Intervention with the Individual Class -2006-2007

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Intervention with the Individual 1

Dr. Harel-Brodsky 

25/10/2006

We will discuss:

1. properties of therapeutic relationship
2. specific terms
3. basic skills
4. my place in the relation

Motives to be a SW:

1. wanting to help others
2. make changes for the better
3. return favor
4. take care of others
5. someone needs me
6. controlling inside and outside

1/11/06

-everyone has anxieties/issues, who deal w/ the with defense mechanisms

-the people who’s defense mechanisms don’t work feel that they are at the verge of falling apart and go get help

      àSome even ask for medication to relieve issues! 

• sometimes when people come for felt, we as therapists feel omnipotent – that we know everything and have a magic, instant solution
• Other times, person comes for several sessions and when they feel better, symptomatically, they disappear.
• others leave b/c they don’t wanna change
• In beginning, relation might be strainful

-some things, therapists cannot do: can’t undo loss of dad but you can help relieve some  of the pain.

-sometimes, “being” and giving warm relation goes a long way 

-so often people go for treatment want to deal w/ personal story

      -the fact that we hear ourselves speak about out problems helps him 

-people are ambivalent about the beginning: they want to change yet do not wanna change

-others go to treatment for satisfaction: want answers, advice/write our BTL instead of them 

Gotta ask the question:

1. what does he want
2. what does he really need

-kid wants toy to the point he is making tantrums in middle of mall,

-he really needs boundaries 

-also gotta have basic trust at first

-we gotta have boundaries as well empathy 

-empathy: taking part in someone else’s world w/o losing our identity

-We try to see clients’ world as if it was ours – it’s not really ours but se want to see his world (yet we know were we are) – we are willing to give up our life-space in order to see his life-space

      àOnly when we “leave” back for our world, we  can help 

-empathy is not joining in feeling/attitudes/Rahamim/”this also happened to me”/can’t always help 

-empathy is not identification! 

-in empathy, there needs to be a diff. b/w therapist and patient 

8/11/2006

-read the empathy articles

-First semester test, second semester a work that is to be handed in at the last class 

-today’s class was a discussion of each student’s feeling of his work  practicum 

Class 15/11/2006

-today, we’re going to speak about the first meeting 

-the therapy contract is what happens the first meeting. It will shape the rest of the therapy process with that person.

-There is a balance b/w you, client, context, etc… 

Here’s some stuff we need for the therapy contract

-We have to remember that we’re dealing w/ people

-the contract really starts in the first phone call

I.e. cancel 24 b/f if you have to cancel, etc… àrules are set into a “contract”

-say what we expect to do there as therapists

4 factors in the therapy  system:

1. Physical conditions – what we put in the room (i.e. if we put family pictures/files of others in the room àhow the room is, that will infl. the non-verbal that person will receive. You can also state the fact that you don’t have a room, so our temporary place is X gotta remember that when we’re part of an organization, we’re bound by they resources, so we have to stress that as part of the organizational rules

2. Contractual factors: privacy/length of meeting, etc…

3. Therapeutic relationship: 1) anonymous, 2)neutrality, 3)non-judgmental 4) this is non-equal since I won’t say my opinion. Those things might not be said explicitly. This is not a social meeting. We might explain that therapy is about thinking about things that come up and thinking about how it influences your life.

àThose things might be said t/w the end of first meeting

-the essence of treatment

      -the contract (and the therapy goals) is flexible 
 

4. therapist idiosyncratic  – the therapist’s personal rules in the bargain – if you leave, h.m. meeting b/f do we work at resolution

Class 22/11/06- empathy

-people come to therapy when they can’t contain themselves. Containment is like holding. W/ small kids, it’s physical. With adults, it is more emotional/mental – i.e. empathy. SW needs to be able to contain person despite all his problems. When people are overwhelmed, they need a place to contain themselves. Don’t need one event to be overwhelmed – it could be a whole long series of chronic stuff. His defenses are strained. He wants to get acceptance of his feelings. Only when he feels that his feelings are ok, is he able to deal w/ the issue. You need to relate to his emotions first – i.e. “must be hard to feel so hopeless!” we have an ability to see beyond problem, not b/c we’re ignoring it but rather b/c we are (as third person) able to see the repetition, etc.. 

Empathy is the ability not to shut up (i.e. ignoring what she’s saying –i.e. you must feel tired of me as a client”, so SW should answer – “you must feel awful thinking that people get tired of you) – deal w/ his feeling. Empathy is not only saying “wow, that sucks”, but also to see the logic behind it. We have to see how the dysfunction was the best way to deal with something in the past. Past reasons for doing something become current motives as well.

-empathy is not feeling sorry for the guy but rather getting into his shoes 
 

-Person often comes to therapy with an externally based view of themselves – “I am XXX [b/c people said XXX about me]”

-therapy will try to help guy find himself, and what he really thinks 

-therapist has to accept that client’s culture/goals are not the same as his

      àYou have to relate to what he sees as his problem- we can’t relate to what we  sees as problem 

-gotta balance b/w his expressed issue for coming to SW and the offer to deal w/ other issues. We can’t force the other issue on him but we can suggest that we’re willing to help 

-in cultures where you go to tribe head/rabbi, and you finally go to treatment, you have to realize how much trouble he is in.

-In different cultures – different explanation for different symptoms (i.e. depression = chemical changes vs. wrath of the gods/god’s will) 

Class of 29/11/06 – cancelled b/c of strike

Class – 6/12/06

-read for test up to article 14

Things to keep in mind

• contract
• interaction:
• relationship
• content
• task

• listening

intake meeting:

• Beginning: we have to explain why we're there. Especially when we initiate the meeting
• Second part of first meeting –exploratory - see what the issue is
• Ending first meeting – summing up what was said/opening the door for next time. Don't open up new stuff at end. Door symptom – saying the most important thing at the door – could run away/hard to separate/fear of exposure – therapist must ask to bring it up next time

-sometimes, we take a trial beginning to see if person really needs this – does the person just ant ńě ůé÷ĺí and that's it? Or does he want/can he benefit from therapy? 

Interpersonal communication:

-the verbal/non-verbal communication is the core of therapeutic work. Through this, the client tells about the past/present/context

-we need to evaluate through this info - how the client expressing through feeling/his characteristics/etc…

• we can have hypothesis here
• ask questions to get more info
• mirroring
• might distort what we're saying [for defensive purposes]

-we have to remember that this meeting is not a friends meeting. Thus the different body languages are differently understood by the context of who is the client. Thus we also have to ask ourselves what the context of setting is – are we working in an institution –is this institution acting under law? This could make the difference in differential non-verbal cue's meaning. 

