Campus Alberta Applied Psychology 605: Working Alliance...

Graduate Centre for Applied Psychology

GCAP 635: Intervening to Facilitate Client Change

Instructor’s Manual

Course Coordinator: Sandra [email protected] (toll free)

mailto:[email protected]

Table of Contents

Table of Contents 2Purpose of GCAP 635: Intervening to Facilitate Client Change 3Relationship to GCAP 671: Developing a Working Alliance 3GCAP 635 On-Line Lessons 4GCAP 635 Summer Institute 4The Importance and Context of Counselling Skills and Working Alliance

Development5

Course Texts 6Instructions to Students 7Summer Institute Content and Guidelines 7Lesson 6: Consolidation and Review 8Lesson 7: Continuing Problem Exploration 10Lesson 8: Capitalizing on Client and Therapist Factors 13

Relationship Patterns in Solution-Focused Therapy 18Lesson 9: Pre-Intervention Screening 20

Some Factors Considered During a Mental Status Examination 22Lesson 10: Expanding on History-Taking 24Lesson 11: Applied Practice in Case Conceptualization 27

Case Conceptualization Exercise Forms 30Lesson 12: Case-Based Intervention Practice: Goal Setting 34Lesson 13: Case-Based Intervention Practice: Initiating an Intervention 37

Potential Indicators of Treatment Duration 40Lesson 14: Case-Based Intervention Practice: Following Up 42

Following Up on Counselling Interventions 45A Primer on Outcome Management 47

Lesson 15: Case-Based Intervention Practice: Evaluation and Termination 50A Framework for Termination in Counselling 53

Lesson 16: Approaches to Psychotherapy Integration 58Pathways to Theoretical Integration 59

Lesson 17: Building on Your Personal Counselling Style and Continuing Competence

63

Therapist Resource Assessment 66Appendix 1: Skill Coding Sheet 70

635 Instructor Manual Revised S14 2

Purpose of GCAP 635: Intervening to Facilitate Client Change


The purpose of this manual is to provide an overview for the Summer Institute (SI) component of GCAP 635.

The SI portion of this course is designed to provide a context for you to:

review the content from the first five online lessons (Lesson 6); practice the generic sequences and processes of case conceptualization and

intervention planning (Lessons 7 to 11); simulate a course of treatment (goal-setting, executing an intervention, following

up, and evaluating and terminating; lessons 12 to 15); and integrating your learning and planning for your continuing competence (lessons

16 and 17).

Although real counselling practice may be quite different, this course is designed to lead you through an analogue of a counselling process so that you will have some sense of what to expect in your supervised practice experience. SI itself is, if I can be forgiven for using a sports metaphor, analogous to training camp, in which players first work on basic skills, and then on set sequences or plays. The real game is yet to come.

Relationship to GCAP 671: Developing a Working Alliance

GCAP 635 and 671 are taken in concert with one another. Although you may take them sequentially (with 671 preceding 635), most of you will take them concurrently. Accordingly, the content of both courses has been arranged to build on each other, both during the online portion of the course and during SI.

The Summer Institute lessons are structured so that you are engaged in 671 both morning and afternoon for the first four days of classes. This allows you to intensely practice the micro-skills and to focus exclusively on 671 during this time. For the next four days, you will be taking 635 in the morning session and 671 in the afternoon. Finally, for the last week of the summer institute, you will engage in 635 in both morning and afternoon classes. This sequencing of courses allows us to structure the skills practice and the content focus of each course to allow flow between the courses. The skills practice foundation established in 671 will carry on into the last week of 635 during Summer Institute.


The following definitions will provide a sense of how we want students to progress through skills practice across these two courses. In 671, the skill practice is designed to shape the your ability to thoroughly explore the client’s presenting concern, to the point where the client can clearly state the problem, and identify the cognitive, affective, and behavioural factors that influence the problem. Throughout the course, we will refer to this as the problem exploration process. You will be itching to move on to goal-setting, tasks, and solutions during 671; however, your instructor and TA will keep you focused on problem exploration. This will help you maintain the focus on creating a way of being and purposefully integrating your skills to establish a solid therapeutic relationship/working alliance with your clients. In GCAP 635, you will focus on integrating the skills they learned in GCAP 671 into conversational patterns that closely resemble actual counselling interactions and interventions.

Problem Exploration (GCAP 671)The process of exploring in detail all aspects of the client’s problem to come to a clear understanding of the factors that affect the problem, the client response to the problem, the facilitative factors and barriers that impact the problem, etc.

Goal Setting (GCAP 635)Problem exploration in turn forms a foundation for moving forward with Goal Setting. Goal setting involves taking the more global understanding of what the current problem is and breaking it down into clear, discrete, theoretically supported, goals and sub-goals, which will become the focus of the counselling process.

GCAP 635 Online Lessons

Lesson 1: Revisiting common factors - The relationship between alliance, assessment, and interventions

Lesson 2: Forming an intervention plan: Case conceptualizationLesson 3: Cultural and contextual issues in intervention planningLesson 4: Client factors and “motivation”Lesson 5: Goal-setting in intervention planning

GCAP 635 Summer Institute

SI promotes the integration of theory with practice. Each lesson has necessary content that will allow students to develop their ability to conceptualize cases and develop intervention plans. These will require them to use the skills they learned in GCAP 671. SI is designed like a lab to facilitate skill practice and application of content, as opposed to introducing a great deal of new content, except as needed to enhance the quality of the practice time. We also want to foster critical thinking about microskills and to encourage students to begin to contextualize them theoretically and culturally. A typical day at SI might include:


Review of conceptual focus and skills practice from previous day(s); Introduction and discussion of the thematic focus for the day; Skill demonstration by the instructor; Skills practice, following the triad handout contained in this manual, or other

practice exercises; and Reflection and debrief on the activities.

Week II

GCAP 635 starts in the second week of SI, and will have only morning classes this week. GCAP 671 will continue in the afternoons in this second week. Students will utilize the skills that they developed the 671 course to practice counselling processes that are common to most, if not all approaches to counselling, regardless of setting, population, or theoretical orientation.

Lesson 6: Consolidation and ReviewLesson 7: Continuing Problem ExplorationLesson 8: Capitalizing on Client and Therapist FactorsLesson 9: Pre-Intervention Screening

Week III

In the third week of SI, GCAP 635 runs full days, and students will develop their skills in adjusting your relationship stance to the presentation of the client, developing a comprehensive case conceptualization that informs your intervention, taking a history, setting measureable goals, devising and implementing an intervention, and evaluating and terminating counselling. The final day will focus on their further development as a counsellor.

Lesson 10: Expanding on History-TakingLesson 11: Applied Practice in Case ConceptualizationLesson 12: Case-Based Intervention Practice: Goal-SettingLesson 13: Case-Based Intervention Practice: Initiating an Intervention Lesson 14: Case-Based Intervention Practice: Following UpLesson 15: Case-Based Intervention Practice: Evaluation and Termination Lesson 16: Approaches to Psychotherapy Integration Lesson 17: Building on Your Personal Counselling Style & Continuing Competence

The Importance and Context of Counselling Skills and Working Alliance Development


The College of Alberta Psychologists (CAP) defines competence as “…Knowledge, Skill, Judgment, and Diligence in specific areas of content and practice in psychology, which are defined by the Standards of Practice, the Canadian Code of Ethics, and Practice Guidelines. The psychologist engages in this professional practice in an accountable manner, across the span of his or her career” (CAP, 2010, p. 9-10). Although this is an Alberta-centric definition, this is a common way to think about competence.

Knowledge entails having absorbed a body of information sufficient to understand and conceptualize the range of professional issues we can reasonably expect to encounter. Skill is the ability to effectively apply knowledge. Judgment involves knowing when to apply which skills under what circumstances, and self-reflection on how our own values, attitudes, experiences, and social context influence our actions, interpretations, choices, and recommendations. Diligence involves consistently attending to our knowledge, skills, and judgment as they are applied in our professional activities, and taking care to put our clients' needs over any other concerns. It involves a willingness to work hard to provide the best service possible for each and every client, and honestly evaluating our own skills and seeking additional training when appropriate. A diligent counsellor seeks out professional standards and guidelines that identify the knowledge, skills, and judgment essential to practice. Being diligent also incorporates self-awareness of any personal or situational circumstances that might diminish our competence (CAP, 2006; Truscott & Crook, 2004).

Understanding this reminds us that our skill practice is relevant beyond SI. Your skill development must be considered in the context of your future work as a professional counsellor. Your SI courses are not simply about generating “good” or “bad” skill demonstrations, but about continuous application of competent and ethical practice.

References

College of Alberta Psychologists (2006). Standards of practice. Edmonton, AB: Author. Retrieved from http://www.cap.ab.ca/pdfs/HPAStandardsofPractice.pdf.

College of Alberta Psychologists (2010). Continuing competence program and self-assessment guide. Edmonton, AB: Author. Retrieved from http://cap.ab.ca/memberpdfs/CCP-ProgramDescription.pdf

Truscott, D., & Crook, K. H. (2004). Ethics for the practice of psychology in Canada. Edmonton, AB: University of Alberta Press.

Course Texts


http://cap.ab.ca/memberpdfs/CCP-ProgramDescription.pdf

http://www.cap.ab.ca/pdfs/HPAStandardsofPractice.pdf

The course texts for 671 and 635 are shared. Both are provided as e-books, directly linked from within the Moodle platform for the course. Students will draw on resources from both Corey (2013) and Cormier, Nurius, and Osborn (2013) for various lessons in both courses. We have tried to pace the lessons and readings across the two courses to make the volume of reading manageable and the flow of content logical for students.

You will notice that the Cormier, Nurius, and Osborn (2013) text is cognitive-behavioural in focus. We have not selected this text for its theoretical foundations. In fact, we hope that you will each continue to bring in connections and reflections on other theoretical models throughout the course. We do not intend this to provide the theoretical foundations for the course; it was selected because of the microskills focus in some chapters and the very concrete and practical approach to some of the key issues and processes addressed in both 671 and 635.


Instructions to Students

1. Photocopying will not be readily available on the Mount Royal University campus. Accordingly, they should print the forms and handouts they will need before arriving at SI.

2. Skill coding sheets are required for lessons 7, 9, 10, 12, 13, 14, and 15. Students must ensure that they have an ample supply of them for each class. They will likely require at least two for each class. A copy can be found as Appendix 1 of this manual.

3. Students are expected to do the preparation required before each class, including new readings, reviewing readings they have already done, bringing a handout or textbook to class, or viewing a video.

4. In lessons that feature skill practice, students will be required to submit their coding sheets to the instructor. These will not be graded, but are requiring to ensure that they derive maximum learning from each session.

Summer Institute Lesson Content and Guidelines

The following section provides details on each of the summer institute lessons. The material is identical to that provided in the student manual (and is, therefore, worded as if students are the target audience).


Lesson 6: Consolidation and Review

Introduction

As you approach the first day of GCAP 635 at Summer Institute, most of you will have already been participating in GCAP 671 “boot camp.” You may have been preoccupied with making sure your questions are open ended, or thinking about how to follow up after reflecting meaning. You may have been anxious about ‘doing it right,’ frustrated with your rate of skill acquisition, or questioning the relevance of these skills and how they are sequenced. You may be excited by having had a taste of applying your preferred counselling model after participating in the modules. You may be wondering how it all fits together.

As we have already stated, GCAP 671 and GCAP 635 are designed to be integrated with one another because this emulates reality. It does not make sense to think of using a tool (whether it is asking an open question or swinging a hammer) outside of the context of the task for which you are employing it (whether it is executing a counselling intervention or building a house). Accordingly, you will notice that you will be using what you learned in GCAP 671 almost right away in GCAP 635. Our intention is that, at least as much as possible without seeing actual clients, it all starts to come together in GCAP 635.

