September 10, 2012
Simulated Group for Females with Alcohol Dependence
Simulated Groups: Adult Women with Substance Abuse or Dependence
Alissa, Corina, Allison, & Kate
i. The purpose of this group is to encourage abstinence from alcohol, build alternative coping skills, and motivate change towards positive behavior. The group is offered to adult gender-identified females who express motivation to make a change in their drinking behavior. This is not a dual diagnosis group.
ii. The problem is that the women have an alcohol use or dependence diagnosis and are attending group to make a positive change in their drinking behavior.
iii. The group leaders will use the stages of change model with motivational interviewing and cognitive behavioral techniques.
iv. The leaders will incorporate psycho-education and will model communication and problem-solving skills. Leaders will create a safe and empathetic environment for clients. Leaders will encourage motivation for change and facilitate group dialogue.
v. A short paper of 1-2 pages about the peer-reviewed, evidence-based practices
There are several different therapeutic group models that are being used in substance abuse treatment. These include psychoeducation, skills development, cognitive-behavioral, support, and interpersonal process groups. All of these models share some characteristics with other models. For example, most skills development groups operate from a cognitive-behavioral orientation (Flores 2005). The current group will use cognitive-behavioral therapy (CBT) as our primary model. The group will employ aspects of psychoeducation, specifically by teaching group members about the stages of change. Additionally, the group will use motivational interviewing (MI) techniques to help group members to increase their intrinsic motivation for change. There are four main principles of MI: express empathy, support self-efficacy, roll with resistance (explore client’s views), and develop discrepancy between client’s behaviors and what they wish for.
According to an analysis conducted by McHugh and colleagues, many large-scale trials and quantitative reviews support the efficacy of cognitive-behavioral therapy in treating alcohol use and dependence (2010). Researchers examined various CBT interventions, including motivational interventions, contingency management (using a nondrug reinforcer, such as a gift card), relapse prevention (identifying and preventing high-risk situations), community reinforcement approach (altering environment to reward sober behavior), and behavioral couples therapy. Researchers concluded that all of these interventions have shown efficacy and that, if combined, these interventions could yield even more positive outcomes.
A meta-analysis conducted by Magill and Ray (2009) found a small but statistically significant treatment effect of CBT for adults diagnosed with alcohol- or illicit-drug-use disorders. Effects were strongest when CBT was compared with no treatment, and the results suggest that the effects may be larger with women than with men and when delivered in a brief format, under 20 sessions. Their findings also showed that the CBT effects diminished around six to nine months and was significantly diminished after 12 months. They found no difference in efficacy due to format (group or individual).
Motivational Interviewing, an approach commonly used and discussed with alcohol abuse treatment, seems to be effective, though further research is needed. A meta-analysis conducted by Smedslund and colleagues (2011) looked at motivational interviewing (MI) in one-on-one individual interventions in comparison to no treatment, to assessment and/or feedback about substance use, and to other active treatment approaches. Researchers found that outcomes were significantly different between the groups. However, the analysis showed that other active treatments could be as effective as MI. At a medium follow-up period (defined as 6 months post-intervention up to, but not including, 12 months) MI proved more effective than for a group that only received assessment and/or feedback regarding substance use. Researchers of the analysis warn that the evidence they gathered is mostly “low quality” and should lead to caution when making use of their results.
vi. The Women’s Center of Ann Arbor will sponsor the group.
vii. The Women’s Center has space for the group to be held and staff to facilitate the group. The Center will provide water, tea, fresh fruit, and vegetables; 8AM-4PM phone support, and links to other resources in the community.
viii. Members are adult, gender-identified females with alcohol abuse or dependent diagnoses.
ix. The agency will recruit members through referrals of existing clients and will also accept referrals from outside agencies.
x. The group will screen clients based on gender, age (18+), and type of substance. The group is strictly alcohol use/dependence and not dual diagnosis.
xi. The group will be strictly adult (18+) and female. People from all identities according to race, ethnicity, ability, sexual orientation, and size will be accepted.
xii. It will be a closed and structured group. The group will meet for 12 sessions once a week for 1 hour.
xiii. Give a description of the types of activities planned for the group:
We will begin the first session by introducing ourselves and stating the goals and objectives of the group. We will then facilitate introductions through a round robin where members will be asked to state their name and one of their strengths or talents. The group leaders will describe a strength or talent of their own first; they will model an example that sets a positive and light tone for opening the session (ie “I’m Allison and I am good at gardening.”)
Next the leaders will facilitate the development of group guidelines with input from all members in a round robin style. Individuals will have the opportunity to “pass” if they don’t want to speak. If not mentioned by group members, the leaders will address the following: Confidentiality (including limits – mandated reporting), Respect (including “step up, step back” guideline), Attendance (“Please try to attend all groups and let us know 24 hours prior if you cannot make it; after three absences, you will be asked to leave the group”), and Promptness.
One of the leaders will also introduce the concept of “check-ins” and explain that in future sessions check-ins will relate to substance abuse and any challenges that have happened during the week. However, given that the group is still getting to know each other, the first “check-in” will be to answer the question, “what do I want to get out of group?” This activity will help us to understand members’ goals, gain a sense of where they might be at according to the Stages of Change, and help us to structure appropriate activities for future sessions. It will also help the group members begin to learn about each other.
Finally, the last activity of the first session will be a psychoeducational segment on the Stages of Change. The leader will explain the stages and then read a vignette. Members will then be asked to analyze where the person in the vignette is on the Stages of Change wheel. For homework the members will be asked to think about where they are on in the Stages of Change. They will be given a hand-out that will help them to identify where they are at on the wheel.
xiv. Agenda for Session I
1. Rationale for group – opening statement: stating the objectives of group, short history of the group and effectiveness of approaches used (hint: evidence-based) 5 min
2. Intro of members – name, ice-breaker: share one of your strengths -10 min
3. Present the agenda – 2 min
4. Discuss group guidelines – 10 to 15 min- offer the chance to brainstorm rules together, and then summarize:
Respect: step up, step back rule
Attendance: Please try to attend all groups and let us know 24 hours prior if you cannot make it, and you can only have two absences
5. Member check-in: 15 min
Introduce the concept of check-in: usually the check-in will be about each person’s substance use over the past week (report of using-keep nonjudgmental but explore what led to the episode, identify internal emotional cues during and after, and consequences), but for today check-in with each person’s goals for self in the group:
What are your goals for yourself in this group?
Psyched: stages of change, handout – the wheel (depicting stages of change), discuss the vignettes (identify where person in case study is at on stages of change) - 15min
7. Homework – Where are you at on Stages of Change? – take home additional hand-out that assists in identifying where you are at
Summarize session – thank participants for attending and for participating in group activities
Session I Group Note
6/18/2012 2:45 PM-3:35 PM SSWB 3816
7 group members and 4 staff attended the weekly alcohol group for gender-identified women. In this initial session, two staff members facilitated introductions of staff and members, stated the rationale for the group, presented the agenda, and discussed group guidelines. Members participated in a go-around to discuss possible guidelines. Guidelines included confidentiality, respect, attendance, and promptness. At this point, two other staff members facilitated a check-in (pertaining to reason for joining the group and goal while in the group) and a psycho-educational discussion about stages of change. Staff provided group members with a handout about the stages of change, and the group discussed these stages pertaining to a case example and then to their own lives. Members are to think about barriers and triggers for the next session.
Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP) Series 41. DHHS Publication No. (SMA) 05-3991. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.
