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Assessing and Conceptualizing Client Problems and Contexts 185 EBA recognizes that assessment involves decision- making in which the practitioner conceptualizes, develops, and tests hunches or hypotheses using data obtained during the assessment process (Hunsley & Mash, 2007). Reliability and Validity Hunsley and Mash (2008) have developed a rating system for various instruments used for specific assessment purposes and for specific clinical disorders. Their rating system requires the demonstra-tion of predetermined psychometric levels in the areas of reliability, validity, and norms across published studies. Haynes, Smith, and Hunsley (2011) have also described issues related to evidence-based assessment. Reliability refers to stability and replicability, or whether an assess-ment measure or procedure produces the same results consistently. It generally is agreed that a measure must be reliable for it to also have validity, meaning that it is correct or accurate in what it measures. However, reli-ability does not guarantee validity! Validity has to do with the representativeness of the measure, or how well something measures what it is supposed to measure. Validity can vary across clients. For example, an assess-ment measure may be valid with clients from one ethnic group but not automatically with clients from another ethnic group. Further, as Haynes (2006) points out, an assessment measure can be valid in one domain but not in another. For example, a practitioner may use an as-sessment in a session to assess a couple's level and kind of marital conflict and may also use the same assessment to assess their conflict in the home domain. The valid-ity of the same measure across the two domains of the clinic setting and the home setting may vary. As Haynes (2006) concludes, validity “is not an unconditional trait of a measure” but rather something that can vary across a number of dimensions (p. 27). While there are many different kinds of validity, in assessment the concept of incremental validity is an im-portant one. It refers to the extent to which one mea-sure adds information above and beyond what is already available through other measures. Haynes (2006) defines incremental validity in this way: “the degree to which additional assessment data increase the power, sensitiv-ity, specificity, and predictive efficacy of judgments” (p. 19). For this reason, we recommend supplementing the interview assessment process with other kinds of assess-ment tools, such as self-observation and monitoring and self-report measures such as behavior checklists, used on a selective basis; more for the sake of more is not necessar-ily better! Without incremental validity, the practitioner may be wasting time and money administering and using multiple assessment strategies that, however, do not add any predictive power. Sound clinical assessment relies on assessment tools that are both accurate and efficient and that involve both idio-graphic and nomothetic instruments (Hunsley & Mash, 2008, p. 7). Idiographic measures are those such as self-monitoring and goal attainment scaling that measure the unique aspects of an individual's experience. Nomothetic measures are those that allow for comparisons between groups of individuals. The psychometric properties of reliability and validity in the nomothetic measures are very important. Also important is whether the measure has either appropriate norms or replicated supporting evidence for the accuracy of cutoff scores (Hunsley & Mash, 2014). Moreover, there needs to be supporting evidence that the EBA is suitable for the client being as-sessed, particularly on demographic characteristics such as age, gender, and ethnicity. As Hunsley and Mash (2010) point out, this means that “careful consideration must be given to the characteristics of the samples on which the supporting scientific evidence was derived” (p. 8). Haynes (2006) points out that even in idiographic assessment, the consideration of reliability and validity is important, particularly content validity. Content validity involves “the degree to which the behaviors and events sampled by the instrument are those most relevant to the client” (Haynes, 2006, p. 38). Practically, this means ensuring that the assessment measures things most germane to the individual client. Self-Monitoring We describe the use of self-observation and self-monitoring as an idiographic data collection tool in Chapter 8. (We also describe the use of idiographic goal attainment scaling in Chapter 8. ) Briefly, self-monitor-ing (also referred to as self-observation or self-assessment) represents strategies that clients use outside of the clinical sessions to observe things about themselves and then to make written notations or recording about these observa-tions that they bring back to the following session. For example, Neacsiu and Linehan (2014) use structured diary cards as a self-monitoring strategy with clients for many purposes, including with clients who engage in self-harm or suicidal ideation and behaviors. These diary cards are used each week by clients to record daily instances of suicidal and nonsuicidal self-injurious behaviors, urges to self-harm or engage in suicide behaviors (on a point rating scale of 0-5), feelings of “misery,” use of substances (legal and illegal), and use of certain behavioral skills (Neacsiu & Linehan, 2014). The cards are reviewed with the helper at the beginning of each session to help assess suicide and self-harm risk. In addition to the use of the diary cards for Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