In this lesson, we will review the online content and reflect on how the modules have changed your outlook. We will overview the Summer Institute lessons and modules and deal with some housekeeping issues pertaining to SI.

Required reading and preparation:

Corey, G. (2013). The art of integrative counselling (3rd ed). [eBook version]. Retrieved from http://www.cengage.com

Chapter 1: Beginning of counselingFocus on how Corey maximizes the common factors.

Cormier, S., Nurius, P. S., & Osborn, C. J. (2013). Interviewing and change strategies for helpers (7th ed.) [eBook version]. Retrieved from http://www.cengage.com. Chapter 9: Clinical decision making and treatment planningThis chapter provides an overview of factors that must be considered when planning counselling interventions.

Learning Objectives:

1. Review the common factors as a basis for conceptualizing and developing counselling interventions and apply them to counselling situations.

2. Apply the common factors to counselling situations.


http://www.cengage.com/


3. Conceptualize the content of the Intervention Modules in light of the common factors.

Key Concepts and Terms:

Common factors: Working alliance Client characteristics and extra-therapeutic factors. Model/technique factors Expectancy, hope, and placebo Maximizing common factors

o Enhance the factors across theories that account for successful outcomeo Use the client's theory of change to guide choice of technique and

integration of various therapy modelso Obtain valid and reliable feedback regarding the client's experience of the

process and outcome of treatmento Become more change-focused in therapy

Session Outline:

1. Introductory activity

2. Common factors review (PowerPoint presentation)

3. Review of cases from Assignments 1 and 2 / Module review

4. Housekeeping detailsa. Video assignment overview

b. Scheduling “Highlighting an Intervention” presentations

c. Miscellaneous


Lesson 7: Continuing Problem Exploration

Introduction

This lesson builds on GCAP 671, Lesson 6 (Problem Exploration) and Lesson 12 (Intake Interview / Client History). Lesson 6 introduced you to conversational habits that will invite clients to discuss their difficulties with you, how to open the conversational space. In Lesson 12, you learned the distinction between merely exploring the problem, and collecting information to understand enough about the problem to plan intervention. Defining the problem in a way that engages the client and describes the problem concretely is necessary to develop useful, client-directed goals that can be evaluated. Because counselling balances empathic, humane listening with task orientation and a change focus, it is necessary to converse about problems to incorporate clients’ desires, hopes, complaints, and wishes with a view toward developing goals. We will examine goal-setting and evaluation in Lesson 12.

In the social sciences, research is sometimes distinguished along the temporal dimension as longitudinal vs. cross-sectional. Longitudinal research follows a group of people over time, sometimes for many years. On the other hand, cross-sectional research describes the characteristics of a group at a certain point in time. This is roughly analogous to the kind of data gathering we do to develop a case conceptualization. We generally start with a present (cross-sectional) analysis, moving to a historical (longitudinal) view depending on the nature of the problem. In this lesson, you will learn how to elicit a cross-sectional snapshot in time that focuses on the problem, and the factors that maintain it, in the present. In Lesson 10, when we discuss history-taking, you will learn some approaches to developing a longitudinal description of the problem.

Each of the skill practice lessons in SI will be discussed with reference to where the client is now, and where the client would like to be. In this lesson we will focus on developing a detailed description of where the client is now, and why and how that is a problem. This lesson will also enable you to obtain enough detail about the problem so that you can begin to formulate some ideas about how to intervene. How one client experiences depression, anxiety, anger problems, marital discord, and so on may be quite different from how this problem is experienced by the next person who enters your office complaining about the ‘same’ problem. Asking about and listening for detailed information about the problem will assist you to begin to distinguish openings for intervention.


Cormier et al. (2013).

Pp. 199-204 address A-B-C analysis. Pp. 230-268 (Chapter 7) describe an assessment interview. Please refamiliarize yourself with this content.


Quick, E. K. (2008). Doing what works in brief therapy: A strategic solution focused approach (2nd ed.) Maryland Heights, MO: Academic Press/Elsevier.

Chapter 2. Read the entire chapter. Use sections of this chapter as a guide and write interview leads for each area, in wording that ‘fits’ for you, to create an interview protocol. Bring it with you to use in class.


1. Distinguish between three approaches to gathering information about the problem.

2. Devise and personalize an interview protocol for eliciting detailed information about the problem.

3. Conduct an interview to elicit a detailed description of the problem.


A-B-C model Antecedents Behaviour Consequences

Relevant aspects of the problem (Quick, 2008) Prioritizing problems Context: Who, what, when, where Personal effects: How is it a problem? Interpersonal dynamics: To whom is it a problem? Temporal dimension: Why now? Constructs to complaints (to goals) Historical aspects: When the problem is the past Problem definition: A different problem every time Clarifying problem as an intervention Expectations of counselling: “What’s the worse thing I might say?”

Session Outline:

1. Highlighting an Intervention presentation, if scheduled

2. Eliciting a Problem Definition (PowerPoint presentation)


3. In groups of three or four, based on today’s readings, prepare an outline to guide questioning to develop a problem definition (15 minutes). Each group will adopt one of the following client scenarios. Please assume the client is motivated for counselling. Make sure that each member of the group rotates through the counsellor and client role (40 minutes). Track the session using the skill coding sheets and make notes of your skill practice and hand them in to your instructor.

Recommended skill pattern:

You will likely use mostly open questions and declarative probes, interspersed with reflects, to elicit a detailed description of the problem, its antecedents, and its consequences. You will likely use structuring skills to conclude one area of inquiry and move on to another topic.

Case scenarios:

Kevin, 22 years old, comes to your counselling centre knowing that he needs to continue his education. He reports that he “barely” graduated from high school as a “C” student, has never liked school, but knows that he will be caught in dead end jobs, like his present job as a gas station attendant, if he does not upgrade his education.

Martha, 43 years old, is a stay-at-home mom. She reports that, although her children are doing well, and her husband is “great,” she has been plagued by chronic depression for as long as she can remember.

April, 38 years old, is a lawyer. She reports she is “sick of being sick” with Crohn’s disease. She acknowledges that when she gets busy at work she does not manage her illness well, wishes “it would just go away,” but realizes that she must change her lifestyle.

Ken, 29 years old, is a sales representative who sells pipe to the oil and gas industry. He reports that he leads his company in sales, receiving commissions of over $200,000 last year. He states that whenever he makes a sales presentation he becomes incredibly anxious. He reports, “I get butterflies in my stomach. I want to throw up. Then my palms get all sweaty and I get the shakes.” He asks for help with what he calls “chronic anxiety.”

Paula, 26 years old, is a single teacher. She states she enjoys teaching, but “sometimes the stress gets to me.” She tells you that recently the one or two glasses of wine she enjoys Fridays after work has developed into “seven or eight.” She then resumes drinking from the time she gets up on Saturday until the wee hours of Sunday morning, and “it’s all I can do to recover in time for school on Monday morning.”


Lesson 8: Capitalizing on Client and Therapist Factors

Introduction

This lesson builds on Lesson 4, which addresses client “motivation” and readiness for change. After reviewing Lesson 4, the core of this lesson will consist of viewing a full-length video of Dr. John Norcross.

To reiterate Lesson 4, we reviewed the client’s contribution of the client to change in therapy (Bohart & Tallman, 2010). We then examined three approaches to thinking about client motivation: transtheoretical model of change (stages of change), relationship patterns in solution-focused therapy, and Motivational Interviewing (MI).

Bohart and Tallman (2010) described the influence of clients in therapy. They noted clients’ great capacity for personal growth and resilience, and are highly involved in therapy. Clients mentally rework therapists’ blunders (this is comforting to novice and experienced clinicians alike). Clients change more quickly than we generally think they will – even before our theoretical models suggest is possible. Rather than being focused on therapists’ techniques, clients are more focused on the general atmosphere or tone of therapy. Accordingly, clinicians should maximize client strengths, resources, and personal agency; believe in their motivation and capacity to change; and promote clients’ involvement.

Clients value therapists’ listening skills, compatible personality, personal connection, and activity level. They feel hindered when therapists make hurtful comments, are authoritarian, fail to listen, remain distant and unresponsive, refuse to give ideas or direction, have a much different personality, and are distant and untrustworthy.

Client factors are maximized by an effective working alliance. Rather than thinking of these as two separate factors, it is useful to think of them as two sides of the same coin. Accordingly, clinicians would do well to tailor their approaches to clients by adjusting both their relationship stance and interventions in accord with the alliance.

There are a number of ways to think of client motivation relative to the discrepancy statement. You may find that some clients spend a great deal of time discussing where they are now, and relatively little time about where they want to be. Or, others may discuss where they want to be, in vague, blaming, or unrealistic ways. Your task is to modulate your approach until you can gently guide them until they can state where they want to be more clearly and with more personal agency. When clients are vague, blaming, or unrealistic, you may need to listen very carefully to learn what they are willing and able to do to get from to where they are now to where they want to be.



Cormier, S., Nurius, P. S., & Osborne, C. J. (2013). Interviewing and change strategies for helpers (7th ed.) (pp. 523-546). [eBook version]. Retrieved from http://www.cengage.com

This chapter describes solution-focused therapy and motivational interviewing as means to overcome “resistance.”

Relationship Patterns in Solution-Focused Therapy (handout)

Review and bring a copy to class


1. Apply the stages of change to case conceptualization and intervention planning.

2. Apply solution-focused relationship patterns to case conceptualization and intervention planning.

3. Apply principles of motivational interviewing to case conceptualization and intervention planning.

4. Articulate the contributions of clients and client characteristics to therapeutic outcome.

5. Adjust your relationship stance to client presentation.


Stages of changeo Precontemplationo Contemplation o Preparationo Actiono Maintenance

Relationship patterns in solution-focused therapyo Visitingo Complainanto Customer

Motivational Interviewing



Matching therapist behaviour with stage of change

Session Outline:


2. Video: Dr. John Norcross, Stages of Change for Addictionshttp://0-ctiv.alexanderstreet.com.aupac.lib.athabascau.ca/View/535739/Clip/11602

3. Learning Activity: Problems, Goals, and Theories – Large Group Challenge


http://0-ctiv.alexanderstreet.com.aupac.lib.athabascau.ca/View/535739/Clip/11602

http://0-ctiv.alexanderstreet.com.aupac.lib.athabascau.ca/View/535739/Clip/11602

Problems and GoalsDon’t trust people (problem)Take some risks (Goal)

Feeling isolated as a new immigrant (problem)Seek out community supports (goal)

Always losing stuff (problem) Be more present in the moment (Goal)

Counsellor not understanding my problem (problem)Find culturally-sensitive services (goal)

Communicating with in-laws (problem)Learn cultural norms for communication (goal)

Obsessive compulsive behaviours (problem)Check the lock only three times (goal)

Can’t focus / always distracted (problem)Make time for self care (goal)

Passed over for job promotion (problem)Advocate for gender equity (goal)

Can’t get a job (problem)Write an effective CV (goal)

Afraid of stop signs (problem) Walk the direct way to work (goal)

Procrastination (problem)Make a to do list (goal)

Bored with my life (problem)Develop a hobby (goal)

Have to give keynote address (problem)Stress / anxiety management (goal)

Not getting along with my daughter (problem)Treat daughter as an adult (goal)

Several friends have died suddenly (problem)Find meaning in work (goal)

Conflict with partner (problem) Set boundaries with extended family (goal)

Committed to too many things (problem)Learn to say “no” (goal)