Hallgren, K.A., Moyers, T.B. (2011). Does readiness to change predict in-session motivational language? Correspondence between two conceptualizations of client motivation. Addiction, 106, 1261-1269.
Le Berre, A. P., Vabret, F., Cauvin, C., Pinon, K., Allain, P., Pitel, A.L., Eustache, F., & Beaunieu, H. (2012). Cognitive barriers to readiness to change in alcohol-dependent patients. Alcoholism, Clinical and Experimental Research.
Magill, M, Ray, LA. (2009). Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials. J Stud Alcohol Drugs;70:516–27
McHugh, K.R., Hearon, B.A., Otto, M.W. (2010). Cognitive behavioral therapy for substance use disorders. Psychiatric Clinics of North America, 33, 3.
Muesser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Persuasion groups. Integrated Treatment for Dual Disorders: A Guide to Effective Practice.
Smedslund, G., Berg, R.C., Hammerstrom K.T., Steiro A., Leiknes, K.A., Dahl, H.M., Karlsen, K. (2011). Motivational interviewing for substance abuse (review). Cochrane Database of Systematic Reviews 2011, Issue 5.
July 02, 2012
Multifamily Group Therapy for Clients with Severe and Persistent Mental Illness
Although there are many forms of therapy which have proven effective for clients with a variety of mental illness diagnoses, there is inconclusive data in regards to schizophrenia. However, one type of therapy has shown to be quite effective: multifamily group therapy (McFarlane 2002). The goals of multifamily groups are to create social networks for families and clients with schizophrenia and bipolar disorder, to educate families about the illness, to reduce symptoms, and to teach problem solving. Research suggests that clients attending multifamily groups have a relapse rate of 50% less than clients not attending the group. Also, over a two year period, clients in the group reported significantly lower negative symptoms (McDonnell et al 2007).
The structure of a multifamily group is important for the integrity and validity of the group. The group runs bi-weekly for two years and typically involves eight families and two leaders. The group begins with two joining sessions in which the leader meets privately with the family and then the client to discuss precipitants, symptoms, coping, and family reactions. Families then attend an educational workshop with other families during a 6 hour session. Usually this is hosted by a multi-disciplinary team which allows family members to ask questions from practitioners with a variety of backgrounds. Next the group begins. The first two sessions are unique in regard to topic. The first session is a “getting to know you” session and illness is not discussed. The second session discusses how the illness has impacted the family.
All later sessions begin with socialization and the bulk of the session is a problem solving activity in which there is a go-around of something good and a struggle. The leader writes all struggles on the board and then chooses one based on severity. The group then discusses possible solutions and writes them on a board. After there are at least 10 options, the group rates the pros and cons of each option. The client then chooses two options to try over the next two weeks.
Group problem solving has proven to be effective because it raises new ideas and options that families may not have considered, and it allows for socialization. The group also follows specific guidelines set by leaders which promote healthy communication and low emotional expression. The role of the leaders is to collaborate with families and facilitate discussion. The leaders are also educators and coaches. These types of groups can be run in any setting and are often led in community mental health facilities.
Art Group Therapy for Clients with Severe and Persistent Mental Illness
As a social work intern at Community Support and Treatment Services (CSTS), I run an art group for clients with severe and persistent mental illness. The group meets weekly for one hour, and typically five clients attend the group. This type of group is unique in that it is not a discussion-based group. At times, I have struggled with how much emphasis I should place on socializations, because some clients attend for social interaction. The group is currently structured in a manner that promotes indirect social interaction.
The group begins with five minutes of introductions which include names and an interesting fact or getting-to-know-you question posed by the leader. The leader also introduces the group, meeting times, and theme of the week. Examples of themes include healing, stigma, mood, and identity. The leader also has a couple project suggestions for clients who prefer to follow a model. Project ideas include: puzzles, print making, paper mache, painting, origami, mobiles, and picture frames. The group has 45 minutes to work on projects, and the leader engages in conversation with clients if they are interested in socializing. The final 10 minutes is a time for sharing projects with the group, and group members provide feedback to the client.
The group has proven to be effective as measured by feedback from members and high rate of attendance by current members. The group also utilizes Yalom’s approaches to group development. The key factors include: instilling hope through peer-peer interactions, imitating behavior, increasing social network, interpersonal learning, universality (reducing stigma), group cohesion, and altruism. The group is centered around art so there is little pressure to speak with other members, but many members choose to engage in peer-peer interactions. The leader is also able to model appropriate social interaction. Finally, members are able to increase confidence by creating unique projects which build self-esteem and reduce the stigma that they feel.
April 04, 2012
Assertive Community Treatment: Efficacy of Therapy
With the creation of Assertive Community Treatment (ACT), many benefited from this new and evidence-based approach to community mental health. ACT provides a much different and progressive type of service than an inpatient facility; it offers community-based, at home care for clients with severe and persistent mental illness. Through ACT, social workers provide mental health care to clients both in the office and in the community. During the hours of 9:00 AM to 11:30 AM, ACT teams travel to the homes of 7-12 clients each day to provide at home care. During this visit, social worker observes clients take AM medications and observes the client set-up his/her medication in a med box up to the next time s/he will be visited. The social worker also conducts a mental status exam and inquires about whether the client needs any resources or assistance; the whole visit lasts approximately 10-15 minutes. In the afternoon, staff involves clients in different support groups such as co-occurring groups, shopping groups, and walking groups. Staff also uses afternoons to see clients in the office and assist clients with miscellaneous appointments and needs.
Although ACT provides clients with unique and necessary services, research studies show that while ACT does prevent hospitalizations, the program does not significantly increase quality of life or reduce symptoms. Although clients benefit from not being hospitalized unless absolutely necessary, this is more of a fiscal improvement than a mental health improvement. Client care should be more focused on symptom reduction and quality of life if it is truly client based. This lends to the question, if ACT is truly an evidence-based approach to improving mental health, what can be done to improve this service so that clients receive the best possible care?
Mental health care has greatly improved over the past few decades, but has recently reached a point where social workers follow the norm of practices rather than using more progressive, evidence-based practices (Mechanic 2008). Although the main focus of these programs is “recovery, community integration, and making services consumer and family centered”, client’s lives are not significantly improved by programs like ACT.
For example, in a study of the ACT program in Japan, clinicians found that clients in the program had decreased hospitalizations but no symptom reduction. These findings are similar to data collected in the United States. However, in Japan, clients were given a quality of life interview (QOLI) at 2 weeks and then again 12 months later. Through this survey, Horiuchi et al. (2006) found that clients in ACT in Japan had increased quality of life but that they had decreased family contacts which were a predictor of rehospitalization. In the study, “it was assumed that satisfaction with family relationships indicates an unmet need for care among this population”. Clearly, more research must be conducted to determine the connection between quality of life and family contacts.
One of the major benefits, but also potential pitfalls of ACT, is that ACT policies are much looser than in other organizations (Powell, Garrow, Woodford & Perron). Social workers are able to make street-level decisions about how often clients are seen, what services or resources clients may be offered, and what type of therapy to use during interventions. This amount of freedom may seem like a huge bonus to working in an ACT setting, but it may be the reason that the program does not increase quality of life and symptom reduction. If social workers are able to have that much freedom, they may not be choosing evidence-based therapies when working with clients, or they may not have the proper certifications to be qualified for different types of interventions. This creates an unequal dynamic among staff members as some staff may use different techniques than others.