Class, 13/11/06

-one of the things in therapeutic meeting: - a two-factored approach: content+relations/content+process 

-perhaps the division b/w what is said and what is beyond the word

-me as a mirror to the outside world. Content is the info, while the relationship reflects more unconscious stuff 

More factors

• what is said vs. our goals – could be seen in wanting to go t/w goal and pulling back
• listening – we have to first listen. But we also have to see what he's saying in his body language. Is there a gap b/w content and non-verbal cues? What does X mean in his cultural? What person negates is also important – i.e. if client speaks about mom all the time, the real question is what's up with dad?
• Our reactions are also read. And our reactions are understood differently in different contexts. We have to be careful about our non-verbal cues b/c it might be read as joining someone else's side/etc…

Some cues we have to be aware of:

• distance b/w therapist and client – men like more distance than women. We can also see how the clients move closer or further depending on where they are. Is our body posture closed/open

class 20/12/06

class cancelled b/c of strike 

class 27/12/06

-most of today’s discussion was a discussion  

Test:

-multiple choice – 2 choice questions – read up to 14^th article.

-articles w/ case study –need to know the dilemmas. Not the details

-need to know basic concepts – need to know the essence and not the small details 

-- 

Question: what do we do in therapeutic intervention?

Answer: until now, we spoke of content/latent content [i.e. what is not said/non-verbal cues:

• at what point person reacts in certain ways
• how is our reaction to the client?
• does the client make us feel something different in a specific meeting. For example, silence in beginning of the process might be different later in the process
• our cues are meant to facilitate their speaking

-we, in essence have to help the client bring forth the internal world of the client

àbut we have to see if he is really to bring up things –for deeper things, need more basic trust an this takes more time. There is an issue of timing – when we bring up things, along the cultural sensitivity/etc…

àbut some of  SW action are always good:

• listening – we’re so busy with what we’re going to say that we’re forgetting that we need to firstly listen and not overcharge the verbal content of the therapy important: we need to listen also to the content, but also the non-verbal/latent info/info given through the acting act. The therapist should limit the amount of speaking he does so the client can speak about his content/associations/etc. àthis is hard b/c of  therapist’s narcissism

class 3/1/07

tools of therapy include:

• listening: don’t control situation/minimal reactions, perhaps when situation is stuck/get more info
• important for us only to do things that are beneficial for the client
• the question: it could be a great tool, but it could be tricky.
• For example, if you know the answer, ask it. For example, could it be that ABC.
• Topic development questions
• Transference questions

Kinds of questions:

• “why” – unpopular w/ therapists – it has a criticizing tone to it – could be felt as intrusion. Also, the client doesn’t also doesn’t always know the answer, so he might feel that he’s being intruded on. You can phrase it differently
• Questions with answer in them: you can’t refute the answer yet they might not reflect his internal life, and he’ll feel it
• Open question: allows chance to really answer us
• Closed questions: don’t allow for real answering

-sometimes we want more info so we ask him:

• what do you mean when you say ABC

silence:

-silence is part of the therapy – you can’t negate it!!! As a therapist, you have to see where the silence is coming from:

• disorganization
• anger
• pleasure
• etc…

-we have to give room to the silence!!! 
 

Echoing

-using his words in order to hear himself. Taking his words and repeating it

C: “it was very hard for me!”

T: “it was very hard for you”

      àhelps person know that you’re firstly listening to his feelings 

Clarification question:

-“do you mean ABC?” 

Mirroring:

One step beyond echoing:

àhere, we’re not only echoing, but also giving words to the things b/w the lines 

i.e.

C: “I don’t like speaking about divorce”

T “you must feel scared of divorce” àleave room for client to disagree 

Interpretation

-some claim say that this is the most important thing in therapy 

-interpretation, gives explanation/logic of client’s actions/speech/etc…

      -it gives light to deeper processes.

            àit helps person organize his deeper feelings and thus better control them 

-gives logic to that which has been experiences as chaotic

-this comes up a bit later in later sessions – not in intro sessions 

Encouraging

-be very careful with this b/c this might come across the wrong way:

• dependency – that I need to verify client’s actions/thoughts

-best encouragement: you’re very brave to do ABC [not “very good”] 

Class 10/1/2007

Class discussion of a specific case of one of the student’s clients 

Class 17/1/2007

-today we’re going to speak about system

-a system is defines as a group of people with certain rules 

Characteristics

Structure/borders/relations b/w factors in system/time 

-social structure is interactions b/w individuals over time. We can even say of an individual that he is a system. A system always as a contexts w/I it, it exists. The surroundings is part of a bigger system. i.e. university is in a neighborhood, which is not part of the university but the bigger [physical] context – there are borders and hierarchies among the systems. The borders are usually somewhat permeable – i.e. some non-students can also enter the university

-a person could be part of many systems: a person is also part of a family/university/work – the different systems influence each other.

-some organizations [i.e. university] ignores the other systems of the person, and this creates an easier life for the university, but not for the student [i.e. if university has certain demands, it ignores other issues that person has do deal with [in other systems] 

-we as therapists have a specific goal, but sometimes the client is somewhere else and it has to be deal with

-borders are diff. for diff. systems. Some have clear borders. Others have less clear border. Some have clear or less clearly defined borders.

-an open system interacts with surroundings. Closed systems have almost no contact with surrounding. This is influenced by how threatening it feels. For example – some feel that it is unacceptable to have TV/radio 

Change in the system:

-occurs when there is tension b/w the ideal and reality. I.e. when someone changes his role of being the black sheep – so the system looks for another one/go to therapy b/c they feel they are falling apart

àThat’s why you need to look at the whole context when you’re treating someone

End of semester 

Class – 7/3/2007

Diagnosis: we get some disorganized data and put them into defined categories (analysis) àits meaning s synthesis 

-we diagnose out of our prior knowledge: we will try to prove or refute our hypothesis based on info we’re constantly getting from various sources 

Diagnosis: is our theory of what is happening – based on facts and explanations of them, as well as some looking at the future [i.e. knowing that by 40, ASPD calms down a bit]. We have to remember each psych approach has its own weights and give diff. emphasis , w/i the diagnosis. Bur whatever approach, we still have to gather external info and have the predictive element. Synthesis – see the connections. So thus, we need to remember which elements to look for in intake 

Intake elements to be looked for:

• time: history/present [what is he doing now]/prognosis
• history:

• dynamic: client’s defense mechanisms/the connections/commentary that we give him
• processes element: today the emphasis could be one thing, with time, things could change

data to be collected:

demographics: - we can find out in various levels according to therapy level

• city
• immigration
• family
• lives w/ today
• housing conditions
• economic situation
• health

-the data may spark new questions; i.e. age gap b/w parents/kid/suicide/old kid living w/ mom/other norms w/i soc 

