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What is Immediacy?
- requires high self-awareness, one of most advanced skills
- can deepen the trust of the relationship, present tense, here and now
- communicate your feelings and concerns about what is occurring in the counseling relationship btw you and the client as it occurs in the session
- attending to issues that could interfere w/ relationship in unresolved or unaddressed
- ask "will it help them grow" "will it facilitate change?" "will it help work toward goals?"
- models to recognize and express feelings
- clarify a reaction you had to client's story
- response to use in a multicultural situation when the client accuses you of bias
- demonstrates cultural competency- response to address cultural differences btw you and client
- addressed issues of dependency
Steps to formulate Immediacy
- active listening, spiraling down
- reflect on one of the 3, 1. your own thoughts and feelings 2. your awareness of some behavior or feeling being expressed nonverbally by the client 3. feelings or thoughts about how you are experiencing the relationship
- consider timing
- communicate specific effect (feelings) of the situation on you, relevant to the topic the client is talking about. Here and now
- own feelings and reactions, remain nonjudgmental and non defensive,
- invite discussion and resolution (is that something you've heard before?)
"this is not meant to be offensive, but I want to make you aware of..."
What is the difference between immediacy and feedback?
- Immediacy is about the relationship in counseling and how I am experiencing you...in the moment. "I feel sad when you talk about your traumatic experience."
- through immediacy clients can become aware of how their behavior affects other people.
Feedback is observations and descriptions, not just about the counselor.
What is Giving Information?
- the verbal communication of giving data and facts about people, activities, events, resources, alternative outcomes, or procedures
- might include making referrals to social services or community resources
- must match client's needs and goals
- must be clear, direct, specific, concise, and concrete
- must be at a point where client is most receptive (timing is important)
What are Evans' 5 types of Information giving responses?
- 1. orienting statement-knowledge based, overview of counseling, intro to a service
- 2. Instructions or directions-test instructions, info describing something and how to carry it out
- 3. Feedback- test results, performance review, outcomes
- 4. Alternative perspective- info about alternative frames of reference describing the situation, half-full or half-empty
- 5. Informational statements- overview of info seeking, occupational information, description of community resources, info about events, resources, etc.
When do clients need info? 4
- When they do not know options
- when clients aren't aware of possible outcomes of a choice or plan
- to correct invalid or inaccurate information or dispel myths
- to help clients examine issues they have been avoiding
What is advice giving? 6
- when counselor gives expert opinion and hopes client will follow suggestions
- recommending or prescribing a solution or course of action
- lecturing and preaching
- counselor doesn't listen to client's story
- counselor is assuming to know all parameters of the problem
- even though they may ask for advice, they really don't listen to it, they do what they want to do anyway...
"I have a hunch that you already thought about what you should do, and you want validation."
3 Differences between advice and information giving
Info - could, might, presenting info about issues, the decision is left up to client
Advice- should, must, recommending or prescribing solution
What is assessment?
gathering info about client and problem
What are examples of formal assessment?
- intake form
- Mental status exam (MSE)
- info from medical records
- interview family, teacher
- info from legal system
- non verbals
what is informal assessment?
ongoing assessment each week, assessing progress toward goals
What is the rule for the 1st session?
Need to spend as much time as possible working on the relationship- get basic info and then work on relationship...if you give clients time to tell you their story, you will get it
What are the 5 steps in Young's roadmap of helping?.
- 1. Relationship building
- 2. Assessment
- 3. Goal Setting
- 4. Intervention and Action
- 5. Evaluation and Reflection
What are 4 basic techniques to elicit relevant info for assessments?
