Case assessment and diagnosis assessment
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ClinicalPracticewithIndividuals_Module5-1.pptxApplication of Cognitive Theory, Narrative Therapy, and Solution-Focused Therapy
Objectives for this Module
Understand the role that thoughts have on our feelings, behaviors, and functioning (see the connections)
Help our client Linda understand the role of her automatic thoughts and schemas/core beliefs in her increased anxiety
Use cognitive-based interventions to help Linda decrease her anxiety and reach her goals
Identify the benefits and need for motivational interviewing approaches when working with clients who may be less motivated to change
Our Client: Linda (pages 135-141)
1. What are some of Linda’s automatic thoughts…..those you can see from her case description and those you guess she might have?
2. Identify and describe some of Linda’s likely core beliefs and schemas….and how might they be impacting her feelings of anxiety?
3. What impact are Linda’s core beliefs/schemas/anxiety having on her behavior and functioning?
4. What cognitive-based interventions or approaches would you use with Linda and how would you use them to help her?
5. Linda appears quite motivated for treatment, but if she was not, how would you use a motivational interviewing approach to engage and help her?
Other Case Examples
Client who was constantly worried that her two sons would die in an accident
Client who never returned anything to the store
Client who would not leave her home due to belief that others were judging her
Client who refused to visit a hospital even though she needed the treatments that were provided there
Police officer who was highly resistant to driving a police patrol vehicle
Student who left his university due to thoughts related to his irritable bowel syndrome (IBS)
Client who placed a glass of water next to her bed every night because she was afraid what might happen to people she loved if she did not do this
Chapter 9 Cognitive Theory A Structural Approach
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History and Definition
Cognitive theory began in 1911
Alfred Adler
Holistic approach (personality as a unified whole)
Reciprocal interaction between what/how one thinks, feels, and behaves
New techniques and strategies
The Therapeutic Relationship
Relationship between client and therapist is based on collaboration
Therapist is not assumed to be the authority figure/expert with all the answers
Therapist is a trusted teacher, trainer, and coach
Research Perspective
Evidence-based practice
Client Characteristics
A Structured Approach
The client and clinician develop a theory and test the validity of automatic thoughts, schemas, and effectiveness of client behaviors
Clients take credit for their change
Rational Emotive Therapy
The ABCs of RET
Activating event
The way that perceived event is evaluated (beliefs)
Emotional and behavioral consequences that stem from beliefs
Frequent Disturbances in Thinking
All-or-none thinking
Rational Emotive Therapy
Jumping to conclusions and negative nonsequiturs
Fortune telling
Focusing on the negative
Disqualifying the positive
Allness and neverness
Minimization
Rational Emotive Therapy
Emotional reasoning
Labeling and overeneralization
Personalizing
Phonyism
Perfectionism
Constructive Perspective
Focuses on the stories that people tell themselves/others about events in their lives
Five positive cognitive mechanisms people use to cope with distressing situations
Individuals who do not cope well and who evidence continuing distress
Beck’s Model of Cognitive Therapy
Arbitrary inferences
Selective abstraction
Overgeneralization
Margnification and minimization
Personalization
Dichotomous thinking
Testing of Automatic Thoughts
Schema Therapy
Disconnection and rejection
Emotional deprivation
Deprivation of nurturance
Deprivation of protection
Deprivation of empathy
Abandonment/instability
Discovering Hannah’s Automatic Thoughts and Schemas
https:// www.youtube.com/watch?v=W3hMmZQAdhw
Downward arrow thought challenging technique
Schema Therapy
Mistrust/abuse
Social isolation/alienation
Defectiveness/shame
Impaired autonomy and performance
Dependence/incompetence
Vulnerability to harm and illness
Schema Therapy
Enmeshment/Undeveloped self
Failure
Impaired Limits
Entitlement/Self-centeredness
Insufficient self-control/self-discipline
Other directedness
Schema Therapy
Subjugation
Subjugation of needs: Suppression of one’s preferences, decisions, and desires
Subjugation of emotions: Especially ager
Self-sacrifice
Approval-seeking/recognition-seeking
Schema Therapy
Overvigilance and inhibition
Negativity/pessimism
Emotional inhibition
Unrelenting/unbalanced standards
Punitiveness
Cognitive Processing Therapy
Positive Psychology
An understanding of suffering and happiness
Character strengths and virtues
Positive psychology interventions that have been evaluated and proved effective
Motivational Interviewing
Motivational Interviewing
Example 1:
https ://www.youtube.com/watch?v=_ VlvanBFkvI
Example 2:
https :// www.youtube.com/watch?v=67I6g1I7Zao
“Client – centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002, p. 25)
Helps clients clarify goals and make commitment to change (on their terms)
Explores reasons for and against change
Reduces ambivalence about change
MI is a style of being with people, an integration of particular clinical skills to foster motivation for change (not a technique) (p. 35)
What is Motivational Interviewing (MI)?
Why MI?