186 Chapter 6 self-harm, these cards are also used to monitor a variety of other kinds of behaviors, including coping skills, wise mind or mindfulness, self-soothing, and acceptance. Electronic diaries and smart phone apps are being used now more frequently, both to provide a cue for record-ing something and also as a tool for entering the self-monitored or observed data (Piasecki, Hufford, Solhan, & T rull, 2007). To enhance the reliability of self-moni-toring, clients can be coached on the process (see Watson & Tharp, 2014). We also describe the use of a number of different kinds of self-report measures in Chapter 8. Although there are many of these available, we recommend judicious screen-ing of such measures before they are chosen for use. Consider, for example, these three guidelines offered by Hunsley and Lee (2014): 1. Is the measure likely to be useful for clinical practitioners? 2. Is there replicated evidence that the measurement data provide reliable and valid information? 3. Does the use of the measure and its resulting data improve upon typical clinical decision making and treatment outcome? (p. 235) For examples of measures utilized in empirical studies that have demonstrated adequate validity and reliability, consult the Assessment Instrument Index in Hunsley and Mash (2008). This index lists all of the instruments that met their rated criteria for sound psychometric proper-ties. Finally, a description of various evidence-based as-sessment measures for selected clinical disorders has been made available by Antony and Barlow (2010). An additional assessment tool that is a generic model with a considerable amount of research support across a wide range of client problems is the functional assessment (Hunsley & Mash, 2008; Haynes et al., 2011). (See also Learning Activity 6. 1 on page 187. ) Functional Assessment: The ABC Model and Chain Analysis Conducting a functional assessment involves LO1 obtaining information about the client's story in a very specific way. It means assessing and conceptualizing clini-cally relevant behaviors within their historical and current context. It involves an analysis of both past and present learning experiences that may be responsible for cur-rent presenting issues (Thyer & Myers, 2000). Haynes, O'Brien, and Kahokula (2011) describe a functional assessment as the clinician's hypothesized and dynamic working model of a client's behavior problem. The func-tional assessment helps both clinician and client deter-mine the functions of the client's problem behaviors. This information is quite important for subsequent treatment planning. For example, consider a child who has a bad experience at school. The next day the child develops a tummy ache and his mom allows him to stay home from school. This continues for several days until the mom takes him to the doctor who can find nothing wrong. The mom sends him back to school but receives a call in late morning from the school indicating that her son has gone to the office and is reporting that he is sick and wants to go home! It doesn't take a rocket scientist to fig-ure out that the function of the child's aches and illness is to avoid school! (However it is entirely possible that the school personnel and/or the parent may miss this). Once this information is gleaned, it becomes easier to develop an intervention plan that targets the identified problem and function of the client's behaviour, in this case, school avoidance. The overall goal of functional assessment is to generate causal hunches or hypotheses from information about client behavior problems and causal variables known as antecedents and consequences. This type of assess-ment is referred to as the ABC model and is based on principles of learning. Although there are many classes of causal variables that are modifiable and could be of interest to the clinician, it is the contiguous antecedents, environmental events, situations, contexts, response contingencies, and cognitive antecedent and consequent variables that are most useful to determine, as research shows that they “exert important triggering or maintain-ing effects on behaviour problems” of clients (Haynes et al., 2011, p. 57). The ABC model of behavior suggests that the behavior (B), something a client does, is influenced by certain events that precede it, called antecedents (A), and by some types of events that follow behavior, called conse-quences (C). An antecedent (A) event can tell a person when to behave in a situation. Antecedents are respon-sible for the behavior being performed in the first place because they “call the behavior up” or stimulate it in some way (Watson & Tharp, 2014, p. 138). A consequence (C) is defined as an event that strengthens or weakens a behavior and determines whether the behavior will occur again (Spiegler & Guevremont, 2010). Notice that these definitions of antecedents and consequences suggest that an individual's behavior is directly related to or influ-enced by certain stimuli such as the presence of another Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 187 learning activity 6. 1 Clinical assessment Influences After reading the case of Mrs. Oliverio, respond to the following: 1. Based on the case and on your clinical hunches or hypotheses, list what you think are the major issues for Mrs. Oliverio. 