- 1. Questions
- 2. Observations
- 3. Constructing Interviews
- 4. Genograms (family tree for 3 generations)
What are the 10 reasons to spend time assessment? Young
- 1. Help determine is client is a good candidate for the help you provide
- 2. Assessment gives crucial info to plan useful and realistic goals
- 3. helps clients discover events related to the problem
- 4. helps us to understand the impact of the client's environment on mental health
- 5. helps us recognize the uniqueness of individuals
- 6. uncovers the potential for violence
- 7. reveals critical historical data
- 8. can highlight strengths, not just weaknesses and pathology
- 9. helps clients become aware of important problems
- 10. helps the helper choose which techniques to use
3 pros of assessment
- a tool to alert you to dangerous behavior, substance abuse, and psychotic symptoms
- gives insights into a client's functioning in areas you may not be aware of asked about
- can use to back up diagnosis and use to make accurate diagnosis
4 cons of assessment
- not the only way to get at the truth
- puts labels on clients
- inappropriate for those who are different culturally than those for whom the test was intended
- reveals little beyond what could be learned in a couple of sessions talking
What are the 7 guidelines for referring clients for testing? (Young)
- 1. Trigger questions indicates violence, severe mental disorders, substance abuse, or suicide.
- 2. Client is evasive or unreliable, could be personality issue of antisocial behavior, incarcerations, hospitalizations, domestic violence or substance abuse
- 3. Client has a physical condition that might be causing problem-
- 4. Client's problems seem to stem from ability to remember things- might have neurological difficulties
- 5. When client has difficulty reading and writing- could indicate learning disabilities or pervasive developmental disorder
- 6. Client seems to be functioning poorly but does not provide enough info to make a diagnosis or conversely appears to have symptoms of several disorders- may need testing to determine which issues are most central.
- 7. when you are unconvinced about a previous diagnostic label
How do you organize info to make diagnosis?
- gather info, sort into problems, then prioritize problems and match with treatment strategies
- identify client's strengths as well as areas for concern in each domain
- talk about test results
Where do I go after spiraling down?
- invite client to open up and engage in self-examination w/in the safe relationship
- challenge client to go deeper and disclose about a lot of topics
- assessment- use skills interview, observe, questions, and genogram to gather crucial data about history, environment, problem, etc.
- now we set SMART goals
- change the problem into goals to be worked on and met through the helping process.
What are SMART goals?
- S- specific, concrete, and positive, what they are working toward (will be able to...)
- M-measurable, everyone must be able to agree when goal is met, mutual do it together
- A-attainable, something they can actually do, culturally relevant
- T-time oriented, when are we supposed to have met goal?
- Behavioral goals
- increase, improve, maintain, establish
What is the miracle question?
If you were to wake up tomorrow and the problem is gone, what would you be doing?
What makes you ______________? (happy, feel good about yourself,)
What does that look like?
Reflect meaning, then help to set goals
What are the 5 stages of change? (Evans)
- 1. Precontemplative- unaware they have a problem or aware, but don't want to do anything about it, or want others to change to solve it.
- 2. Contemplation- begin to acknowledge they have a problem, but not yet committed to change, no method of dealing w/ problem has been developed.
- 3. Preparing for Action- decide to work toward goal and actively developing an action plan
- 4. Action- execute the action plan
- 5. Maintenance- clients actively work to maintain the change made during the action phase.
How do you focus on the client? 3 ways
- 1. when reflecting, do not blame others for client's feelings or behavior, "you feel" not "others feel" prevents client from blaming others and external circumstances
- does not encourage passive acceptance of behavior, but challenges client to become responsible for the problem and the ability to do something about it
- develop insight and take responsibility for feelings
What is the importance of goal setting?
- once you set goal, you don't talk about anything else in the rest of the sessions, you are focused on this goal
- that's why it's important to set the right goal
- have to work w/ clients to get it right.
when counseling is over, client will be able to....
then choose strategies to achieve goal...
________________ drives your strategies and interventions.
How do you evaluate the effectiveness of counseling?
- program evaluation- school counseling curriculum
- program notes
- global measures and specific symptom measures (beck depression scale, etc)
- subjective scaling and self report (ask client to write down how many times he felt anxious)
- monitoring by outside support (parents, staff, etc.) measureable
- client satisfaction forms
- goal attainment measures- chunk goal and describe goal in pieces talk about strategies w/ client and get their feedback.
Counseling is a process because...
- every relationship is defined by beginning and end
- loss or threat of loss is what brought client to counseling- loss of relationship, physical (tangible) loss, psychological or emotional loss
- like other relationships, counseling will end
5 questions to ask yourself when thinking of terminating.
- 1. Is the presenting problem under control?
- 2. Has client reduced the initial level of distress by developing better coping skills?
- 3. Has the client achieved greater self-awareness and better relationships?