Feeling depressed (problem)Make positive self-statements (goal)

Death of a parent (problem)Able to laugh again (goal)

Loss of a job (problem)Increased self-esteem (goal)

Increasing debt load (problem)Money management skills (goal)

Nobody love me (problem)Stop eating worms (goal)

Can’t sleep (problem)Reduce obsessive thinking (goal)


Theoretical OrientationsAdlerian Theory Narrative Therapy Psychodynamic

TheoryCognitive Therapy

Solution–focused Therapy

Gestalt Therapy Art Therapy Transactional Analysis

Existential Therapy

Feminist Therapy

Reference

Bohart, A. C., & Tallman, K. (2010). Clients: The neglected common factor in psychotherapy. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed.) (pp. 83-111). Washington, DC: American Psychological Association. doi: 10.1037/12075-003


GCAP 635: Intervening to Facilitate Client ChangeLesson 8: Capitalizing on Client and Therapist Characteristics

Relationship Patterns in Solution-Focused Therapy

Remember:

relationship patterns are fluid and can change depending upon the presence of other people and the negotiated goal

relationship patterns should not be considered classifications of persons, but temporary descriptions of relationships

relationship patterns should not be used to label or pathologize persons

“Customer” relationship pattern:Definition: The client perceives that there is a problem and is

willing to take action to develop a solutionRelationship stance: Active, goal-oriented, change-focused; perhaps

directiveInterview strategies

discussion of real-life exceptions and how the client can do more of them explicit negotiation of goals, plans, and strategies challenging thinking, confronting maladaptive cognitions instruction/didactic interaction confrontation

Tasks: Tasks of action

“Complainant” relationship pattern:Definition: The client perceives that there is a problem, typically

someone or something external to the client. The client may not see the point in taking action because he/she does not see any action to take toward solution development.

Relationship stance: Empathizing, watchful for evidence of change, listening for the client’s motivation and passion


Interview strategies empathizing coping questions (“How do you deal with this situation?”) relationship questions (“How will others know when things are different?”) indirect suggestion/implied change of views metaphorical stories of change discussing hypothetical solutions: The Miracle Question, etc. “What does it look like when things are different?” (without implying that

the client should do it)Tasks: Tasks of observation, prediction, and reflection

“Visiting” relationship pattern: The client has no perception that there is a problem and is not willing to take any action toward solution development (often involuntary or coerced clients)

Relationship stance: Empathizing, watchful for evidence of change, listening for the client’s motivation and passion

Interview strategies listening sympathetically and commiserating socializing and hosting complimenting not arguing in favour of change; perhaps discussing dangers of change looking for the "hidden customer" (someone in the client’s world who might

be motivated)Tasks: Compliments, no demands for change


Lesson 9: Pre-Intervention Screening

Introduction

In the early stages of counselling with a new client, we encounter issues that are at the edges of our competence and that may require the intervention of other professionals. At times, we will encounter individuals or families in crises who require active management or reporting to a statutory authority.

In this lesson, we will review issues of risk (suicide, violence, and abuse), substance abuse, and biological/neurological factors that may affect behavior. We provide you with a brief orientation to each of these serious issues. While at this stage in your development, it is necessary for you to obtain clinical supervision to work with clients in actual counselling situations, we want to emphasize that obtaining consultation or supervision is even more important with these serious issues. Even experienced practitioners need support to deal with many of the issues that we will be covering today. The purpose of this lesson is to help you notice these issues, conceptualize them, and seek consultation knowledgeably. This lesson does not make you competent to screen or assess for these issues, but will merely help you recognize them.

Screening for serious issues can assist you to clarify if you can help the client to get to where he/she would like to be, and if so, what support or information you may need from other professionals or systems.

Required reading:

Centre for Addiction and Mental Health (2010). CAMH suicide prevention and assessment handbook. Retrieved from http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/suicide/Documents/sp_handbook_final_feb_2011.pdf

Read pp. 3-16; print and bring to class for reference.

Cormier, S., Nurius, P. S., & Osborne, C. J. (2013). Interviewing and change strategies for helpers (7th ed.) (pp. 210-212). [eBook version]. Retrieved from http://www.cengage.com.

Hirschfeld, R. M. A., & Russell, J. M. (1997). Assessment and treatment of suicidal patients. The New England Journal of Medicine, 337(13), 910-917.

Database article. Read before class and bring a hard copy of Table 1, Figure 2, and Figure 3.

Handout: Some Factors Considered During a Mental Status Examination

Review and bring to class


Supplementary reading:

Greene, K., & Bogo, M. (2002). The different faces of intimate violence: Implications for assessment and treatment. Journal of Marital and Family Therapy, 28(4), 455-466.Database article.


1. Assess your scope of practice and competence in pre-intervention screening.

2. Articulate cues for clinical issues that may require referral or consultation.

3. Distinguish between depressive symptoms and severe depression.

4. Distinguish among static, dynamic, and future risk factors for suicide.

5. Distinguish between varieties of intimate partner violence.

6. Screen for substance abuse.

7. Screen for biological and neurological factors.

8. Devise and personalize an interview protocol for history-taking.

9. Incorporate inquiry about personal agency into the interview process.



Competence and scope of practice Symptoms of depression: first, second, and third level Static, dynamic, and future risk factors for suicide Patriarchal terrorism vs. common couple violence Cues for child abuse Cues and framework for assessing substance abuse Cues for biological/neurological issues Mental Status Examination

Session Outline:


2. PowerPoint presentation: Pre-Intervention Screening

3. Skill practice: Assessment of suicidality (see PowerPoint presentation for instructions)


GCAP 635: Intervening to Facilitate Client ChangeLesson 9 – Pre-Intervention Screening

Some Factors Considered During a Mental Status Examination

1. Is the client's appearance unusual?

2. Is the nature and quality of the client's interaction with the examining therapist and others (such as family members or friends) appropriate?

3. Is the client oriented to person, place, and time (orientation to time includes the ability to specify the month, the day of the month, the day of the week, the year, and the season of the year)?

4. Is the client oriented to the circumstances? Does the client understand the nature of the therapist/client relationship and have an appropriate manner?

5. What is the client's affect (predominant emotional tone)?

6. What is the client's mood (reported emotional state)? Is the reported mood congruent with the therapist's perception of affect?

7. Is there evidence of an abnormality in the sphere of language? Consider rate, intonation, modulation, nonverbal gestures and expressions, and whether these are congruent with content. Is there evidence of aphasia?

8. Is the content of the client's thought noteworthy? Is there evidence of delusions, obsessions, or unnecessary worry or phobias?

9. Is there abnormality in any of the five senses? Are there reports of hallucinations or delusions?

10.Are the client's attention and concentration impaired?

11.Are defects in short- or long-term memory reported or detected on formal examination of these abilities?

12. Is the client's social and moral judgment within the limits of his or her cultural group?


13.Does the client have suicidal or homicidal ideation or intent? Does the client have the means to carry out any plans to harm self or others? What is the client's level of impulse control?

14.Can the client perform calculations with the speed and accuracy expected of someone with the same educational and occupational background?

15. Is the client properly oriented in space? Does the client distinguish between right and left?

16.Does the client have the sense of direction that is expected? (Are there reports of getting lost when traveling repeated routes?)

17. Is the client's ability to think abstractly commensurate with his or her educational background?

18.Can the client copy geometric figures?

Adapted from:

Dilsaver, S. C. (1990). From phenomenon to mechanism: An investigational strategy. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 14(4), 449-458.


Lesson 10: Expanding on History-Taking

Introduction

This lesson builds on GCAP 671, Lesson 12. In that lesson, you practiced taking history in the context of the intake interview, using your working alliance skills. In this lesson, we will revisit history-taking, examining several different approaches to interviewing clients about their history.

History-taking is not simply a matter of obtaining, as Sgt. Joe Friday would say in the 1950s TV detective series, Dragnet, “Just the facts, ma’am.” There are certainly historical facts to be gathered about family patterns, strengths, resources, and problems that will serve as a rich source of hypotheses, particularly when they are filtered through your preferred theory of counselling. As you learned in GCAP 631, it is important to keep in mind that our theories influence the information we choose to collect and the dynamics to which we attend. Accordingly, our history-taking and intake interviews are not neutral. The four approaches to history-taking we will review in this lesson differ theoretically. We invite you to reflect on how they differ in their effects on clients.

Gathering relevant history helps us in a number of ways, as we consider where the client is now and where the client would like to be. Some clients consider their history the problem, so it is important to learn what they mean by this. Learning about history may tell us about the factors that maintain the client’s unsatisfactory present. Learning about history can also tell us about the resources that clients ‘bring to the table,’ and their past attempts to get where they would like to be, whether successful or unsuccessful.

Required reading:

Corey, G. (2013). The art of integrative counseling (3rd ed.) [eBook version]. Retrieved from http://www.cengage.com.

Textbook:Chapter 11: Understanding how the past influences the presentYou read this previously in GCAP 671. Please review it again in preparation for class discussion

Cormier, S., Nurius, P. S., & Osborne, C. J. (2013). Interviewing and change strategies for helpers (6th ed.) (pp. 212-216). [eBook version]. Retrieved from http://www.cengage.com.

Textbook:Please bring the textbook to class, as you will need to refer to it


1. Distinguish among four approaches to history-taking in counselling.



2. Critically evaluate the social and cultural influences on history-taking.

3. Purposefully select a rationale for history-taking.

4. Devise and personalize an interview protocol for history-taking.

5. Incorporate inquiry about personal agency into the history-taking process.


“Objectivity” in interviewing

Cultural influences on history-taking and interviewing

Approaches to history-taking: Gathering “objective” information Understanding clients’ narratives and meaning construction Developing theory-based hypotheses Using historical information to distinguish patterns

Incorporating historical data into case conceptualization

Stylistic and personal factors in interviewing

Session Outline:



2. Expanding on History-Taking (PowerPoint presentation)

3. In the same groups as yesterday, and with the same “client” (i.e., Kevin, Martha, April, Ken, or Paula), develop a history-taking interview protocol focused on the client’s stated area of concern. Pick up where you left off in the previous lesson. Begin with a structuring move that permits you to transition to the history-taking segment of your interview. Continue to interview, tracking your colleagues’ skill usage on the skill coding sheets.

Recommended skill pattern:

You will likely use mostly open questions and declarative probes, interspersed with reflects, to elicit a detailed description of historical factors, and the client’s view of the connection between history and his/her present difficulties. You will likely use structuring skills to conclude one area of inquiry and move on to another topic.

4. Select videos for lessons 11-15.


Lesson 11: Applied Practice in Case Conceptualization

Introduction

As Gehart (2010, p. 17) said, “The heart of therapy – the seeming brilliance of a great therapist – has always been in the viewing. The most useful question for new therapists to ask their supervisors is: What should I be noticing and listening for when I talk with this client?”

This lesson provides you with a framework for connecting what you learned in GCAP 631 and 633, what you have learned about common factors, exploring and defining the problem, screening for severe problems, and tailoring your approach to the therapeutic relationship. The integration of this content, in addition to the content of this lesson, will permit you to develop a coherent case conceptualization for a specific counselling case. A comprehensive conceptualization provides an overall view of the case that makes theoretical sense, and incorporates all relevant client characteristics.

A comprehensive case conceptualization provides a coherent map of how the client will move from where he/she is now to where he/she want to be. A case conceptualization will inform the focus of the work, what feature of the problem will be targeted by the intervention, and what intervention will entail.


Cormier, S., Nurius, P. S., & Osborne, C. J. (2013). Interviewing and change strategies for helpers (7th ed.) (Chapter 6) [eBook version]. Retrieved from http://www.cengage.com

Please review this chapter, which you read in an earlier lesson.

