1018PSY EOT Notes PDF

Week 7: - Resistance: An apparent lack of cooperation or motivation or the therapeutic process - Being late /postponing - Deflecting away from particular content and emotions - Telling the same story repeatedly - Avoiding particular activities - Re-enacting unhelpful behaviour...

Week 7: - Resistance: An apparent lack of cooperation or motivation or the therapeutic process - Being late /postponing - Deflecting away from particular content and emotions - Telling the same story repeatedly - Avoiding particular activities - Re-enacting unhelpful behaviour pattens - Can be a major obstacle + cause ruptures in the therapeutic relationship, yet also offer opportunities for change - May be experienced as difficult by the counsellor - Feels like bad behaviour - Can trigger countertransference - Yet, meaningful when understood within the context of the client's emotional background, affect regulation, and coping - What drives resistance? - Fear - failure, taking risks\... - Struggle for power - Transference reaction - Dependency - Shame - Exhaustion - Feeling unsafe, unheard, misunderstood - \"Stuckness\" - not knowing how to be in charge - \"Stuckness\" as resistance: - Seeing resistance as initially \"helpful\" or essential - Don\'t label it resistance, even in your mind - Remain open to the client + respond effectively - Clients possess their own wisdom as to how quickly they can become open to change - Clients often have valid objections to therapy + therapists - referred to as \"realistic resistance\" - Therapeutic Rupture: A tension or breakdown in the collaborative relationship between patient and therapist - Resistance mis/unmanaged can lead to rupture - Vary in intensity -- major tensions, which one or both of the participants may be only vaguely aware of, to major breakdowns in collaboration, understanding, or communication - Why? - Empathetic failure - Therapeutic impasse - Misunderstanding the event - Clients often reluctant to raise the issue - Therapist responsibility to initiate - Explain what is happening between therapist and client, as well as the client's experience - Encourage client being open about their experience of therapy - Beginning of work, explaining the counselling process -- normalise in advance - Respond in open and non-defensive fashion - Accept responsibility for contribution to the interaction - Empathise, validate, acknowledge and encourage - 'Here and Now' Techniques - Based in Gestalt therapy -- 1940's -- revision of psychoanalysis based in humanistic psychology - Integration of experience, not duality of body and mind - Context matters -- the whole is greater than the sum of its parts - Goal = client and therapist collaborate to increase personal awareness and actively challenge 'blocks' getting in the way of change and psychological wellness - Focus on present physiological experience, energy, or tension in the body that comes with resistance - Made possible with the I -Thou (us I-It ) relationship (Madin Buber) - Allows for full empathy between subjects that can be transformative, in contrast to the I-It relationship which objectifies the other - When focused on the relationship, its known as 'Immediacy' - Immediacy: The ability of the counsellor/helper to use the immediate state of the situation to invite the client to look at what is going on between them in the relationship. It often feels risky or unfamiliar - Using the 'here and now' - Acknowledge, validate, honour the clients resistance or ambivalence - Skills of feedback to the client - Gently noting observations of resistant behaviours - Facilitate awareness and exploration of resistance and behaviours - Processing of fears and concerns - Making choices, including the choice not to deal with an issue - Reflections, with observational empathy - Open-ended questions ("What's it like... right now?") - Silence - Enable the client to explore their own immediate personal experience, difficult emotions, even if uncomfortable - Therapists must develop skills in managing their own internal discomfort and navigate tension in the room - Compassionately work in the 'here and now' rather than reinforce operant avoidant responses (block dialogue) - Allows for anchoring the session \> movement and change more possible - Re-focuses if there is a 3^rd^ person in the room - Working where the issue is 'hot' - Working with what is occurring for the client right now - Alternate viewpoint -- resistance as a phenomena that emerges between client and therapist - Considering attachment developmental systems theory perspectives, the counsellor-client relationship is metaphorically and structurally related to the earlier infant-caregiver system - Realistic resistance (Rennie, 1994): Therapists general approach, particular techniques, or behaviours verbal or non-verbal responses - Peddling our own agenda: Resistances and blocks to treatment usually exist when therapists have specific notions of what the patient is supposed to do - Elevated emotional arousal reduces cognitive processing capacity for both parties - Mental fog, unable to see things clearly or consider other perspectives - Can't see options and possible pathways of action - Habitual negative thought patterns can correspond with hopelessness - Intense emotions are habitual negative thought patterns that drain energy - Make change harder - Whether emotions are visible or supressed - Resistance in therapy is a natural, if not necessary part of every client experience - Don't ignore it -- it can become a big issue (Collusive resistance, rupture...) - Transference: Reflects the immediacy of the counselling relationship -- The client behaves towards the counsellor as though they were a person from their life (usually from past behavioural patterns learned in relationships) - Parental, sibling, non-familial, social - Can lead to the counsellor falling into that role, in the way they respond to the client - Transference can be a powerful tool for promoting understanding and change -- it is inevitable E.g., projection in other areas of life - Counter-Transference: Therapist emotional reaction to a client based on their own personal experience - Unconsciously transferring feelings and attitudes from a person or situation in the past - Aspects of the client or their story, or the contextual setting may be triggered (e.g., school, relationship dynamics...) - Ethical issues: - Boundaries, conflict of interest - Self-disclosure - Competence - Encountering resistance is likely evidence that therapy is taking place - Research indicates that successful therapy can be highly related to increases in resistance - Low resistance = negative outcomes - What helps life resistance? - Self-awareness and therapist regulation (in the collaboration) - Validating and normalising - Empathetic responding: Down regulate emotions, clear mental fog, increase capacity for openness to explore - Matching mode of awareness with language and metaphor - Exploring the underlying factors (working in the here and now) - Facilitating perspective shift -- advanced skills like reframing - Being heard at a deeper level clears mental space