• why did you now? [this also underlines his way of thinking, and possible solutions] – we can see if he speaks abut problems in other/over-intellectualism/prob. w/o solution [i.e. it is in my blood]/conditions that client sets that blocks therapy – i.e. b/c my dad died – so he can’t change anything given that condition àthis warrants the question of whether the person is scared of change

-at the end of all of this, we will say something about this guy’s personality/interpersonal and internal life 

Personality: is the homeostasis b/w energies w/I person: id/ego and its functions/superego/conflicts b/w them 

14/3/07

-info about past – imp. For current life – b/c we learn why person specifically deals emotionally w/ certain issues. Did baby have good dependency/continuity  

Things we look at in beginning

• early relationships
• The ability to leave ôřăĺú – i.e. leaving high-school/army
• Tasks in self-achievement
• Interpersonals; does he have close friends/trust/ask for help
• Intimate relations: what kind of partner/parenting does parent things he has [i.e. does he only define himself as parent/can person speak of himself as a partner
• Important events. Does person bring it forth? How does he define it

àthen find connections b/w them based in our professional knowledge of:

• normative development
• psychopathology
• relationships in families
• internal world of person –i.e. defense/personality organization/maturity

àthen we have evaluation: personality/life space/skills and weakness/his vs. contextual influence/ etc… [seeing the gestalt – the whole person/his situations/systems]

àlook  at past/present/future àfor future, got to see person’s motivation as well

            àthe evaluation infl. How we will proceed in  
 

Questions

• what?
• Why did you come [how do you see the problem]? [perception problem]
• why did you come now? [timing question]
• i.e. if one kid went to therapy and b/c ok àwhy did other brother b/c problematic [identified patient]

-also imp. to see:

• where he lives w/I context of society: 35 year old living w/ mom
• personality:
• what is the maximum he can do/is he rehabilitable
• motivation – i.e. does he want to change/what does he want to change
• how much can he tolerate change
• is his expectations realistic

Personality structure

• relationship b/w id/ego/superego
• see personality w/I specific current situation – people b/h diff. in diff. situations
• Thought process:
• are there signs of things from past? Thought is supposed to be the spontaneous/creative part of life. The question is if ego constantly represses creative impulses
• mature love: Capacity for concern/consistent love/balance b/w emotions and intellect

class 21/3/2007

things we’ll look at w/ meeting a person

• personality structure
• ego functions
• defense mechanisms

personality structure

-some questions are asked when meeting a person:

• past events still haunting him?
• Does this infl. His thinking? This infl. His emotions too
• does ego regulate impulses – ĺéńĺú řâůĺú
• is person able to have mature love –i.e. mutual care
• does person not have balance?
• Too emotional to intellectually understand what’s flying, or vise-versa
• is there stability or lability in emotion?
• Anger t/w parents which makes function in present?
• Is person able to see goals in conflict
• Reality perception: does he distort reality?
• How much is his identity coherent? How does he perceive himself? [grandiose/degrading] àCan person deal w/ criticism w/o it breaking up my whole personality
• How does person deal w/ organization he’s in [i.e. also take responsibility]
• Is intelligence w/I normal range [vs. below or above]
• ST/LT memory problems?
• Is concentration ok?
• Got to watch out for diff. in culture

Defense mechanisms:

-supposed to keep balance in internal life

àdefend against emotional pain

      àjust like baby sleeps in order avoid over-stimulus 

-when we have intrapsychic conflict:

• drive vs. drive
• reality vs. superego
• superego vs. is
• id vs. reality

-so this causes anxiety and defense mechanisms are supposed to help us run our lives normally 

The differences in the defense mechanisms is:

• primitive [i.e. less integrative] vs. mature
• rigid vs. flexible

-we all have defense mechanisms. But the ones coming to therapy are the ones where the defense mechanisms aren’t helping as much as he’d like or distorts reality/our functioning 

Class – 2/5/2007 

-today, we’re gonna speak about the 12 functions of the ego

Freud: there are 3 structures making up the person

• Id: most inate things stem from here
• Ego: helps id deal w/ reality – develops later
• Super-ego: after things of the ego have been internalized in “my own” – it is  an internal motivating force

12 functions of ego:

Reality testing

-seeing that person’s action or thinking are reality/normative

àthe main thing is: seeing the difference between inside me and reality

àif not: psychosis 

Judgment

-Does person understand cause-and effect? Also socially? 
 

Reality experience:

-the experience of reality and myself] as being real. If not: derealization [reality is foreign to me] or depersonalization [I am foreign to me –i.e. eating disorder: this is not really my body] those are often seen in panic attacks

-in psychosis, it is extreme 

Drive management:

-the ability to deal w/ drives: know when to hold in frustration. i.e. not shouting back at boss/dealing and holding w/ anxiety

-also: how do I express drives: do I deal w/ drives: blow things up/acting out or dealing w/ it is more subtle ways: talking about it later. The other extreme is holding in drives too much. i.e. the one who doesn’t see/speak about his anger. The ability to express emotions/drives is the integration of socialization and temperament/constitution [i.e. inborn drive level]

àof course, we have to see how this plays out in reality: i.e. if we deal w/ something extreme, i.e. news of a death. There, we’d expect les of a person to deal w/ frustration than the regular frustrations of life 

-ĺéńĺú řâůĺú 

Object relations

-those theories deal w/ how I interact w/ others – i.e.:

• how do I choose my friends
• how symbiotic am I/how distant vs. close am I?
• how long does relationship last?
• Object constancy [i.e. how much can I maintain the relationship even if the other is not here?
• How differentiated am I?  [i.e. narcissists see their kids as extensions of me]

Those things develop w/ therapy 

Thinking processes;

-the thinking level relates to perception/concentration/memory/expressing verbally the thoughts 

Primary thought: no time/space/logic –the wills are real: “I need”. There is no concept of cause-and-effect. There is no symbolization in primary thought –it is overly concrete. Thus, dreams are not necessarily all symbolic. 

Secondary thought: more rational/has time-and-space/cause-and effect. I don’t “need”, but I “want”. It has symbolization 

Winnicot/ogden: there are people who think in “a-dog-is-a-dog” fashion – can’t see the symbolism here! [case-study: kid who sees puppet-play and got confused: couldn’t see the point – was too busy thinking how it was done, and not about the plot or the message or underlying themes] 

Class 8/5/2007

Assignment discussion:

-also relate to ways of thinking in anamnesis of work

-speak about ego functions

-add when problem started 

When does therapy end? How do you conclude a therapy?

Views:

1. symptoms are reduced
2. ability to have intimate relationships – it usually develops fully by the end of adolescence –i.e. fully see person as a fully separate person- if not, lower differentiation [i.e. what I/he wants are enmeshed]
3. structural difference in personality – i.e. more mature defenses/more varied defenses
4. changes in transference/counter-transference: allows for better interactions

-those above views relate to unforced ending. It contains mutuality. But then there are cases of forced ending; end of practicum, birth/fleeing from therapy/etc. in those settings, the ending is not necessarily processed or mutual 

-we don’t want the ending process to be rushed, so the client can process. We may meet previous endings of client which were traumatized, and are now reactivated. 