Sperry, L. (2005). Case conceptualization: A strategy for incorporating individual, couple, and family dynamics in the treatment process. American Journal of Family Therapy, 33(5), 353-364. doi: 10.1080/01926180500341598

Please review this chapter, which you read in an earlier lesson.

Review one of the following videos as assigned in class yesterday.

Download, print, and bring to class: Case Conceptualization Exercise Form Case Conceptualization Exercise with Commentary



1. Distinguish between symptom-based, theory-based, and client-based approaches to case conceptualization.

2. Describe and apply Sperry’s ‘pattern analysis’ approach to case conceptualization and intervention planning.

3. Integrate previous lessons on client motivation and readiness, problem exploration and definition, pre-intervention screening, and taking a client history into your case conceptualization.

4. Incorporate client strengths into case conceptualization.


Case conceptualizationo Symptom-basedo Theory-basedo Client-basedo Preparationo Actiono Maintenance

Pattern analysiso Precipitantso Presentationo Predispositionso Perpetuants

Client strengths


Session Outline:


2. PowerPoint presentation: Pulling it all Together: Case Conceptualization

3. Case conceptualization exercise.

Reference

Gehart, D. (2010). Mastering competencies in family therapy: A practical approach to theories and clinical case documentation. Belmont, CA: Brooks/Cole


Case Conceptualization Exercise Form

Client name: _____________________________ Age: ____________________________________Occupation or educational status: ______________________________________________________Family members: _____________________________________________________________________________________________________________________________________________________Presenting problem(s)

Precipitants

Predisposing factors

Perpetuating factors


Issue and stage of change

Issue and stage of change

Client strengthsIndividual abilities and personal qualities

Relational and systemic resources

SolutionsConsidered (not attempted)

Attempted (unsuccessful, partially/temporarily successful)

Possible foci for intervention


Case Conceptualization Exercise Form

Client name: _____________________________ Age: ____________________________________Occupation or educational status: ______________________________________________________Family members: ______________________________________________________________________________________________________________ Ethnicity: ______________________________

Presenting problem(s)What is the problem as described by the client and the referral source? This is the “B” in the A-B-C analysis (Cormier et al., 2013). Is the problem described differently by anyone else (e.g., referral source, parents, spouse)? In your problem exploration and problem definition interviews, elicit a “video with voice over” description of the problem as it manifests itself in the client’s experience. If you cannot “run the video” in your head, ask more open questions until you do. Your summary here should be similar to a summary you might offer in an interview.Are there times when the problem is less frequent, less severe, not as problematic, or shorter in duration? Are these differences random or does the client do something to bring them about?Is there a psychiatric diagnosis? Where did it originate? What is the client’s understanding of the diagnosis?Does the current problem require crisis intervention or referral for psychiatric consultation?PrecipitantsThis is the “A” in the A-B-C analysis. What are the precursors to the problem? What are the situations in which the problem occurs? Are some situations worse than others? What is the pattern or sequence of events leading up to the problem? Is anyone else involved? If so, could the other person do something that would make a difference?

Predisposing factorsWhat historical factors may be contributing to the problem pattern? Is there a history, either in the family, or in the client of:

trauma or abuse immigration/geographical dislocation substance abuse mental illness maladaptive parenting/high conflict post-divorce parenting

any other issues associated with future problems?

chronic health problems a family life cycle transition How does the client make sense of a difficult history? What has he/she done to overcome the negative effects of history? What is the history of individual and family coping/resilience? What are the positive and maladaptive aspects of coping? Does the client display any characteristic behavioural or emotional tendencies that may help or hinder?Perpetuating factors How is the problem maintained? The “C” in the A-B-C analysis suggests that the consequences perpetuate the problem. Is it an intrapersonal pattern (maladaptive belief, cognitive, or narrative; a script or role)? Or it is an interactional pattern? Who else is involved? Are there some attempted solutions that seem to be backfiring or ‘digging the client in deeper’?


Issues and stage of change/relationship pattern.There may be more than one problem requiring clinical attention. What is your evaluation of the client’s ‘motivation’?

Client strengthsIndividual abilities and personal qualitiesWhat skills or personal qualities can be utilized? Could the ‘flip side’ of the problem be reframed as a strength? Relational and systemic resourcesWho or what is in the client’s social context that can be helpful? Who are the client’s practical and emotional supporters? What social connections does the client have, apart from the problem, that allow him/her to exercise competence? Who can provide support with the problem, or to ease the burden?

SolutionsConsidered (not attempted)What has the client thought about doing, but not done yet? If it seems like something the client is interested in or willing to do, is the timing right? Is there something that restrains the client from implementing the idea?

Attempted (unsuccessful, partially/temporarily successful)What’s worked, even a little bit, for a short time? Is there some root of a potential intervention/solution there?

Possible foci for interventionBased on your clear definition of the problem, your clear description of the problem pattern, and the client’s account of his/her history, what openings can you see for intervention? Can you distinguish:

An interactional pattern that could be interrupted? An intrapersonal pattern – a problematic cognition, a script, or a narrative, that could be altered? A skill that the client could learn? A behaviour the client could do, but doesn’t? What gets in the way? A problematic affect that interferes with the client’s life? A dilemma or decision that must be solved or reframed? A relationship that could be enhanced? A partial solution or an exception to the problem on which you can build?

Other considerations: How can you frame this in a way that will invite the client’s ‘buy-in’ based on the client’s theory

of change and the client’s readiness level? How does the client prioritize the concerns? For this client, which domain (affect, behaviour,

cognition, sensation, interpersonal) is most amenable to intervention? What ideas does the client have about how to intervene? Is there a skill, talent, or ability you can utilize as a template for intervention?


Lesson 12: Case-Based Intervention Practice: Goal Setting

Introduction

Setting outcome goals assists the counselling process by orienting clients and counsellors to what they are working on. Given that clients typically come to counselling without clearly defined outcome statements, it is necessary to assist them to refine their goals. This lesson provides you with a brief review of goal-setting and provides you with time to practice using your working alliance skills to assist clients to develop workable goals.

In the context of the discrepancy statement, setting clear goals allows us to further clarify where the client wants to be in precise terms. Clearly defined goals permit clients to evaluate to what extent goals have been met and if it is appropriate to terminate.


Corey, G. (2013). The art of integrative counseling (3rd ed.) [eBook version]. Retrieved from http://www.cengage.com (Chapter 3).

This brief chapter, which you have already read, describes Corey’s integrative approach to goal-setting. Please review.

Cormier, S., Nurius, P. S., & Osborne, C. J. (2013). Interviewing and change strategies for helpers (7th ed.) (Chapter 8). [eBook version]. Retrieved from http://www.cengage.com

Please review pp. 269-282, which you read in an earlier lesson.

Dryden, W. (2006). Counselling in a nutshell. Retrieved from http://0-site.ebrary.com.aupac.lib.athabascau.ca/lib/athabasca/docDetail.action?docID=10285215.

Chapter 4: Dryden describes a pragmatic, nonmodel-specific approach to setting goals, with a specific focus on the relationship between goals and the working alliance.



1. Justify the benefit of goal-setting in counselling.

2. Connect discrepancy statements with goal-setting.

3. Develop well-formed goals.

4. Develop evaluation methodology for goal achievement.

5. Demonstrate purposeful interviewing skills to elicit at least one goal and two sub-goals.


Rationale for goal-setting Transforming vague discrepancy statements into goals Criteria for well-formed goals:

o Salient to the client(s)o Small rather than largeo Described as the presence rather than the absence of somethingo Described as the beginning rather than the end of somethingo Described in specific, concrete, and behavioural wayso Described in social interaction termso Perceived as "hard work"o Practical and doable in the context of the client's life

Session Outline:


2. PowerPoint presentation: Applied Practice in Goal-Setting

3. Goal-setting interviewing practice

Continue to work in the same triads and simulated client situation as yesterday. Use the case conceptualization that you developed as your starting point. Alternate as client, counsellor, and observer. As you rotate through each role, continue to simulate the same client. Your responses as a counsellor must follow logically from the dialogue that the last student in the role of counsellor conducted.

Generate at least one overall goal that is relevant to the client situation and acceptable to the ‘client.’ Then develop at least two sub-goals that meet the criteria for well-formed goals as per today’s PowerPoint Presentation. Track your session using the Skill Coding Sheet and submit it to the instructor.


a. suggested skill pattern:

i. Use structuring skills (e.g., overviewing, transitions, giving information) to describe the case conceptualization. If your case conceptualization is theory-based, explain the ideas of that theory in simple terminology and without jargon.

ii. Use questions and/or declarative probes and structuring skills (summaries, overviews, and transitions) to confirm that the case conceptualization and the problem definition are consistent with her/his understanding. If your case conceptualization has generated many potential areas of focus, select an area of focus that is acceptable to the client, using questions and declarative probes to prioritize goals.

iii. Use questions and/or declarative probes to establish at least one goal and two sub-goals, using structuring skills to periodically confirm that you and the client are ‘on the same page.’ Develop more goals or sub-goals if you have time.

b. Select an evaluation measure that you can use in the next two days to track your client’s progress.

c. While keeping the same client scenario, rotate roles every 20 minutes. Pause to consult if needed.

d. Return to the large group to debrief.


Lesson 13: Case-Based Intervention Practice: Initiating an Intervention

Introduction

In this lesson, you combine your interviewing skills and your knowledge of case conceptualization and counselling interventions to select an intervention that you will introduce and deliver to your ‘client.’ Using the same client scenario as in our last two lessons, your triad will select an intervention, tailored for your particular client, from ideas drawn from sources you have used in the course so far.

In this lesson, you will also consider the issue of treatment duration. While most publicly funded and many private sector service providers (e.g., Employee Assistance Programs) require brief interventions, there are times when longer-term treatment is required. The handout for this lesson will provide some guidance on this issue.

In considering the content of this lesson in the context of the discrepancy statement, you will introduce an intervention, based on your case conceptualization and your consideration of client characteristics, that you have concluded may help the client meet his/her goals. You will partner with the client to adjust the specific intervention so that it better serves as a vehicle for get the client where he/she wants to be.


Cormier, S., Nurius, P. S., & Osborne, C. J. (2013). Interviewing and change strategies for helpers (7th ed.) (Chapter 9). [eBook version]. Retrieved from http://www.cengage.com.


Dryden, W. (2006). Counselling in a nutshell . Retrieved from http://0- site.ebrary.com.aupac.lib.athabascau.ca/lib/athabasca/docDetail.action?docID=10285215.

Chapter 5: Tasks. In pp. 79-86, Dryden provides ten criteria counsellors should consider when requesting clients do therapeutic tasks. Print these pages so that you can refer to them in class. The rest of the chapter provides useful perspectives on the relationship between therapeutic tasks and the counsellor's competence, varying your use of tasks, and fitting tasks with clients' preferred learning modalities and stages of change.

Bring notes and handouts from:

the GCAP 635 modules in which you participated Highlighting an Intervention presentations from your classmates


http://0-site.ebrary.com.aupac.lib.athabascau.ca/lib/athabasca/docDetail.action?docID=10285215.




http://0-site.ebrary.com.aupac.lib.athabascau.ca/lib/athabasca/docDetail.action?docID=10285215

In preparation for this class, review descriptions of specific intervention strategies and come prepared to discuss it with your triad as you decide on an intervention to use.


