Work With Individuals

1
Work With Individuals

• Step Five of the Decision Tree
• Chapter 12

2
Direct PracticeWork with Individuals

• Direct practice with individuals encompasses
• Step one Fiduciary responsibilities
• Step two Crisis Intervention
• Step three Case management
• Step four Individual or case advocacy
• Step five Therapy
• This chapter (12) guides the practitioner when
  therapy is the course of action based on the
  facts of the case.

3
Therapy Method Choices

• When the facts of the case at-hand indicate
  
• that therapy is the intervention of choice,
• social work clinicians must still decide
  which method of therapy is the most appropriate
• (1) Step 5 Individual method- worker to one
  client
• or dyad (parent/child
  couple)
• (2) Step 6 Family method worker to one
  family
• (3) Step 6 Group method worker to one group

4
TherapyTheory Choice

• Once a method is chosen, the clinician must then
  choose a theory-based therapy to enact a
  therapeutic process.
• The determination of best practices requires that
  the clinician evaluate potential theory-based
  therapies and the evidence for or against them
  when deciding upon a specific treatment.

5
Key Assumptions Best Practices

• Competent practice is tied to open assessment and
  case-specific model building.
• Best practices may require the use of more than
  one method and more than one theory.
• Best practices requires that interventions be
  evidenced-based ( e.g. based on what works)
• See case example Chapter 13

6
Beginnings Point of Entry

• Point of entry refers to the intersect of help
  seeking and help giving.
• A clients point of entry with a help giver
  begins with an interview by phone and/or in
  person.
• How a client enters service is pivotal in the
  conceptualization of the profession and its
  planned change processes.
• Practitioners are defined by their field of
  practice (area of expertise), public or private
  auspice and their setting. See chapter three.

7
The Interview

• The interview is used for three purposes
• To establish rapport or a working relationship
  with a client
• To gather information (facts) relevant to the
  request for service or need for therapy and to
  arrive at a definition of the problem, its
  possible causality the course to be followed
  for recovery
• To enact a therapeutic process designed to change
  feelings, cognitions, attitudes, beliefs,
  personal or interpersonal functioning (behavior),
  or some or all of the above.

8
Historical Perspective The 5 Ws of Social
Work

• The parameters of who receives help for what,
  where, when, and why (why is there a problem) has
  driven the conceptualization of direct social
  work practice since its inception.

9
1W- Who is the Client?

• 1. The person (Richmond, Hollis, Perlman)
• 2. The environment (Robinson, Reynolds,
• Smalley)
• 3. Person-in-the environment (Karls Wandrei
  
• Germain and Gitterman)
• 4. The highly vulnerable and poverty stricken
  
• individual and the traditional
  middle-upper
• class client (Rothman)
• 5. Population age groups children,
  adolescents,
• adults and the elderly

10
2W- What is the Matter

1. Primary and persistent developmental, health, and
   mental health conditions
2. Persistent problems in social functioning
   secondary to primary conditions
3. Acute and temporary problems in living
   developmental or situational
4. Exposure to extraordinary circumstances
5. Inability to perform normative roles (welfare) or
   conform to societal rules (criminal justice).

11
3W- Where Practice Auspice

• Public Welfare Agencies
• Not-for profit agencies
• For-profit agencies
• Managed care agencies
• Faith-based agencies
• Private Practice

12
4W-When

• When there is a need for concrete services
• When the client feels subjective discomfort and
  voluntarily seeks help
• When the client is encouraged to seek help by
  someone in authority parent, teacher, employer,
  spouse.
• When the client is court-ordered or mandated

13
5W- Why Is There a Problem?Proximate and Distal
Causality

• Proximate time causality why is the client
  seeking help now?
• Distal time causality refers to identification
• of the dynamic forces that created the
  situation (there and then past) or that sustain
  and maintain it (here and now current).