and enables a shift from - Energy-zapping to weight of pushing emotions away - Disempowerment and helplessness, to sense of agency and change - Should, ought to, have to, and must, to choice and freedom - Summarising: - Similar to paraphrasing - Sums up main themes that are emerging - Focuses on key aspects, provides an overview - Picks out salient points - Draws them together - Reflects back clearly - Communicates you are listening, developing understanding - Helper focuses on main issues, feelings and meaning - As a part of the ongoing session -- important for both the client and the counsellor - Keeping on track and clarifying - Developing a shared understanding - Working towards agreed purpose or goal setting - Review the work down so far and to take stock - Monitoring progress - Use in summarising: - Your thinking - Your relationship - Your past - Your family - Your strengths - What you pay attention to - When to use summarising? - Can help warp up a session and draw it to a close - Could begin a subsequent session -- bridging sessions - Helpful supporting focusing on scattered thoughts and feelings - Help promote the client forward and stimulate reflection and movement Week 8: - The counselling process: - Preparation - Joining - Active listening - Emphasis on emotions - Clarifying the problem - Restructuring thoughts - Emphasis on behaviour - Closure - Clarifying the problem: - Even people who voluntarily seek counselling, may not have a clear idea of what the problem is - There could be a few problems - The problem characterisation can change - We need to work collaboratively with clients to prioritise which is the problem that we want to address/focus on first - The Integrative Approach: - What is an integrative approach? - Should we all use an integrative approach? - Pros and cons? - A postmodern conceptualisation: - We can\'t talk about process, without clarifying what therapeutic modality is informing our lens - Postmodern approaches such as Narrative Therapy, Solution Focused Therapy, Collaborative Therapy... - From a postmodern approach, counselling process is about facilitating a \"storytelling\" process - Stories: - Consist of events - Linked in sequence - Occur across time - According to a plot - Example: Story of Henry\'s driving abilities - Exploring existing stories and re-constructing new preferred stories: - *Co-Construction:* Tell as many stories as possible about past and present circumstances and even desired future states: expanding the initially narrow story - *Deconstruction:* What things could have resulted in appearance and emergence of the problem, and also how the person resists the problem? What hopes or values help the person to stand strong in the face of the problem? - *Reconstruction:* Using all those past life themes and their personal values, to weave a new and preferred unified narrative - *Construction:* Living new plans, decisions, and actions to move in certain directions - Summary: The counselling process begins by uncovering **previously untold stories**. In this initial phase (Step 1: Co-Construction) the counsellor and client collaborate in **exploring the past and present... stories** of the client. This collaborative exploratory environment opens up **space** (Step 2: De-Construction) for uncovering **alternative perspectives** and exploring life roles, life themes, values, interests, and motivations. This second step prepares and enables clients to assess the past life themes and their values, allowing them (Step 3: Re-Construction) to weave together a new and preferred unified narrative about their life. Finally, going through the previous three steps and learning about how different experiences, life events, and socialisations have influences their progress in life, clients can now (Step 4: Construction) look for new ways of action to move in certain directions and make new decisions - Change Requires Safety: - Counsellors are motivated by the desire to support others, and hence promote change - Possible rush or push, causing rupture -\> hindering change - Establish safety first, so the client can: - Process the nature of the problem - Navigate/explore barriers that hinder change - Achieve their desired outcome/not necessarily changing the client but changing their relationship with the problem - Clients who feel safe take more action and even \'risks\': i.e. are more prepared to try out new behaviours -\> thus more opportunity for change   **8.2: Joining to Action Plans** - Combining and integrating skills to facilitate change - How people develop problems in their lives OR How problems develop in the lives of people - Modern vs Postmodern conceptualisation of counselling process - Similarities: e.g. Macro and micro skills are shared - Differences: e.g. Emphasis on emotions, thoughts, and behaviours is informed by a modern approach - Joining: The person seeking help and the counsellor meet and a relationship starts to be established (combination of counsellor process and process of the person seeking help) - Inviting the client to talk - Facilitating, opening up and creating a space for the client to talk - Using reflections to clarify the situation/context in which the problem exists and operates - Active Listening: - Minimal encouragers - Eye contact - Reflections of feeling and content - Questions (Open-ended, exploratory, respectful, non-judgemental, and collaborative) - Summarising if relevant - In the context of... - The counsellor\'s process: The counsellor invites the person to tell their story - The person seeking help\'s process: The person tells their story - Emphasis on Emotions: - Why should we focus on exploring emotions first? - How do we do this? - Reflection of feeling - Open questions - Empathy and curiosity - An emotionally literate person: - Can notice and name the emotions they are feeling and those they see in other people - Understands the message an emotion is aiming to communicate (i.e. cause and effect) - Selects the emotion that they are experiencing and chooses what to communicate - Accepts emotions as normal part of life and is at ease talking about and working with them with the people they trust - In the context of: - The counsellor\'s process: The counsellor facilitates a process which enables the person to get in touch with and release emotions - The person seeking help\'s process: The person continues to tell their story and may get in touch with and release emotions - Emphasis on Thoughts: - First - Clarifying the nature of the problem - why is this important? - How do we do this? - Reflections - Questions - Normalising previously discussed emotions/thoughts/actions in light of the problem - Summaries - Other methods we learn later such as externalising (characterising the problem) - In the context of: - The counsellor\'s process: The counsellor helps the person to clarify their problem - The person seeking help\'s process: The person\'s confusion is replaced by a clearer picture - Emphasis on Thoughts (Disputing/Modern): - Then - Addressing unhelpful beliefs and thoughts / dominant problem stories - How do we do this? (major difference among approaches) - The