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