14
5W Type and Number of Problems to be Worked

• Nominal definitions refer to the type of problem
  to be worked because of.. truancy, eviction,
  suicidal ideation, school failure, job loss,
  domestic violence, mental illness, parenting
  problems etc
• Number of problems refers to whether the focus of
  intervention is on a single problem or on
  multiple problems.

15
5W CausalityProblem Source and Duration

• Problem exploration determines the source of
  possible causality social or individual e.g
  what is the source of the problem?
• Problem duration determines whether treatment
  should be directed at prevention, early
  intervention, or tertiary (remedial) intervention.

16
Historical Perspective The Planned Change
Process

• The profession, whether engaged in direct or
  indirect social work practice, has used a generic
  model of a planned change process to describe
  what it does.
• The planned change process consists of five major
  activities (1) establishment of rapport, (2)
  assessment, (3) contracting and goal setting, (4)
  intervention, (5) evaluation.

17
Historical Perspective Direct Practice Overtime

• As individual casework
• As crisis intervention
• As case management
• As case advocacy
• As individual therapy
• As family and child welfare services
• As family therapy
• As clinical group work
• As generalist practice

18
Historical PerspectiveConceptualization of
Therapy Overtime

• The therapeutic process has been viewed and
  conceptualized as
• (1) pharmacological
• (2) crisis intervention
• (3) psychodynamic analytic
• (4) psychodynamic interpersonal
• (5) behavioral-learning
• (6) cognitive-behavioral

19
Conceptualizations of TherapiesContinued

• (7) solution-focused
• (8) strengths-based
• (9) empowerment
• (10) post modern
• (11) socialization conformity to norms
• This list is not exhaustive.

20
Conceptualizations of Indirect Practice Overtime

• As policy practice
• As administrative or management practice work
  with organizations
• As community practice inter-group relations
• As class advocacy rights advocacy, organizing
• As political social work
• As grant writing, fund raising and program
  evaluation
• As generalist practice

21
Value Base of Clinical Social Work Core Values

• Biestek identified the following as core social
  work values in direct clinical practice
• (1) Confidentiality
• (2) Self-determination
• (3) Non-judgmental attitude
• (4) Acceptance
• These were discussed in full in chapter two (the
  fiduciary model and legal context of direct
  practice).

22
Knowledge Of Human BehaviorTherapy

• Therapists need knowledge of human behavior to
  enact a therapeutic process.
• Each theory of human behavior contains
  assumptive premises of cause-effect.
• Common biological, psychological, and
  sociological theories of human behavior are
  described and differentiated in exhibit 12.1
• Taught and learned knowledge is referred to as
  declarative knowledge.

23
Declarative KnowledgeDefinition

• Declarative knowledge begins with a cognitive map
  of learned (taught) concepts
• The declarative knowledge needed to enact a
  therapeutic process depends on causal knowledge
  of individual resilience (normality) and
  vulnerability (abnormality).
• Knowing what interferes with the unfolding of
  resilience leads to practice theories (procedural
  knowing) about how to prevent or correct missteps

24
Procedural Knowledge Fresh Client Data

• Learned (taught) theoretical concepts are stored
  in memory as schemas.
• When faced with fresh client data, the novice
  tries to match the facts of the clients case
  with the stored knowledge s/he has learned this
  is referred to as procedural knowing.
• The novice has beginning competency when s/he
  applies learned concepts to client data e.g. the
  thinking column in a process recording.

25
Procedural KnowingSupervision/Mentorship

• Reflection on action (thinking) is facilitated by
  the use of process recordings.
• Supervised by a master clinician, the novice
  (student) advances her/his expertise by using
  process recordings in supervision.
• In contrast, the master clinician engages in
  tacit knowing.

26
Tacit KnowingDefinition

• Tacit knowing relies on highly disciplined and
  automatic procedural knowledge and on a highly
  refined self-regulated ability to allow for
  reflection and adjustment of performance in the
  therapeutic moment.
• Tacit knowing is reflection in action in the
  therapeutic moment.
• Tacit knowing distinguishes the master clinician
  from the novice.