CBT approach for example: - Challenging thoughts: More than just \'positive thinking\' - Unhelpful thinking: Should, ought, must... - Reframing - In the context of: - The counsellor\'s process: The counsellor facilitates change in the person\'s thinking - The person seeking help\'s process: The person starts to think differently about the problem - Emphasis on Thoughts (Re-construction/Postmodern): - Then - Addressing unhelpful beliefs and thoughts / dominant problem stories - How do we do this? (major difference among approaches) - The Narrative approach for example: - Externalising conversations - Re-Authorising stories - From what the \'problem story\' dictated so far, to what the client prefers - From thin descriptions about self to thick descriptions that include many alternative stories - In the context of: - The counsellor\'s process: The counsellor facilitates changes in the person\'s thinking) - The person seeking help\'s process: The person starts to think differently about the problem - Emphasis on Action (Behaviour): - Exploring options - What could be different? What could the client do differently? - Non-pressured - Collaborative - Future-focused - Facilitating action - In the context of: - The counsellor\'s process: The counsellor encourages exploration of dilemmas ad options + The counsellor inquires about the future - The person seeking help\'s process: The person resolves dilemmas and explores options + The person makes decisions about future behaviour - Facilitating Change in Counselling: - Clients attend counselling to achieve change and often have tried to different ways already to change their situation - Change can mean many different things: - Changing from emotional distress to a calmer response/state of being - Changing ways of thinking/perspectives (e.g. a new relationship with the problem) - Changing actions - Changing behaviour -\> might mean expanding our repertoire (thoughts, feelings, actions) to include new ways of responding - Blocks to Awareness and Action: Choices and actions may be blocked by internalised fears and anxieties (often because of external influences) including the following... - You\'re unable to deal with your own feelings - Fear the consequences - Do you remember what happened last time? Fear the repetition of bad experiences - You must be perfect, otherwise you\'re not worthy - The intrusion of inappropriate \'shoulds\', \'musts\', and \'oughts\' - You\'ll lose something comfortable or rewarding - You don\'t really have the skills to do this neatly - To carry out the desired action - What are you going to do to cope with the reactions of others when you mess it up? - Facilitating Action Review: - Psychological Preparation - Identifying the goal - Identify the first step - Concretising the first step - How to carry out the first step - Acquiring the skills - Decide when - Carry out the first step - Rewarding/Acknowledging - Reassessing the overall goal   **8.3: Closing a Session:** - Closure: - Summarise the important points - Respecting the person\'s own pace and process - In the counsellor\'s process: The counsellor draws the session to a close - In the person seeking help\'s process: The person moves towards a more comfortable position - Together: The person seeking help and the counsellor agree to terminate counselling or to create contract regarding future work - Change often occurs between sessions as a person processes what they have discovered in a session! - Reflecting and Summarising: Getting stuck? Remember your theory! - Reflection serves 2 key purposes: i. To let the client know you are listening ad checking in your understanding with them, and ii. To provide a mirror or sounding board for the client to hear their own story - This is crucial, as hearing your own story back provides us with a trigger to reflect, reconsider, elaborate, etc... remember, you want the client to develop their own self-awareness, their own new stories - Reflecting effectively, not just repeating words: i. Am I genuinely trying to make sense of this person\'s overall story? ii. Am I using my attending skills to observe everything about the client - what they say, how they say it, their non-verbals (posture, facial expressions, body tense or relaxed?...) - Reflecting the story as they tell it, but also what is happening for them right now as they hear it (perhaps for the first time?) - Clients will become an audience to their own performances - Steps for closing a session: - Indication of Need to Close: i. \"I\'m conscious that our time will be up soon...\" - Positive Affirmation/Feedback: i. \"Knowing you really didn\'t want to come here today, I am really impressed with your ability to face the discomfort you felt and despite that shared your story with me...\" ii. \"Hearing your story, I can really appreciate your courage in sharing this with me... iii. \"...Thank you for sharing some really difficult experiences with me... It is a privilege to be a witness to your acts of resistance...\" - Brief Summary: i. Summarise important discoveries ii. Avoid summarising the whole session iii. Focus on key points - Agreement on Goal/Future Appointment: i. \"Out of al the things we\'ve explored today, what feels like the most important for us to work on in our next session?\" ii. \"Ok, lets agree to focus on that next time we meet\" iii. E.g. \"I sense that what is important for you right now is to work on reducing the influence of \'worry\' in your studies - do you agree? Is that right?\" iv. \"Ok, lets focus on that next time\" - Avoid responding in a way that will invite a continuation of the session - Dadirri: The deep inner spring inside us Week 9: Case Conceptualisation (aka case formulation): - Client-therapist collaboration, foundational to effective therapy, communication within and beyond session - Brings 2 sets of expertise - Underpinned by theoretical/therapeutic framework - the origins of the client\'s difficulties, how the resenting issues are caused and maintained - The collection, organization, synthesis, and interpretation of client interpretation - We see the **client in the context** of their inner and external life realities, significant past and current experiences, and personality and physiological influences (Systemic Perspective) - Framework provides a broad lens to see **patterns and connections** - Involves (shared) hypothesis making, discerning **meaning** - a more complete and informed understanding of the client - Facilitates reciprocal process of empathy - Case conceptualisation is not diagnosis - 2 people may present with the same \'presenting problem\', yet perceive, see, experience, and act upon it differently - Requires seeing each unique person, identify and discriminate between into that is essential and that which isn\'t - All therapy needs to be able to flexibly adjust to the idiosyncratic behaviours and needs of each   Underlying Premise of Conceptualisation: - Client\'s experiences are influenced by many, and varied, internal and external factors - The most central factors that shapes how the client responds to their situation is **what they perceive and understand