Tricks of the Trade: Specific Techniques to Use with Difficult Clients

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Tricks of the TradeSpecific Techniques to Use
with Difficult Clients

• Region VIII Employment Conference
• October 17-19
• Spearfish, SD
• Presented by
• Robert H. Arnio, Ph.D.
• Psychological Associates of the Black Hills
• 1818 West Fulton St. 201
• Rapid City, SD
• Rarnio_at_rushmore.com

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Agenda

• Major Processes in Counseling
• Methods or procedures best suited in the
  vocational rehabilitation setting
• Discussion and demonstration of specific
  techniques

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Role of Counseling in RehabilitationParker and
Szymanski Rehabilitation Counseling, 1998

• Without adequate counseling, the core ingredient
  of rehabilitation counseling, many rehabilitation
  clients would be unable to achieve the goals of
  the rehabilitation process. The ultimate goal of
  rehabilitation the independent, effective, and
  full functioning of clients is predicated upon
  and intimately linked to, intensive counseling by
  a skilled, professional rehabilitation counselor
  . . . Consequently, the primary task of
  rehabilitation counseling is the removal of such
  barriers, whether inflicted by oneself, or by
  society.

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Role of Counseling in RehabilitationParker and
Szymanski Rehabilitation Counseling, 1998

• In search for a personal vantage point in
  counseling with the rehabilitation client, the
  student and the practitioner have the option of
  selecting from more than a dozen major
  approaches. For purposes of presentation, these
  approaches are categorized as psychoanalytic,
  humanistic, rational, behavioral, cognitive, and
  eclectic (or integrative. p 224) (Gives 8
  guidelines for deciding on a theory)

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Therapeutic Components Shared by All 250
PsychotherapiesJ. Frank, 1980

• Psychotherapy
• (Professional Counseling)
• A planned, emotionally charged, confiding
  interaction between a socially sanctioned healer
  and a sufferer(s), in which the healer seeks to
  reduce or eliminate the sufferers distress or
  disability through symbolic communications
  (usually words, but sometimes exercises). The
  healer may or may not involve the sufferers
  relatives or significant others. This process
  may also include helping the sufferer accept the
  distress as an inevitable aspect of life and an
  opportunity for personal growth.

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What type of counseling to use?

• Counselor characteristics
• 1/3 of change is based on Counselor
• Same counselor, different techniques
• Client characteristics
• Demographics
• Psychological Characteristics
• Diagnosis (Diagnostic Related Groups)

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Problem Centered ApproachW. Pinsof, Northwestern
University

• Psychotherapy is human problem solving.Patients
  view of their problems constitute the presenting
  problem. Every problem has its own, unique
  maintenance system. The problem maintenance
  system exerts constraints on the clients so that
  solutions to the problem are not successfully
  developed and implemented. What started the
  problem and what keeps it from being solved may
  no longer be the same thing. Different
  counseling approaches need to be used with
  different problem maintenance structures.
• (e.g. workaholic injured)

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Example
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Example
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Solution Focused TherapyJohn Littrell

• Gregory Bateson and Milton Erickson
• Mental Research Institute (MRI)
• Steve de Shazer Bill OHanlon Insoo Kim Berg
• The person is so saturated in thinking about the
  problem, they cannot see the solution that is
  available to them.

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Research

• Client Codes
• Change
• Non change (everything
• not in change)
• Therapist Codes
• E Elicit Change
• A Amplify Change
• I Initiate Change (future)
• N Non-change (all other)
• Constructing Change A Research
• View of interviewing Gingerich,
• de Shazer, Weiner-Davis 1989

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Solution Focused Model

• Concerned with building solutions, not problem
  solving.
• Task is to build solutions tx concerned with
  the nature of the solutions, not the nature of
  the problems.