Evidence-based, relatively brief, specifiable, complementary to other treatment methods
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Layperson’s definition
A collaborative conversation style for strengthening a person’s own motivation & commitment to change
Practitioner’s definition
A person-centered counseling style for addressing the common problem of ambivalence about change
Motivational Interviewing Definitions
MI is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.
(Miller & Rollnick, 2013, pp. 12 & 29)
Technical Definition – How Does MI Work?
Instead of phases and principles of MI, now the approach comprises of four broad processes:
Engaging
Focusing
Evoking
Planning
The “spirit” of MI hasn’t changed – that it involves a collaborative partnership with clients, a respectful evoking of their own motivation and wisdom, a radical acceptance recognizing whether change happens is each person’s own choice (autonomy)
(Miller & Rollnick, 2013, p. viii)
Then & Now
Stages of Change
Pre-contemplation
Contemplation
Preparation
Action
Behavior Maintenance
Recycling
Preparing for Change Transtheoreticial Model
Pre-contemplation
Minimize and rationalize problems – no intention to change in the foreseeable future; may be unaware or under-aware of problems
Show support for client’s anxiety about change
Stages of Change
Contemplation
Dawning awareness problem
exists and of need for change
Thinking seriously about over-
coming it, but no commitment
to take action yet
Weighing pros and cons of
the problem and its solution
Stages of Change
Preparation
Combines intention and behavior – action is planned within the next month, has been unsuccessful within the last year
Determines problem and makes a decision to change
Some reductions have been made in problem behaviors, but a criterion for effective action has not been reached
Stages of Change
Action
Behavior, experiences, or environment are modified to overcome the problem
Takes steps to change behavior or deal with issue
Keep steps small and manageable
Temptation to return to old habits is normal
Stages of Change
Treatment is in a Stage-Wise Fashion
Pre-contemplation — Engagement
Assertive outreach, practical help (housing, entitlements, other), and an introduction to individual, family, group, and self-help treatment formats
Contemplation and Preparation — Persuasion
Education, goal setting, and building awareness of problem through motivational counseling
Action — Active treatment
Counseling and treatment based on cognitive-behavioral techniques, skills training, and support from families and self-help groups
Maintenance —
Relapse prevention
Continued counseling and treatment based on relapse prevention techniques, skill building, and ongoing support to promote recovery
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Behavior maintenance
Becomes more comfortable with new self, but must persist because relapse is always a possibility
Remaining free from addictive behavior and engaging consistently in a new incompatible behavior for more than 6 months
Make changes in environment
Review reasons why client made the change
Stages of Change
The change process is cyclical, individuals generally move back and forth between the stages and cycle through the stages at different rates.
For most substance-using individuals, progress through the stages of change is circular or spiral. Recurrence is a normal event. Many client will cycle through the different stages several times before achieving stable change.
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Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Continuum of Communication Styles
Miller & Rollnick, p. 4 & 5 Table of verbs associated with each communication style
Directing – providing information, instruction, and advice
Guiding – good listener who assists when asked
Following – takes an interest in what is being stated, doesn’t impose own thoughts and opinions, allows exploration
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Directing
Guiding
Following
Ambivalence is “simultaneously wanting and not wanting something, or wanting both of two incompatible things”. (Miller & Rollnick, p. 6)
Clients get stuck on their way to changing secondary to ambivalence
“Path out of ambivalence is to choose a direction & follow it, to keep moving in the chosen direction” (p. 7)
Ambivalence
Acceptance involves the inherent worth and potential, unconditional positive regard
Awareness of client’s unique individuality
Respect
Affirmation
Autonomy
Empathy
Worth
Collaboration
Evocation
Compassion (new) – promote the other’s welfare, give priority to other’s needs
Key Components
Four Aspects of Acceptance
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Acceptance
Absolute Worth
Autonomy
Accurate Empathy
Affirmation
Taken together, these four person-centered conditions convey what we mean by “acceptance”.
“One honors each person’s absolute worth and potential as a human being, recognizes and supports the person’s autonomy to choose his or her own way, seeks through accurate empathy to understand the other’s perspective, and affirms the person’s strengths and efforts.” (p. 19)
Acceptance
MI Spirit
MI Spirit in the middle
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Collaboration
Acceptance
Evocation
compassion
Key Components
Collaboration – partnership between social worker and client
partnership that honors the client’s expertise and perspectives; avoids an authoritarian one-up stance, instead communicating a partner-like relationship
Focus is on motivational struggles, issues of change for which a person is not ready or is ambivalent
Motivational Interviewing (MI)
Motivation and personal change is linked. The goal is to facilitate changes in the client’s’ maladaptive and unhealthy behaviors.
40
Evocation – the interviewer’s tone is not one of imparting things (such as wisdom, insight) but rather eliciting, of finding these things within and drawing them out from the person.