of their experiences** - A person\'s perceptions, evaluation, and interpretation of the situation are highly influential in their experience, and shape their reactions and behaviours - Need to think beyond \'the story\' and understand the client\'s unique \'**psychological situation\'**   Case Conceptualisation Process: - Part of therapy, facilitating insight, developing shared goals and client change - Enables both to be focused in sessions vs moving without **direction** - Facilitates considering the best ways for working towards change, and supports **intervention planning** - Beyond diagnosis - draws together all aspects of a client\'s experience, and draws on a client\'s resources and strengths - How have they survived, coped with often very challenging life situations? - Begins during initial therapy session/s (with ongoing review) - With the counsellor and client **collaboratively** developing a shared understanding of the client\'s reasons for seeking help - Exploring what might be relevant information - NB: This is **not a mechanical process, but rather it continues as a dynamic exchange** - While building the therapeutic relationship, demonstrating empathy, and holding the client, not via a battery of targeted questions - Power remains with the client and their expertise of their own life, rather than the therapist \"assessing\" or judging the client\'s state of being   Key Skills: - Active listening, deliberately and intentionally - Empathetic responding, and reflection of feeling and content - Effective use of open (and sometimes closed) questions - \"Tell me more about... your experience of...\" - \"What is it like when...\" - \"Let\'s explore...\" - Exploration of context for the client - Exploration of internal and external strengths and resources (where necessary, identification of risk)   Case Conceptualisation Process Cont.: - After the first session/s, the therapist reviews information gathered and creates a \'map\' - Often meets with supervisor/team and reviews - Therapist shares the case conceptualisation with the client and they discuss/refine it together - Collaborative approach, strengthens alliance - Further understand and expands conceptualisation with client input -\> reorienting to the client/s internal frame of reference - Importantly - facilitates self-understanding (key for change)   **9.2: Different models of conceptualisation - 5P framework, Biopsychosocial model, Culturally informed conceptualisation**   Common Frameworks: - Depends on therapeutic modality, and organisational context - Can be combined or integrated to suit client and therapist - NB: The \'ideal\' cannot always be achieved - context, client needs, consistency, purpose...   The 5P Framework: 1. Predisposing Factors (Vulnerabilities): \"Why me?\" What made this person vulnerable to the present challenges, to experiencing distress in the recent events? Past events? Mental, physical factors? 2. Precipitating Factors (Triggers): \"Why now?\" What situations/experiences just before, that may have brought about the presenting problems? Brought the client to therapy? 3. Presenting Issues (Purpose): What are the issues the person is experiencing that brings distress or difficulty? What does the person want to achieve in therapy 4. Perpetuating (Maintaining) Factors: \"Why does it continue?\" What things seem to keep the problem going? E.g. thoughts and beliefs, what they do/avoid doing, their relationships, external factors 5. Positive or Protective Factors: \"What can I rely on?\" What factors are positive for the person\'s sense of self-efficacy, or reduce the adverse impact of current or past circumstances?   The Biopsychosocial Model: - George Engel (1977) - now common in both medical and mental health circles - Three interdependent factors 1. Biological Domain: Family history? Taking medication? Physical or neurological impairments? 2. Psychological Domain: Patterns of thinking, feeling, and responding? Core beliefs about self and the world? Strengths and vulnerabilities? 3. Social and Cultural Domain: Relationships? Friendships? Family? Community? Work? Finances? Experience of \'power\'?   Culturally-Informed Conceptualisation: - The APS 2016 - formal apology to Aboriginal and Torrs Strait Islander People - \"Listen more and talk less\", to \"Follow more and steer less\", and to \"Collaborate more and command less\" - Culturally informed, culturally safe practice - Increase knowledge and use of Indigenous conceptualisations of mental health and mental illness - Focus on understanding and strengthening social and emotional wellbeing (SEWB), with the broader social context - Acknowledges systemic factors shape social network factors, which, in turn, influence psychosocial mechanisms - Takes a SEWB and cross-cultural approach - Integrates bioecological and integrative 5P/biopsychosocial models   Integrating Models: - In all cases, we want to know similar things - What the client is struggling with - What factors are important contributors to the client\'s struggle (to be understood, and/or to be factored into the approach to change) - How the client\'s issue extends in their broader life context (what it is effecting, what isn\'t being impacted) - What brings relief or allows the client to function as they need and want to - The biopsychosocial and 5P frameworks can be combined, and also integrated into most therapeutic modalities - Cultural factors always need to be considered (because \"we\" / \"I\" is never the same)   The Challenge of Liminality: - By keeping open-minded, curious, listening and continuously interested in the client, the counsellor will develop an increasingly deeper understanding of the client and their presenting problems - Liminal: The space between neither this nor that   **9.3: Practice Issues - Case notes and records, referral and termination**   Records and Case Notes Could Include: - Date of the session - Factual information given by the person - Details of the person\'s problems, issues or dilemmas - The process that occurred during the session - The outcome of the counselling session - Interventions used by the counsellor - Any goals identified - Any contract between the person and the counsellor - Matters to be considered at subsequent sessions - The counsellor\'s own feelings relating to the parson and the counselling process   Case Note Example: - Client Information: - Married 13 years, no children, life husband twice in last 2 years of short periods, had affair 10 years ago but husband is not aware of this - Independent financial resources, reduced social support system (one identified friend) - Suspects husband is having an affair, afraid to ask, confused, about feelings and meaning of affair for long term - Has been unable to decide to confront, leave, or continue marriage. Described relationship as unsatisfactory - Does not with to consider relationship counselling. Sates husband would not agree - Process: - Initially had difficulty talking freely, but more comfortable and open as the counselling relationship developed, explored confusion about feelings and possible options - Unable to decide action, but appeared