27
Tacit KnowingImprovisation-Creativity

• The master clinician can reshape understanding of
  the situation and depart from established
  procedures to respond to novel and unexpected
  conditions.
• The master clinician uses tacit knowing to
  readjust her/his definition of the problem and
  adjust strategies and tactics accordingly.
• Tacit knowing reflects mastery of the art of
  therapy.

28
6 Common FactorsProcedural Knowing

• According to Binder (2004) every theory-based
  therapy has the following 6 factors in common.
• Each theory-based therapy possesses
• (1) some view of personality interpersonal
• functioning (though not necessarily the
  same
• view).
• (2) some theory about cognitive, affective,
  and
• behavioral processes that are activated
  (or not)
• during the process of therapy
• .

29
6 Common FactorsContinued

• (3) specific guidance on how to formulate the
• problem to be worked
• (4) knowledge of salient maladaptive patterns of
• behavior and a theory of how change occurs
  and
• problems are solved e.g. explanation and
  change
• (5) criteria (goals) to track the course of
  therapy and
• measure its outcome success
• (6) strategies for managing therapeutic missteps
  
• the therapeutic relationship

30
Therapeutic AllianceGeneric or Common Factors

• At a minimum, a therapeutic alliance begins with
  belief in the helping relationship e.g. belief
  bonding ( see chapters 4 and 6).
• Empathy is a common factor in establishing belief
  bonding or rapport.

31
Therapeutic AllianceTheory-Specific

• Beyond common factors, the therapeutic process of
  relationship is theory-bound.
• The use of self in therapeutic alliance depends
  on ones theory of therapy.
• Models of talk therapy are based on different
  theories of how change (the therapeutic process)
  occurs.
• Not all theories of change require the same level
  of relationship intensity.

32
MiddlesTherapeutic Enactment

• Intervention is the middle phase of the social
  work change process. It follows assessment (a
  theory of what is the matter) and contracting.
• Contracting involves worker-client agreement on
  what is the matter and agreement on the change
  process (a theory of change).
• Therapy involves theory choice and appraisal of
  the evidence for or against treatment options.
• Such options must be evaluated for their cultural
  relevance.

33
Theory-Based TherapyExample Learning Theory

• According to this theory, all behavior is learned
  and can therefore be unlearned. What has not been
  learned can be taught.
• Learning can occur incrementally (shaping) or in
  large chunks. One can learn through trial and
  error or vicariously through observation.
• There are five schools of thought within learning
  theory (1) classical conditioning, (2) operant
  conditioning, (3) cognitive-behavioral, (4)
  social learning and (5) stress management e.g
  relaxation techniques, guided imagery etc.

34
ExampleBehavior Modification

• ABC assessment
• A Antecedant events SStimulus cues
  (Classical
• conditioning) what triggers the
  behavior
• B The behavior, affect, or thought that has
  been
• defined as problematic its frequency
  baseline
• C Consequence- R responses that increase,
• decrease or extinguish the behavior
  (Operant
• conditioning reinforcement).

35
Behavior-ModificationTechniques

• Social Learning Theory. The worker models
  appropriate behavior client rehearses worker
  coaches.
• Classical conditioning. The worker unpairs the
  S-R. Desensitization. The stimulus cues are
  changed or the client is taught an incompatible
  response to the cue i.e. running rather than
  eating when upset.
• Operant conditioning. The worker changes the
  consequent conditions uses positive or negative
  reinforcement. Punishment may be used to
  extinguish behavior.

36
Behavior ModificationRelationship

• Client as his/her own therapist client can be
  taught to manage his/her own behavior.
  Biofeedback, guided imagery relaxation skills
  help the client manage the physiology of tension.
  
• Others as therapists the worker teaches others
  in the clients environment how to act as
  antecedent and consequent events in the clients
  life ( parents, teachers, guardians).
• See process recording on Kyle in chapter 13.