Although it was previously believed that clients with severe and persistent mental illnesses, like schizophrenia, would not benefit from therapy, researchers have recently challenged these assumptions. It seems that once a client is stabilized, therapy is beneficial in increasing medication compliance for longer periods of time, and therapy increases quality of life (Zygmunt, Olfson, Boyer, & Mechanic). Much research has been conducted on individual types of therapy and how they may be implemented by ACT, but no single researcher has compared the major types of therapy and found a perfect solution as to which, if any, to implement into the ACT model.
One important component to increased quality of life lies in medication adherence, because clients who refuse medications experience distressing symptoms. Zygmunt et al. reviewed literature about the necessity of medication adherence for clients with schizophrenia, stating that 50% of those diagnosed with schizophrenia will stop taking medications within a year after first discharge (2002). Once clients have stopped taking medications, they will experience increased risk of relapse (3.7% greater than compliant clients), and symptoms can negatively impact quality of life. Researchers then researched psychosocial techniques and therapies for improving medication compliance. Zygmunt el al. did find that programs such as ACT were more effective, as was motivational interviewing, because each focused on behavioral training. Findings suggest that clients will be more compliant when given concrete instructions and problem-solving strategies. Behavioral training was effective because clients were provided direct feedback for compliance.
Based on the results of the study, it seems evident that evidence-based practices such as CBT and DBT might be paired with the ACT model to increase quality of life and reduce symptoms because both types of therapy are rooted in behavior. Pinninti et al. (2010) have researched the benefits and difficulties of utilizing CBT in an ACT program. First and foremost researchers maintain that medication compliance is critical for ACT clients, but that CBT and training can improve client’s functioning and reduce symptoms because it provides skills training and helps clients improve coping skills for dealing with their mental illness. Pinninti et al. believes that “the improvement in functioning included interventions, such as helping clients make appropriate life decisions, improving social and leisure skills, and dealing with barriers to employment”. However, data suggests that CBT in an ACT setting does not seem to be beneficial for clients who are being treated for substance use. Contrary to Zygmunt et al. (2002), Pinninti et al. (2010) found that there was no correlation between CBT and medication compliance. They also did not find a correlation between CBT and hospitalizations, but this may be due to already reduced rate of hospitalizations because of the ACT model.
Another potential behavioral model that might be beneficial in an ACT program is DBT. While DBT is primarily utilized for clients with Borderline Personality Disorder (BPD), any clients who suffer from emotional dysregulation may also benefit from this type of therapy. While ACT focuses primarily on Axis I conditions, in recent years, data suggests that 26% of clients have a co-morbid personality disorder (Burroughs et al. 2012). Furthermore, “ACT programs appear to lack a theoretical framework for addressing the behavioral concerns typically associated with clients who are diagnosed with personality disorders”. Although Burroughs et al. discuss the lack of framework for clients with personality disorders; it also reflects the more general lack of framework which is associated with ACT in regard to symptom reduction and quality of life. Researchers suggest that using DBT in an ACT program can be beneficial to clients because this type of therapy helps clients regulate emotions, impulsivity, and parasuicidal behavior. It also would be easy to implement into the structure of the program because staff are available 24/7 as is also required by DBT training. Also, staff is already used to seeing clients with increased needs, and would be able to reinforce the client’s skills training when they are providing services to the client in the community. Not only that, but “ACT has the staffing infrastructure necessary to implement DBT with an average ration of staff to clients of 10:1”.
Although it seems as though there are many benefits to implementing the DBT model, there are some serious considerations as well. Problems include the cost and time commitment of becoming certified to practice DBT. For ACT to implement DBT, all staff would need to be trained, and the training is quite expensive at $2400 per person for a 7-day training seminar (Burroughs 2012). Another concern is that there is a high rate of turnover for ACT employees, so the county would need to pay to certify every new employee. Overall, the cost-benefit ratio makes agencies second guess implementing this type of intervention.
The final type of therapy suggested by Zygmunt et al. is motivational interviewing (MI). While this was originally created for clients who use substances, the techniques can be adapted to other Axis I diagnoses as well (Miller 2012). The theory behind motivational interviewing is that clients are stuck in a pattern in which change is difficult and they often do not see a need to change. Clients may also not view themselves as having a problem, which is quite common among schizophrenics, and is often the reason that clients stop taking medications. Based on this, the premise of motivational interviewing is for the client to recognize the reasons for and importance of change. An importance difference between this type of therapy and others is that there is no certification required to use MI. Also, the resources are free on the website, and there are online training modules that staff can use to become proficient. The only potential pitfall of MI is that because there is no certification, staff may be practicing the technique without proficiency.
It is also worth mentioning, that similar to MI, small scale efforts to improve client’s quality of life and symptom reduction can also be implemented. For example, Lang et al. (1999) found that the more engaged clients were involved in creating their treatment plan, and had higher quality of life. The reason for this is that clients sometimes values differed from that of the psychiatrist in the surveys. Clients found pride in smaller scale improvements that clinicians did not notice as much.
In research conducted by Zygmunt et al., researchers found that behavioral therapies and motivational interviewing proved to be effective ways of reducing client’s symptoms and improving quality of life. Within behavioral therapies are DBT and CBT. It seems thus reasonable that if ACT were to implement an evidence-based therapy model, it be CBT, DBT, or MI, as these are also considered in some circles to be three of the five most utilized forms of treatment (Adlaf 2012). Due to the exceedingly high cost and the large amount of training in DBT, this can be ruled out as a formal treatment method. However, some of the skills associated with it, such as validation and emotional regulation, can be used. Also, because the data on CBT suggests that it does not help as consistently when paired with ACT, and also because it has not proven to be helpful with substance users, it should be ruled out as well.Overall, motivational interviewing appears to be the best approach to working with clients in ACT settings. Both substance users and clients with other axis I diagnosis can benefit from the skills training in MI. MI is also a better option because it is easier for clinicians to become proficient in MI than for other therapies, and also it has no costs nor special certification.
ACTA (2012). ACT model. Assertive Community Treatment Association. http://www.actassociation.org/. Retrieved March 1, 2012.
Adlaf, A. (2012). Syllabus. Interpersonal Practice with Adults.
Burroughs, T., & Somerville, J. (2012). Utilization of evidence based dialectical behavioral therapy in assertive community treatment: Examining feasibility and challenges. Community Mental Health.
Horiuchi, K., Nisihio, M., Oshima, I., Ito, J., Matsuoka, H., & Tsukada, K. (2006). The quality of life among persons with severe mental illness enrolled in an assertive community treatment program in Japan: 1-year follow-up and analyses. Clinical Practice Epidemiology Mental Health, 2, 18.
Lang, M. A., Davidson, L., Bailey, P., Levine, M. S. (1999). Clinicians’ and clients’ perspectives on the impact of assertive community treatment. Psychiatry Services, 50, 10: 1331-40.
Mechanic, D. (2008). In mental health and social policy: Beyond managed care. Pearson Education, Inc: pp.xi-xvi.
Miller, B. (2011). MI basics. Motivational Interviewing. www.motivationalinterview.org. Retrieved March 10, 2012.
Pinninti, N.R., Fisher, J., Thompson, K., & Steer, R. (2010). Feasibility and usefulness of training assertive community treatment team in cognitive behavioral therapy. Community Mental Health., 46, 4, 337-41.
Powell, Garrow, Woodford & Perron: Policy Making Opportunities for Direct Practitioners in Mental Health and Addiction Services. Mental Health Policy. Retrieved March 1, 2012.
Zygmunt, A., Olfon, M., Boyer C., & Mechanic, D.(2002) Interventions to improve medication adherence in schizophrenia. Am J Psychiatry, 159, 10. 1653-64.