-there is a bereavement process in loss 

Expected stages:

1. shocks
2. accepting the loss – anger might come up. Davis speaks of the sense of rejection in the following way: you scammed us into their relationship and now you’re laving, after I invested emotional energy into this! –the anger might be turned inwards – I am now worthy of relationship. There may have very primary forms of dealing with loss coming up: i.e. splitting [you’re the best – system sucks for stopping the therapy], rationalization [i.e. its no ones fault – yet no dealing w/ the pain], etc…
3. accepting the loss

-we can use our emotions to see what is going on into the room – i.e. if therapist feels guilt for leaving, then there may be idealization by the client, etc… 

Imp:! we need to allow the client also to speak of the pain/anger/sense of disappointment or rejection/etc… 

-we may have some less mature parts us who feel anger or something for the client leaving off, but we also have to relate to our more mature part that says: “ok – it is what he wants” 

-even in forced concluding of therapy, there is also room for summary –of what did take place/what you can work on in the future [of course, after the anger phase of the client]

àsometimes, client moves on to other therapists, but sometimes he doesn’t – we have to prepare client for either case – in ay case, we must allow for his feelings to come up 

Ending stage:

-this ends the concluding part:

-important to speak about what happened in the therapy/ speak about what growth took place/what he internalized from the therapist [i.e. next time X happen, what would you say/what would I as your therapist say]. What is hard about the termination of therapy? What is client scared of will happen after ending of therapy? – speaking about the ‘day after” the therapy, reduces the stress/pain of the loss of completion of the therapy 
 

You might see:

• Anger/denial/new material [don’t let that happen]/renewing the therapy – i.e. through regressing/speaking with more detail – as if to say – “see, Mr. Therapist! We did not do anything yet!”
• direct blaming
• passive-aggressive – won’t speak/interrupt the therapist/etc…
• sadness
• anxiety of what will happen after the therapy
• blaming oneself
• regression  -symptoms reemerge
• person comes late/forgets sessions
• experience of rejection by therapist – so I control what’s up – so I, and not you say: “it is me and not you”
• it is important to speak about those things, b/c this may be the first time/place he’s speaking about emotions

-we may also be ambivalent so we need to hold him as well as deal w/ our own uncomfortable feelings about the conclusion 

Class 30/5/2007

Evaluations: example

ăĺ"ç äňřëä – ůí, ú.ć.

čě, ëúĺáú

ř÷ň:

áď 26, éěéă ŕĺ÷řŕéđä, ňěä á1923 (ŕá ěáď 3 ĺáú 2), îâĺřř áçĺěĺď. îĺáčě ĺîú÷ééí î÷öáú áč"ě, ňě ř÷ň... ĺâí ŕáçđä ňí éů

• kid’s info about his pregnancy, health, etc…
• developmental stages, and how he was describes at those stages [i.e. withdrawn/no friends]
• family background and info – what parents do/work/relationship/diseases/new family/ parents divorced or remarried/parent’s atmosphere/etc…but tell the story through patient’s eyes
• Schooling [add problems if they exist]
• Army [and problems if they exist]
• Work history [and problems if they exist]
• When problem got worse/outbreak and history of problem/hospitalization – current treatment and problem status
• Family background:
• Mom’s history/job/health/personality as how it comes out t/w patient/relationship w/ patient
• Relationships in the family [be specific!]

-the first part should be very objective – no interpretations 
 
 

--6/6/2007--

After that:

reason for referral  it gives baseline for therapy/prognosis. It also says a lot about motivation, defenses [my wife is…./I need welfare benefits]

àyou got to ask: why did he come now? What happened now? [why did her defenses collapse?] 
 

Then:

• current therapeutic relation – can you say something about patient through the therapy
• personality: i.e.:
• Intelligence
• Defense mechanisms – i.e. tends to run away/poor emotional regulation in times of stress/projections/splits
• Interpersonal relations – i.e. close vs. distance conflict and he chooses extreme closeness and then throws them out

            àspeak about experiences and also using dynamic terms

àdependency/existential threat/locus of control [i.e. black sheep]/ego strengths/is his feeling of competence realistic? Diff. b/w her abilities and her perception of them. Is the parts of her personality integrated? Can she make that integration 

Dynamic formulation: this is an open clause for what we  think: what we think is the external logic àmaking sense of everything we said until now. i.e. in the past, she had many unprocessed losses, so she gets sucked into relationships w/ separation anxieties. And w/ differentiation hardships, she does splits b/c that is her way to deal w/ separations/losses 

• got to see motivation – does he want the help? Can he deal w/o treatment when he doesn’t want
• is what we offer what the person really needs?
• What are the goals of our treatment plan?
• Prognosis: will it help? Does he really need our help

-- 
 

Class-13/6/2007

Ego functions

• Reality testing =past/present/outside-vs.-inside differentiation
• ůéôĺč – ability to see future based on what we do now
• Drive regulation = how do I react – aggression
• Object relationship = the quality of relationships w/ others
• when well developed – ability to see personality nuances/all parts of the person
• neurotic – we can’t see all parts of others b/c we are too busy looking at ourselves – i.e. We’re too busy w/ our neurotic narcissism, we’re looking at his evaluations
• depressive – do the split à good and bad
• too busy w/ themselves – too busy looking at selves to see others – person is a function/extension of me
• borderline – no integrated sense of the other – idealization vs. devaluation
• schizophrenic –empty
• thought processes – perception/memory/verbal expression of thought
• Regression in the service of the ego –
• regression could also be good – when moving from reality to looking inside/fantasies/creativity àwhen they cause pleasure and are adaptive. If not adaptive, then it is bad and feels that way too
• Very rigid regression
• Chronic regression = bad àneed to be able to get out of fantasy
• Regression w/o inspiration vs. those who are able to use fantasy to build something –i.e. comics/artists/speakers/etc…
• Defense mechanisms – are a measure of ability to deal w/ internal conflicts/conflicts b/w inside and outside world. The main question is how much they serve my ability to adapt to reality àwhen they collapse, the person b/c overwhelmed
• Some are more primitive – usually unable to reduce anxiety
• Projection: I am perfect while other
• Split [related to projection] – I split and then project all the bad to others
• Extreme denial
• Reaction formation
• Somatization
• more mature defenses
• rationalization
• displacement
• internalization
• stimulus threshold ài.e. how we filter our stimulus – can I deal w/ overly intense emotions? Do I need strong stimulus in order to react
• sublimation

• Mastering
• Competence – is he able to do tasks
• What is self-evaluation regarding task = able/failure
• The link b/w them = if there is a bigger gap =more of a problem
• synthetic/integration factor – the ability to deal w/ ambivalence/internal contradiction in stance/emotions = able to have conflict. i.e. id v. superego and reality or ego’s multiple [contradictory] tasks –i.e. integrating both loving and hating t/w same person ài.e. opposite of split àintegration of all emotions/stance/reality àis our experience more 3-D/full?