1. Use case conceptualization and outcome goals to inform an intervention strategy fitting the client’s needs.

2. Justify the rationale for the selection of an intervention strategy.

3. Demonstrate purposeful interviewing skills to initiate the intervention strategy with the client.


Criteria for intervention selectiono Case conceptualization acceptable to cliento Area of focus acceptable to cliento Stage of change or relationship patterno Domain of intervention acceptable to client

Session Outline:


2. Selecting and initiating an intervention

Part 1

Meet in your triads. Using the same client scenario, your case conceptualization, and your stated outcome goal, select an appropriate intervention. Consider factors like the client’s stage of change/relationship pattern, cultural background, preferred domain (affect, behaviour, cognition) for intervention, detailed problem definition and description, and any other factors that you would use to fit your intervention to the client.

After you have selected the intervention you wish to use, ensure that you have a clear procedural outline to follow. Develop some leads for introducing and providing an overview for your intervention of choice.

Part 2

Initiate the intervention with your simulated client. Code the counsellor-client interactions.


Suggested skill pattern:

a. Use structuring skills (e.g., overviewing, transitions, giving information) to describe the intervention. If the intervention is based on a specific theory, describe the theory in simple terminology, without jargon.

b. Use open questions and/or declarative probes and structuring skills (summaries, overviews, and transitions) to confirm that the client is agreeable to intervention or to address any questions and concerns about it.

c. Deliver the core of the intervention strategy. Use a purposeful combination of structuring, questioning skills, and reflects as required by the particular intervention strategy.

d. Use a purposeful combination of structuring, questioning skills, and reflects to:

i. Set up an evaluation frameworkii. Assign a homework task, if appropriate to the intervention strategyiii. Arrange a next ‘appointment’

e. While keeping the same client scenario, rotate roles every 20 minutes. Pause to consult if needed.

f. Return to the large group to debrief.


GCAP 635: Intervening to Facilitate Client Change Lesson 13: Case-Based Intervention Practice – Initiating an Intervention

Potential Indicators of Treatment Duration

Indicators for crisis intervention

1. There is a severe disruption in client's or family's normal functioning.

2. Client is extremely overwhelmed and highly stressed in response to an event.

3. A sudden external event has caused considerable psychological or emotional instability.

4. Family or client has been traumatized by an external event or a developmental change.

5. Client is in danger of harming self or others.

6. Client's symptoms have intensified to the point of causing incapacitation.

Indicators for brief therapy

1. Agency or institutional policy dictates a limited number of visits.

2. Client's goals for therapy are essentially symptom-focused.

3. Client or family is receptive to therapy and willing to change.

4. Client or family has additional resources available to support and integrate change.

5. Clear changes in behaviour are observed.

6. Client's or family's history is not a primary concern.

Indicators for long-term therapy

1. Client's or family's history has significant bearing on presenting concerns.

2. Client or family can engage in a longer-term therapeutic relationship.

3. Client's concerns go beyond behavioural issues and involve underlying dynamics or causes.

4. Client's goals for therapy include identifying and sustaining changes during therapy.


5. There is a significant amount of anxiety and concern that warrants longer-term work.

Adapted from:

Patterson, J., Williams, L., Edwards, T. M., Chamow, L., & Grauf-Grounds, C. (2009). Essential skills in family therapy: From the first interview to termination (2nd ed.) New York, NY: Guilford Press.


Lesson 14: Case-Based Intervention Practice: Following Up

Introduction

In this lesson, you will continue to utilize your counselling skills to follow up on the intervention you initiated in the last lesson. Now that you have learned some specific methods of intervention, what should you do next? How does one follow up? How can we tell if counselling is progressing? And, how can we (the counsellor and the client) tell when we can stop meeting this way? It may be tempting to think of intervention as something that is delivered or administered to the client, as opposed to an interactional, co-constructive process. Our thinking about follow-up may conjure up the idea of visiting your family physician and being asked if the medication that was prescribed is working. Our view of the collaborative nature of counselling asserts that the interview, in and of itself, is an intervention (Tomm, 1988). How we conduct our conversations frames issues for the client in certain ways, imparts information and assumptions, and sensitizes the client to notice certain things. In this section, we take examine the issues of follow-up, evaluation, and termination in turn.

Evaluation tells us if we are on track relative to where the client wants to be, and how close we are to accomplishing this.


Corey, G. (2013). The art of integrative counseling (3rd ed.) ([eBook version]. Retrieved from http://www.cengage.com (Chapter 3).

Cormier, S., Nurius, P. S., & Osborne, C. J. (2013). Interviewing and change strategies for helpers (7th ed.) (Chapter 9). [eBook version]. Retrieved from http://www.cengage.com

Review pp. 296-303


Chapter 5: Tasks. In pp. 79-86, Dryden provides ten criteria counsellors should consider when requesting clients do therapeutic tasks. Print these pages so that you can refer to them in class. The rest of the chapter provides useful perspectives on the relationship between therapeutic tasks and the counsellor's competence, varying your use of tasks, and fitting tasks with clients' preferred learning modalities and stages of change.

Bring notes and handouts from: the GCAP 635 modules in which you participated Highlighting an Intervention presentations from your classmates



In preparation for this class, review descriptions of how to follow up on the specific intervention strategy. Bring these resources to class to guide your preparation for the follow-up session.

Handout: A Generic Framework for Following Up on Counselling Interventions

Instructor Commentary: A Primer on Outcome Management

Read these two sources to gain and overview of the follow-up process, including the importance of gaining feedback on the working alliance.


1. Articulate a generic framework for how to follow up on a counselling intervention strategy.

2. Demonstrate how to respond to clients’ presentation and responses while following up on a counselling intervention.

3. Demonstrate how to track client progress with a summative evaluation process.

4. Demonstrate how to adjust your approach based on clients’ readiness and/or relationship pattern.


Stages of change Relationship stances Tasks of observation and prediction Decisional balance interventions Personal agency

Session Outline:


2. Instructor demonstration: Following Up On a Counselling Intervention.

3. Case-Based Intervention Practice: Following Up

Part 1


Meet in your triads. Using the same client scenario, resume your course of intervention as if you are in a second session. The triad member who takes the position of the client should present as having experienced some change. Rotate in the roles of client, counsellor, and observer.


a. Use structuring skills (e.g., overviewing, transitions, giving information) to introduce the focus of the session (i.e., following up on the interventions intiated in the last session).

b. Use questions and/or declarative probes and structuring skills (summaries, overviews, and transitions) to:

i. follow up on progressii. invite the client to describe changesiii. plan for further intervention, including homework tasks

c. While keeping the same client scenario, rotate roles every 20 minutes. Pause to consult if needed.

d. Return to the large group to debrief.

Reference

Tomm, K. (1988). Interventive interviewing: Part III. Intending to ask lineal, circular, strategic, or reflexive questions? Family Process, 27(1), 1-15. doi: 10.1111/j.1545-5300.1988.00001.x


GCAP 635: Intervening to Facilitate Client Change

Lesson 14: Case-Based Intervention Practice – Following UpFollowing Up on Counselling Interventions

Following up on counselling interventions is not simply a matter of administering a protocol. It requires listening carefully and responding to clients’ responses. A common factors approach (Duncan, 2010) suggests that we be change-focused, ensure that our interventions fit with clients’ world-view and theory of change, fit our relationship stance with clients’ readiness, and utilize clients’ strengths, resources, and change processes outside of the therapy room. What follows is a nonmodel-specific approach to follow-up that implements Duncan’s recommendations.

I. Start by asking about progress since the last appointment. In keeping with a change focus, it is more useful to ask, “What’s been better?” or “What’s been on the right track?” since the last session, if this can be done while being sensitive to the client.

If there has been relevant progress that the client can attribute to his/her own efforts, continue a change focus by asking for a description of the changes and what the client has done to bring them about. As you did when you interviewed about the problem, obtain a detailed “video with voice over” description.

If there has been some progress or improvement toward the outcome goal, but the client cannot attribute them to his/her efforts, or, if there are changes in other domains that do not seem related to the outcome goal, inquire about those changes. Again, listen carefully for evidence of personal agency and clues to what the client has done to bring them about. Obtain a detailed “video with voice over” description. This can yield useful client strengths and resources and change efforts outside of counselling. If the client does show some kind of movement toward personal agency within a few sessions, consider points b, c, d, and e below.

If the client reports no improvement or decline:a. Inquire about what the client is doing to keep things from getting even

worse, ‘hold off’ further decline, or ‘hold their own.’ Sometimes, this can yield usable descriptions of personal agency and extratherapeutic factors.

b. Consider whether you have misjudged the client’s stage of change or relationship pattern. Perhaps you have mistaken a client in precontemplation for one in preparation. Maybe you thought you were in a customer relationship when the client perceives a complainant relationship.


c. Ask about whether the pacing of change efforts is appropriate.d. Reflect on whether the problem definition you negotiated with the client

is consistent with the client’s understanding.e. Think about whether the specific intervention strategy you are

implementing is consistent with the client’s theory of change.

II. Quantify progressEvaluation of progress assists clients to stay on track, provides important information about our performance, and permits accountability to service purchasers. In all cases, quantify the progress in terms of the evaluation metric you are using.

In the case of option 1 above (there has been relevant progress that the client can attribute to his/her own efforts):

If progress is acceptable to the client, terminate. If progress on this issue is acceptable to the client, and there are other

issues that must be addressed, negotiate a new goal. If progress is not yet sufficient, plan for further intervention.

If there has been some progress or improvement, but the client cannot attribute them to his/her efforts, or if there are changes in other domains that do not seem related to the outcome goal, continue to listen carefully and highlight instances of personal agency. This may assist the client to develop a sense of mastery over the problem, which you can then utilize.

If the client reports no improvement or decline, consider points a. to e. above.

III. Plan for further intervention.In keeping with a change focus, build on changes, if any, since the last session.

If there has been some relevant progress that the client can attribute to his/her own efforts, inquire about what is necessary to maintain these changes. This could include:

What the client can to do to keep the changes going The next step, component, or ‘lesson’ in the intervention strategy, or any

adjustments that are necessary What homework task might you agree upon that would maintain and

extend the changes

In all other cases, keep pace with the client’s presentation and attributions of change, and listen for opportunities to highlight personal agency. Modulate your relationship stance so that your approach is consistent with the client’s stage of change. As appropriate, give clients:

information (e.g., effects of persisting with problematic behaviour, risks and benefits of change);


tasks of observation and prediction; or other cognitive change and decisional balance (pros and cons)

interventions.

It is unlikely that these clients will engage in behavioural tasks.

References

Duncan, B. L. (2010). On becoming a better therapist. Washington, DC: American Psychological Association. doi: 10.1037/12080-001


GCAP 635: Intervening to Facilitate Client ChangeLesson 14: Case-Based Intervention Practice – Following Up

A Primer on Outcome Management

This brief overview of outcome management is designed to provide context for the readings you will be doing in this lesson. As you will recall, rather than endorse or prefer one theoretical approach to human problems, counselling, or assessment, we at GCAP have chosen to emphasize the common factors that contribute to therapeutic outcomes. The therapeutic alliance is the biggest contributor to therapeutic change over which we have any influence. Accordingly, it is useful to track the strength of the working alliance.

Of course, most counsellors, unless they are absolutely insensitive (in which case I question whether they are in the right business), are concerned about developing a strong therapeutic alliance and maintaining it. It is worth noting, however, that counsellors and clients often have a different estimate of the strength of the working alliance (Bachelor & Horvath, 1999) – and it’s the client’s perception that carries the day. If clients have not experienced a viable working alliance within the first three sessions, they are unlikely to wait around any longer for this to happen. Since many clients (estimates run from 30 to 50%) withdraw from counselling before they derive much benefit, and generally do so without raising concerns about the working alliance, it is important that counsellors ask for feedback. The good news is that when counsellors ask clients for feedback about the alliance, and follow it, the alliance and therefore counselling outcomes are enhanced. Also, requests for feedback should be frequent, if not constant, because if feedback is ceased, the alliance and therefore the therapeutic outcome is eroded.