Analysis of Treatment Modalities
Cognitive Behavioral Therapy
Of all the different types of therapies, I entered the class with the most previous knowledge about CBT in comparison to the other types. Although I knew about the premise of CBT, I did not actually know the steps and activities associated with the therapy. I really enjoyed the worksheets and the information about how to progress in therapy. Such as, identifying negative thought patterns or then using the 10 most common negative thought patterns to help client’s self-identify. This is followed by analyzing the negative thought and restructuring the cognitive schema. I think this is also an easy therapy to explain to clients because of examples such as the two different reactions to the dog (picture) and the question: can you make yourself feel a certain type of emotion and how (through thinking). I think it’s important for client’s to relate to the therapy this way, and it’s easy to see how CBT will work.
I think CBT also takes away some of the stigma of mental illness because it is less focused on symptoms, and more focused on cognition. Clients can feel empowered as they recognize how they think and how thinking this way affects their mood and behavior. It does require a lot of effort on the part of the client because of the weekly homework assignments, but I think that most clients will find it beneficial and take the time to work on their thought processes. Also, CBT can be tailored for different disorders (depression, specific phobias, Obsessive Compulsive Disorder, etc.). CBT can also work for clients of any cultures because it focuses on client’s maladaptive cognitions, and usually the client has insight about what his/her illogical thoughts are. Because of this, CBT can be utilized to help clients work through feelings of cultural topics such as prejudice and discrimination, but it can help clients work through any other life problems as well.
My only concern, and the reason that I might not be able to use CBT very often, is because of the population I work with. At ACT, most of my clients have severe and persistent mental illness and often have low cognitive functioning. For CBT to work, a client needs to have good insight, and most of my client have very poor insight about their mental illness. For clients who are more stable and insightful, I can try to use CBT. Although, a second concern is the time frame. Many of the activities and conversations about schema require a substantial amount of time (probably at least 30 minutes per session), and at ACT, I only see clients in 15 minute increments.
However, next semester I may be able to do individual therapy in longer sessions, so perhaps I will try CBT with clients who have more insight. This may be especially good for ACT clients who are not always compliant with taking their medications, because it can help them dissect their thoughts about their medications and analyze if these negative thoughts about their medications are true. One of the greatest criticisms of ACT programs is that while they do reduce costs because they deter hospitalizations, they do not help improve symptoms or increase quality of life. Perhaps implementing CBT with medication management would help clients even more.
Another reason that this treatment modality could benefit these clients is that many of my clients have a history of trauma and have experienced abuse. Clients who have been abused view the world through a very skewed lens, and cognitive restructuring would be one of the best ways to aid this population. The set-back of this (although it would likely be a set-back for any modality) is that clients will need to face their trauma head-on. And from the experiences that I have had with clients, many do not want to discuss their trauma, let alone analyze it and spend more time thinking about it. But I think that this could be a key in helping many clients.
Dialectical Behavioral Therapy
Entering class, I had some basic knowledge about DBT, such as that it is used for clients with Borderline Personality disorder and was created by Marsha Linehan, but I did not know much about the specifics. For example, I one of the most beneficial aspects of DBT is that it can also be used for clients who have difficulty with emotional regulation problems and interpersonal problems. Because of this aspect, DBT would be a good technique for some clients with severe and persistent mental illness because they have do not have strong social networks and many would like to make friends and be closer to others. However, like CBT, DBT requires a great deal of insight into the client’s mental illness, behaviors, and thought patterns. Because of this, it may be a challenge to help my clients with emotional regulation problems.
The technique that seems the most powerful of DBT is validation. Clients who struggle with BPD or emotional regulation problems have often been invalidated by parents and those around them from an early age. Clients have created maladaptive ways of coping with stress because they were told that their original ways were inappropriate in some way. In other types of therapy, clinicians may question client’s thought and behavior patterns without recognizing how these actions help clients in some way. That is why DBT is so unique. It is a therapy style in which clinicians truly listen to client’s and help them feel worthy and not put-down. Already, at field, I have tried this and found great success. I work with a client who has paranoid schizophrenia and trouble regulating emotion. His affect at baseline is extremely labile. I have taken the approach to validate his treatment concerns (he is on an ATO), and tell him that it isn’t fair that he must be seen by ACT but that I know he can do a better job taking care of himself to be relieved of his ATO. When I validate his concerns, he often opens up and speaks to me more and calms down. This is a big difference from his usual screaming about “unconstitutional” services.
Although there are many positive aspects of DBT, one of the difficulties is that the clinician must be willing to be available 24/7 per the treatment contract. With agencies, like ACT, this may be difficult, because while there is someone on call at all times, the person is not always the same. Another problem with DBT in an ACT setting is that clinicians must be trained in DBT and also provide weekly individual therapy and group therapy. This all requires a lot of time that ACT staff may not always have from week to week. ACT currently runs a co-occurring substance use group, so creating a DBT group may be possible, but it would be difficult to have enough time for individual therapy sessions for all clients. Next semester, my supervisor told me that I will be able to conduct therapy sessions with 2-3 clients, and perhaps I will be able to try some DBT techniques, but I will not have the resources to conduct therapy according to an actual DBT model.
I do not think that DBT necessarily needs to be modified for different cultures because of the aspect of validation. DBT hopes to consider the client’s perspective and understand where the client is coming from regardless of race, religion, ability, age, etc. The only aspect that may be different from culture to culture might be the way that emotion is expressed and what is acceptable might be different among different groups. Because of this, having an understanding of the population and their views on expressed emotion is necessary when working with clients.
This briefer intervention might be more useful in an ACT setting than the other types of therapy simply because clients generally are not looking for long-term, if any, therapy. Clients are used to seeing caseworkers anywhere from 1-6 times each week, so this type of therapy, which has less worksheets and homework might be better implemented. Also, the majority of the concerns that clients with severe and persistent mental illness have are either about psychosocial education relating to medication management or interpersonal problems. Thus, this type of therapy could greatly benefit clients who want to work on their relationships with others.
However, the problem with Interpersonal therapy is that it is structured more for clients struggling with depression. So, while the focus on interpersonal conflict is good for ACT settings, the structure and ideas behind it which are based in depression may not be the best, since most clients have schizophrenia or bipolar disorder. Another similar problem is that Interpersonal Therapy is only beneficial to use with clients with mild to moderate symptoms. So, perhaps this type of therapy could be used for clients who are down to 1-2 days per week and those with good insight into their mental illness. Then again, clients who are seen so infrequently generally do not wish to seek therapy or other services because they do not think they ‘need’ ACT services anymore.
Some of the beneficial aspects of this type of treatment include the implementation of treatment goals, the structure, and the functions of the ‘sick role’. First, it is important for clients to create goals for treatment, so that there is a focus for each session. When spending extra time with clients, I have tried to implement this aspect so that there is a focus for the conversation with a measurable outcome. However, I have found that it is very difficult for clients to set goals for longer sessions because, while they would love to talk to me, they do not want ‘therapy’. They would prefer that the time is unstructured and referred to as “extra time with staff”. Another problem with using this type of therapy with clients with severe and persistent mental illness is that while they would like their quality of life to improve, they often cannot identify what steps need to be taken for improvement. Even when I suggest goals or ways to form goals, they do not see a need to make any lifestyle changes.