àlack of this is for example laughing at tragedies/living day to day w/o big plan

End of Course!

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Bloom article

Specifying Problems and Goals: Targets of Intervention

Bloom, Fisher, Orme (1995)


1. Intro: From General Problems to Specific Targets of Intervention
1. If you clearly define a problem you have taken a major step towards its solution
2. Professional service begins with the question: what client problems need to be solved and what goals need to be achieved?
3. Specifying the problem is essentially the beginning step – identification and clarification of problems and goals are difficult because of the many ways one might try to get hold of these complex human events
4. Target refers to the specific object of preventative or interventive services that is relevant in a given situation – there are several ways to think about what aspects of the client’s life situation we want to influence
5. Operationalizing means that you clearly specify the actions you would go through in order to observe or measure the client’s problem – this can be done through standardized test or recording certain repeated actions (ex: how many times a patient cries during an interview can be a measurement of how depressed a client is)
6. There are many ways to specify measurable operations that indicate the nature and extent of the target – which ones you select depends on the nature of the case
7. Being clear and specific about the problems and goals allows for the selection of both specific intervention procedures and specific measures related to these identified problems and goals – by repeating such measures you can know explicitly what changes are occurring in the target and adopt suitable responses
8. Sometimes you may need to break down a complex problem into component parts if possible – as each component is changed, the enire complex problem becomes modified
9. Specifying problems and goals lead to more precise selection of intervention methods and related procedures, clearer evaluation of results, ad more effective services
2. Specifying Client Concerns: Identifying and Clarifying Problems and Potentials (move from an area of concern felt by the client as problematic to a target on which client and practitioner can agree to work)
1. Preliminary Steps in Identifying Problems
1. Survey Client Concerns: Starting Where the Client Is
1. Review all the matters of concern to the client
2. This is a preliminary survey of the problem bout how the client perceives the problem
3. This can be done through a list from scratch or a check list
4. It isn’t necessary to go into too much detail at the beginning
5. Go over the list with the client to make sure it is complete
2. Select a Problem
1. Its very difficult to focus on one problem and be as specific as possible in defining it
2. Some practitioners prefer not to select a problem until a more comprehensive assessment has been conducted and others prefer to select a problem prior to the formal assessment process
3. Problem selection involves two steps: 1. determining the priorities within the problem/situation, and 2. specifying the problem per se, or moving from the vague to the specific
4. It is recommended to focus on strengths or assets when possible and attempting to increase or build on these strengths rather than trying to decrease deficits because: 1. it is easier to build on strengths than decrease negative behavior, 2. by focusing on increasing positive behavior you will more likely receive support from your client, and 3. it is more compatible with our values as helping professionals
3. Prioritize Problems
1. Review the written list of concerns that was developed earlier with the client
2. Select one concern because this is the best way to marshal resources
3. You should attempt to work with the problem that meets as many of the following criteria as possible:
1. It is one that clients prefer to start with or about which they are most concerned
2. It has the greatest likelihood of being changed
3. It is relatively concrete and specific
4. It can be readily worked with by you given your resources
5. It has the greatest chance of producing the most negative consequences if not handled
6. It has to be handled before other problems can be tackled
7. Changes in the problem will result in tangible observable changes which will increase the patient’s motivation to work on other problems
2. Guidelines for Going from the Vague to the Specific: Operational Definition of the Target of Intervention
1. Help the client operationalize problems – help them redefine them in more precise, observable terms
2. This helps the client and practitioner get a clearer understanding of the agreement about the nature and occurrence of the problem so that they can take action on it and so that they will agree on what is to be changed
3. This also helps the client and practitioner evaluate their practice
4. The problem becomes operationalized as the target of intervention
5. The use of this model will help clarify some of the conditions that may be affecting particular occurrences of the problem
6. Clarity
1. The job of the practitioner in these cases is to help translate vague or even inaccurate descriptions into specific and accurate ones
2. Ask the client to give concrete examples of the occurrence of the problem
3. Ask the client to try to identify when and where the problem occurs, perhaps to actually observe and record its occurrence
4. Consider doing a function analysis of the relationship between the problem and the personal, interpersonal or environmental events that could be affecting the occurrence of the problem
5. A-B-C model: A refers to antecedents of the problem ; B refers to the behavior or the actual occurrence of the problem; C refers to consequences, what happened as a result of B
6. A-B-C model will help clarify the problem and may even give some preliminary ideas of intervention
7. Countability
1. Think in terms of counting in order to start thinking in terms of how often the problem occurs and how long it occurs for
2. Turning vague, global statements into specifics can help pinpoint the problem
3. Focus on specific occurrences rather than on generalizations or motives
8. Verifying Sources
1. Try to find a way of knowing that the problem does in fact exist and a way for documenting when, where, and how often it occurs
2. You can do this by observing the client’s behavior or looking into agency records
3. Think of the problem in terms of the possibility of two or more people being able to agree on its occurrence
4. When it is possible and agreement between client and practitioner is reached, you should have more precise idea of the nature of the problem
9. Dereify
1. One major impediment to defining problems in specific terms and with real world referents is what is called reification – refers to the treating of abstractions or constructs as though they were real things
2. In order to avoid this you must convert the abstraction into an adjective, for example: turn “mary is aggressive” into “mary demonstrates aggressive behaviors” – then you need to identify what those behaviors are and then describe the situation in which the behavior occurs
10. Increasing and Decreasing
1. Thinking of what needs to be increased and decreased almost automatically helps you pinpoint and specify problems
2. This can also be used as a guide for intervention techniques – focus on increasing or decreasing behaviors, thoughts, or feelings