2. Examine the issues you named. Do they reflect some-thing about Mrs. Oliverio as an individual, something about Mrs. Oliverio's environment, or both? If both, how do you see the issues as related? 3. Speculate about the following aspects to explore in your clinical assessment with Mrs. Oliverio: a. Learning components of the case b. Neurobiological components of the case c. Developmental components of the case d. Environmental/cultural components of the case e. Levels of environmental and individual strengths and resources in the case 4. Discuss your responses with a classmate or your instructor. The Case of Mrs. Oliverio Mrs. Oliverio is a 28-year-old married woman who reports that an excessive fear that her husband will die has led her to seek therapy. She further states that because this is her second marriage, it is important for her to work out her problem so that it doesn't ultimately interfere with her relationship with her husband. Her husband is a sales representative and occasionally has to attend out-of-town meetings. According to Mrs. Oliverio, whenever he has gone away on a trip during the 2 years of their marriage, she “goes to pieces” and feels “utterly devastated” because of recurring thoughts that he will die and not return. She states that this is a very intense fear and occurs even when he is gone on short trips, such as a half day or a day. She is not aware of any coping thoughts or behaviors she uses at these times. She indicates that she feels great as soon as her husband gets home. She states that this was also a problem for her in her first marriage, which ended in divorce 5 years ago. She believes the thoughts occur be-cause her father died unexpectedly when she was 11 years old. Whenever her husband tells her he has to leave or actually does leave, she re-experiences the pain of being told her father has died. She feels plagued with thoughts that her husband will not return and then feels intense anxiety. She is constantly thinking about never seeing her husband again during these anxiety episodes. According to Mrs. Oliverio, her husband has been very supportive and patient and has spent a considerable amount of time trying to reassure her and to convince her, through reasoning, that he will return from a trip. She states that this has not helped her to stop worrying excessively that he will die and not return. She also states that in the past few months her husband has canceled several business trips just to avoid putting her through all this pain. Mrs. Oliverio also reports that this anxiety has resulted in some insomnia during the past 2 years. She states that as soon as her husband informs her that he must leave town, she has difficulty going to sleep that evening. When he has to be gone on an overnight trip, she doesn't sleep at all. She simply lies in bed and worries about her husband dying and also feels very frustrated that it is getting later and later and that she is still awake. She reports sleeping fairly well as long as her husband is home and a trip is not impending. Mrs. Oliverio reports that she feels very satisfied with her present marriage except for some occasional times when she finds herself thinking that her husband does not fulfill all her expectations. She is not sure exactly what her expec-tations are, but she is aware of feeling anger toward him after this happens. When she gets angry, she just “explodes” and feels as though she lashes out at her husband for no ap-parent reason. She reports that she doesn't like to explode at her husband like this but feels relieved after it happens. She indicates that her husband continues to be very sup-portive and protective despite her occasional outbursts. She suspects the anger may be her way of getting back at him for going away on a trip and leaving her alone. She also expresses feelings of hurt and anger since her father's death in being unable to find a “father substitute. ” She also reports feeling intense anger toward her ex-husband after the divorce—anger she still sometimes experiences. Mrs. Oliverio has no children. She is employed in a re-sponsible position as an administrative assistant and makes $38,500 per year. She reports that she enjoys her work, although she constantly worries that her boss might not be pleased with her and that she could lose her job even though her work evaluations have been satisfactory. She reports that another event she has been worried about is the health of her brother, who was injured in a car accident this past year. She further reports that she has an excellent relationship with her brother and strong ties to her church. individual or a particular setting. For example, a behav-ior that appears to be controlled by antecedent events such as anger may also be maintained or strengthened by consequences such as reactions from other people. Generally speaking, once the ABCs are identified, change is maximized by identifying and using change interven-tion strategies that alter as many of the ABCs as possible (Watson & Tharp, 2014). As a very simple example of the ABC model, consider a behavior (B) that most of us engage in frequently: Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