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Different assumptions

• Client has the beginning of the solutions
• Find out about exceptions to the problem
• These provide the cues or keys to what the client
  needs to do to build solutions

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Solution Focused Assumptions

• People can change rapidly
• People have many resources, both internal and
  external they are not aware of
• People are doing their best at any given time.
• A small change in one persons behavior can lead
  to far reaching changes in others
• When you focus on the solution, there is much you
  do not need to know

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Nature of Solutions

• Solutions come from the clients and therefore are
  natural and fitting. Solutions are generated by
  the client so they fit their natural way of doing
  things, ie. Natural way of finding solutions so
  therefore it happens quickly but is long lasting.
• Ask these questions within the context of the
  therapeutic relationship and therefore the client
  finds their own solutions.

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Four Step Processin the Solution Focused Approach

• Describe the problem specifically
• Examine attempted solutions and exceptions to the
  problem
• Define a Goal
• Give compliments and assign a task

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5 Useful Questions

• Questions Highlighting Pre-session change
• Exception-finding Questions Enhancing Existing
  and Past Successes
• Miracle Questions
• Scaling Questions
• Coping Questions

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All interviews are composed of questions and
answers

• Exception finding questions
• Miracle Question Client hypothetical solution
  What life would be like after they have a
  solution how they want their life to be
  different
• Scaling questions are client generated. Not what
  is normal or abnormal. Is way the client
  measures change.
• Externalization of the symptom (problem)
•  

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Goal Negotiation - occurs right after the social
stage of the interview

• What do you think needs to happen as the result
  of your coming here?
• What needs to happen for you to say that his was
  a good idea that we did this (coming to the
  session)?
• Aside from that, what would you like to see
  different in you life circumstances?

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Deliver the Message

• Compliments acknowledge and validate clients
  points of view about their life and their
  problems.
• Bridging statement Some sort of rationale about
  why they should do the task that the tx is going
  to suggest
• Homework or task the tx suggestsdesigned to
  implement the solutions implemented by the
  clients in their own setting. Great deal of
  attention to the clients life in the real world,
  not in the therapy room.

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Miracle Question

• After we talk today, go home and go to bed
  tonight and when the house is quiet, the miracle
  happens. The problem that brought you here today
  is gone. It has disappeared. So when you wake
  up in the AM what would be the first small clue
  that something has happened, the problem is gone.
  What would you first notice?

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Miracle Question

• What will you notice different in (other family
  member) so you know that the miracle has happened
  for them. If that were to happen, what would you
  do that you are not doing now? What would
  happened after that.

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Miracle Question

• What would you notice different about X and Y now
  that the miracle has happened.
• Now suppose you do this, what would you do. What
  would you do different.
• What would you notice different about X to let
  you know that a miracle has happened and the
  problem is solved.

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Second Sessions

• Second session
• Whats been better since the last session?
• What kind of solution has the client generated?
• Clients come up with ways that are good for
  them.

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• Tasks of the second session
• Elicit anything that is better What have you
  noticed that is different about X an what have
  you noticed thats different about Y.
• Amplify the difference then
  look at the ripple effect (circular impact)
• Reinforcing much of which is
  indirect, e.g. Wow, how did you do
  that. Reiterate the above procedure. Use
  scaling questions as to where things are at right
  now

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• What else would be different if the miracle has
  happened
•  
• I guess any one who \developed a vocational
  problem would . Normalization negative feelings
  and anxieties
•  
• When was the last time even little pieces of this
  miracle has happened.?
• When you see that little bit of a miracle
  happen, what seems to happened different? The
  make it circular.

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• Scaling questions
• Day after the Miracle
• 10 need not come back (close the case)
• 1 where they were when you called.
• Where to you think things are at right now?
• Whats helped during the session
• What needs to happen so that you
  
  can be 10 percent better or closer to your
  goals?

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Problems Solutions

• Trend Toward Trend Toward
• Complexity Simplicity
• Many Kinds of Problems Many Kinds of
• Many Kinds of Problems A
• Solutions Handful of
• Solutions

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Example
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Responding to Visitors, Complainants and
CustomersInsoo Kim Berg, Family Therapy
Networker, Jan-Feb, 1989

• Visitors have no complaint, except maybe that
  someone has made them come see you.
• Complainants have a complaint but do not see
  themselves as part of the solution.
• Customers have a complaint, and indicate they
  are ready and willing to do something about it
  with the therapists help.