37
Theory-Based TherapyCognitive-Behavioral

• In contrast to the time sequence of behavior
  modification (S-R) cognitive behavioral therapy
  is perceptual and mediational.
• The attributions made about an event are held to
  explain dysfunctional emotions (anxiety, anger,
  depression) or behavior.
• An individuals attributions (world views) are
  learned and can be unlearned
• See process recording of Lily in chapter 13.

38
Cognitive-BehavioralAssessment

• The ABC paradigm in this model refers to
• A Activating event (stimulus)
• B Belief an activating event is
• interpreted by learned core beliefs or
  by
• learned distorted cognitions
• C The affect or behavior that results
• (consequence) is mediated by the
  meaning the
• individual attributes to the event or
  his/her
• belief about the event.

39
Cognitive-BehavioralTechniques

• Intervention targets the core beliefs
  (perceptions) or distorted cognitions of the
  individual.
• Techniques include
• (1) keeping an automatic thought record
• (2) Socratic questioning
• (3) challenging distorted cognitions by
  asking for
• evidence e.g. how do you know that?
• (4) substituting functional thought patterns
  for
• dysfunctional patterns.

40
Example Psychodynamic TheoryMajor Premises

• According to this theory all behavior has a
  purpose but one is not always aware of the
  purpose of his/her behavior.
• Behavior is a product of nature and nurture
• Behavior is a product of past current
  experiential history.
• Behavior is both developmental and interpersonal
  (self-other).
• There are four major psychodynamic schools of
  thought briefly discussed in this chapter.

41
4 Psychodynamic Schools of Thought

• Analytic- Traditional Freudian- Drive Theory
• Ego Supportive Problem Solving
• Relational
• -Object relations psychology (Mahler)
• -Interpersonal psychoanalysis (Sullivan)
• -Self psychology (Kohut)
• 4. Narrative therapy

42
Psychodynamic Theory Example Analytic Therapy

• Assessment
• Typographical model Mental activities are
  conscious, preconscious, and sub or unconscious
• Structural model Personality is composed of the
  Id, Ego, and Superego.
• Drive or Dynamic model energy is finite and
  affects development and functioning
• Energy is encumbered by impulses (drives).
  Internal conflict (personality structures) makes
  energy unavailable for other uses.

43
Psychodynamic TheoryAnalytic Therapy Techniques

• Relies on free association, dream analysis,
• and interpretation of defense mechanism in a
  therapeutic environment that is capable of
  keeping the individual safe as the unconscious is
  made conscious
• When the unconscious is made conscious, energy is
  freed to solve problems, to increase resilience,
  and to enjoy life.

44
Psychodynamic ThoughtExample Ego Supportive

• Assessment focus is on painful or maladaptive
  behavior caused by
• (1) emotional trauma
• (2) developmental crises
• (3) situational crises
• (4) difficulties in social functioning role
• performance
• (5) difficulties in interpersonal
  relationships
• See Process recording on Mrs. Jones in chapter
  13.

45
Psychodynamic Ego Supportive Techniques

• Through empathic responding the worker becomes a
  powerful significant other to the client in
  therapy.
• Worker acts as a holding environment the worker
  acts as an emotional bridge that prevents the
  client from harming self or others until the
  client is able to reassert emotional control for
  him/herself.
• Worker lends ego support to help client problem
  solve until client regains capacity for
  autonomous problem solving.
• .

46
Ego Supportive Techniques -Continued

• Skills training is a major technique of this
  model skills increase competency and mastery of
  self and ones environment.
• The model builds on and strengthens the coping
  capacities thereby increasing client resilience
  and decreasing client vulnerability.
• The model is reality focused interventions
  target inside and outside realities. It is
  reflective and action-oriented.

47
Psychodynamic ThoughtExample Relational
Paradigms

• According to Bordon (2000), the relational
  paradigm has replaced drive psychology as the
  central paradigm in contemporary psychodynamic
  thought.
• There are three schools of thought within the
  relational paradigm (1) object relations theory,
  (2) interpersonal psychoanalysis, and (3)
  self-psychology.