- 4. Are life and work more enjoyable for the client?
- 5. Does the client now feel capable of living without the therapeutic relationship?
How to terminate counseling relationship.
- Want to help them to become their own therapist in the future
- a transition rather than an event
- a symbolic conclusion, an acknowledgement that the relationship had importance and that reality dictates that it end
- a reflective moment in the history of counseling relationship
- helping client to acknowledge what he has achieved during counseling
- determining the nature or timing of any future contacts and/or referrals
- takes place in 2 or 3 sessions
How to terminate
- Must give adequate preparation and opportunity to work through thoughts and feelings about ending the relationship (time for counselor to use immediacy and talk about your feelings w/ client)
- maintain therapeutic gains and prevent relapse
- think about work that needs to be done in the future (support group, religious groups,)
- talk about the nature and timing of any future contacts and referrals, door is not closed, if they need to come back it's ok.
- write a termination summary report
When might you have resistance to termination?
- clients who are unable to verbalize their anxiety about stopping counseling
- a way to suggest their uneasiness to end counseling-backslide, regression, act out
- don't get caught up in behavior, listen to message underneath,
- use advanced challenging skills-fading, interpret behavior, consider extending time, plan follow-up meeting
What about unplanned endings/ premature termination?
- 1/3 of all clients do not return to counseling after 1 or 2 sessions
- no single characteristic can predict premature termination
- appears to be associated w/ a deterioration of the therapeutic relationship or a flight to health
- many possible reasons- money, transportation, work, relationship, etc.
What is the medical model for designing a treatment plan?
- diagnose, which is basis for determining treatment client will receive.
What is the theoretical orientation model for designing a treatment plan?
- based on theory counselor subscribes
- those who take an eclectic or integrated approach can utilize the techniques of different theories
What is the REPLAN model?
- goal oriented treatment planning model using the 6 curative factors
- does not conflict w/ making a DSM4 diagnosis or using theoretically oriented models
- a brief treatment model, but not incompatible with long term
What are the 3 steps in REPLAN?
- 1st step- set goals
- 2nd step- use curative factors to set up strategies,
- 3rd step-revisit every 6 weeks, to move to new problems as old issues are resolved
R in REPLAN?
- develop and maintain a therapeutic bond
- nonjudgmental listening
- being culturally sensative
- using skill of immediacy
E in REPLAN
- Enhancing Efficacy and Self-esteem
- focus on client strengths
- decrease irrational beliefs and develop more realistic ones- decrease negative self-talk
- move clients to pay more attention to their strengths and abilities
- countering-identify the negative self talk and replace it with positive
- Thought-stopping- emergency
- Assertiveness training- done well in groups, so they have a chance to practice
What is the difference between Self-efficacy and self-esteem?
Efficacy is the expectation that one can perform a specific task, usually tied to certain tasks and experience
Self-esteem is like self-worth, a feeling that one has the right to exist that one is basically good and worth to live, self-approval.
What are 7 irrational beliefs? (Ellis)
- 1. need to loved and approved by everyone
- 2. one should be competent and achieving in all aspects
- 3. certain people are bad and they should be punished
- 4. it's awful and a catastrophe when things aren't the way we want them to be
- 5. human unhappiness is externally caused and we have no control over terrors or disturbances
- 6. it's easier to avoid life's difficulties and self-responsibilities than to face them
- 7. one's past history is an all important determinant of present behavior
What are the 5 steps of countering?
- 1. Do a brief assessment-self-monitoring
- 2. identify the negative thought patterns and core beliefs- using the self monitoring assessments, chose 3 or 4
- 3. identify Effective counters- way of talking back to oneself and disputing self criticism, to be effective, it should be consistent with client's beliefs, NOT a list supplied by counselor
- 4. Test counters and modify them- evaluate counters in session
- 5. Practice and Report-follow up and gauge progress and seek more effective counters,
What are precautions when teaching countering?
- some are more potent than others- counselor may suggest words that might refine it or make it more effective, and produce more self-confidence
- counters should be realistic- not just affirmations, but really should dispute negative ideas
- counter should be in the same mode of thought as the thought it's disputing- angry thoughts should be countered with compassionate ones, passive with assertive,
- shorter counters tend to be more effective than longer ones
What are the 3 steps to thought stopping?