less distressed - Intervention: - Used PCT to develop relationship, guided relaxation to manage distress - Goals: - Confront husband, but unsure of ability to do so yet; feeling sad and determined. Wants to use the counselling process to develop courage - Agreed on weekly sessions for the next month   Melinda Case Note Example: - Presenting Issue? - Not feeling myself/anxious/depressed - Precipitating factors? - End of 18-year relationship, was not her choice (grief/loss) - Predisposing factors? - Genetic predisposition: mother depressed, unstable - Father strict with high expectations that were hard/impossible to meet - Family environment and caregiver relationships that did not meet emotional needs - Perpetuating factors? - Alcohol use - Grief/loss - Protective factors? - Friends (friendship network) - Employed - Insight/help seeking   Terminating: - When do we terminate counselling? - Therapeutic goals have been met, and client is ready to move forward without counselling - Ethical obligation re: competency, conflict of interest, other practical issues - How to prepare for the final session? - Conversation, agreement, and countdown - Who makes the decision? - Ideally, this is a collaborative process - How do we deal with the loss of the relationship? - Booster sessions or follow-up sessions? Need to consider what is our rationale - How to achieve closure of the relationship?   Termination Process: 1. Prepare explicitly for termination 2. Process feelings of client and therapist 3. Reflect on client gains 4. Express in client\'s progress and mutual relationship 5. Discuss client\'s future functioning and coping 6. Facilitate client using new skills beyond therapy, affirm post-therapy growth 7. Acknowledge persona development as ongoing   Disagreement About Ending? a. Client wants to terminate: - Has there been a rupture in the relationship? - Are there issues they do not want to work with? - Where is the client at? - Are they not ready? Age, resources, other demands? - So consider: - What resources do they have, and what else is happening? - Do they need time to consolidate what they have gained? b. Client does not want to terminate: - More unresolved issues that have not yet been shared? - Do they want more sessions because of dependency? If dependency is present, counsellor needs to address it   Dependency: - Intimacy and attachment (for both) - Lack of other supports, relationship - Self-efficacy - When there is a problem, who do you call? - Dealing with dependency - Reframing, normalising - Monitoring process - Acknowledging inevitable mourning - \'Weaning\', and follow-up appointments Week 10: **10.1: Advanced Skills (pt. 1)** - Temet Nosce \"Know Thyself\" - All of us have... - Strengths and weaknesses - Assets and flaws - Likes and dislikes - Values and biases - We are ethically bound to treat our clients with respect and sensitivity, and to be non-judgemental practitioners, irrespective of a client\'s lifestyle, values, gender, age, ability, culture, religion, spirituality, or sexual identity - These questions and considerations always impact the way we work with people! Acknowledge your position and lens from which you see people! Maybe even share \"your approach to people and their problems\" with your clients. What is your lens? - Know thy triggers - We simply cannot apply our values or worldviews to our client\'s life - What lens are you using? - Skills and techniques: - Counselling skills are a therapist\'s tools. We learn and need lots of tools! - Being a good therapist isn\'t just about having a massive amount of tools - its about knowing which tool is used for what job - Using the wrong tool for the job - you might get it done - but likely not - Using the right tool for the job with skill = much better chance - Choice of tools or techniques is also linked with your position on the nature of human beings and the way you see the world - Choice of tool is thus linked with your choice of therapeutic modalities/theories - Normalising: Conveying to a client your perception or assessment of the normality of their experience of distress or discomfort - A useful tool when people perceive themselves as \'going crazy\' when experiencing a particularly emotionally charged event - More than just \'being nice\' to our clients - Often times, easier to do for others than it is to do for ourselves - Examples: Either Emotional or Action/Developmental - \"I can\'t imagine what that must be like... I think it would be really hard for anyone to have to hear that\" - \"That sounds like such a human response to such a difficult situation\" - \"Anyone in your position would have done the same thing\" - \"I think the way you handled that was a completely normal response to a completely normal experience\" - Normalising is not... - Minimising, discounting, or devaluating a person\'s concerns or pain - Saying \"Oh, that\'s no big deal, everybody has to go through that at some point\" - Always helpful in all situations - sometimes we might be tempted to normalise things that are not \'normal\' - Usually, better to use normalising when the client is - somehow - asking you about the \'okayness\' of their experience   **10.2: Here and Now + Polarities** - Here and Now: - Basis in Gestalt Therapy - Using what happens in the room (client/therapist/reactions/emotions/behaviours) for a therapeutic purpose - Idea that a client\'s issues will emerge or play our in-session or in the therapeutic relationship - E.g. A woman who comes to therapy who is struggling with feelings of frustration will likely experience frustration in-session - A child who comes to session with emotion regulation difficulties will likely experience this in-session - Things to watch while using Here and Now... - Noticing client\'s non-verbal changes - Posture, movement, voice tone, speed of speech... - Noticing client\'s verbals - What did they say exactly - what emotion, what thought, what behaviour... - What aren\'t they saying, avoiding,... ? - Understanding your own reactions - Noticing your own automatic reactions - thoughts, feelings, behaviours... - Shine the spotlight - \"I noticed as you said that about how your partner makes you angry you started to tear up... so this is really emotionally upsetting for you?\" - \"I noticed as you said that \"a part of you distances away\"... you didn\'t finish the sentence. What could be going on for you?\" - \"I noticed as you talk about the painfulness of that experience and despite saying how much you hate it all, you laughed. What could be going on there for you? What is that about, do you think?