The social worker’s task is to “evoke” the change
Assumption is people have what they need, “together we will find it” (strengths-based)
Key Components of MI
Autonomy - affirm the client’s right to self-determination and facilitate informed choice
Responsibility for change is left up to the client
Overall goal is to increase intrinsic motivation, so that change arises from within rather than being imposed from without and so the change serves the person’s own goals and values
It is the client rather than the counselor
who presents the arguments for change
(Miller & Rollnick, 2013, p. )
Key Components of MI
Four Processes in MI (questions regarding MI processes, p. 32)
Each later process builds upon those that were laid down before and continue to run beneath it as a foundation.
Focusing – what did the person come to talk about; develop and maintain a specific direction in the conversation about change
Evoking the client’s own motivation for change; only occurs when a change goal has been clarified
Planning – developing commitment to change and formulating a specific plan of action
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Engaging
Focusing
Evoking
Planning
Core Communications Skills (OARS)
Open-ended questions
Affirmations (or validation)
Reflective listening
Summarization
Asking open questions invites a person to reflect, explore, and elaborate
Affirming of client’s own personal strengths, resources, efforts
Reflective listening assists in deepening understanding of what the client is sharing
Summarizing
Informing & advising with permission
Core Communication Skills (OARS)
Stating what you think the client is saying:
State the problem as the client sees it without emotional words.
Focus on the issue to promote discussion on the client’s feelings and/or circumstances.
Don’t give advice, don’t defend yourself, don’t reassure.
Don’t make it right for the client.
Keep the responsibility on the client.
Reflective Listening
Reflective Listening Possible Phrases
Phrases when you think perceptions are accurate
Phrases when you have difficulty understanding
I see the situation as…
I wonder if…
From where you stand…
As I hear it. You…
You feel…
I really hearing you saying…
I’m picking up that…
You think…
Could it be…
I wonder if…
Does it sound reasonable that you…
This is what I think I hear you saying…
Let me see if I understand you; you…
I’m not certain I understand; you’re feeling…
Professional relationships involve uneven power and thereby incur special responsibilities.
Social work has its own set of ethical standards for practice, which tends to reflect a common set of values.
The National Research Council identified four broad ethical principles:
Ethical Values with MI
Nonmaleficience – “do no harm”
Beneficence – clinical interventions are meant to provide benefit (offer evidence-based treatments)
Autonomy – respect for human freedom and dignity
Justice – fairness with equitable access to the benefits of treatment and protections against risk
SW – Dignity & worth of the person; Importance of human relationships; Competence; Social justice; Integrity; Service
Ethical Principles
Develop discrepancy – how best to present an unpleasant reality so that the person can confront it and be changed by it.
Intentionally directive – directed toward the resolution of ambivalence toward positive change
The client rather than the counselor should present the arguments for change
Change is motivated by a perceived discrepancy between present behavior and important personal goals or values (Rollnick & Miller, 2002)
General Principles of MI
Roll with Resistance
Avoid arguing for change
Resistance is not directly
opposed but one flows with it
New perspectives are invited but
not imposed
Client is a primary resource in
finding answers and solutions
Resistance is a signal to respond differently
General Principles of MI
Support self-efficacy – refers to a person’s belief in his or her ability to carry out and succeed with a specific task
A person’s belief in the possibility of change is an important motivator
The client, not the counselor, is responsible for choosing and carrying out change
The counselor’s own belief in the person’s ability to change becomes a self-fulfilling prophecy
General Principles of MI
By specifying the process of creating discrepancy and establishing viable goals,
motivational interviewing operationalizes strengths-based values
The Goal is for clients to talk themselves into changing, if it is compatible with their own values and aspirations!
Strengths-Based Values
Do you mind if we talk about your…
What have you noticed about your drinking?
Tell me a little more about your…concerns about black-outs, etc.
Would you be interested in learning more about the health effects of your drinking?
May I make a suggestion?
Would it be alright if I tell you one concern I have about this plan?
In the Beginning…Ask Permission
Practitioners can elicit self-motivational statement in several ways:
Direct questions
“What do you think will happen with your (health) if you continue to (do) as you have been doing?”
Develop discrepancy – what do clients like or don’t like about their current behavior
Client-centered interview strategies like reflective listening to encourage them to expand on their concerns by taking a “what else” or “tell me more” approach to help them examine and clarify areas of ambivalent conflict
MI: Strategies & Tactics
Client: “All my friends drink and I feel like they would look at me differently if I quit…like I wouldn’t belong anymore.”
Instead of: “Would you rather die from liver disease?”
Try: “Drinking helps you fit in.”
Simple Reflections
Client: “It’s impossible to get through the day if I can’t look forward to a little break and a beer. I have 3 kids and a full time job. I’m exhausted!”
Instead of: “Look, if you don’t care about yourself, think of the kids. It is really important for you to quit drinking before something really serious happens.”
Try: “You have a lot of responsibilities right now.”
Simple Reflections
Serena is a feisty 17 y/o whose mother insisted she come to see you after being caught smoking marijuana in a car with a few of her high school friends.
Serena: “Who are you to be giving me advice? What do you know about having a good time with your friends? You’ve probably spent all your time studying and never even smoked a joint!”
SW: “It’s hard to imagine how I could possibly understand.”
Simple Reflections