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Responding to Visitors, Complainants and Customers

• Visitors have no complaint, except maybe that
  someone has made them come see you.
• Sympathize with their plight of being forced to
  see you
• Avoid trying to get them to admit they can do
  something to help the problem
• Compliment them for whatever they are doing that
  is good for them, or whatever they do that they
  do well.
• Allow the possibility they may eventually come up
  with a complaint that they will talk about with
  you.

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Responding to Visitors, Complainants and Customers

• Complainants have a complaint but do not see
  themselves as part of the solution.
• Compliment them for the helpful information they
  have provided about the situation, for anything
  they are doing that is good for them, and for
  whatever they do they are good at.
• Consider giving them a task to think about or
  observe something that may provide a better
  understanding of the complaint. Do Not give a
  task that involves behavior change.
• Be patient, knowing that in time they may move to
  recognizing that they can be part of the
  solution.

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Responding to Visitors, Complainants and
Customers

• Customers have a complaint, and indicate they
  are ready and willing to do something about it
  with the therapists help.
• Compliment them on the positive things they are
  doing for themselves and for anything they are
  doing that might be a step toward resolving the
  complaint.
• Give tasks to think about, observe or take action
  regarding the complaint in accordance with their
  style of cooperating.

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Stages of Change

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance

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Stages of Change

• Precontemplation
• The person does not consider the behavior of
  focus to be a problem and/or is not currently
  considering changing the behavior. For a person
  at this stage, the benefits of the behavior are
  greater than the costs.

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Stages of Change

• Precontemplation
• Help the person engage in the counseling process
  and begin considering patterns and potential
  effects of not solving the issues that brought
  them to your office.
• Decontaminate the referral process
• Explore the meaning of the events that brought
  them to your office.

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Stages of Change

• Contemplation
• The person is considering that there may be a
  problem and is seriously contemplating changing
  behavior, but is struggling with mixed feelings
  about changing.

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Stages of Change

• Contemplation
• Help the person see the big picture. Discover
  discrepancies between their current behavior and
  their goals for the future, and consider making
  some changes.
• Normalize ambivalence
• Weigh pros and cons of changing
• Imagine the future
• Elicit change and self motivation statement and
  amplify those for the client

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Stages of Change

• Preparation
• Help the person resolve the ambivalence about
  changing, develop a sense of ability to change
  (if it has already happened, it is probably
  possible), and make the initial plans for going
  about changing.
• Clarify the clients own goals and strategies
• Help develop plan for change
• Assist client in decreasing barriers to change

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Stages of Change

• Action
• Help client initiate change, cope with
  difficulties in the change process, and gain
  social support for new ways of being.
• Support small steps toward change
• Only offer expertise or advice with clients
  permission
• Emphasize that setbacks and lapses are unintended
  failures of the planning process and help to
  improve long-term plans. (adjusting courses in
  flight)

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Stages of Change

• Maintenance
• Help client cope with difficult situations,
  maintain commitment and energy, initiate new
  facets of living to help client integrate them,
  and process discouragement when it happens.
• Affirm clients resolve and self-efficacy
• Assist client in making transition to working on
  long other term goals

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After Example
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Symptoms of Brain Injury and Alcohol Abuse

• Difficulty initiating meaningful activity
• Brain Injury
• Fatigue
• Both
• Impulsivity
• Both
• Motor problems (gait and balance)
• Brain Damage
• Diminished Judgment
• Both
• Slowed thinking
• Both

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Symptoms of Brain Injury and Alcohol Abuse

• Depression
• Both
• Personality changes
• Both
• Trouble tracking conversations
• Brain Damage
• Limited insight
• Brain Damage

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Symptoms of Brain Injury and Alcohol Abuse

• Word finding difficulties
• Brain Injury
• Short-term memory loss
• Both
• Sequencing difficulties
• Brain Injury
• Concrete thinking abstract metaphors
• Brain Injury
• Emotional dysregulation
• Both