With Interpersonal Therapy, I also like that there is emphasis on the sick role because many clients do not want to view themselves as ill or mentally ill. Clients want to feel like they have full control over their lives and do not need to take a step back from responsibilities. Allowing clients to understand that this is an illness similar to a physical illness can be very powerful in removing the shame from obtaining treatment or from not being able to do things as well or as frequently as before. Also, I appreciate the structure of Interpersonal Therapy because it gives an itinerary of sorts for the sessions, which is helpful in maintaining evidence-based practices.
Cultural diversity needs to be taken into account for this type of therapy because clients of different ethnic groups may view interpersonal relations (the roles in different relationships and ways of communicating) differently from cultural to cultural. Confronting someone may be acceptable in some cultures and not in others. When working with an African American client who is having difficulty with a friend of twenty years, she has a mentality that friends are for life and even though this ‘friend’ treats her extremely poorly and takes advantage of her, that it is wrong to cut her out of her life.
The goal of psychodynamic therapy is to make the unconscious conscious by asking questions like, “where did you learn to think that way?”. This can be powerful because it allows clients to release some of the guilt and shame they might feel by identifying the source of this belief or behavior. It may help clients make connections between their present actions and how these are learned from parents, family, or friends. Already I have been able to utilize this powerful question in working with a client who feels a lot of guilt. When I asked him, where do you think you learned to feel that way? He became tearful and quiet and said he did not want to speak anymore. Although the conversation did not continue at that point, it was a breakthrough and has led to many good conversations in the last few weeks because it allowed him to think about where these ideas and personal narrative come from.
Another important aspect of psychodynamic therapy is that it explores how the past shapes people today. Clients are able to discuss the pains and joys of their life and make connection about how their past is affecting their present in order to change the cycle for a better future. This can be somewhat difficult to utilize in a way that leads towards a better future because clients can get caught in problem saturation. If clients have no guidance with discussing the past, they will tell many stories about the pains of their lives. However, making the links from how the past relates to current behavior and how it can alter the future is very powerful. Once again though, clients need insight for this to truly work.
Clients must have insight into their mental illness and be able to self-reflect, and oftentimes this is not the case. But it can be utilized with the clients who are seen 1-2 times a week and have more insight. While a traditional psychodynamic therapy model may benefit some clients, the brief psychodynamic psychotherapy would be better for an ACT setting because clients are generally not interested in long-term therapy, and clients may not be in the program for many years, which is often the length of time required for traditional psychotherapy. Another problem with this type of treatment is that, similar to Interpersonal Therapy, this is utilized more for clients with depression and anxiety.
Some of the aspects that I like include the roles of the id, ego, and superego, and the descriptions of the defense mechanisms. The visual depictions of the trio that make the personality would be beneficial for clients who are more visually oriented. It may also be beneficial for clients to imagine the id, ego, and superego in order to identify what plays a role in their decision making. Teaching clients about the defense mechanisms would benefit clients because it would help them identify how they cope with stress and problems in order to analyze their ways of dealing with the world and see if it is helpful or harmful.
Of all the types of therapy that were discussed in class, Motivational Interviewing is the most utilized treatment modality at ACT in Ypsilanti. I do not know if this is the case for all teams or simply because we have a large percentage of substance users and run a pre-contemplation co-occurring group that also utilized motivational interviewing. Also, I conducted research on treatment modalities in ACT settings for another course (Mental Health Policy) and found that Motivational Interviewing seems to be the most beneficial type of treatment to use in ACT settings. CBT was a close second but produced similar results to ACT itself as an evidence-based practice and did not show greater results when paired with ACT.
One of the reasons that Motivational Interviewing is so effective is that the client is at the center of recovery. The client has the choice to heal rather than receiving advice from the therapist. The therapist and client have a balanced relationship where the two are equals, rather than the therapist being on a pedestal and telling the client what needs to be accomplished. This type of therapy seem similar to solution-focused therapy and goal-focused therapy based on the therapeutic alliance and the idea that the client is the expert on him/her self and has the answers, and the therapist used OCEAN techniques to help the client attain self-actualization.
The OCEAN techniques are useful and clear techniques for the therapist to use, especially empathy and affirmations (similar to validation in DBT) and reflective listening. While reflective listening is definitely a skill that needs practice, I do not know how effective it is for clients with severe and persistent mental illness. I have attempted these techniques with clients, and reflective listening is quite difficult, because often clients just give a brief response and sit in silence. Even waiting them out does not phase them! They have so much going on in their minds that sitting in silence is not uncomfortable.
Motivational Interviewing is also especially useful in ACT settings because of the high rate of co-occurrence of substance use. Because this treatment modality is structured to be utilized with this population it can serve a double purpose at ACT. Motivational Interviewing is also beneficial because it can be easily modified for group settings and does not require a certain amount of time per visit with a client to be effective. The only problem that is more of a ‘user error’ is keeping the emphasis on positive behaviors and goals. I have been getting tangled in reflections and affirmations and have not made as much ground work with actually moving towards any type of change or resolution when I use this modality with clients. But with more training, this may be the most beneficial treatment for ACT clients.
December 13, 2011
Solution Focused Therapy
A: What would you like to talk about?
C: I have a problem with my friend. We’re not as close as we used to be. We both kind of went off and did our own thing the last couple years, which was great, and we maintained a friendship that was manageable long distance. And we had phone calls every now and then and get togethers when we were in town, but now that I’m home again, we’re just finding that we don’t have a lot in common anymore. Which sort of makes it difficult to hang out or do much other than just get a coffee once every other week.
A: What have you been doing other than getting a coffee?
C: We’ve just been getting coffees, or going for a walk.
A: How was it when you went for a walk?
C: It was fine. It was fun, but we didn’t really do anything. It was just like small talk and catching up, conversation. It wasn’t going to do something fun, per se. I didn’t really get much enjoyment out of it.
A: What are some of the things that you used to do together before?
C: We would do really silly things, like go for drives to random places or we would plan trips together. We went to Chicago once, and she came to Europe once, to visit me when I was done with school. And we would carve pumpkins together, and like I don’t know, just do random activities that were fun. We baked things together, we made cakes a lot.
A:It sounds like you really had a lot of fun together!
C: We did. It was great.
A: Have you brought up any of these ideas to her recently when making plans to get together? Like instead of going to get coffee or go for a walk?
C: Yes and no. She’s very busy now, or she represents herself as being very busy. Which, I don’t know if I necessarily agree with entirely. I mean, she’s busy, but I don’t think she’s that busy. But, it just often comes down to, we don’t have the time to watch a movie, or we don’t have time to watch a whole movie. Or we don’t have the time to bake a whole cake. Or, for example, if we are carving pumpkins, she’ll have already done it with her boyfriend, or something. And a lot of the things we used to do, she does with her boyfriend, or she doesn’t have the time to do.
A: It sounds like, when she says she’s busy, you’re wondering, is she too busy for me, rather than maybe busy in general?
C: Yeah, I think that’s a fair statement.
A: So you said you had kind of and kind of not brought up this idea before, about doing something different. Can you tell me about a time when you brought up a new idea.
C: I’ll just suggest something, and she’ll just say, oh yeah, that would be fun, but then she’ll follow up, ‘but, I have a paper’ or ‘but I told my mom I’d do this with her’, and it just seems that time and time again there’s always a but, and so I just stop asking after awhile.
A: What could you say to her to express how you feel, like how you’re telling me right now?
C: I have a feeling that if I said anything blatant about it, we would both sort of realize that it’s sort of true that we don’t have much in common, or that we both have additional priorities that sometimes take away from our friendship. So I have a feeling that even if I brought it up, we would both realize some things that I just don’t want to realize.