Miller, Duncan, and colleagues (Miller, Duncan, Brown, Sorrell, & Chalk, 2006), as implied by the term “outcome management,” believe that outcome must be managed. This is different from using an assessment technique (informal or formal) to sample “baseline” functioning, again after counselling has begun to “work,” and again at termination. For example, in a course of counselling with a “depressed” client, a counsellor could use a standardized instrument like the Beck Depression Inventory-II (BDI-II) (Beck, Steer, Brown, 1996) or a nonstandardized assessment technique like the Subjective Units of Disturbance Scale (SUDS) (Wolpe, 1969). Miller, Duncan, and colleagues would assert that this falls short for three reasons: while the SUDS is brief (the client simply responds by rating distress on a scale of 1 to 100), and the BDI is not particularly long, they would argue that even greater brevity would invite counsellors to ask for feedback at each session. If they need more detailed information, they can use other measures. But most importantly, using only outcome measures does not sample the working alliance, the most potent contributor to therapeutic outcome.

In summary, outcome management combines a systematic effort to track the client’s perception of the working alliance and simple outcome measures, and improves outcome significantly.


References

Bachelor, A., & Horvath, A. (1999). The therapeutic relationship. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 133-178). Washington, DC: American Psychological Association. doi: 10.1037/11132-000

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). The Beck Depression Inventory-II. New York, NY: The Psychological Corporation.

Miller, S.D., Duncan, B.L., Brown, J., Sorrell, R., & Chalk, M.B. (2006). Using formal client feedback to improve retention and outcomes. Journal of Brief Therapy, 5(1), 5-22. http://www.journalbrieftherapy.com/

Wolpe, J. (1969). The practice of behavior therapy. New York, NY: Pergamon Press.


Lesson 15: Case-Based Intervention Practice: Evaluation and Termination

Introduction

This lesson presents a framework for reviewing, evaluating, and terminating counselling. As you already know, intervening with clients is not simply a matter of administering a treatment. Competent intervention combines a coherent conceptualization, a supportable (either empirically or theoretically) intervention, and sensitive management of the working alliance.

In this lesson, we will examine different approaches to termination. Termination, in effect, is simply an extension of what the counsellor has been already doing to track both progress and the working alliance, resulting in a joint evaluation that goals are met, and a joint decision that counselling has been completed. Termination asks the question, “Are we there (where the client wants to be) yet?” If so, termination is appropriate.


Brownlee, K., Vis, J., & McKenna, A. (2009). Review of the reflecting team process: Strengths, challenges, and clinical implications. The Family Journal, 17(2), 139-145. doi: 10.1177/1066480709332713

Reflecting teams (RTs) are a powerful method for providing feedback to clients. This article reviews the clinical uses of RTs with a variety of populations and problems. Please read before class.


Corey provides an integrative view of termination.


Chapter 6: Focus on pp. 114-115, which address ending counselling.

Oliver, M., Nelson, K. W., Cade, R., & Cueva, C. (2007). Therapeutic letter writing in school counseling. Professional School Counseling, 10(5), 510-513.

This article summarizes therapeutic letters, another powerful way of providing client feedback and anchoring clients’ experience in their personal agency.


Instructor Commentary: A Framework for Termination in Counselling

A pragmatic summary of termination. Please read before class.


1. Distinguish between termination as loss and a brief intermittent therapy framework for termination.

2. Articulate a framework for termination in counselling.

3. Demonstrate a termination session.

4. Develop a personal framework for termination in counselling.

5. Incorporate expanded techniques to develop an account of progress in counselling.

Key Terms and Concepts

1. Terminationa. Termination as lossb. Brief intermittent therapy

2. Reviewing changea. Reflecting teamsb. Therapeutic lettersc. Celebrations and awards

Session Outline:


2. Instructor demonstration: Termination Session.

3. Exercise: Termination Session.

Part 1

Meet in your triads to do a termination session. Assume that the client has experienced some change, based on the same client scenario you have been working with since Lesson 11. Before commencing the interview, spend some time mapping out the direction of the session based on the instructor demonstration, the Instructor Commentary, and the readings.

Then conduct a termination interview. Rotate in the roles of client, counsellor, and observer.



a. Use structuring skills (e.g., overviewing, transitions, giving information) to introduce the focus of the session.

b. Use questions and/or declarative probes, and structuring skills (summaries, overviews, and transitions) to review progress.

c. Use questions and/or declarative probes and structuring skills (summaries, overviews, and transitions) to elicit the client’s plan to forestall relapse.

d. Use immediacy and descriptive praise to give feedback about clients’ positive changes.

e. While keeping the same client scenario, rotate roles every 20 minutes. Pause to consult if needed.

f. Return to the large group to debrief.


GCAP 635: Intervening to Facilitate Client ChangeLesson 15: Case-Based Intervention Practice – Evaluation and Termination

A Framework for Termination in Counselling

“Termination,” as applied to counselling and psychotherapy, was first considered by Freud (1937). He identified two conditions of appropriate termination:

… first, that the patient shall no longer be suffering from his symptoms and shall have overcome his anxieties and his inhibitions; and secondly, that the analyst shall judge that so much repressed material has been made conscious, so much that was unintelligible has been explained, and so much internal resistance conquered, that there is no need to fear a repetition of the pathological processes concerned (p. 219).

Although the counselling models we have learned in GCAP have not focused much on “repressed material,” “internal resistance,” or “pathological processes,” we likely can agree with Freud that termination should occur when goals are met and we are confident that relapse will not occur. Joyce, Piper, Ogrodniczuk, and Klein (2007), writing from a psychodynamic perspective, suggested that termination is a time to “[review] the work and gains of therapy, examin[e] the patient-therapist relationship, and reinforc[e] the internalization of therapeutic functions).” Narrative therapists might inquire about how the client’s identity has been reauthored via counselling (White & Epston, 1990).

Traditionally, termination as been conceptualized using a “termination as loss model” (Quintana, 1993). The therapist-client relationship is the container for feelings of transference and countertransference (representing unresolved aspects of the parent-child relationship) to be worked through; the loss of the therapeutic relationship is a life crisis. On the other hand, Nicholas Cummings (1990), the father of managed behavioural health care in the United States, suggested that many clients think of counselling as a periodic service in which they engage to deal with crises throughout the lifespan, much as patients periodically visit primary care physicians. This is more like how most counsellors in community or agency practice deliver their services. Cummings (1990, p. 173) stated:

In brief, intermittent psychotherapy throughout the life cycle, you can free yourself from the concept of the ideal therapist, where each of us (i.e., counsellors and therapists) has to be all things to all people. You can free yourself from the concept of cure, and you can free yourself from the bother of termination (parentheses added).

Cummings is using “bother” to refer to how termination is conceptualized by psychodynamic therapists. This lesson is based on a view of termination as a pragmatic process and as an opportunity to consolidate client change. The therapeutic relationship, or as we have labeled it, the working alliance, is constituted to support clients to meet their goals – to earn its keep, as it were – to support the changes that clients wish to make. It truly is a working alliance.


The steps to termination described here assume that clients have met their counselling goals. Around 30% of clients who terminate counselling without meeting their stated outcome goals are considered to be in the contemplation stage (Brogan, Prochaska, & Prochaska, 1999). As noted in the previous lesson, when clients are not engaged in goal achievement, you should consider their stage of change, whether the goal is actually mutual, and whether your suggested intervention strategies respect the client’s theory of change.

It is also useful to note that it is the clients’ view of whether they have met their goals that counts. Clients may have attained a desired level of goal attainment, but may not be confident that it will continue. The client’s perspective should have priority over our estimate of whether goals are met. Solution-focused therapists use scaling questions to track progress and motivation, but also to elicit clients’ estimates of optimism that change will continue. They typically do not terminate until both progress and optimism are rated highly (typically, at least 7 of 10 on both, but remember, the customer is always right).

While Joyce et al. (2007) suggested that termination entails review of progress, examination of the therapeutic relationship, and relapse prevention, a common factors approach asserts that we should track the working alliance all throughout counselling. In this view of termination, the focus is on reviewing changes and preventing relapse.

Review and highlight the changes that the client has made.

This can be accomplished in several ways, but the key points are: Highlight personal agency. Elicit a detailed ‘video description’ of the changes. Paint a ‘before and after picture.’

In addition to simply interviewing, three other methods are frequently used:

Therapeutic letters. One effective way to summarize therapeutic changes is to prepare a therapeutic letter. Although letters have been used for this purpose for many years, and from many theoretical orientations, most recently they have become known as a narrative therapy practice (Moules, 2003; Oliver, Nelson, Cade, & Cueva, 2007). Therapeutic letters describe the client situation before the beginning of therapy (often portraying the problem in externalized terms), identify the changes that the client has made with attention to the client’s role in these changes, speculate about what new identities have emerged as the result of therapy, and ask what might come next as clients maintain their changes. With young people, letters can be circulated to key persons in the child’s social context, with the permission of the guardian.


Reflecting teams. Reflecting teams (RTs) provide a transparent collaborative way to share the perspective of a team. Often used in training (Chang, 2010), in RTs, the team, who has been observing the session from behind a one-way mirror, exchange places with the client and offer their observations. This can be an effective way to review progress and speculate about the future (Brownlee, Vis, & McKenna, 2009).

Celebrations and rituals. Therapeutic change is something to celebrate. Letters and RTs can be used in the context of celebrations. Having an actual party in session is usually something we do with children and youth, but can also be appropriate with adults. A small gift (of minimal monetary value so the client does not feel beholden to you), can be used to symbolize the changes the client has made. Certificates, describing the achievements of the client, are a nice touch with children (White & Epston, 1990).

Forestall relapse

Both therapeutic letters and reflecting teams look into the future, wondering, “Now that you have made these changes, how will your future be different? What aspects of yourself have come forth that will help to make that happen?” This line of questioning forms the focus of an interviewing strategy you would use in a termination session.

Some other interview strategies that can be used to forestall relapse are:

Predicting relapse and planning for it. A number of interview strategies can be used to predict relapse. While some may see this as a paradoxical injunction that clients may wish to disprove, it is a truism that change is ‘two steps forward, one step back.’ It is not realistic to think that change will be linear and straightforward. Ask anyone who has made a New Year’s resolution, sworn to quit smoking, or tried to develop a fitness regime. Keep in mind that these questions represent a direction for interviewing, not a single question:

Questioning about what you will do when a relapse occurs:o “How will you respond to a setback?” Continue to interview to elicit

a ‘video description’ of how the client(s) will respond.o In cases where one person in a family might be reluctant to bring

up the fact that things are slipping back, they can arrange for a signal for family members (e.g., turning a family picture backward).

o Ask, “Who will be most likely to see a setback and say to him/herself, ‘This is just part of the process. Let’s just take it in stride.’ Who would be most likely to ‘freak out’? Who would just say, ‘This is just a warning or a wake-up call?’ Who would be most likely to think, ‘OMG, we are back to square one’?” The answers are important, enabling the counsellor to plan ahead with clients so they don’t overreact to slips. On the other hand, simply asking the question embeds the message that clients must be vigilant and respond thoughtlfully.


o Ask, “What would you have to do to make things go back to the way they were?” This is often fun with young people and their families, and can elicit some entertaining enactments. Again, it provides a way to talk about the possibility that clients will encounter setbacks.