\" - Here and Now - Incongruence - Roger\'s defined congruence as the matching of experience and awareness - Clients are not (necessarily) aware of their own congruence - Be on the lookout for when the client says one ting but shows what appears to be a mismatched emotion: - Angry, but laughs - Anxious, but speaks in frustrated tones - Sad, but speaks in an upbeat tone - We can start looking at and working with what is being communicated both implicitly and explicitly and explore both dimensions and integrate them into awareness   - Polarities: - Informed by Gestalt Therapy - Two sides of the same coin? - Polster and Polster: \"Whenever an individual recognizes one aspect of himself, the presence of its anti-thesis or polar quality becomes implicit. There it rests as background, giving dimension to present experience and yet powerful enough to emerge as a figure in its own right, if it gathers enough force. When this force is supported, integration can develop\" (1973) - \"Helping a person feel better about accepting and owning what they believe are undesirable or negative qualities or emotions\" - Helping clients integrate two seemingly opposing polarities - showing that these can co-exist with harmony within us, and what we don\'t always \'have to choose\' - The Empty Chair Technique (Polarities): - Need: 1 therapist, 1 client, 3 chairs - Get the client comfortable in their chair in their \'primary state\' (State A). Ask them questions around their primary state, which is talk to them as you normally do about their beliefs, fears, concerns, anger... Unpack primary state - Get them to address their concerns to an \'other\' relevant person, who they envisage sitting in the chair (State B). This can be a friend, family member, ancestor, unborn person, or even a part of themselves, one aspect of their identity that they are struggling to see or haven\'t seen for a long time - When a person has had a \'complete\' experience of State A, we see them switch to State B - and switch them to sit in the empty chair. Now, they take the perspective of that other person. Theory here that the pendulum swing facilitates movement - the opposite of \'stuckness\' - Draw attention to the body - the emotional and physiological experience of exploring the polarity - E.g. For example, someone who has previously seen themselves as timid may recognise an inner ability to be assertive. Having recognised this, they then have the choice to move along the continuum - timid to assertive - to a position that suits them at any particular time and in any particular situation   **10.3: Post-Modern Therapy** - All postmodern approaches to therapy are built on certain philosophical assumptions about the nature of reality (e.g. constructivism, social constructivism, post-structuralism, hermeneutics...) - The most popular postmodern approaches: - Solution focused therapy - Narrative therapy - Collaboration therapy - Feminist therapy - Recently a more integrated post-modern approach is emerging using concepts from all of the above, as they sometimes overlap   - Solution-Focused Therapy (SFT): - Some work environments prioritise the use of SFT - SFT is goal-directed and collaborative - SFT is less concerned with historical factors of a client\'s life, and more concerned with present and future goals - where do they want to be, rather than where they have been - However, some SFT skills do stray into the past - albeit briefly - Seeking Exceptions: - A technique which aims to help clients see their strengths or times when the problem is not at its best - Often times, clients struggle with this as they only see themselves in light of one version of themselves - New exceptional times, provide a point of entry for solutions to expand or emerge - E.g. Client says \"I\'m concerned because I\'m drinking every night\" - Explore exceptions to this! - Therapist says \"Has there been any nights where you haven\'t had a drink?\" - Client says \"Well, not that many nights recently... but yes. When I go to basketball on Tuesday nights, I don\'t really feel like drinking afterwards. And it\'s pretty late by then, anyway\" - The Miracle Question: - Useful for times when we have a client overwhelmed with problems - Enables the client to take a moment to imagine a future where the \'problem\' is not present - The aim is not merely the answers or that moment, but the opening to a wide range of possibilities and options as it provides clues about the client\'s ideal life, preferences, desired values, or goals - 6 Steps: i. Laying the foundation and setting the scene for the client to imagine the future without the problem: - \"I have a strange, perhaps unusual question, a question that takes some imagination...\" - \"Suppose... After we finish here, you go home tonight, watch TV, do your usual chores, etc. and then go to bed and to sleep.. Mm?..\" - \"And, while you are sleeping, a miracle happens...\" - \"And, the problems that brought you here are solved, just like that!\" - But, here is a big BUT, this happens while you are sleeping, so you cannot know that it has happened...\" ii. Constructing a new perspective on the \'state of the miracle-day\': - \"Once you wake up in the morning, how will you go about discovering that this miracle has happened to you?\" - \"Once you wake up in the morning, how will your father or best friend know that this miracle happened to you?\" iii. Becoming curious about exceptional times: - \"Now, do you recall, when was the most recent time (perhaps days, or hours, or weeks) that you can remember when things were sort of like this day after the miracle?\" iv. Scaling questions towards broadening of exceptional times (using progress scales): - \"On a scale of 0 to 10, with 10 standing for how things are the day after the miracle and zero standing for how things were at the point you called to arrange this appointment, where are you at this point (now)?\" - \"On the same scale, where do you think your best friend would say you are?\" - \"On the same scale, where would you say things were when things were sort of like this miracle day?\" v. Following up in the next session (reinforcing the miracle scene): - \"So, what is better?\" vi. Repeat using a progress scale: - \"Remember that scale where 10 stands for the day after the miracle? Where would you say you are today on that scale?\"   **10.4: Narrative Therapy** - Narrative therapy seeks to be a respectful, non-blaming approach to counselling and community work, which centres people as the experts in their own lives. It views problems as separate from people and assumes people have many skills, competencies, beliefs, values, commitments, and abilities that will assist them to reduce the influence of problems in their lives - Externalising Conversations: - Our social context and certain dominant forces in our societies, repeatedly convey the message that problems reside within us - People, therefore, often see problems as an inherent part of themselves and their identity - E.g. A person might say: \"I am a nervous person\" or \"I am an anxious person\" - Externalising the problem helps the person to see themselves as someone who is being influenced by \"nervousness\" in some settings, or at some points - Major phrases in NT: The person is not the problem- the problem is the problem - Aim to separate the problem from the person - Creates distance that allows space to emerge around the person - This new space fosters the realisation that the person is more than the problem (rather than being engulfed by it) - Externalising is an opportunity for seeing how the issue affects the person\'s life and what mechanisms are at play (intersects with skill of looking for