A: It’s interesting to me that at first you had mentioned that it was that you don’t have anything in common anymore, and you just said that you think she has additional priorities now. Is it more about your changing interests, or is it about the amount of time that she has to spend with you?
C: I think she has less time, and because of that, we don’t do things. So then I think that we don’t have as much in common. So I guess, deep down, we probably both like the same things, but we also like different things. We’ve both grown to like different things when we were apart. And those things aren’t necessarily the same, which may intersect with time obligations, as well. So I think it’s a compilation of things, but ultimately at the end of the day, I feel that we don’t have that much in common because it seems like we can never actually get together to do something, other than just catch up.
A: What are some things that you still do have in common?
C: We love to kayak. This summer I suggested kayaking on multiple occasions, and she was always too busy. She had legitimate excuses, I thought, like going up north for the weekend, or it was someone’s birthday, a family member. It’s not like she just said no, but we ended up not going out at all this year. Which was really sort of upsetting because summer is quite long and there’s so many weekends, and really you can go in Spring, Summer, or Fall. So I just felt like it was kind of pathetic that we could never really find a time. Especially since I’m pretty available. I don’t have that much going on, and I just felt like it was kind of weird that it wasn’t more of a priority for her to then come back and suggest a time that she was free.
A: What are some other things that you have in common?
C: Well, I mean we like a lot of the same music groups, so sometimes we would get together and share music a lot or we might send each other emails, saying have you heard of this band. And occasionally, we’ll send each other songs still, but it’s nothing like it was, and I feel like a big part of my music collection came from her. But then, and this sort of comes in to where we changed, she just sort of got bitter when I was away, and I’d be listening to the radio, to pop hits, and she would turn to me and say, “How can you listen to that shit?” And like something really blunt, and almost borderline offensive. And she said, I took this feminist class where we analyzed the lyrics and they’re so degrading to women. And I can understand that, because they are not nice lyrics often, but I don’t sit there and like think about the cultural ramifications of the youth of America. I just want to dance, and it’s just little things like that that just drove this little splinter into my hand, figuratively, and just little things began to set us off, and the things that we had in common, I started to resent, so it’s just this transition.
A: It sounds like you’ve been friends for a long time and have grown and changed a lot during those years, and she has too. Has there been other times in your relationship when you’ve noticed yourself growing apart from her and how did you work through that?
C: It really started when I moved away to undergrad. She stayed at home and still lives with her parents. She’s never left, so I just felt like she wasn’t stuck in the same high school mentality. She definitely changed in a way, but she had a couple of boyfriends in that time. And she went from being really giggly and carefree to not. She had one boyfriend who she thought thought she was really stupid, so then she got really strict and straight laced and never laughed and never smiled, and now she whips her new boyfriend around like she’s the boss of him. I think after that relationship, she changed, and also, since I was away, it could have been gradual, it could have happened over 2 or 3 years, but since I was gone, I just saw the before and after, and it was kind of a shock.
A: It seems like your interests have really changed in the last few years. Also how she’s reacting to you. What changes have there been in the past few years that you view as positive?
C: She’s certainly changed for the positive, but it’s hard to compare two things, because I’ve changed too, so I don’t know if it’s her change that makes me uncomfortable or my change that makes me feel uncomfortable. So that’s one thing, but I don’t know.
A: People do grow and change, and it is hard, when you’re friends and you come back and see them as a different person. If you think about what your relationship was before and you both have grown now, and your relationship is different now, what would you like your relationship to look like?
C: That’s a really good question because I was sort of evaluating that myself, awhile back, and thinking what are my expectations, and I’ve actually grown more content with our current level that I had been, in the last couple months. It was sort of discomforting knowing we were so different, but then I sort of grew, and I’m not one hundred percent with it, but I’m okay with where it’s at now, and at this exact moment, I don’t want to go back and have it be what it was in high school. Because we are different, and there’s no point in going back and recreating something that’s not real for the sake of doing it, but at the same time, not that she’s a stranger, but just that I’m not an active part of her life, and she’s not an active part of my life, and even though we live like a four minute drive away, I feel like I’m closer with my friend who lives out in Boston, and I feel like I never communicate with Jen as much, which is both of our faults, for that aspect of it, but I guess it’s turning into what it is, and I guess I’m more okay with it, and in a way, I’ve found new friends that fill certain voids in my life because I’m still going out and doing fun things, they’re just with different people, and in new contexts, and it’s just a new direction in a way. And while it is unsettling at the same time, I do see some good that can come of it because it just develops into a new type of friendship.
A: So you can see how you both have changed, and you don’t have the same the same things in common. You know, it’s curious to me, because when we first started out, you talked about how it’s really bothering you how you don’t have things in common anymore and how you feel like you’re not a priority to her anymore, and now when I ask you what you’re looking for in a relationship with her and how you’d like it to be, it’s almost like you’re saying ‘as it is’. Tell me more about that.
C: I guess change is always unsettling in some form and takes getting used to, but I mean, it bothers me because it feels like a loss, and I’m starting to understand that it’s not really a loss, it’s a change. So, it’s unsettling, but I’m getting used to it, and I guess I don’t know if I’m okay with it. I’m trying to convince myself that I’m okay with it, to make it less awkward, because I think that if I tell myself that this is what it is, there’s not much that you can do, so as long as you’re happy you can embrace it, kind of thing. I think it wouldn’t help anyone if I was just like ‘I need you’, ‘I want you’, ‘be my friend’. Because it’s just not what it is, and you know, it’s not like I don’t see her at all, we’re just different. It’s just hurtful in a way because we’re not as close. I don’t tend to share things with her that are close and personal. So, I feel like, the role she used to play in my life, like a support role, she doesn’t really play that role anymore. And that was kind of a hard change too. And since I’m not telling her, I’m at fault too, certainly. Because it’s not like she wouldn’t want to listen to it. She’d be more than willing to chat and stuff, but I have reservations because of the situation, so it’s not really like it’s her fault at all.
A: It’s really interesting to me because you’re main concern initially was your relationship with her, but to me it almost sounds like it’s more of an internal struggle. Maybe not really improving your relationship with her, but accepting your relationship with her inside yourself, and recognizing that you have all these other people in your life who are maybe stepping up and fulfilling these roles that she used to play, like your friend in Boston, who you mentioned feeling very close to. Would you say that that’s a fair statement?
C: Definitely, and it’s just that internal struggle and finding like what’s comfortable and dealing with the uncomfortable aspects. And I think it’s just a control thing. I think a lot of things come down to control and how what once was isn’t, and there’s nothing I can really do about it, and I’m starting to figure out that it’s not necessarily a bad thing.
The move I used is matching. It was effective because I was hoping for him to clarify his thoughts about her being too busy for him. Evidence: “Yeah, I think that’s a fair statement”.
The move I used was a closed question. It was an ineffective move. My desired outcome was to find an exception, but it didn’t work because I used a closed question. Evidence: “I’ll just suggest something, and she’ll just say, oh yeah, that would be fun, but then she’ll follow up, ‘but, I have a paper’”.
The move I used was role play. It was an Ineffective move. My desired outcome was to encourage him to think about what he would say to her, as a form of planning, but he did not think talking to her about their relationship would be effective in solving the problem. Evidence: “So I have a feeling that even if I brought it up, we would both realize some things that I just don’t want to realize.”
This move was my attempt at thinking laterally, but it was an Ineffective move. I hoped to find an exception, but it led to problem saturation instead. Evidence: “She definitely changed in a way, but she had a couple of boyfriends in that time... I think after that relationship, she changed, and also, since I was away, it could have been gradual, it could have happened over 2 or 3 years, but since I was gone, I just saw the before and after, and it was kind of a shock.”