Immediacy and self-disclosure. Clients often do things that are frankly amazing. They are courageous in overcoming adversity and taking a stand against problems. It’s fine to tell them you are impressed with them. It’s most useful when this does not come from a ‘one-up’ position, but is expressed tentatively (“I found you very courageous when you did _____. Does that fit for you?”), and followed up questions that invite the client to describe what he or she did. You can also tell the client what you have learned from him/her. Of course, it is important to be sincere in doing so. Another option is to combine descriptive praise and summarization skills by summarizing, in detail, what the client has done to create change. Sometimes hearing their accomplishments listed in detail can be quite compelling for clients.

Telling metaphorical stories about your or others’ attempts to implement change. You can poke a bit of fun at yourself by comically telling your own stories of attempted change to the extent you are comfortable doing so. You can also tell anonymized or composite stories about other clients’ efforts. Stories about learning a new sport, skill, or musical instrument can also provide useful parallels for clients in the early stage of therapy.

References

Brogan, M., Prochaska, J. O., & Prochaska, J. (1999). Predicting termination and continuation status in psychotherapy using the transtheoretical model. Psychotherapy: Theory, Research, Practice, Training, 36, 105–113. doi: 10.1037/h0087773

Brownlee, K., Vis, J., & McKenna, A. (2009). Review of the reflecting team process: Strengths, challenges, and clinical implications. The Family Journal, 17(2), 139-145. doi: 10.1177/1066480709332713

Chang, J. (2010). The reflecting team: A training method for family counselors. The Family Journal: Counseling and Therapy for Couples and Families, 18(1), 36-44. doi: 10.1177/1066480709357731

Cummings, N. (1990). Brief intermittent psychotherapy throughout the life cycle. In J. K. Zeig & S. G. Gilligan (Eds.), Brief therapy: Myths, methods, and metaphors (pp. 169-184). Philadelphia, PA: Brunner/Mazel.

Freud, S. (1937). Analysis: Terminable and interminable. International Journal of Psychoanalysis, 18(4), 373-405 (Trans. Joan Riviere).


Joyce, A. S., Piper, W. E., Ogrodniczuk, J. S., & Klein, R. H. (2007). Termination in psychotherapy: A psychodynamic model of processes and outcomes. Washington, DC: American Psychological Association. doi: 10.1037/11545-000

Moules, N. J. (2003). Therapy on paper: Therapeutic letters and the tone of relationship. Journal of Systemic Therapies, 22(1), 33-49. Retrieved from http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/jnst.htm&dir=periodicals/per_psych&cart_id=

Oliver, M., Nelson, K. W., Cade, R., & Cueva, C. (2007). Therapeutic letter writing in school counseling. Professional School Counseling, 10(5), 510-513.

Quintana, S. M. (1993). Toward an expanded and updated conceptualization of termination: Implications for short-term, individual psychotherapy. Professional Psychology: Research and Practice, 24(4), 426-432. doi: 10.1037/0735-7028.24.4.426

White, M., & Epston, D. (1990). Narrative ends to therapeutic means. New York, NY: W. W. Norton.


Lesson 16: Approaches to Psychotherapy Integration

Introduction

In this lesson, we begin a summing-up process, a process of pulling together all the threads of this course and setting the stage for developing your competence. Perhaps you have felt like the content in this course has pulled you in several different directions. While this course has been built on a pragmatic foundation, and not on one particular approach, you may have felt concerned that you should select one theory, or that you do not want to get locked into doing things one particular way. So far in this course, we have examined common factors as a framework for planning and executing interventions; specific interventions strategies; and how to follow up, evaluate, and terminate counselling. In this lesson, you will develop a framework for further developing your theoretical approach to counselling.

Learning Objectives


1. Locate the approach to psychotherapy integration that most closely fits your development at this time.

2. Apply these approaches to your development as a counsellor.


1. Psychotherapy integrationa. Common factorsb. Assimilative integrationc. Technical eclecticism d. Theoretical integration

2. Syncretism3. Responsible caring4. Using supported services5. Continuing competence.


Read the Instructor Commentary, Pathways to Theoretical Integration. Place yourself in the position of the people whose stories are told in the commentary. What do you imagine your struggles would be if you were in the same position? Spend a few minutes reflecting on the struggles you have making sense of all the different theories you have encountered.

Session Outline:

1. PowerPoint presentation: Approaches to Psychotherapy Integration

2. Group discussion: Psychotherapy Integration

GCAP 635: Intervening to Facilitate Client ChangeLesson 16: Approaches to Psychotherapy Integration

Pathways to Theoretical Integration

Alas, our theory is too poor for experience.—Albert Einstein

No, no! Experience is too rich for our theory.—Niels Bohr


Einstein and Bohr, as physicists, were referring to the study of the interrelationship between the behaviour of particles and waves – the field that eventually became known as quantum mechanics. However, this sentiment seems to apply to our theories of counselling as well. At this stage in your development as a counsellor, after learning some theories of counselling, and seeing and experiencing how they operate in the consulting room, you may now think that the theories you have read about and practiced are not “big enough” to portray the complexity of human problems and change. Either our theory is too poor for our experience, or our experience is too rich for our theory.

Moreover, pre-practicum counselling students often feel that the task of “choosing” a theory of counselling is arbitrary (Chang, 2011). In a counselling theories course like GCAP 631, you may have felt “forced” to choose with limited information and no experience, simply for the sake of completing an assignment. Now, as you again face the perhaps bewildering array of theories, you may be wondering, “How do I go about figuring out what theory I will use?” or “Does that mean I have to ‘stick with it’ forever?” Some counsellors do latch onto a model and adhere to it for the rest of their careers. Most, however, start with something that provides them a home base, which they use to organize their observations, guide their case conceptualizations, and structure their interventions. Should you follow this path, in all likelihood, you will later augment, adapt, and perhaps “loosen your grip” on your model. Studies of how counsellors change as they move through their careers (Fontes, Piercy, Thomas, & Sprenkle, 1998; Goldfried, 2001; Skovholt & Rønnestad, 1995) found that counsellors tend to be less interested in specific models of counselling, and more integrative in their approach, the longer they have been practicing. This may be changing, however, as graduate programs, like ours, seem to be trending away from training students in one particular model instead encouraging them to be integrative “right from the get-go.”

As a new counsellor, you might be surprised to know that counselling and psychotherapy used to be characterized by fierce fights about which approaches were “better” and appeals to theoretical purity (Goldfried, Pachankis & Bell, 2005). However, as Norcross (2005, p. 5) wryly pointed out, “… psychotherapists secretly recognized that their orientations did not adequately assist them in all they encountered in practice….” Now, there are still controversies within psychotherapy (Do I stick to empirically supported treatments or look to a common factors approach? How do “body-centred” therapies work, anyhow? How should advances in neuroscience and neuro-imaging influence our practice? Why not just use pharmacological treatments?). But most everyone agrees that there are certain commonalities to all effective therapy. This leads to another trend that therapists may not immediately admit to, but which is borne out by surveys: A great many practitioners prefer to work integratively, as opposed to practicing a model in its pure form. The “secret” to which Norcross referred was not such a secret after all.

On the other hand, integration should not be carried out in willy-nilly, random way. This lesson will provide you will some examples of, and some “handles” for, organizing your integrative efforts.


Because many, if not most practicing counsellors use an integrative, not a “pure” approach, it is important for you, as a new counsellor, to have some frameworks for integrating your work. In this lesson, your instructor will present four approaches to psychotherapy integration. But first, read these three stories about how others have done it. The first is my own story. The others are people I’ve known, with some details changed to obscure their identities.

Dr. Jeff Chang

In the mid-80s, I was working on my Master’s degree and employed at a child and youth day treatment program. Some of my colleagues were into brief and strategic approaches to therapy (Haley, 1973; Watzlawick, Weakland, & Fisch, 1974), which were “hot” at the time. The interventions seemed radical, and the outcomes were dramatic – single-session cures of persistent problems by “prescribing the symptom” – whoa! I was a newbie Master’s student looking for a magic bullet, and thought I that if I could “crack the code,” I too could bring about miraculous one-session cures.

My supervisor, who was the sensible skeptic at our program, thought I might be interested in a book, Keys to Solution in Brief Therapy, by Steve de Shazer (1985). It was not the magic bullet I craved, but it provided a systematic way to do brief therapy. I was hooked, and spent the next three years devouring everything on SFT I could find, until I “met” (on videotape, and later in person) Michael White (White, 1984, 1986; White & Epston, 1990). Some new colleagues and I spotted some similarities, but there were differences as well (Chang & Phillips, 1993). I admit it, I was a “therapy geek.” I could be found poring over videotapes, reading everything I could find, and generally mastering SFT, with a little narrative therapy thrown in, so that I could respond nearly automatically to almost any client situation. When I went to trainings at the Brief Family Therapy Center, where de Shazer and Insoo Kim Berg worked, I would discuss my use of narrative techniques, like externalizing the problem (White, 1984, 1988). Other trainees asked, “Why are you doing that? It’s problem-focused, not solution-focused,” to which I responded, “Because I get really bored with myself – doing the same thing over and over again.”

While I think that the roots of SFT and narrative therapy are very different, I think they share a very important common assumption. Both are based on a social constructionist view of language that says a counsellor can use the therapeutic interview to construct a different reality for the client.

Linda Milton (pseudonym)


Linda was Master’s student in counselling. She was 48 years old when she entered the program, and had worked as a domestic violence shelter counsellor about 25 years. Watching her via video in practicum classes was a treat. She was obviously a highly skilled counsellor. She tracked client process carefully, noticing nonverbals and changes in clients’ physical presentation (e.g., breathing, skin pallor, muscle tension) that I could not, with over 15 years post-Masters experience under my belt. But she could not articulate what she was doing, and why she was doing it, if her life depended on it. She declared that she was “not interested in theories; I’m just interested in learning how to help people better.” She had almost failed the Theories course – it had been apparent that she just threw her paper together to comply with the assignment. She was at risk for poor grades in her Practicum seminar because she had a great deal of difficulty articulating the ideas that were guiding her behaviour as a therapist. Without the ability to do this, it would be very difficult for her to critically and reflectively improve her practice, which is a competency that Master’s graduates must possess.

In a practicum seminar, we watched Linda’s work on tape. When she asked a particular question about the client’s feelings, I asked her what her intent was. She could not answer. When she responded to a client’s change in posture – the client looked down, bent over, and drew her arms in, almost hugging herself – I asked Linda what meaning she attached to the client’s bodily positioning. She could not say. She was getting frustrated with me pushing her to be theoretically coherent, and I was getting frustrated with her lack of theoretical coherence.

Eventually, I thought of asking her to approach things differently. Since she was motivated to get a good grade in the practicum seminar, she was open to a new idea. Rather than adopt an established theory and perform it, I asked her to figure out what her theory was, inductively. I asked her to return to her practicum site and unpack what she was doing. I asked her to examine her behaviours as a counsellor and ask herself:

What led me to do that particular thing at that time? What client outcome was I going for? Did it “work”? Was the outcome what I had intended? How did I respond to the client’s response?

At our next practicum seminar, Linda was able to articulate the “Linda Milton Theory.” She noted that she had borrowed from client-centred therapy (Rogers, 1951), “inner child” work (Bradshaw, 1990), and experiential work (Greenberg & Paivio, 1997). She also noticed that she seemed to do similar things at similar stages in counselling. We used this to co-develop a reasonably coherent model of counselling, complete with a rough outline of procedural steps. She even thanked me for “helping me get clear about what I do. I no longer feel that I am flying by the seat of my pants.”


