Wk 11 - Process issues Flashcards
What are process issues? (x2)
Processes that take place during therapy,
Within and outside the therapy setting
Why is process important? (x2 plus e.g. x3)
Can significantly impact on outcome of therapy
If therapist simply responds to the content, could miss the important process issues
Person challenges group therapist on the first morning of a substance abuse treatment group -
“How old are you? What are your qualifications? Have you ever used drugs before?”
Really want to know: “Do you have the life experience to help me with my problem? Can I relate to you? Are you going to judge me?”
What are the client’s process issues in the following e.g.? (x2)
Deeply depressed client has brought back his activity scheduling homework and you make positive comments about his mood ratings of up to 8/10 associated with doing pleasant activities. He looks away and shakes his head sadly, then says “you’re just like the other therapists – no-one takes my depression seriously”
Long history of suicidal, complex depression –
Didn’t want momentary improvements to interfere with ongoing understanding
What might process issues for client be at initial contact? (x9)
Expectations of therapist (gender, age, experience)
Expectations of role as client
Costs? commitment?
Anxious to be understood
Fearful of being judged, labelled
Uncomfortable with perceived power differential
Is this going to be worthwhile?
Any knowledge or prior experience of counselling
Trust, confidentiality?
When establishing a therapeutic framework, how might you set the scene for the client? (x4)
Explaining goals of initial session
Roles of client and therapist
Communicating hope
Setting boundaries
When establishing a therapeutic framework, how might you establish a therapeutic relationship? (x3)
Empathy
Unconditional positive regard
Genuineness
What do clients report as helpful in the process of establishing a therapeutic relationship? (x6)
Talking (to someone who listens) Being understood Hope Warmth Calmness and objectivity Truthfulness and honesty
During the assessment process, how might you go about ensuring honest, detailed and comprehensive reporting from client? (x3)
Explaining purpose and role of assessment
Explaining your role and the client’s role
If using psychometric tools, ensure client understands what is expected of them
What might process issues be at assessment? (x2)
And it’s important to remember that… (x1)
Extra burden
Is my private information going to be secure?
Client’s report may be different from others’ reports
What is the process involved in case formulation? (x4)
How well you explain the issues, as they’ve told you,
In a theoretical framework they can relate to
And also communicate well and
Clarify any issues they might raise
What process difficulties/solutions might arise with case formulation? (x3 and x3)
Client does not understand:
Too complex
Too abstract
Not well explained
Client does not agree:
Explore areas of concern
Modify formulation
If no agreement, discuss options
What is involved in the process of goal setting? (x4)
Establishing clear, attainable goals “I want to get my life back on track” vs “I’d like to decrease my depression symptoms and reconnect with my friends” Therapist’s role Involving the client Clarifying expectations
What is involved in the process of ‘session agendas’? (x3)
Setting agenda with client
Keeping to agenda
Deviations from agenda – is there a pattern?
Why might there be repeated deviations from the agenda? (x3)
Resistance
Unclear expectations
Therapist confidence and role
What is resistance? (x1 and x3)
Any client behaviour that is unhelpful to their progress in therapy
Westra et al., 2012: “Resistance is an interpersonal phenomenon heavily influenced by the therapist, and
Sustained client resistance can be considered a clinical skill error.” (moving away from ‘difficult clients’…)
How might resistance manifest? (x6)
Lack of engagement in therapeutic dialogue
Late for sessions
Not attending
Cancelling several sessions
Failure to complete homework
Resisting addressing particular areas of concern
What might client-based reasons for resistance be? (x3)
And when does this often manifest? (x1)
Anxiety about discussing personal issues
Lack of motivation
Resentment for referral
5-6 sessions in, feeling better, but getting to the core issues…
What might therapist-based reasons for resistance be? (x2)
look here if there’s a pattern of drop-out
Personal characteristics
Therapeutic style
What might environment-based reasons for resistance be? (x3)
Stigma related to accepting diagnosis and treatment - ‘course’ vs ‘group therapy’
Secondary gain for not changing
Cultural norms - talking over problems with strangers, gender/parenting roles
What are five ways to deal with resistance?
Predicting resistance Address the issue Explore causes of resistance Explore barriers Problem solving
What are some aspects of process that might encourage client commitment? (x4)
Encouraging and validating commitment - motivate by highlighting benefits of completion
Explore reasons for lack of commitment
Problem solve barriers - better time to resume?