This move is transforming. It was effective because he was focusing a lot on the problem and the negatives, and my desired outcome was for him to think about the positive changes in the relationship, which for him was a new way of viewing it. Evidence: “so I don’t know if it’s her change that makes me uncomfortable or my change that makes me feel uncomfortable”.
This is the miracle question. My desired outcome was for him to think about what a realistic relationship would look like now that they have both grown and changed. It was effective. Evidence: “That’s a really good question because I was sort of evaluating that myself, awhile back, and thinking what are my expectations, and I’ve actually grown more content with our current level that I had been, in the last couple months.”
2nd Transcript: Narrative Therapy between Helper (Alissa) and Help Seeker (Susan)
A: What is something that you’ve been struggling with lately?
S: I have this friend who I went to college with and who was my roommate that recently decided to move to Colorado and followed a boy who’s not very good to her there and to take a job that pays very little money. She has lots and lots of loans. She’s in pretty serious debt and she didn’t really think through any of her decisions. And when she was leaving was very cold and now that she’s there things are going terribly and she’s talked to me about wanting to come back and has asked if she could live with me, which I’m very hesitant to do because of how she acted before.
A: Wow! It sounds like you have a lot on your plate. That’s really tough. How has all of that which has been going on with her been affecting you?
S: It just stresses me out a lot because I worry about her and her money situation is very scary. And in the past I’ve helped her a few times with it, just trying to help her get out of a hole, but I kind of feel like she’s abused that in some ways and now she’s kind of taking advantage of the fact that she knows I have a hard time saying no to her and that’s why she feels comfortable even though she was pretty mean when she was leaving, asking me to help her out again and possibly let her live with me. So that’s a huge stress because I feel like our relationship isn’t the same, and I wouldn’t be comfortable letting her come live with me.
A: It sounds like things have probably changed because she’s been gone so long and making these decisions. You mentioned that it’s been stressing you out and causing you to worry. What does that look like? How do you act when you’re worried or stressed out?
S: It’s very hard for me to sleep. That’s probably the biggest one. I lose a lot of sleep over things that stress me out because it’s very hard for me to kind of turn my mind off at night. When I’m stressed I just constantly play over things that are happening and try to think of solutions to the problem. And I definitely lose sleep over it.
A: Sleep is important, I can see how that would not be a good thing to be losing out on sleep. So, how long has this been going on?
S: She moved at the end of August, but kind of all summer long she was kind of distancing herself when she was preparing to make this move, even though she didn’t get this job till the end of August, and the day she got it, she left. And even though she didn’t know anything about it, like she didn’t know how much she’d be making, and she didn’t plan ahead, she already kind of made up her mind to go live with this guy who is not very nice to her and has treated her poorly in the past. So that was, you know, in the summer, and then she started distancing herself and just kind of pushing people who were important to her away. And so it’s been going on awhile and now that she is really far away, I don’t really feel as bad about our friendship anymore. It’s just easier to forget about it and let it go.
A: It sounds like this has been going on for quite awhile if it was happening even before she left during the summer. During that whole time when she was being distant and after she moved, have there been times when your relationship has been good and you’ve felt positive about your friendship?
S: Not really. I feel like the times she’s called me are when she was feeling lonely and felt like she didn’t really have anybody, you know living in a new place, so she doesn’t really have any friends. So when she calls and is friendly and acts like nothing’s wrong, that just kind of tells me that things aren’t really going well for her and she needs somebody that she knows she can count on but because of how she treated me before she left, I really don’t feel good about her. I don’t feel we have a normal conversation anymore. I try to make it normal, but I feel differently about the entire situation.
A: That makes sense. How would you like your relationship with her to be different? If you could have a miracle happen, and you wake up tomorrow and your relationship is exactly as you would like it, what would that look like?
S: I don’t know. It’s hard to kind of picture that because of how she acted. I’d like for her to be able to call and have a talk and share things that are going on in our lives and such, but not have me feel weird about it and think I’m being used again. But because of everything that’s happened, I don’t think I could actually feel that way. I’d like to stay friends and be able to call her when something’s wrong and have her be able to call me when something’s wrong, but because I’ve felt kind of used before, I don’t see how that could happen.
A: Right. I’d like to kind of challenge you to describe a time since she’s moved away that you’ve talked and haven’t felt used.
S: I can’t really think of a time. She sometimes calls or texts me when something funny has happened or something reminds her of me and things like that, so I guess that’s ok and those are nice things. But generally she calls because she’s upset about something and something has gone terribly wrong again and she needs help.
A: Tell me about one of those times when she’s called you and said something that’s positive.
S: She just called me and said she made it through the first stage of the teach for American process, and so she just jumped through one hoop and has other things to do, but she did call with good news.
A: How do those conversations with her differ from the ones in which she’s kind of using you?
S: Yeah, they’re different. I think that when she calls with something good like that, which doesn’t happen very often, but when she does, she kind of tells me her good news and then she’s more, it’s more likely that she’ll ask me about me. And how things are going with me if things are going good with her, and she’s in a good mood. But when it’s the opposite, then she mostly just kind of talks about her and her problems.
A: Right now if we were looking at a scale from one to ten and one was that you’re relationship was absolutely horrible and ten would be that you have the perfect relationship with her, where would you fall right now?
S: Probably a three.
A: If we wanted to make that three in to a four, not making huge strides and going to a ten, but if we wanted to turn this into a four, what do you think would have to happen for it to become a four?
S: I’d really like to hear her admit that she’s messed up and made some mistakes and didn’t treat her friends as well as she should have when she was leaving.
A: Have you talked to her about that at all since she’s been gone?
S: She has talked a couple times about how she thinks it might have been a mistake to move out there, which is sort of nice to hear, but she hasn’t said anything about how she’s acted. And she still continues to act defiant if any one of my friends tries to talk to her about her actions and the things she did and said to people. So, I feel like she’s sort of made those steps, but the thing that hurts the most is the way she treated everybody.
A: It sounds to me like it’s really her actions that are causing you to feel a lot of stress and worry and lose sleep over it. And when I asked what you would like to be different, you said that you wanted her to admit that this was a mistake and was wrong, but that’s really looking at something that you want her to do. What is something you can do to kind of feel better about the situation and to improve the situation?
S: I mean, I could bring up how I feel and let her know what’s going on in my mind and how this causes me stress. I guess what worries me about that is that she’s going to completely block me out because she’s very stubborn and her way is usually the right way, and if she doesn’t see that she’s treated people poorly, then she’s not going to listen to anything that I have to say.
Effective Move: “It’s very hard for me to sleep”. She externalizes who emotion by stating how it effects her behavior.
Ineffective Move: “And even though she didn’t know anything about it, like she didn’t know how much she’d be making, and she didn’t plan ahead, she already kind of made up her mind to go live with this guy who is not very nice to her and has treated her poorly in the past.” This question causes her to problem saturate and go deeper into the problem instead of continuing in a goal-directed manner.
Ineffective Move: “Not really. I feel like the times she’s called me are when she was feeling lonely and felt like she didn’t really have anybody, you know living in a new place, so she doesn’t really have any friends”. I was trying to find an exception, but since I used a closed question, she said no instead of finding an exception.
Effective Move” “they’re different…she kind of tells me her good news…it’s more likely that she’ll ask me about me”. She finds an exception and start to notice the positive aspects of the relationship.