h. Measurability

1. Consider diff ways a given problem can be, or has been measured
2. One of the key guidelines to think about when helping clients define their problems is how these might be sensitively, but more or less objectively, measured including how other practitioners have measured them sensitively in the past
3. Case Illustrations of Operationalized Problems
1. Many examples of cases
2. Each case share some basic characteristics in how they operationalized the problem
3. All of the measures used were indicators of the problem, and to be successful, they had to be as close as possible to the problem without being burdensome for anyone to use
4. The measures involved thoughts, feelings, actions of individuals, as well as collective actions of groups or clusters of people
5. Practitioners had to be careful about whom they asked to collect the data
6. Every practitioner can come up with some reasonable and innovative measures customized to the situation at hand
3. Specifying Goals and Objectives
1. Problems involve what currently hurts or disturbs the client; goals are preferences about the future
2. Goals indicate what the client would prefer to happen, to do, or to be, when the intervention is completed
3. Goals provide the standard or frame of reference for evaluating whether the client is moving, and whether the destination is met
4. Goals provide the opportunity for ongoing feedback and help decide whether the end has been attained
5. Unfortunately, goals are stated in abstract or vague terms
6. Definition of Terms: Goals and Objectives
1. Goals are statements about what the client and relevant others would like to happen or do, or be when the intervention is completed
2. It is necessary to first move through a sequence of manageable steps or sub-goals (intermediate goals, objectives, outcome objectives) which are defined in exactly the same terms as goals
3. A objective for one client may be a goal for another
4. Objectives or goals are outcomes for the client rather than interventive activities or tasks in which the practitioner is engaged in – all goal and objective statements refer to client or client-system attainments; interventive tasks can be specified in a separate statement
5. Expect that the intervention will have an effect on the selected targets – a target that isn’t the focus of an intervention is unlikely to improve in response to that intervention, and this can give the misleading impression that the intervention is ineffective
6. Goals are directly related to the problem and should reflect that relationship
7. Components of Specific Goal Statements
1. Specify the problem and then it’s the practitioner’s task to develop clear and specific outcome objectives and goals that can serve to guide the rest of the intervention process
2. Try to develop specific outcome goals for each problem encountered – might need multiple goals for one general problem area
3. Goals and interventions should have at least 4 components
1. Who?
1. Objective and goals should be stated in terms of intermediate and ultimate outcomes for the client (do not state goals in terms of what the practitioner will do; that can be defined as intervention methods or procedural objectives)
2. Outcome goals should be stated in terms of what the client will do or be like when the intervention is completed
2. Will do what?
1. Attempt to state in measurable terms what clients actually will be doing to show that they have achieved the goal
2. Some performances are obvious and others are hidden
3. Think in terms of indicators – when you have some direct way that will indicate the presence of the alleged performance; this direct way becomes the key measurement indicator
4. May be helpful to think in terms of increasing or decreasing the targeted problem – stating the goal in terms of what the client will be doing, linking interventions with this goal, and suggesting ways of measuring outcome
5. Try to state the goals in positive, not negative, terms
3. To what extent?
1. Establish how well and how often the target event occurs – establish a level of performance (criterion level) that will be acceptable
2. It is important to establish a baseline in order to use for comparison with changes in the target during the intervention program
3. Sub-goals are most important because the achievement of them will then serve as additional reinforcement or motivation for continuing on the next step
4. Sub-goals should be set in ways that are as close to achieving the goal as possible but that are comfortable and realistic for the client
5. Success or failure in achieving one objective can provide information on what the next objective should be
8. Using Statistics to Set Goals
1. Must be precise in identifying what you are shooting for in terms of an actual target; when this isn’t easy it is recommended to use statistics
2. Goal setting is usually done in the context of client and societal values or physical realities; use statistics when there are no natural markers and social values are unclear
3. Use baseline information to set a level for the intervention phase at which the change will be statistically significant – plot the data received from the intervention phase on your chart and see whether it is significant
4. Setting Goals in Groups
1. Difficult to identify and operatonalize goals for any client but its even more difficult to do it for a group – maybe because fewer practitioners have been trained to think about groups as groups, or about the problems or objectives of groups
2. Must distinguish true group problems and objectives from the individual problems and objectives of people who may be seen in groups
3. The practitioner should always reflect as fully and faithfully as possible the nature of the group being evaluated
4. It may be useful to collect individual scores on related topics so that the relative status of each individual may be compared with the group as a whole
5. If group norms are related to individual behavior, then an individual’s score that shows an inconsistency with the norm may suggest the need for extra counseling or enhanced group efforts to help this particular individual
5. Goal Attainment Scaling (GAS)
1. Widely used method for establishing and tracking goals (assists in goal definition and goal measurement) – can apply to goal-setting activities for both individuals and organizations
2. Used by many members of the helping professions
3. Its basic procedures involve identifying client problems, assigning individualized weights to those problems, estimating the client’s expected outcome/goals for each problem area, and averaging outcomes across all problems for each client or all clients within a given program
4. Basic Guidelines for Using GAS
1. Collecting Information – standard sources of assessment are used, including interviews, direct observation, questionnaires, reports from those in the environment, and/or any methods of data collection prescribed by a particular agency
2. Designation of Problem Areas (look at chart on page 86)
1. Break down the assessment data into a series of “problem areas” – identify those positive areas or strengths that should be increased and those undesired areas that should be decreased; all of the problems are listed and prioritized
2. For each problem area a scale of behaviors is developed
3. Each problem area is given a title – the problem can then be described in more specific but brief detail under each title
4. Since the problems are prioritized, you can weigh each one in the space next to the title – without weights, each scale or problem is seen as equally relevant
3. Predictions for Each Problem Area
1. GAS is intended to operate within a time limit so a specific follow-up point should be set for each scale or problem area
2. A series of predictions is made for each scale and a most desirable variable should be used as a measure – for each of the variables a range of outcomes is possible (range from very negative to positive)
3. Most important point on the scale is the “expected level” or midpoint because this is the most realistic prediction of outcome – this should be the first part of the scale that is developed
4. GAS can be used as a context to help establish goal statements, and the results of repeated collections of data on the target problem can be used for regular monitoring
4. Follow-Up “Interview”
1. Evaluation of the outcome which can be done by the practitioner with the client
2. Because the expected length of intervention is preset, this part of the process should not be a surprise to anyone
3. Care should be taken so that the interviewer avoids overly subjective or biased evaluations
4. To record level of success achieved, a check or asterisk can be inserted in the appropriate box of the follow-up guide
5. If the problem areas are broken down into more or less objective, or highly specific, variables, outcome will be relatively easy to determine
6. GAS contains no built-in systems for regular feedback which can be problematic
6. Problems and Issues in Setting Goals
1. Anticipate Negative Outcomes – anticipate results and examine them with clients so that they will be prepared
2. Who Sets the Goals?
1. Client should have the major, if not sole, say in setting goals – practitioner is there is help the client be more specific about what he or she wants
2. Whenever possible the client should have the predominant say but if this isn’t completely possible then the practitioner needs to at least be sensitive to the client’s interests and desires
3. Goals must be acceptable to both client and practitioner
4. It is the practitioner’s responsibility to provide as accurate and as honest information as possible in evaluating how workable the goal is
3. Anticipate Impediments – list of 12 in the article
4. Case Illustrations of Goals in the Context of Problems and Interventions (tables and charts)

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The First Session: An Interpersonal Encounter