Discuss options, referral, termination
What might you address if a client does not seem committed to therapy? (x4)
Resistance
Motivations
Hope
Self-efficacy, control issues
What reasons might there be for a lack of progress in therapy?(x7)
Motivations Resistance Misunderstanding/lack of understanding Barriers Stress, other pressures Concern about therapy ending if client gets better - lose their lifeline with you ? Identity without mental health problem
What can you do if client (feels like?) is making no progress? (x6)
Discuss progress – e.g. improvement on OutcomeQuestionnaire45 scores
Explore reasons for lack of progress
Clarify understanding
Discuss barriers and stressors and problem solve
Discuss motivations and priorities
Termination/referral
What are some reasons for homework non-completion? (x6)
Resistance Lack of understanding of task Lack of understanding of importance of task Lack of reinforcement for completion Barriers Additional stressors
What processes might you undertake to ensure homework completion? (x7)
Address resistance
Explain homework clearly and check for understanding
Complete example of homework
Explain importance of doing homework
Check homework at the beginning of next session
Reinforce client for completing homework
Address barriers and stressors
What are some strategies you might use with clients who talk (incessantly)? (x5)
Communicate interest and understanding Interrupting Use of reflection, paraphrasing Clarifying expectations Setting clear limits on how much of session is ventilation and how much is new learning
What are four reasons your client may not talk?
Resistance
Difficult issues to talk about
Not talkative, little experience
Unsure of roles, expectations
What four strategies might you use with clients that don’t want to talk?
Addressing resistance
Use of silence
Communicating empathy
Clarifying expectations
What can you do about one person dominating the session in couple therapy? (x3)
Involving the other partner
Attempting balance in contributions
Sometimes need to act like referee…
What if one partner in couple therapy makes hurtful comments? Or if they fight in session? (x2)
Setting rules for interaction
Or if heated, step in and call a break
What are some process issues that might arise when working with parents? (x6)
Expectations
Roles/responsibilities in family – often parents think kid is problem, please fix them
Often more about working with most influential parent – build their skills at dealing with the kids issues
Can go very badly if one gets involved, but other doesn’t – very different parenting styles at home
Confidentiality – parents feel they have a right to the info, as they’re paying, while kid might not want you telling them everything
Balance in contributions
What are some process considerations when doing child therapy? (x5)
Therapeutic relationship
Trust
Language
Delivery of content – ways of engaging child (don’t want to be there, don’t know why they are)
Behaviour management – use of reinforcers
What are some process considerations when doing group therapy? (x5)
Selecting group participants Setting context Expectations Roles and responsibilities of therapist and group members Rules for working in a group
What are some process problems that might arise when doing group therapy? (x3)
What if one person dominates?
What if group member(s) don’t contribute?
What if a group member is clearly not appropriate for the group? (e.g. PD that makes it hard for anyone else to gain)
What are some process issues for therapists? (x7)
Care with non verbal behaviour
Setting limits while still conveying empathy
Self awareness - knowledge of limitations
Expectations of self/clientInput from other professionals (referral info)
Anxiety and insecurity over competence
Experience with other similar clients?
Concern about whether a therapeutic relationship will be established
What does the Australian Psychological Society Code of Ethics give you? (x2)
Doesn’t give you the answers,
But a set of principles that you then apply when making decisions
What is involved in learning about ethics as you build your counselling skills? (x3)
Becoming familiar with ethical standards of your profession
Understanding ethical issues that you may encounter
Learning to apply your knowledge in everyday practice
What are morals? (x1)
Versus ethics? (x3)
Individuals own ideals and principles
Standards of conduct or actions in relation to others
Moral principles adopted by a group to provide rules for right conduct
Which can be enforced by various agencies in civil society, e.g. professional association, police, legal system
What are the ethical issues in this scenario and what steps would you consider taking? (x8)
A mother refers her 14 year old daughter Tracey for therapy because of conflict in the home and Tracey’s school truancy. Tracey tells you that she’s using intravenous drugs with her 17 year old boyfriend. She is also in a sexual relationship with her boyfriend
Confidentiality
Potential for harm
Legal issues - underage sex, drug use
Might have reporting responsibility - mandatory, or at your agency?
If you break confidentiality, who are you going to talk to first? Hostile relationship with mother – what if Tracey threatens to discontinue if you tell mum
What if boyfriend is best, most stable support she currently has?
You would need to seek advice to ensure you do the best thing for clients well-being
What is the difference between mandatory and aspirational ethics? (x2)
Minimum level of professional practice, vs
Highest standards of conduct to which a professional can aspire
What are three purpose of a code of ethics?
Educate about responsibilities
Provide basis for accountability - and complaint (identifiable breaches)
Provide basis for reflecting on and improving one’s professional practice
What three psychological bodies have codes of ethics in Australia?
Australian Psychological Society
Australian Counselling Association
Psychotherapy and Counselling Federation of Australia
What are the three general principles of the APS code of ethics?
Which encompasses… (x2)
Respect for rights and dignity of people and peoples (ie how psychologist treats others)
Propriety (i.e. fitness to practice psychology)
Integrity (i.e. broader conduct - e.g. the christmas party)
Psychologists’ responsibilities to their clients, community and society at large,
To the profession and to colleagues
What is covered by General Principle A of code of ethics: Respect for the rights and dignity of people and peoples? (x7)
Justice - fairness, discrimination
Respect
Informed Consent
Privacy
Confidentiality
Release of information to clients - rights un FOI, but what about what you’re communicating to other professionals?