Ineffective Move: “And she still continues to act defiant if any one of my friends tries to talk to her about her actions and the things she did and said to people.” I used a closed question and got a closed answer. She shuts down and doesn’t move towards a goal.
Effective Move: “I could bring up how I feel and let her know what’s going on in my mind and how this causes me stress.” She recognizes that she can’t change her friend, but she can do something to improve her relationship.
Goal Directed Therapy
Goal-Directed Therapy between Helper (Alissa Bleecker) and Help-Seeker (Lorraine)
A: Hi Lorraine, what would you like to talk to me about today.
L: Well before I go to sleep at night, I always think about my son, Jeff, and that goes on and on and on.
A: Well what have you been worried about with him lately?
L: About his future and the decisions he makes, you know, the ups and downs of his telephone call. Sometime he talks to me and he’s all concerned and the next night he doesn’t bring up the problem again. So I don’t know if he’s dealing with it. I don’t know how he…and then I can’t get a feeling for it. And I don’t get together with him because he’s always so busy. So it’s one thing to talk to a person in person and actually see the facial and physical reactions when we’re talking or I’m listening. And I’m not getting that. It’s worse than…it’s similar to texting or email. You know, to hear the words and the expressions over the phone, but yeah I’m really worried about his future.
A: You’ve just mention two different concerns to me. The first, from what I understand, being your worries about the things he’s struggling with in his life right now, and the second being your inability to communicate with him properly about these things based on the cell phone or technology in general. Which is the most concerning to you?1
L: Well I think it’s all related. When he talks to me over the phone it’s about his decisions that he’s making, or lack of them. And I don’t know if he understands everything about his future.
A: How would you like it to be different?
L: I would like him, as I said to him awhile back, to move on and make a go of his business. And Jodi, his sister said the same thing. He seems to be kind of a night person. He does most things at night, instead of in the morning when his employees are there, and he’s got to correct that. It’s not healthy. He’s gotten his life turned around. And as a result of that, he’s in the dark. Then people take advantage of him because of his hours. And I feel that he…and I ask, and he really doesn’t want to hear that.
A: It sounds like if…
L: If he were there then people wouldn’t be out smoking all the time, do you know what I mean?
A: It sounds to me that you’re very concerned about him and you said that the thing that concerns you the most is his lifestyle. How do you think…I mean you told me how you want that to be different, but those are his life decisions, and seeing that you can’t control what he does, what can you do so that you yourself don’t have to stress out so much about what he’s doing?
L: Well, first of all, I feel that there’s no one else that he can confide it other than me because he has had these physical problems and my husband and I were always there for him. And we went through a great deal of ups and downs.
A: Ok, but right now you’re talking a lot about what’s already happened. What are some ways that you can now deal with the stress in dealing with him?
L: I just tell myself, it’s in his hands. He is making these decisions, and this is all I can do is listen to him and give him some advice, and I try to find answers. Saying, you know to deal with life differently. Perhaps to deal with your employees differently, you won’t have these problems, and you’ll be more efficient.
A: I understand that Jeff is having a difficult time right now, but the things that he’s dealing with in everyday life are not the things that you’re dealing with. What you’re dealing with is him talking to you about these things, and the way he’s doing it is also stressing you out. What are some ways you can make your life less stressful? Maybe in the way you both communicate? Or is your primary stress his actions in general?
L: What I’m telling you is that the way he talks to me is, it’s a need he has. He has this need to talk things over and be in touch. Although I don’t know that much about his relationships. I’m concerned for his future, you know, he’s 52 and I want a good life for him, and he came real close to it, but then things happen when you get hit by a car, hit and run driver. And then he had a rod placed in his leg and he’s still in a wheel chair. So I was hoping he’d be getting around a lot better, but he still needs help going up and down just one or two steps. I think that he really has more problems than he’s had in the past. So I just don’t know about his future, really. And I’m his mother.
A: What about you? What can you do to make your life less stressful?
L: Get a good night sleep.
A: Didn’t you say earlier that he was calling you at night?
L: yep. And that way too, I just enjoy the moment. I try to find beauty in my life. There’s a lot of beauty in my life that I see, and I enjoy those moments. And I am just very aware that I make decisions all the time. And I’m healthy and am aware of an organ in my body that helps me to realize that I’m making decisions all the time. If I feel unhealthy, I try to change the way I’m thinking. I say, you know what? This is really making me uncomfortable, these thoughts, and I don’t like that. So then I try to have other thoughts, and through my illness, I learned to be kind to myself.
A: It sounds like you stay really positive by finding the beauty in life. How can you find beauty in life when you’re feeling stressed out or down?
L: Just to enjoy humor, to enjoy life as it comes, being with my family is very important to me. Knowing that what we have is precious. I don’t take it for granted at all.
A: Based on your enjoyment of humor and family, what are some specific things that you can do to help you feel beauty in life when you’re feeling stressed out about Jeff.
L: I’m an artist, I can enjoy just color. I get up in the morning and enjoy colors. And I enjoy nature. In fact, my husband would say, I would be real worried about something, and I would say, I’m going to go do some gardening, and I would be kind of sad and then I would return to the house, and I was just a different person. And I was relieved, and I didn’t feel all the stress that I felt on the way out. And Don asked, well how does that work out? And I would just work through things. Another thing that I’ve discovered and discussed with other people is when one prunes, it can almost become a spiritual experience. Because you’re out of your body. You’re working on beauty and watching the branches of the tree and you’re completing centered on that trunk and project. And I can do that. And I told me neighbor, and he rolled his eyes because he goes out there with the electric tool and gets everything down at the same level and all, and he gets the job done quickly, and I see the beauty in the bush. Then I can watch it grow.
A: That’s great. So next time you talk to Jeff, if you’re feeling a bit stressed after your conversation, do you think you could do some gardening or art afterwards? Would that help make you feel more relaxed?
L: Not at nine at night. What I do is find comfort in my bed at that hour, and fortunately it works, because I have my favorite blanket and all that stuff, and I’m very comfortable in the bedroom. It’s very warm, and I feel comfort in the room.
A: You’ve mentioned a couple times about him calling at night. And it doesn’t seem like an ideal situation for you. Do you think that it would be better for you, if he were to call you during the day, because if he did, then you’d still be able to talk to him about the things he’s experiencing and at a better hour for you?
L: No, I won’t request that because he has the need for it at night. He’s a night person, so no, I’m willing to do it because I feel I can deal with it. Another thing that I’ve done, I don’t ask him any questions that could make him feel miserable. To go through all the stressful times. I feel a little guilty about not asking some of these things, but if it bothers him enough, he will share it with me. And I don’t bring up the things he’s shared with me in the conversation the night or two nights before. I’ve learned not to deal with the heavier things.
A: That’s good, that you have that system working for you. Could you make it a goal to continue to avoid those topics in order to feel better before bed?
L: Yes, I think I can do that, since he can still talk to me and reach out to me if he wants to.
Examples of Moves and Desired Outcomes:
Leading. Desired outcome: She had mentioned a few concerns, and I wanted to narrow it down to the main one.
Transforming. Desired outcome: For Lorraine to think about what would be a positive and ideal change.
Eliciting Goals. Desired outcome: For Lorraine to make a goal about what she can do to make the situation more positive for her.
Eliciting Goals. Desired outcome: Attempting to lead her into forming a goal instead of problem saturating.
Smalling. Desired outcome: For her to identify small steps towards approaching her problem.
Compliments. Desired outcome: To praise her outlook on life and encourage her to use this as a way to approach her goal.