- 1. Stating the thought
- 2. Creating a startling interruption
- 3. substituting a new thought
What is the P in REPLAN?
- Practicing new behaviors
- psychoeducational approach- they need basic knowledge- get rid of old habits and replace with new ones
- Imagery- practice in session
- Psychodramatic role play- special training required, client acts out past situation using others in group
- Role play- not about the past, but about the future, something you need to learn, social skills, etc.
- Homework-practice new behavior btw sessions, replace old habit by practicing new behavior- bibleotherapy, creative arts, don't give self-help books, shifts responsibility to client
- aids- someone in client's social network and have them come in and discuss, works w/ children and their parents
- journaling, blogging, client can find insight, make sure it's client specific expectation
What are the 3 precautions of role playing?
- 1. Stage fright- insufficient warm up time, inadequate preparation time, client's lack of confidence, inadequate reassurance from counselor
- 2. Very powerful, so client and helper may be unprepared for the strength of the emotion that is evoked- most of time in scenes from past...not in practicing for new behavior
- 3. because most helpers focus on client's thoughts and feelings, we sometimes have trouble thinking in dramatic terms. Show instead of tell, the helper learns more about the context of behavior
What are the 7 steps to role playing?
- 1. warm up
- 2. scene setting
- 3. selecting roles and role reversal
- 4. enactment
- 5. sharing and feedback
- 6. reenactment
- 7. homework and follow up
Why give homework?
- provide follow up or treatment continuance btw sessions
- turn insight and awareness into tangible behaviors and prevent helping from being a place to unload one's feelings
- transfer of training to real world situations
- shift of control from the helper to the client, so they attribute progress to his own effort, greater efficacy and esteem will result
What are types of homework?
- Journaling or record keeping
What are precautions with homework? 5
- 1. HW that have high probability of success should be chosen, esp. early in the relationship to keep client's hope alive. client learns that change is gradual
- 2. HW strategies should be individually tailored for each client
- 3. Practicing regularly is important, 10 min per day instead of 60 at once
- 4. HW should be simple and fit easy into lifestyle
- 5. As client progresses, HW should increase in difficulty or discomfort.
What is the L in REPLAN?
- Lowering and Raising Emotional Arousal
- overall goal-reduce impact of negative emotion (most common- depression/guilt, anxiety, anger)
- most fundamental method for helping clients reduce arousal is deep muscle relaxation- practice in session and help client to practice outside session.
- meditation- spiritual or mindfulness
- catharsis- giving opportunity to express emotions
- using creative arts
- creating positive emotions, have to replace the old emotions
What is the A in REPLAN?
- Activate client expectations, hope and motivation
- Recognize the client's stage of motivation to change
- motivational interviewing (reflective listening)
- enhance client expectation, must instill some hope that the problem is solvable (in first session) here to help you...
- ask change questions or strategic questions, scaling questions, miracle question, goal questions
- encouragement- using paraphrasing, meaning reflecting, feedback, immediacy intentionally to give client's courage)
- careful not to praise b/c praise is judgmental
- I statement reflecting observations
Who benefits most from encouragement?
- people who are dependent
- cut off from social support systems
- suffering from low self-esteem
- excessive need for attention, power, or control
- avoid participation and responsibility
encouragement is helping someone discover the courage to be imperfect.
3 categories of encouraging responses
- 1. focusing on positive and the changeable- optimism
- 2. Emphasizing equality and individuality of the client
- 3. Pushing with enthusiasm- element of confrontation and effort to produce movement of the client
What is the N in REPLAN?
- New learning experiences
- 2 basic helping techniques- give new info or skills ( get them to think differently), help clients to change inappropriate beliefs, perceptions, and outlooks (ah-ha moment, figure out patterns)
- Modeling-client has to be able to identify w/ model (child, adult, female, male, black, white, etc.)
- Metaphors and stories - invite discussions, open questions
- Exposure to avoided stimuli- systematic desensitization
- Linguistic changes- help client to change words, "feel like" "always" "never"
- Reframing- look at it a different way, perspective
- direct instruction- social skills, assertiveness, discussion groups, etc.