exceptions) - Hence, opens possibilities for engaging with problem differently: - The way it is experienced and understood, and - What options the person has to live differently - Can encourage the person to take control, and increase their sense of capacity to cope and change - Externalising Conversations: A way of speaking in which the problem may be spoken of as if it were a distinct entity separate from the person - It\'s the first step in separating the person from the problem and this kind of language continues throughout the rest of our work with a client - Objectifies or personifies the problem - Disempowers the problem - Decreases the problem - Opens pathways for action - Promotes cooperative effort - What the Wildman, the Dragon-Arguing Monster and Camellia the Chameleon taught me about externalising conversations by Maggie Carey (2002) - Statement of Position Map 1: Externalising Conversations - Characterise the Problem: Characterise the problem in an experience-near way - Do you remember/know about the Empty Chair Technique? Imagine you are about to ask the problem to sit on that chair as you and the client start to look at it from now on and explore its tactics and operations - Give the problem a persona: The Depression, The Anorexia, The Wildman, The Dark Hole... - Translate the verbs to nouns: When The Depression (or The Wildman) takes over... - Negotiation of an experience-near, particular, and non-structuralist definition of the problem/concern (as an alternative to an experience-distant, global, and structuralist definition of the problem/concern) - Mapping the Effects of the Problem: Mapping of the effects/influence of the problem with its antecedents, and various life contexts of the person - An exploration of the various domains of the client\'s life in which complications are identified: home, workplace, school, peer contexts, familial relationships, one\'s relationship with oneself, friendships, purposes, hopes, dreams, aspirations and values, life\'s horizon, one\'s future possibilities, etc. - To provide a full acknowledgement of the effects of the problem - To link/situate the problem in time, relationships, and context - E.g. Ask about the effects of \"The Problem\" on the subject\'s relationships with ithers, its impact on the person\'s feelings, its interference in the subject\'s thoughts, its effects on the person\'s story about who they are as a person, how it has the client treating their own life, and so on - Evaluation of the Effects of the Problem: Describe your experience of the effects of the problem and evaluate your position on the effects of the problem - Evaluation of the effects/influence of the problem in various life domains/contexts that we just explored. We do this to help the person develop a position on those effects and in relation to \'The Problem\' - The asking of a \'position description\' in relation to what the problem is doing, might be surprising for some clients as they assume we are here to advise them on the undesirability of the effects the problem, like many others in their life perhaps - Example questions to evaluate the effects and invite a position development: - \"Is this okay with you?\" - \"How do you feel about this?\" - \"How is this by you? Where do you stand on this?\" - \"What is your position on this?\" - \"Is this a positive or negative development? Or would you say both a positive and a negative development, or neither of these? Or would you say an in-between development?\" - Justification of the Evaluations: Why is/isn\'t this effects okay for you? Why do you feel this way about this development? - After helping the person to clearly articulate their position on the effects of the problem (previous step), we invite them to justify their position through some further curious questions - Client position: \"Of course I don't like this. This is really not something that I wanted or imagined would ever happen; this whole thing is very strange as it was completely fine for me to go our with people\" - Now we inquire about some kind of justification on the above position/evaluation: - \"Why is/isn\'t this okay for you?\" - \"Why do you feel this way about this development?\" - \"How come you\'re taking this stand/position on this development?\" - \"Would you tell me a story about your life that would help me understand why you would take this position on this development?\" - The location of externalising conversation in the overall process of narrative therapy - Tracing the history and emergence of the problem (in a social context) - Mapping the influence of the problem, evaluating its effects and justification of those evaluations - Searching for unique outcomes (exceptional circumstances) - Thickening the new alternative stories and re-authoring Week 11: - Why might people pretend, ignore, or dissociate from their \'check engine\' light? - Habit-forming - Secondary gains - The ability to return to an emotional set point is a crucial process for life long social and physical wellbeing - In therapy, it is a strong alliance that can help build positive outcomes - Why emotion regulation? - Emotions in everyday life - Humans are a problem-solving, certainty creating machine - Problem? Negative, painful experiences - Avoid or soothe - Internal and external sources for regulation - e.g... - Caregivers - Nature - Therapy can include both - Emotion Regulation can be described as.. - A diverse set of psychological processes by which emotions are amplified, reduced, or maintained - The set of processes whereby people seek to redirect the spontaneous flow of their emotions - Emotional down-regulation processes aim to achieve a steeper exit gradient, resulting in a speedier return to the baseline - However, not all emotion regulation strategies are positive or helpful over the long-term - Emotion regulation involves changes in emotional responding - May amplify, maintain, or reduce positive and negative emotions - What is experienced, when and how - Changes along dimensions such as valence, arousal, approach avoidance - Ideally brings people closer to the desired emotion but often counter-intuitive - Chronic deficits in emotion regulation contribute to all major forms of psychopathology - Many evidence-based treatments focus on training clients in skills to help regulate - Types of Emotion Regulation Strategies: - Attention Strategies: E.g., positive thinking, attentional avoidance/distraction, thought suppression, grounding techniques, meditation, mindfulness - Knowledge Strategies: E.g., cognitive dissonance reduction/resolution, cognitive reappraisal, expressive writing (e.g., letter to self or others) - Body Strategies: E.g., stress-induced eating, alcohol or drug use, exercise, venting, sensory modulation, controlled breathing (square snake, balloon techniques), progressive muscle relaxation - Which are helpful? Short term vs long term? - Regulation is not always a single player game! - Interpersonal relationships play an important role (e.g., parent-infant dyads, romantic relationships...) - Regulation is impacted by the internal emotional state, and the emotional states of