and communication style can shed light on protective factors against crisis.

Problem Solving Processes

​A final critical component of family resilience is its communication style and problem solving patterns (Walsh, 2003). Communication styles that are adaptive to crisis provide its members with open access to information. The clear and effective communication of information, and thoughts and emotional perspectives is found to aid in recovery of crisis. This open communication style, provides a relational resilience for resolving conflicts and problems with a family. Resilient problem solving processes bring family members together rather than drive them apart. They are found to grow and learn from the experience in ways they hadn’t foreseen (Walsh, 2003).

References

Patterson, J., Williams, L, Edwards, T., Chamow, L. & Grauf-Grounds, C. (2009). Essential Skills in Family Therapy: From the First Interview to Termination. New York: Guilford Press.
Walsh, F. (2003). Family resilience: A framework for clinical practice. Family Process, 42(1), 1-18.

Paper #4 (termination)

Abstract

This assignment focuses on a fictional family, the Banyans. For this paper we are to address the issue of termination.   After providing a list of goals for my final therapy session, I will review key issues I hope to address with this family. This paper concludes with a review of theoretical techniques and methods useful during this final meeting.

Introduction

For this assignment we follow a hypothetical family who, after six months of therapy is terminating services. During these six months, the Banyons have seen the therapist for a total of sixteen sessions, twelve of which include the couple’s sessions for the parents. While significant progress has been made, I’m personally concerned the family terminating services at this time. It is important to keep in mind, though, that the family’s reason for entering therapy is to discuss their concerns about Glenda’s declining health.   Although, as a therapist I see an array of other issues, the family’s main concern was how to address Glenda’s increasing self-care needs.   In this hypothetical scenario, it is unknown the reason for termination. At times, insurance companies set limits on the amount of therapy they will pay so this could play a factor in their decision. Alternatively, it is possible that the treatment plan was limited to those issues the family desired to discussed.   While I do believe a client’s wishes should be respected, there are several issues I’m concerned about that are still not addressed. Firstly, Thomas’s history of suicide ideation is concerning, and I’m unsure how he might handle the upcoming transition. Secondly, it is still unclear as to whether or not Mary and Ben have discussed Mary’s secrets openly in their sessions, although this seems unlikely. While I must respect Mary’s right to confidentiality, I have mixed reservations ethically about not providing them a chance to discuss this openly. As we learned in class, keeping secrets such as these are likely to create a well of unresolved issues that will only perpetuate endlessly until addressed openly. Finally, when reviewing past information on this family, I’m concerned about Ben’s relationship with Jacob. At one point, it is mentioned that Ben spank’s Jacob, and he fears his father. This is troubling in light of Ben’s own history of abuse. It is unknown from this case scenario, how bad these “spankings” are. However, I understanding that realistically, not all client relationships terminate as we might hope they do. Additionally, we can’t make a client address issues we are concerned about, if they don’t consider them important.   With these reservations in mind, the next section reviews my goals for the final session.

Goals for Final Session

Ben & Mary

            Mary and Ben have been married over 20 years and have completed twelve sessions as a couple during the last six months. Mary is a 43-year-old stay-at-home mother who hopes to return to work soon.   Ben is 45-years-old and owns a construction company. His own family includes a history of drug addiction and abuse. The couple seeks therapy in order to work through disagreements regarding Glenda’s declining health and how to address this.   As a therapist, I am also quite concerned about Mary’s drinking lately, as well as the secret she has kept about a previous affair and Jacob’s questionable paternity. However, it appears from this hypothetical scenario, they are terminating therapy, and these issues appear to not be addressed.

Firstly, since Mary revealed this secret in confidence, I intend to respect. However, I would want to schedule one final individual meeting with Mary. I would share my concerns about her drinking and working through her feelings regarding this secret and any complex feelings surrounding it. If she is interested, I would be offer to continue working with her individually. I might bring up this issue, by complimenting her on all the progress she has made. I could offer these services as an adjunct to her current participation in the YWCA women’s group. During this final session, I would focus on the progress they made as a couple, and review many of the skills they have learned. Hopefully, we could take some time to discuss the changes in their relationship, in an effort to motivate them to maintain their relationship improvements.

Thomas

            While it is clear, (for whatever reason), that the Banyon’s are terminating services, I’m still quite concerned about Thomas. Most of the sessions, thus far, have been devoted to working with the couple individually. Thomas is a 22-year-old who has a history of suicidal ideation with one previous attempt. He still lives alone, isolates quite a bit, and has little to no motivation to work or go to school.   As a therapist, I’m quite concerned about this depression since it appears to have been undiagnosed and untreated for many years.   As the Banyon family’s time in therapy comes to an end, we learn that he has six months to move out. It is clear based on prior notes on this case, that that this fact produces a high degree of stress in Thomas. For this reason, I would offer my services to him on an individual basis. Currently, there is inadequate information to determine how open he and his family is to continuing with therapy individually. I would begin by expressing my concerns to his parents, and try to schedule at least one session, so I could assess Thomas more closely.   I would also state to Thomas that this could provide him some guidance throughout this transition into a fully independent life.

Jacob

            Jacob is the youngest of the Banyon children at 12-years-old. In six months time, he will be the only child left in the home.   We don’t know much about Jacob currently, but it is mentioned in this week’s assignment that he is now seeing a child therapist for anxiety. I would forward my case notes and concerns to this therapist. It might mention the “spankings” to the therapist and history of medical issues for further exploration.   Finally, since I plan to continue seeing Mary and Thomas individually, I would work to solidify a working relationship with this new therapist.   For the final session, I would do some brief psycho-education on the importance of parental participation in Jacob’s therapy.

Glenda

            Glenda is 71-years-old and was recently diagnosed with Alzheimer’s. Currently she lives alone and is hoping to sell her house soon. As Ben’s mother, it is unclear how close they are, although it is important to note that his father abused them. This, in all likelihood, adds a layer of complexity to their relationship. The Banyon family originally entered therapy to discuss how they might handle her declining health.   As therapy comes to a close, it appears that Ben and Mary are hoping eventually move Glenda in. They plan to hire a part-time nurse’s aid and utilize adult day care services.   In order to prepare for this final session, I would seek referrals for the Banyons, so they could develop clearer long-term plans for Glenda.   Their current plan is useful for mild to moderate cases of Alzheimer’s cases. Having cared for Alzheimer’s patients before, as the disease progresses, personality changes occur, and daily care needs increase exponentially. This couple really needs to speak with a specialist in neurocognitive disorders like this, in order to understand what is in store for Glenda long-term.

Orientation and Approach

For this final session, I have no specific therapeutic approach in mind. However, goals for this final session are to respect the client’s wishes while voicing my own personal concerns. This involves providing them with an array of information for them to review with referral services as necessary. As stated earlier, I’m quite concerned about this family discontinuing services so early. At the same time, as Patterson, et al, (2009) notes, termination doesn’t always go as we might hope.

References

Patterson, J., Williams, L, Edwards, T., Chamow, L. & Grauf-Grounds, C. (2009). Essential Skills in Family Therapy: From the First Interview to Termination. New York: Guilford Press.

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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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