Elsa Marziali


1. Various factors influence both the process and the outcome of the first sessions between worker and therapist
2. Clients and workers approach the first interview with different motivations and expectations
1. The worker reveals very little about himself while the client is expected to reveal the most intimate details about himself
3. The worker hopes that he will obtain an accurate understanding of the client’s problems and the circumstances of those problems
1. He feels he must collect a large amount of information in a single interview
2. The worker hopes for a cooperative client
3. If the client is unable/unwilling to reveal the required information then the worker must set aside his agenda and attend to the blocks that hinder the client’s cooperation
4. The interview may take one of two courses
1. The worker will help the client explore those factors that contribute to the client’s reluctance to participate in the therapeutic process
1. The worker will reassure the client that his confusion can be understood and that his expectations of the therapist are not invalid
2. When the client feels that his emotions, behaviors, and thoughts are accepted and understood then he will feel more comfortable sharing more information with the therapist
3. After this process the therapist will have demonstrated how treatment works and what the client might hope to gain from it
2. The worker will avoid acknowledging or dealing with the client’s blocks
1. The worker continues asking the client questions and the information that is gained under these circumstances is factual and uninformative
2. The client’s reluctance may be because he is afraid the worker will judge him and respond negatively
3. The worker hides behind his professional status and blames the client for being uncooperative
5. There are complex variables in the client-worker relationship
1. Clients who are cooperative and engaging are more readily helped because they match the worker’s expectations
2. Frightened or angry clients are less willing to open up and expose aspects of their problems which in turn tax the worker’s skills and confidence and ability to help
3. The needs to be emphasis on observing and managing these psychological phenomena in the first meeting
6. Subjective Contracting
1. Contracting is when the client and worker reach a shared definition of the problem and express mutual agreement about goals, tasks, and respective roles
2. The therapist must be aware that the subjective-interpersonal factors that aren’t discussed can either interfere with or enhance the therapeutic process
3. If the subjective factors aren’t recognized by the worker as they come up throughout the first meeting then they wont be managed in a therapeutic manner
4. Only when the important interpersonal factors are acknowledged and managed can the client begin to be treated in a correct manner
5. The therapist must remember and acknowledge that the treatment of problems occurs in the context of human relationships
7. Clinical Perspective
1. Supervision is the teaching-learning practice that is used to help SW trainees integrate the theoretical education into clinical practice
2. There needs to be a huge focus on inter-subjective factors in supervision because the student must realize how important personality and situation factors are
3. In the first meeting the worker must make attempts to understand the interpersonal elements of the therapeutic relationship – the student is helped to observe subjective reactions to clients and use these observations to enhance their understanding of the client (which in turn communicates to the client understanding)
8. Research Perspective
1. There is an increasing number of clients who fail to return for a second interview
2. Many studies have considered that when the therapist-client expectations are similar there is be more reason for continuance of therapy
3. Some say that when clients feel understood by the worker they want to attend the next appointment
4. The socioeconomic status of the client also influences whether or not they will return
5. Both clients and workers felt that a feeling of alliance after the first session led to more productive sessions in the future
9. Summary and Conclusions
1. The first interview has three aims
1. Establishment of an initial collaborative alliance
2. Collection of data necessary for understanding the client’s problem and for making appropriate treatment recommendations
3. Demonstration of treatment interventions that contribute positively to the first encounter and that illustrate to the client how treatment works
2. Important information about the client’s problematic status can be obtained only in the context of a beginning, positive working relationship
3. Must be able to examine both the descriptive data and the subjective contributions to the therapeutic interaction
4. The feelings of both the client and worker must be recognized
5. Supervision which emphasizes awareness of the subjective phenomena is also important
6. A therapist must demonstrate a capacity for grasping the many levels of meaning that the client attempts to communicate

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The Preliminary Phase of Work

