Title: Tricks of the Trade: Specific Techniques to Use with Difficult Clients
1Tricks of the TradeSpecific Techniques to Use
with Difficult Clients
- Region VIII Employment Conference
- October 17-19
- Spearfish, SD
- Presented by
- Robert H. Arnio, Ph.D.
- Psychological Associates of the Black Hills
- 1818 West Fulton St. 201
- Rapid City, SD
- Rarnio_at_rushmore.com
2Agenda
- Major Processes in Counseling
- Methods or procedures best suited in the
vocational rehabilitation setting - Discussion and demonstration of specific
techniques
3Role of Counseling in RehabilitationParker and
Szymanski Rehabilitation Counseling, 1998
- Without adequate counseling, the core ingredient
of rehabilitation counseling, many rehabilitation
clients would be unable to achieve the goals of
the rehabilitation process. The ultimate goal of
rehabilitation the independent, effective, and
full functioning of clients is predicated upon
and intimately linked to, intensive counseling by
a skilled, professional rehabilitation counselor
. . . Consequently, the primary task of
rehabilitation counseling is the removal of such
barriers, whether inflicted by oneself, or by
society.
4Role of Counseling in RehabilitationParker and
Szymanski Rehabilitation Counseling, 1998
- In search for a personal vantage point in
counseling with the rehabilitation client, the
student and the practitioner have the option of
selecting from more than a dozen major
approaches. For purposes of presentation, these
approaches are categorized as psychoanalytic,
humanistic, rational, behavioral, cognitive, and
eclectic (or integrative. p 224) (Gives 8
guidelines for deciding on a theory)
5Therapeutic Components Shared by All 250
PsychotherapiesJ. Frank, 1980
- Psychotherapy
- (Professional Counseling)
- A planned, emotionally charged, confiding
interaction between a socially sanctioned healer
and a sufferer(s), in which the healer seeks to
reduce or eliminate the sufferers distress or
disability through symbolic communications
(usually words, but sometimes exercises). The
healer may or may not involve the sufferers
relatives or significant others. This process
may also include helping the sufferer accept the
distress as an inevitable aspect of life and an
opportunity for personal growth.
6What type of counseling to use?
- Counselor characteristics
- 1/3 of change is based on Counselor
- Same counselor, different techniques
- Client characteristics
- Demographics
- Psychological Characteristics
- Diagnosis (Diagnostic Related Groups)
7Problem Centered ApproachW. Pinsof, Northwestern
University
- Psychotherapy is human problem solving.Patients
view of their problems constitute the presenting
problem. Every problem has its own, unique
maintenance system. The problem maintenance
system exerts constraints on the clients so that
solutions to the problem are not successfully
developed and implemented. What started the
problem and what keeps it from being solved may
no longer be the same thing. Different
counseling approaches need to be used with
different problem maintenance structures. - (e.g. workaholic injured)
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10Example
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12Example
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14Solution Focused TherapyJohn Littrell
- Gregory Bateson and Milton Erickson
- Mental Research Institute (MRI)
- Steve de Shazer Bill OHanlon Insoo Kim Berg
- The person is so saturated in thinking about the
problem, they cannot see the solution that is
available to them.
15Research
- Client Codes
- Change
- Non change (everything
- not in change)
- Therapist Codes
- E Elicit Change
- A Amplify Change
- I Initiate Change (future)
- N Non-change (all other)
- Constructing Change A Research
- View of interviewing Gingerich,
- de Shazer, Weiner-Davis 1989
16Solution Focused Model
- Concerned with building solutions, not problem
solving. - Task is to build solutions tx concerned with
the nature of the solutions, not the nature of
the problems.
17Different assumptions
- Client has the beginning of the solutions
- Find out about exceptions to the problem
- These provide the cues or keys to what the client
needs to do to build solutions
18Solution Focused Assumptions
- People can change rapidly
- People have many resources, both internal and
external they are not aware of - People are doing their best at any given time.