48
Example Objects Relations Major Premises

• An alternative to drive theory, this theory is
  based on internalization of interpersonal
  experience.
• Personality is viewed as an outcome of a series
  of chronologically ordered phases autistic,
  symbiotic separation-individuation, and object
  constancy.
• The personality consists of core representations
  of self, others (objects), and modes of relating
  (self in relation to other).
• Attachment, early care giving, and connection to
  others are foci of assessment.

49
Object RelationsMajor Premises -Continued

• The model holds that previous relational
  conflicts play out in current relationships
  through repetition compulsion.
• Current maladaptive interpersonal functioning is
  related to earlier emotionally traumatizing
  relationships.

50
Object RelationsTechniques

• Within the therapeutic alliance, a triangle forms
  between the client , an other (a person in the
  clients past or current life) and the clinician.
  
• The social work clinician works with transference
  to correct past failures in relationship in the
  here and now interactive moment (corrective
  emotional experience)
• Clients experience new ways of being related to
  and new ways of relating to others in the safety
  of the therapeutic alliance.

51
Psychodynamic ThoughtExample Self Psychology

• This model accepts that personality develops
  because of a primary need for connection.
• The model assumes that there has been a failure
  in empathic response by the clients primary
  figures.
• Disorders of self are characterized by
  difficulties in negotiating need, regulating
  emotion, maintaining self esteem and pursuing
  meaningful goals
• The personality is perceived as living on the
  border between anxiety and psychoses.

52
Self PsychologyTechniques

• Therapeutic actions are based in a responsive
  self-object milieue.g. therapeutic atunement to
  the clients subjective state.
• Managing the therapeutic relationship is critical
  in this model transference and
  counter-transference

53
Psychodynamic ThoughtExample Interpersonal
Therapy

• This model holds that personality develops as a
  consequence of interactive experience in
  relational fields throughout life.
• The motivation to interact is based in the need
  for satisfaction and security.
• Assessment focus is on the problematic aspects of
  interactions with others.

54
Example Interpersonal TherapyTechniques

• The clinician is a participant observer in the
  interactive field of the client both subject and
  object.
• The clinician uses the interactive moment in
  session to experience (assess) what is wrong and
  based on corrective attunement to respond
  (intervention) in a healing manner.
• The clinician is a tool of corrective
  interpersonal learning and healing.

55
Psychodynamic ThoughtExample Narrative Therapy

• According to this model, ones social context
  influences how one processes interpersonal
  interactions the personal is political.
• Unlike other models, this theory allows the
  worker and client to take into account political,
  economic, and cultural factors that impact
  interpersonal interactions.
• It is held that the telling of ones story
  reviews experiential history in an attempt to
  make sense of it.

56
Example Narrative TherapyTechniques

• The therapeutic alliance is used to facilitate
  the telling of the clients story(narrative)
• The clinician acts as a co-participant in the
  clients effort to review experience, consider
  alternative views of his/her life, reconstruct
  meaning and elaborate adaptive life stories.
• Therapy challenges the social constructions of
  others about the clients story.
• New meanings are co-constructed within the
  therapeutic alliance.

57
Errors and Missteps in The Therapeutic Alliance

• According to Binder, errors in therapist
  technique include (1) misunderstanding of the
  meaning of client communication or intention, (2)
  vague communication by the therapist to the
  client, (3) mistimed interventions, (4) failure
  to recognize the implications of client
  communication, (5) awkward use of transference
  interpretation (6) sending mixed messages with
  implicit hostile meanings,

58
Errors and MisstepsContinued

• (7) not being able to identify salient
  interpersonal themes that should be the focus of
  work, (8) failure to recognize disguised
  allusions, and (9) failure to track a central
  issue consistently and (10) failure to manage
  transference and counter-transference

59
Transference and Counter-Transference
Psychodynamic Theory

• From a psychodynamic perspective, relationship is
  created and recreated by the behaviors engaged in
  by participants in interactive dialog.
• Because the worker-client relationship is
  grounded in interaction, it is subject to
  transference.
• Managing potential ruptures and missteps in the
  therapeutic alliance due to transference and
  counter-transference requires that the clinician
  monitor her/his use of self during the
  therapeutic process.