Collection of client information from associated parties
What is covered by General Principle B of the code of ethics: Propriety (x14)
Competence Record keeping Professional responsibility Provision of psychological services at request of third party Provision of psychological services to multiple clients Delegation of professional tasks Use of interpreters Collaborating with others for benefit of clients Accepting clients of other professionals Suspension of psychological services Termination of psychological services Conflicting demands Psychological assessments Research
What is covered by General Principle C of the code of ethics: Integrity? (x7)
Reputable behaviour Communication Conflict of interest Non-exploitation Authorship Financial arrangements Ethics investigations and concerns
What are the limitations of the code of ethics? (x4)
Do not make the decisions for you
Often challenging to interpret and apply to specific situations
Not static
Impossible to be comprehensive
What are the steps in making an ethical decision? (x8)
Identify the problem Identify the potential issues Examine relevant ethical codes Know applicable laws and regulations Seek consultation Brainstorm possible courses of action List consequences of actions Decide on best course of action
What is involved/beneficial about the right to informed consent? (x2)
Education about rights and responsibilities = empowerment and a trusting relationship
Informed choices = greater client autonomy and active participation in own treatment
What is involved in providing the opportunity for informed consent? (x7)
Explaining nature and purposes of procedures
Clarifying risks, adverse effects, possible disadvantages
Explaining how information will be collected, recorded, stored, and who will have access
Advising clients that they can decline to participate/withdraw and also consequences of
Clarifying fees, services, length of therapy
Discussing termination
Explaining confidentiality and limits to confidentiality
What might you address when gaining informed consent for exposure therapy? (x2)
Need to make them understand that anxiety is going to get worse before better,
Making sure they have good coping strategies
What are four guidelines for informed consent?
Discuss issues early
Be consistent
Provide information in writing
Use appropriate language
Can a young person give informed consent? (x plus e.g. x2)
In Australia, a young person is capable of giving informed consent when he or she “achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed”
15yo where parent has recommended their attendance, but kid is the one who is giving consent in session
You get debates around youth, but also older people
Why is confidentiality so important?
Central to developing trusting and productive relationship
What are the limits to confidentiality? (x4)
Clear and imminent risk of harm to the self or others
Child abuse or neglect
Court action – your notes and files can be subpoenaed at any time
Client request – clients can request access to their files through informal or formal (FOI) channels
What are three guidelines to managing confidentiality?
Discuss confidentiality and its limits with clients
Keep records secure
Always seek client permission for accessing or releasing information
What was the Tarasoff case? (x2)
And its impacts on the breaking of confidentiality regarding psychological treatment? (x4)
1969 - student having a relationship with another, she wasn’t taking it seriously, he did
Ended up stalking her, eventually murder her – despite his ongoing psychiatric treatment, prior interview with police
Supreme Court of California - mental health professionals have duty to protect individuals being threatened by a patient.
Original 1974 decision mandated warning the threatened individual, but
1976 rehearing called for “duty to protect” intended victim.
May discharge the duty in several ways - notifying police, warning intended victim, and/or taking other reasonable steps
What was the relationship of the Tarasoff case to the Colorado Cinema Shooting in 2012? (x3)
Duty to warn of immanent threat that is made clear to a mental health professional
Problems in comparison to Tarasoff – no explicit threat against an individual, and he had also dropped out of uni/treatment before incident
What is a ‘multiple relationship’ in the context of therapy? (x4)
When a counsellor also is or has been:
In a non-professional relationship with same client or an associated party
In a different professional relationship with same client
A recipient of a service provided by the same client
Give 8 egs of multiple relationships
Teacher/supervisor and therapist Bartering Borrowing money Providing therapy for relative, friend or employee Engaging in social relationship with client Accepting an expensive gift Becoming emotionally/sexually involved Going into business with a client
Why are multiple relationships a problem? (x3)
But on the other hand, they are… (x3)
Can impair objectivity
Exploitative
Potentially harmful
Sometimes difficult to avoid
Not always clear-cut
Interpersonal boundaries are not static
How can you minimise the risks of multiple relationships? (x4)
Set healthy boundaries
Consultation
Work under supervision
Self-monitor
What are the ethical considerations in client vs therapist needs? (x4)
Professional relationships exist to benefit clients
Issues to consider:
Satisfying own needs
Promoting own agenda
Imposing values
Specific APS ethical guidelines are available for…
Working with people who pose high risk to others
Teaching and use of hypnosis
Psychological services/products on the internet
Psychological practice with lesbian, gay and bisexual clients
Services for and research with older adults
Professional boundaries and multiple relationships
Many other specific issues and populations – e.g. Culturally and Linguistically Diverse (CALD) clients