- A small change in one persons behavior can lead
to far reaching changes in others - When you focus on the solution, there is much you
do not need to know
19Nature of Solutions
- Solutions come from the clients and therefore are
natural and fitting. Solutions are generated by
the client so they fit their natural way of doing
things, ie. Natural way of finding solutions so
therefore it happens quickly but is long lasting. - Ask these questions within the context of the
therapeutic relationship and therefore the client
finds their own solutions.
20Four Step Processin the Solution Focused Approach
- Describe the problem specifically
- Examine attempted solutions and exceptions to the
problem - Define a Goal
- Give compliments and assign a task
215 Useful Questions
- Questions Highlighting Pre-session change
- Exception-finding Questions Enhancing Existing
and Past Successes - Miracle Questions
- Scaling Questions
- Coping Questions
22All interviews are composed of questions and
answers
- Exception finding questions
- Miracle Question Client hypothetical solution
What life would be like after they have a
solution how they want their life to be
different - Scaling questions are client generated. Not what
is normal or abnormal. Is way the client
measures change. - Externalization of the symptom (problem)
-
-
23Goal Negotiation - occurs right after the social
stage of the interview
-
- What do you think needs to happen as the result
of your coming here? - What needs to happen for you to say that his was
a good idea that we did this (coming to the
session)? - Aside from that, what would you like to see
different in you life circumstances?
24Deliver the Message
- Compliments acknowledge and validate clients
points of view about their life and their
problems. - Bridging statement Some sort of rationale about
why they should do the task that the tx is going
to suggest - Homework or task the tx suggestsdesigned to
implement the solutions implemented by the
clients in their own setting. Great deal of
attention to the clients life in the real world,
not in the therapy room.
25Miracle Question
- After we talk today, go home and go to bed
tonight and when the house is quiet, the miracle
happens. The problem that brought you here today
is gone. It has disappeared. So when you wake
up in the AM what would be the first small clue
that something has happened, the problem is gone.
What would you first notice?
26Miracle Question
- What will you notice different in (other family
member) so you know that the miracle has happened
for them. If that were to happen, what would you
do that you are not doing now? What would
happened after that.
27Miracle Question
- What would you notice different about X and Y now
that the miracle has happened. - Now suppose you do this, what would you do. What
would you do different. - What would you notice different about X to let
you know that a miracle has happened and the
problem is solved. -
28Second Sessions
- Second session
- Whats been better since the last session?
- What kind of solution has the client generated?
- Clients come up with ways that are good for
them.
29 - Tasks of the second session
- Elicit anything that is better What have you
noticed that is different about X an what have
you noticed thats different about Y. - Amplify the difference then
look at the ripple effect (circular impact) - Reinforcing much of which is
indirect, e.g. Wow, how did you do
that. Reiterate the above procedure. Use
scaling questions as to where things are at right
now
30- What else would be different if the miracle has
happened -
- I guess any one who \developed a vocational
problem would . Normalization negative feelings
and anxieties -
- When was the last time even little pieces of this
miracle has happened.? - When you see that little bit of a miracle
happen, what seems to happened different? The
make it circular.
31- Scaling questions
- Day after the Miracle
- 10 need not come back (close the case)
- 1 where they were when you called.
- Where to you think things are at right now?
- Whats helped during the session
- What needs to happen so that you
can be 10 percent better or closer to your
goals?
32 Problems Solutions
- Trend Toward Trend Toward
- Complexity Simplicity
- Many Kinds of Problems Many Kinds of
- Many Kinds of Problems A
- Solutions Handful of
- Solutions
33Example
34Responding to Visitors, Complainants and
CustomersInsoo Kim Berg, Family Therapy
Networker, Jan-Feb, 1989
- Visitors have no complaint, except maybe that
someone has made them come see you. - Complainants have a complaint but do not see
themselves as part of the solution. - Customers have a complaint, and indicate they
are ready and willing to do something about it
with the therapists help.