188 Chapter 6 talking. Our talking behavior is usually occasioned by certain antecedent events, such as being asked a ques-tion or being in the presence of a friend. Antecedents that might decrease the likelihood that we will talk may include worry about getting approval for what we say or how we answer the question or being in a hurry to get somewhere. Our talking behavior may be maintained by the verbal and nonverbal attention we receive from another person, which is a very powerful consequence, or reinforcer. Other positive consequences that might maintain our talking behavior may be that we are feeling good or happy and engaging in positive self-statements or evaluations about the usefulness or relevance of what we are saying. We may talk less when the other person's eye contact wanders, although the meaning of eye con-tact varies across cultures, or when the other person tells us more explicitly that we've talked enough. These are negative consequences (C) or punishments that decrease our talking behavior. Other negative consequences that may decrease our talking behavior could include bodily sensations of fatigue or vocal hoarseness that occur after we talk for a while, or thoughts and images that what we are saying is of little value to attract the interest of oth-ers. As you will see, behavior often varies among clients, and what functions as an antecedent or consequence for one person in one environment is often very different for someone else in a different environment. Behavior: External and Internal Behavior can be both overt and covert. Overt behavior is behavior that is visible or could be detected by an observer, such as verbal behavior (talking), nonverbal behavior (for example, gesturing or smiling), or motoric behavior (engaging in some action such as walking). Covert behavior includes events that are usually inter-nal— inside the client—and are not so readily visible to an observer, who must rely on client self-report and nonverbal behavior to detect them. Examples of co-vert behavior include thoughts, beliefs, images, feelings, moods, and body sensations. We include the role of cognition, primarily represented as internal speech, as well as its effect on emotion in our model. This model assumes that client behaviors are also influenced by the cognitive schemas and internal dialogues or self-talk of the individual. Cognitive schemas and self-talk can com-prise part of the identifying behavioral issues or can also function as either an antecedent or a consequence to the identified problem behaviors. These cognitive schemas and self-talk exert effects on client feelings or emotions. As Haynes et al. (2011) point out, most client problem behaviors have multiple response modes. And, over the course of therapy, these response modes may change. For instance, at the beginning of counseling, for the school-avoidant child with the stomach aches, the stomach pain might be the most relevant response mode while later in counseling the more relevant response mode for this child might shift to emotional reactivity concerning bullying at school. These various overt and covert response modes are typically not independent of each other, but overlap, too (Haynes et al., 2011). As we indicated, behavior that clients report rarely occurs in isolated fashion. Most undesired behaviors are typically part of a larger chain or set of behaviors (see also our discussion of chain analysis). Moreover, each behavior mentioned usually has more than one component. For example, a client who complains of anxiety or depression is most likely using the label to refer to an experience con-sisting of an affective component (feelings and mood states), a somatic component (physiological and body-related sensation), a behavioral component (what the client does or doesn't do), and a cognitive compo-nent (thoughts, beliefs, images, schemas, and inter-nal dialogue). Additionally, the experience of anxiety or depression may vary for the client, depending on contextual factors (time, place, concurrent events, de-velopmental transitions, gender, culture, sociopolitical climate, and environmental events), and on relational factors such as the presence or absence of other people. All these components may or may not be related to a particular reported concern. As an example, suppose the client who reports “anxiety” is afraid to venture out in public places except for work because of heightened anxiety and/or panic attacks. She is an adult single woman in her 40s who still lives at her parental home, and she provides care to her elderly mother, whom she also describes as dependent and helpless. She has lived all of her life in a small, rural community. She reports mistrust of strangers, especially those whom she did not know while growing up. She states she would like to leave and be out on her own and move away, but she is too afraid. Her reported concern of anxiety seems to be part of a chain that starts with a cognitive component in which she thinks worried thoughts and produces images in which she sees herself alone and unable to cope or to get the assistance of others if necessary. These thoughts and images support her underlying cognitive schema or structure of limited autonomy, despite her chronological age and developmental stage of middle adulthood. The cognitive component leads to somatic discomfort and tension and to feelings of apprehension and dread, Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 189 Conditioned responses (such as fear) Response contingencies (avoidance, positive and negative reinforcement, escape) These types of causal variables must be defined con-cretely for each client behavior problem and should not include elements of the behavior problem itself (Haynes et al., 2011, p. 168). Further as these authors indicate, the causal variables need sufficient delinea-tion to be measureable, because