others with whom one is interacting - Two emotional tasks therapists may engage in during psychotherapy: - Respond to a client in a way that helps them to manage their emotional arousal, and - Manage a complementary pull from clients that may lead the therapist to become more emotionally aroused during the session - Macro-skills: Empathetic responding, genuineness, presence, holding space, and collaboration - Soma et al. (2020): - Study of 227 therapy sessions found moment to moment bidirectional linkage to therapist and client emotional experience (vocal fundamental frequency - validated and minimally invasive measure of vocally encoded emotional arousal) - Therapists tended to begin with higher arousal indicating engagement, presence, to create safety, but reduced over time in response to client - Client arousal increased in response to therapist, indicating feeling safer to express emotion - Similarly, research shows individual tolerance to physical pain is higher in the presence of another person - Emotion contagion in the room - Use of empathy is vital - involved experiencing emotional resonance, and emotion regulation within the counsellor - So - what about us? - Remember, this is not your story (externalise, bubble, etc.) - Emotion regulation in session (diaphragmatic breathing training) - Is there countertransference? -\> supervision - What is going on for you? -\> own therapy - Have your own empathy experience (debrief, supervision, self-compassion training)   **Mini-Lecture 11.2: Empathetic Confrontation** - Origins in Gestalt therapy in addressing avoidance behaviours - Often used when observed mixed messages or incongruities in the client\'s words, behaviours, feelings, or thoughts - Movement in therapy often occurs by helping clients to understand how their behaviours and choices are affecting them - May require skilful, empathetic confrontation to create a self-understanding, and perspective shift - Empathetic confrontation: - A firm yet gentle and respectful identification, reflection, and exploration of a client\'s incongruencies and inconsistencies for a therapeutic benefit - Not a direct or violent challenge - involved listening to the client with careful and gentle respect - don't forget empathetic responding - Why use empathetic confrontation? - Brings client\'s attention to it to promote awareness, analysis and insight - Unhelpful ways of thinking - Deeper feelings - Unhelpful actions and behaviours that keep the client stuck - Awareness and self-understanding facilitates choice and a greater sese of control or efficacy - Can be important for reducing resistance - When to use empathetic confrontation: - Avoidance issues - Failing to recognise serious consequences - Making contradictory statements - Locked into the past rather than the present - Using incongruent verbal and non-verbal behaviour - Must consider: - Client readiness - Client behavioural risk factors - Client emotional stability - Effective confrontation often includes: - A reflection/brief summary of what client has shared - A concise statement of the counsellor\'s present feelings - A directive statement of what has been observed/notices (e.g., the incongruence) - All in a non-threatening way - Hot tips! - The stronger the therapeutic relationship, the less likely the client will respond defensively - Don\'t let your own values invade your client\'s therapeutic space - Checks when using confrontation: - Self-examine and discern: - What has prompted me to want to use confrontation at this moment? - Whats my intention - what do I want to achieve? - What about myself in this decision (what is happening for me) - does it serve me or the client? - Is there something that indicates that confrontation shouldn't be used? - Alternative technique?   **Mini-Lecture 11.3: Reframing** - We create frames for what we see, hear, and experience all the time - both informs and limits the way we think - Reframing is about looking at a situation, thought, or feeling from another angle - Usually where there is a rigid way of responding/thinking driven by emotion, based in long-term patterns - Opens up insight to options and possibilities \> facilitates a shift towards a change - \"When we are no longer able to change a situation, we are challenged to change ourselves\" - Being able to question and shift your frame of reference is important as it can... - Reveal completely different insights, many more possibilities - Enhance mental flexibility - Takes effort, attention, and practice - Seeing the world from other people\'s perspectives - Asking questions that help you see beyond your current frame of reference - All questions are the frame into which the answers fall - What is the difference between the following two questions? - \"What is the sum of 5 plus 5?\" (only one answer - very limited) - \"Which two numbers add up to 10?\" (limitless answers - open to interpretation) - An effective reframe typically goes beyond thinking differently, and is experienced with feelings or emotion - May need to tune into emotional arousal and regulation first - Observe receptiveness - attentional gates open? - Not intended to deny the person of their perspective - Counsellor must provide the reframe with sensitivity, honesty, and respect - The person must feel comfortable either taking on a new perspective or rejecting an old perspective - Externalising first can be helpful, opening the receptive gates - E.g. Glass 50% water 50% air = technically, completely full   **Mini-Lecture 11.4: Challenging Self-Destructive Beliefs** - Self-destructive beliefs often involves - Labels or rules: Lazy, unmotivated, perfectionistic, worthless, should, must... - Unrealistic expectations of self or others - Beliefs that no longer fit our environment - Our constant, every day commentary is often highly self-critical - 80,000+ thoughts per day... how many do we actively choose? - The presence of self-defeating beliefs is revealed through self-critical dialogue. Look for this in session - Part of our work is helping identify these self-critical thoughts - and then go deeper (offering a mirror) - Some common versions of self-destructive beliefs: - I am not good enough - I will never succeed - I am not worth it - I am alone - I am ugly - I am powerless to change my life - I am not smart enough - They are all subjective!! - Explore vs negotiate - (e.g., \"It\'ll all be ok!\") Sometimes, this is just what we need to hear from friends and family, but it is not always enough - Clients \"own it\" when they come to this realisation through their own self-actualisation - We ask questions designed to shine a light on their experience, so that the client can see things from a different, more objective, more fair, more reasonable perspective - Look for patterns of thinking, feeling, and responding to share through you reflections - common cognitive distortions - Respect client perspective; guide client to reappraise events - Use skills such as confrontation + reframing to help the client explore their own beliefs and the consequences of these beliefs - The ABCDE Model: - Activating events - Beliefs - helpful or unhelpful \