35Responding to Visitors, Complainants and Customers
- Visitors have no complaint, except maybe that
someone has made them come see you. - Sympathize with their plight of being forced to
see you - Avoid trying to get them to admit they can do
something to help the problem - Compliment them for whatever they are doing that
is good for them, or whatever they do that they
do well. - Allow the possibility they may eventually come up
with a complaint that they will talk about with
you.
36Responding to Visitors, Complainants and Customers
- Complainants have a complaint but do not see
themselves as part of the solution. - Compliment them for the helpful information they
have provided about the situation, for anything
they are doing that is good for them, and for
whatever they do they are good at. - Consider giving them a task to think about or
observe something that may provide a better
understanding of the complaint. Do Not give a
task that involves behavior change. - Be patient, knowing that in time they may move to
recognizing that they can be part of the
solution.
37 Responding to Visitors, Complainants and
Customers
- Customers have a complaint, and indicate they
are ready and willing to do something about it
with the therapists help. - Compliment them on the positive things they are
doing for themselves and for anything they are
doing that might be a step toward resolving the
complaint. - Give tasks to think about, observe or take action
regarding the complaint in accordance with their
style of cooperating.
38Stages of Change
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance
39Stages of Change
- Precontemplation
- The person does not consider the behavior of
focus to be a problem and/or is not currently
considering changing the behavior. For a person
at this stage, the benefits of the behavior are
greater than the costs.
40Stages of Change
- Precontemplation
- Help the person engage in the counseling process
and begin considering patterns and potential
effects of not solving the issues that brought
them to your office. - Decontaminate the referral process
- Explore the meaning of the events that brought
them to your office.
41Stages of Change
- Contemplation
- The person is considering that there may be a
problem and is seriously contemplating changing
behavior, but is struggling with mixed feelings
about changing.
42Stages of Change
- Contemplation
- Help the person see the big picture. Discover
discrepancies between their current behavior and
their goals for the future, and consider making
some changes. - Normalize ambivalence
- Weigh pros and cons of changing
- Imagine the future
- Elicit change and self motivation statement and
amplify those for the client
43Stages of Change
- Preparation
- Help the person resolve the ambivalence about
changing, develop a sense of ability to change
(if it has already happened, it is probably
possible), and make the initial plans for going
about changing. - Clarify the clients own goals and strategies
- Help develop plan for change
- Assist client in decreasing barriers to change
44Stages of Change
- Action
- Help client initiate change, cope with
difficulties in the change process, and gain
social support for new ways of being. - Support small steps toward change
- Only offer expertise or advice with clients
permission - Emphasize that setbacks and lapses are unintended
failures of the planning process and help to
improve long-term plans. (adjusting courses in
flight)
45Stages of Change
- Maintenance
- Help client cope with difficult situations,
maintain commitment and energy, initiate new
facets of living to help client integrate them,
and process discouragement when it happens. - Affirm clients resolve and self-efficacy
- Assist client in making transition to working on
long other term goals
46After Example
47Thats all folks
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50Symptoms of Brain Injury and Alcohol Abuse
- Difficulty initiating meaningful activity
- Brain Injury
- Fatigue
- Both
- Impulsivity
- Both
- Motor problems (gait and balance)
- Brain Damage
- Diminished Judgment
- Both
- Slowed thinking
- Both
51Symptoms of Brain Injury and Alcohol Abuse
- Depression
- Both
- Personality changes
- Both
- Trouble tracking conversations
- Brain Damage
- Limited insight
- Brain Damage
52Symptoms of Brain Injury and Alcohol Abuse
- Word finding difficulties
- Brain Injury
- Short-term memory loss
- Both
- Sequencing difficulties
- Brain Injury
- Concrete thinking abstract metaphors
- Brain Injury
- Emotional dysregulation
- Both