Dr. Michael Polansky (pseudonym)

In our Masters’ program, Michael was the instructor we most admired as a therapist. In fact, we were in awe of him. It probably had something to do with the fact that he was not a full-time professor, but a private practitioner. He was a master at Ericksonian hypnosis and strategic therapy (Haley, 1973; Watzlawick, Weakland, & Fisch, 1974).

I lost track of Michael after completing my Master’s and moving to Calgary. Almost 20 years later, I ran into him when I went to another city for training in Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro, 1995). He was one of the sponsors of the training. After catching up a bit, I asked him, “So, Michael, how is it that you got into EMDR?” His reply was a little unexpected: “This stuff is so great, it’s all I do now. If you want to talk about problems, you have to go somewhere else. I just don’t do that anymore. It just doesn’t work as well as EMDR.”

Michael went on to explain how he shifted his therapeutic perspective: “I thought it might be just another version of hypnosis at first. But as I studied it more, I found that it was different – totally different. In hypnosis, you utilize the client’s experiences, but in EMDR, the whole focus is on integrating the client’s experiences and bringing them back into line with each other, instead of letting one channel of experience [the trauma] dominate the client’s experience. It’s totally different.”

When I asked him whether he still used any of what he had learned as an Ericksonian hypnotherapist, he replied, “Yeah I suppose I do. I still use the observational skills I learned in hypnosis. I am really attuned to the client’s responses to what I am doing. But aside from that, not really. Technique-wise – not at all. I think people change, especially when they are recovering from trauma, because the trauma gets reprocessed neurologically. It gets stored differently, in a way that allows people to not have the trauma take over. It’s a totally different theory of change from hypnosis.”

Reflect on these three examples during your subsequent discussion.

References

Bradshaw, J. (1990). Homecoming: Reclaiming and championing your inner child. New York: Bantam.

Chang, J. (2011). An interpretative account of counsellor development. Canadian Journal of Counselling and Psychotherapy, 45(4), 406–428.

Chang, J., & Phillips, M. (1993). Michael White and Steve de Shazer: New directions in family therapy. In S. G. Gilligan & R. Price (Eds.), Therapeutic conversations (pp. 95-111). New York, NY: Norton.

de Shazer, S. (1985). Keys to solution in brief therapy. New York: W. W. Norton.


Fontes, L., Piercy, F., Thomas, V., & Sprenkle, D. (1998). Self issues for family therapy educators. Journal of Marital and Family Therapy, 24, 305-320. Retrieved from http://www.aamft.org/iMIS15/AAMFT/MFT_Resources/Journal_of_MFT/Content/JMFT/JMFT_page.aspx?hkey=6babf2ce-de8e-4ae7-ac75-cb991ab350a3

Goldfried, M. R. (Ed.). (2001). How therapists change. Washington, DC: American Psychological Association. doi: 10.1037/10392-000

Goldfried, M. R., Pachankis, J. E., & Bell, A. C. (2005). A history of psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed.) (pp. 24-60). New York, NY: Oxford University Press.

Greenberg, L., & Paivio, S. (1997). Working with emotion in psychotherapy. New York, NY: Guilford Press.

Haley, J. (1973). Uncommon therapy: The psychiatric techniques of Milton H. Erickson, M.D. New York, NY: W. W. Norton.

Norcross, J. C. (2005). A primer on psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed.) (pp. 3-23). New York, NY: Oxford University Press

Rogers, C. (1951). Client-centered therapy: Its current practice, implications and theory. London, UK: Constable.

Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York, NY: Guilford Press.

Skovholt, T. M., & Rønnestad, M. H. (1995). The evolving professional self: Stages and themes in therapist and counselor development. New York, NY: Wiley.

Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York, NY: W. W. Norton.

White, M. (1984). Pseudo-encopresis: From avalanche to victory, from vicious to virtuous cycles. Family Systems Medicine, 2(2), 150-160. doi: 10.1037/h0091651

White, M. (1986). Negative explanation, restraint, and double description: A template for family therapy. Family Process, 25(2), 169-183. doi: 10.1111/j.1545-5300.1986.00169.x

White, M. (1988, Summer). The externalizing of the problem and the reauthoring of lives and relationships. Dulwich Centre Newsletter.

White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York, NY: W. W. Norton.


http://www.aamft.org/iMIS15/AAMFT/MFT_Resources/Journal_of_MFT/Content/JMFT/JMFT_page.aspx?hkey=6babf2ce-de8e-4ae7-ac75-cb991ab350a3

http://www.aamft.org/iMIS15/AAMFT/MFT_Resources/Journal_of_MFT/Content/JMFT/JMFT_page.aspx?hkey=6babf2ce-de8e-4ae7-ac75-cb991ab350a3

Lesson 17: Building on Your Personal Counselling Style and Continuing Competence

Introduction

This lesson invites you to explore your personal counselling style and approach and develop a plan for developing competence. In the first portion of this lesson, the class will develop and share their plans for continuing competence, using a process based on that of the College of Alberta Psychologists. This will orient you to the continuing competence program of a regulatory body.

The second portion of the lesson will be used to discuss the Therapist Resource Assessment, adapted from Keeney (1990). This will provide some interesting, novel, and fun ways to consider your development as a counsellor.


1. Articulate your personal style of counselling.

2. Integrate the principle of Responsible Caring into your counselling practice and ethical decision-making.

3. Apply self-reflection to develop a continuing competence program.


1. Personal counselling style2. Therapist resource assessment3. Responsible caring4. Continuing competence


Bring Therapist Resource Assessment to class

Canadian Psychological Association. (2000). Canadian code of ethics for psychologists (3rd ed.). Ottawa, ON: Author. Retrieved from http://www.cpa.ca/cpasite/userfiles/Documents/Canadian%20Code%20of%20Ethics%20for%20Psycho.pdf

As you saw in GCAP 632, the Code regulates the ethical behaviour of psychologists in Canada. In this lesson, we will focus on the section on Responsible Caring (pp. 15-21). Consider how your understanding of responsible caring has changed now that you have had introductory exposure to principles of intervention planning and learned some specific intervention strategies.


http://www.cpa.ca/cpasite/userfiles/Documents/Canadian%20Code%20of%20Ethics%20for%20Psycho.pdf

http://www.cpa.ca/cpasite/userfiles/Documents/Canadian%20Code%20of%20Ethics%20for%20Psycho.pdf

College of Alberta Psychologists (2010). Continuing competence program and self-assessment guide. Edmonton, AB: Author. Retrieved from http://cap.ab.ca/memberpdfs/CCP-ProgramDescription.pdf

Although we are aware that most of our students will not seek registration as psychologists in Alberta, we have selected this document to illustrate a self-directed continuing competence program that has been created to meet the standards required of a self-regulating profession.

The Graduate Centre for Applied Psychology, Athabasca University, gratefully acknowledges the permission of the College of Alberta Psychologists (CAP) to use this document and the accompanying forms. CAP developed this Continuing Competence Program. It is currently a pilot program, and the document and forms displayed here are subject to change.

Read pp. 1-11 before class. Bring the program description and the forms to class. Please print three (3) copies of tables 1 and 2.

Session Outline:

1. Class discussion and group work: Developing a continuing competence plan.

2. Group discussion: Therapist Resource Assessment.

3. Closing activity


http://cap.ab.ca/memberpdfs/CCP-ProgramDescription.pdf

GCAP 635: Intervening to Facilitate Client ChangeLesson 17: Building on Your Personal Counselling Style and Continuing

Competence Therapist Resource Assessment

We will use these questions in class to discuss your personal counselling style.

1. Of all the existing schools of therapy, if you had been the author or inventor of one, which would you select?

2. Do you enjoy telling stories?

3. In rank order, which of the following words best characterize your style of relating to clients?

mothering instructing nursingfathering directing choreographingcoaching doctoring others (please specify)

4. Think of several therapists you know whose work you admire. Make a list of what they do that you wish you could do.

5. What one word best characterizes your work as a therapist?

6. If you were to attend a school for the performing arts, what theatrical skill(s) would you want to learn the most?

7. Think of your favorite therapeutic techniques. Choose several words that best convey what these techniques have in common.

8. Fantasize directing a movie entitled, "The World's Most Successful Psychotherapist." Use a brief phrase to describe how you would choose to characterize this therapist's work.

9. What one word is the least descriptive of your work? Now, what is the opposite of that word?

10. Do you place a high value on interpretation in therapy?

11. Do you usually try to have clients define a problem to work on?

12. If you attended the most rewarding and meaningful workshop imaginable, what would be its title?

13. Make up a title for a book on psychotherapy that you would go immediately to a bookstore to purchase.


14. If you could spend several hours with any therapist deceased or alive, who would it be?

15. If you had to teach a course on psychotherapy and could use only one book, what would it be?

16. Imagine writing a book on psychotherapy. What key word would be listed most frequently in the index?

17. Imagine writing to the therapist you respect most and asking for a one-sentence summary of advice. What's your best guess as to what would be said?

18. What is it about you that people enjoy the most?

19. What one word best describes how you communicate?

20. If you were to be cast in theatrical plays, what kind of characters would you portray best?

21. Imagine having a fan club of admirers who regard you as a brilliant therapist. What would they find most admirable about your work?

22. If you were to conduct a one-day workshop on "the art of effective psychotherapy," what would be the general outline of topics you would present?

23. Invent a therapeutic case story that would exemplify the way you would like to work as a therapist.

24. Choose a story or movie you are familiar with in which a major problem takes place. Create a way of solving it if your service as a psychotherapist were inserted into the tale.

25. What genre of humor do you think you're best at conveying?

26. Make a list of all the schools or orientations to therapy you know something about. Next to each name of a therapy, write the one word best characterizing it. Rank order this list in terms of importance, however you define it.

27. How important is it for you to explore "history" in a case?

28. How important is it to focus on the here-and-now?

29. Do you enjoy giving directives, tasks, or homework?

30. Do you enjoy a sense of the absurd?

31. Are you more "rational" or "irrational" in your work?


32. How important is a sense of play in your work?

33. What are the most outrageous things you've ever done in your therapeutic work?

34. What kind of people do you enjoy working with the most? Using one word, characterize what you do with these clients.

35. Think of three cases you've conducted in the past. Create a fantasy about what you could have done differently with those cases to make them major contributions to the psychotherapeutic literature.

36. How important is social context to your therapeutic work?

37. If you spent five years training under the top dozen therapists in the world, describe three things you think you would learn.

38. What's the best advice you can give to a beginning therapist?

39. What's the best question you can ask a seasoned therapist?

40. In one sentence, define the most positive characteristic of your speaking style.

41. What's the most positive statement you can make about your listening style?

42. Which movie star, living or deceased, would make the best psychotherapist?

43. If you wrote three tips to keep you at your best in therapy, what would they be?

44. What themes in therapy are most interesting to you?

45. What are you most curious about in the realm of human experience?

46. In one sentence, what is the most mysterious aspect of psychotherapy?

47. What do you like best and least about your clinical office?

48. If you could hire an expert to design your clinical office, what changes can you fantasize being made?

49. If you weren't a therapist and had to choose another profession, what would it be?

50. If you were asked to write one intervention that you could give to every client entering your office, what would it be?


51. If you were asked to write one understanding or interpretation to share with all clients, what would it be?

52. Name three things you would never talk about in a session.

53. Name three tasks you would never ask a client to perform.

54. Are you "wild" or "tame" in your finest moments of therapy?

55. Is your best work chaotic or clearly organized?

56. When you are getting to know a new therapist, what clinical stories do you tell about your work?

57. What are your favorite case stories about someone else's work?

58. What are the three most special memories you have of your clinical work?


Appendix 1: Skill Coding Sheet

Counsellor Client Observer

Skill #

Counsellor Skill

Counsellor Transcript Domain Frame

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20


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