60
Managing Transference and Counter- Transference

• The clinician monitors her/his use of self
  through supervision, consultation, and ones own
  therapy if warranted. Students monitor their use
  of self in supervision through the third column
  of process recordings.
• Premise it is important that the client replay
  earlier relationships (transference) through the
  therapeutic alliance however, the worker must not
  replay his/her earlier relationships
  (counter-transference) as to do so would
  interfere with the helping process.

61
Therapeutic Missteps

• Hepworth, Rooney, and Larsen (2002) offer the
  following list of 14 therapeutic missteps
• (1) failing to sense important feelings
  experienced
• by the client
• (2) being inattentive or tuning out clients
• (3) sending messages that clients interpret as
  
• criticisms or put-downs
• (4) failing to acknowledge incremental
  successes
• achieved by clients

62
Therapeutic Missteps-Continued

• (5) employing inept or poorly timed
  interpretations
• or confrontations
• (6) exhibiting lapses of memory about important
• information
• (7) being tardy or canceling appointments
• (8) appearing fidgety or drowsy
• (9) disagreeing, arguing, or giving excessive
  advice
• (10) taking sides against the client

63
Therapeutic Missteps-Continued

• (11) not allowing a client to be an active
  participant
• in planning his/her own treatment
• (12) dominating discussion or frequently
  interrupting
• clients
• (13) failing to recognize client limitations by
  giving
• assignments that they cannot carry out.
• (14) Using power beyond the range of legal
• mandates

64
Indicators That The Therapeutic Process is Not
Going Well

• Hepworth, Rooney, and Larsen (2002) identify the
  following 17 client behaviors
• (1) mental blocking
• (2) lengthy periods of silence
• (3) inattention or mind wandering
• (4) rambling at length dwelling on
• unimportant details
• (5) restlessness or fidgeting
• (6) discussing superficialities or irrelevant
  matters

65
Indicators-Continued

• (7) lying or misrepresenting the facts
• (8) avoiding feelings and problems by
• focusing on abstract ideas
• (9) changing the subject
• (10) forgetting details of a distressing
  event
• (11) being tardy, forgetting, changing or
  canceling
• appointments
• (12) minimizing problems or claiming
  miraculous
• improvement

66
Indicators-Continued

• (13) bringing up important material at the
• end of the session
• (14) not paying fees
• (15) not applying skills or insight gained to
  
• daily life
• (16) assuming a stance of helplessness
• (17) using verbal ploys to justify not taking
  
• corrective actions

67
Counseling vs. TherapyIs There a Difference?

• The terms counseling and therapy are
  frequently used to distinguish the BSW from the
  MSW clinical practitioner.
• The BSW graduate and the MSW foundation year
  student are educational and experiential novices
  in the art of therapy.
• Second year MSW students may(or may not) choose
  an educational or practice trajectory that will
  advance their clinical skills.

68
Counseling vs. TherapyContinued

• Clinical social work practitioners continue to be
  supervised while employed, leading to mastery of
  the art of therapy.
• This is reflected in the type and level of
  licensing they earn.
• Some social work clinicians get advanced clinical
  training as doctoral students in clinical social
  work programs or as students in clinical programs
  staffed by psychologists and psychiatrists.
• Accreditation as a skilled Analytic
  psychotherapist requires additional training.

69
Examples

• See exhibit 12. Guidelines for Selecting a
  Theory-based Talk Therapy at the end of the
  chapter.
• See chapter 13 for an explication of a case
  focused on work with an individual.
• See decision schemas 12. direct practice and
  decision schema 12. Therapeutic Process at the
  the end of the chapter.