Shulman


1. Communications in Practice
1. Human Communications
1. An idea must be encoded and transmitted
2. The message must be received
3. Massage must be decoded
4. The recipient must acknowledge the message by providing the sender with some form of feedback
2. Obstacles to Direct Communications
1. In the helping relationship additional factors can complicate the process
2. The obstacles usually result in a client employing indirect methods to express thoughts and feelings
1. Ambivalence - Because society puts a lot of value in independence, a client may feel uncertain about asking for help and may present concerns in an indirect manner
2. Societal Taboos – Taboos in society may make it hard for a client to speak about certain things which may cause him to use indirect methods of communication
3. Painful Feelings – A client may not want to discuss painful feelings which can lead to him sharing the facts of an issue while ignoring his own feelings (can lead to a poorly adaptive defense)
4. Powerful Authority Figures – Some people in the helping profession have power over the lives of their clients and this power can become a major obstacle
3. Examples of Indirect Communications in Practice
1. Hinting is an important indirect cue; the client makes a comment or asks a question that contains a portion of the message (ex: a mother asking a worker if she has children can be an indirect question of “will this worker be able to understand me?”) or the client’s behavior can also hint to something (ex: a child acting out)
2. Metaphor and allegory can be used by clients as means of indirect communication where the worker must use his skills to reach for the underlying message
3. Nonverbal forms of communication also send important indirect messages (ex: negative behavior can be a client sending an indirect message to the worker)
4. A worker must learn how to “tune in” to what the client is saying in any of the above cases
2. The Preliminary Phase: Tuning into Self and to the Client
1. Tuning in involves the worker getting in touch with the feelings and concerns of the client in order to help the worker become more sensitive to the client’s situation (preparatory empathy)
2. When the worker tunes in he will be able to hear the client’s indirect cues and be able to respond; he will be able to help the client manage his feelings
3. Tuning into the Authority Theme
1. This allows the worker to focus on issues related to the relationship between the client and social worker – for example, this is important when the worker is young and unmarried and the client is married and has 5 kids
2. It is normal for clients to wonder if new workers will be able to relate to them or if they will be like previous unhelpful workers
3. Workers should be tuned in to clients’ potential concerns in order to prepare responses before they are even brought up
4. Sometimes it is appropriate for the worker to share his concerns about being able to relate to the client because otherwise the energy invested in suppressing those concerns won’t be able to be used to help the client himself
5. It is important for the worker to come off as being sincere and genuine and tuning in can help this
6. “Reflection” (repeating what the client has said) can be damaging to the helping relationship, instead “containment” (staying quiet for a few moments and trying to feel what the client is feeling/has felt) should be used in order to respond with more sincere reactions that may deepen the conversation
7. The “working relationship” is a precondition for helping a client
1. through his activities the worker can develop a positive working relationship with the client
2. the way the worker and client talk and listen to one another helps this relationship develop
3. it is untrue that the worker must establish a relationship first and then begin to work; the relationship grows out of the work itself and a worker needs to get down to business quickly
4. the relationship is a part of the work
8. There are many elements to a working relationship
1. Rapport – general sense on the client’s part that he or she gets along well with the worker
2. Trust – the client’s perception that he can risk sharing thoughts, feelings, mistakes, and failures with the worker
3. Caring – the client senses the worker is concerned about him as a client and that the worker wishes to help him with those concerns that the client feels are important
9. The ability of the worker to tune into the unspoken feelings/concerns of the client and then to articulate these to the client contributes to the working relationship
10. Skills for helping the client manage their feelings were found to have a positive effect on the client at the beginning of the working relationship
11. If a worker has passed over a client’s indirect cues in the past then they can go back and reopen what he may feels is “unfinished business” – clients also love it when workers share mistakes because it shows them as a human being
12. Skillful practice involves learning how to shorten the time when a worker makes a mistake and when a he catches it – the best is to catch a mistake in the session that the mistake it made (active mistakes)
13. Silences are full of meaning but sometimes are hard to interpret
14. Workers are usually more effective than they think they have been – they tend to underestimate the positive effect they have on their clients
15. Workers should always learn from past clients in order to improve the way they interact with future clients – it will be hard for a worker to help a client manage his feelings of guilt is the worker is overly judgmental of his own work
4. Affective Versus Intellectual Tuning In
1. To tune in effectively the worker must try to actually experience the client’s feelings – recall similar experiences in order to put him in touch with feelings related to those of the client
2. The struggle to deal with one’s own feelings persists throughout one’s professional life – the worker should reach out for additional support from colleagues (those who do are more effective at providing the same support for their clients)
5. Tuning into the Worker’s Own Feelings
1. Its important for the worker to get in touch with his own feelings – how we feel can have a great deal to do with how we act
2. By tuning into one’s own feelings and experiencing them before the engagement, their power to block the worker can be lessened – the helping process is one in which workers learn a great deal about their own feelings as they relate to their professional function
3. The worker needs to learn to understand his feelings instead of pretending to deny their existence
6. Different Levels of Tuning In
1. Tune in to the general category of the client (social worker at a residential center for delinquent adolescent boys would tune into the general category of adolescents – the worker must try to remember what it was like to be an adolescent)
2. Tune in to the specific client (youngsters who are in trouble with the law)
3. Tune in to the specific phase of work (an adolescent has been judged a delinquent and is about to enter a new residential setting)
4. The first efforts of tuning in always pick up resistance which reflects the worker’s frustrating past experiences – it is a statement of the worker’s concerns that the client won’t want help
5. The worker must have a sense for the client’s potential for change otherwise the worker’s pessimistic stereotype of the client will meet head on with the client’s pessimistic stereotype of the worker – tuning in is the first step in trying to break this self-defeating cycle
6. There is a danger in tuning in that the worker may develop a view of the client that is far removed from what the client actually thinks and feels – the worker must put all hunches aside at the beginning of the interaction
7. What the worker responds to in the first contacts are the direct and indirect cues that emerge in conversation with the client
8. The worker must only reach tentatively for indirect messages and be prepared for client to share different and unexpected responses – tuning in is designed to sensitize the worker to potential concerns and feelings
9. If tuning in produces a new stereotype of the client then it will be self-defeating
3. Responding Directly to Indirect Cues
1. The advantage to a direct response opens up an area of important conversation that can deepen the working relationship
2. Some say a direct response can cause the worker to “lead” the client or hurt the client if he isn’t ready to deal with that particular feeling – this fear can lead workers not to use a direct response and let the information come gradually from the client
3. Shulman favors direct responses because the client employs indirect communications at the beginning of the interaction because he is unsure that he is able to risk communicating directly to some of the more difficult and taboo feelings – direct responses shows the client what type of a helping person the worker is
4. If the worker’s guess is “off base” then the client will usually let it be known – straight out or through other cues like hesitation and lack of affective response and then the worker can then respond directly to these cues
5. When clients speak about past unhelpful workers they are usually referring to the new worker indirectly – a discussion of the past relationship can be cast in the context of this new one; the worker can then be clear about how the relationship will operate (expectations from both sides, etc)
6. Clients respond to workers in the early sessions based on stereotypes and also based on what they heard about the worker through the grape vine
7. The worker must allow the client room not to respond to direct responses by the worker – this can occur because of either lack of trust or lack of readiness
8. The direct response can serve as a message that the worker does understand and is ready to deal with the taboo area when the client is ready – shows the worker as a feeling, caring, direct person who can see the world through the client’s eyes and not judge harshly
9. There are skills (very difficult to develop) that the worker can use to help a client manage his feelings – using these skills positively impacted on the development of the worker’s caring and the worker was seen by the client as helpful
1. Reaching inside of silences
2. Putting the client’s feelings into words
3. Displaying understanding of the client’s feelings
4. Sharing the worker’s feelings
10. When the above skills were used in the beginning phase of practice to help clients manage their feelings it had a moderately strong predictive ability for both the caring and trust elements of the working relationship
11. Workers should use these skills of tuning in and responding to indirect cues at the beginning of the relationship because clients tend to have a difficulty articulating their own feelings in the beginning of a new relationship
12. A worker’s own ambivalence about exploring an area of work can produce the block – workers can end up not speaking about a taboo subject because they are really just protecting themselves and not the client
13. Workers will also have difficulties in reaching for cues in taboo areas – workers have experienced the same set of taboos and have observed the same set of norms of behavior as have clients so it will take training and support from supervisors for the workers to feel comfortable enough to give clients permission to explore these areas of work
4. Agency Records, Referral Reports, and the Agency Culture: Avoiding the Trap of Stereotyping the Client
1. Prior information on a client can be helpful or can itself become a block to the worker
2. Information can allow the worker to develop the preliminary empathy needed to prepare for the first session – it can reveal potential themes of concern to which the new worker can be alert and it may help in developing a feel for the emotional state of the client
3. But the information can also cause the worker to develop a stereotype of the client and can cause a block in the development of the working relationship
4. The agency culture will usually have an impact on the new worker in terms of developing stereotypical views of a client (this holds true of a client who has been with the agency for a long time)
5. When we experience difficulty in working with others who are different our inherent racism, sexism, homophobia, and so on emerge in an effort to explain our feelings of being ineffective
6. When workers are conscious of the impact of differences between them and clients it can lead to a good working relationship
7. Interactional Paradigm
1. This is used in order to get a feeling for the reciprocal interaction between client and worker in order to view the client’s actions in relation to the actions of others
2. Usually the client’s actions are explainable in relation to the worker’s efforts
3. After this exploration the client is seen as more multidimensional
4. If the worker is using previous information then he should keep in mind not only the tentativeness of the information but also the need to see the client in interaction rather than as a static entity
5. The worker needs to clear all of these facts, opinions, and his own tuning-in guesses from his own mind as the first interview begins
5. Summary
1. A worker could increase his sensitivity to indirect communications by “tuning in”
2. The worker must tune into his own feelings first, particularly those related to anxiety about the first meetings