without measurability it is hard to obtain good baseline data for outcome evaluation (see also Chapter 8). In the following two sections, you will see how anteced-ents and consequences are defined for the client example described. Antecedents According to Mischel (1973), behavior is situationally determined. This means that given behaviors tend to occur only in certain situations. For example, most of us brush our teeth in a public or private bathroom rather than during a concert or a spiritual service. Antecedents may elicit emotional and physiological reactions such as anger, fear, joy, headaches, or elevated blood pressure. Antecedents influence behavior by either increasing or decreasing its likelihood of occurrence. For example, a child in a first-grade class may behave differently at school than at home, or differently with a substitute than with the regular teacher. Antecedent events that occur immediately before a spe-cific behavior exert influence on it. Events that are not in temporal proximity to the behavior can similarly increase or decrease the probability that the behavior will occur. Antecedents that occur in immediate temporal proximity to the specified behavior are technically called stimulus events (Bijou & Baer, 1976) and include any external or internal event or condition that either cues the behav-ior or makes it more or less likely to occur under that condition. Antecedents that are temporally distant from the specified behavior are called setting events (Kantor, 1970). Setting events may end well before the behavior yet, like stimulus events, still aid or inhibit its occurrence. Examples of setting events to consider in assessing client issues are: the client's age, developmental stage, and physi-ological state; characteristics of the client's work, home, or school setting; multicultural factors; and behaviors that emerge to affect subsequent behaviors. Both stimulus and setting antecedent conditions must be identified and defined individually for each client. Further, as Haynes et al. (2011) suggest, contemporary or proximal antecedents which she rates at a high level of intensity (90 on a 100-point scale). These three components work together to influence her overt behavior. For the past few years, she has successfully avoided almost all public places. She states that, on average, she has left the house to go somewhere by herself several times per year, pointing to a low response rate of this behavior. Consequently, she depends on the support of friends to help her on the few occasions when she attends public activities. These people form her relational network. This support, although no doubt useful to her, also has helped to maintain her avoidance of venturing out to public places alone without being accompanied by other persons. At the same time that you see these apparent behaviors and their concomitant dimensions (intensity of apprehension, rate of leaving the house alone), bear in mind this client will also demonstrate both overt and covert behaviors that represent strengths, resources, and coping skills. The very act of courage it takes to come and see you is an overt behavioral strength and action of initiative. Her recognition of some conflicting feelings and beliefs about her life choices is a covert behavioral strength. Her network of friends and her steady work situation are examples of environmental strengths; being a part of a small, close-knit community can be a cultural strength. It is important to determine the relative importance of each component of the reported behavior to select appropriate intervention strategies. It is often valuable to list, in writing, the various components identified for any given behavior. Causal Variables Once the problem behaviors have been defined, it is time to identify the causal variables and their relationship to the problem behaviors. In the functional analysis we define these causal variables as antecedents and consequences. Like behavior problems, antecedents and consequences can also have multiple components or at-tributes. In addition, for most client behavior problems, there are usually multiple causal variables. Haynes et al. (2011, p. 167) list the most useful types of causal variables to identify in the functional analysis assessment: Antecedent stimuli and settings Cognitive events (beliefs and self-statements)Emotional states Psychophysiologcal context (medication state, fatigue, pain, substance status) Psychosocial context (recent history of social networks)Early learning history Genetic makeup Neurophysiologic factors Impairments and limitations (cognitive, neuropsychological, neurophysiological, physical) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
190 Chapter 6 usually have more clinical usefulness than historical or distal antecedents. This is because the distal ones have more to do with the emergence of the behavior problem while the proximal ones have more to do with the day-to-day aspects of the client's behavior (Haynes et al., 2011, p. 169). Categories of Antecedents Antecedents also usually in-volve more than one category or type of event. Categories of antecedents may be affective (feelings, mood states), somatic (physiological and body-related sensations), behavioral (verbal, nonverbal, and motoric responses), cognitive (schemas, thoughts, beliefs, images, internal dialogue), contextual (time, place, multicultural factors, concurrent environmental events), and relational (pres-ence or absence of other people). For example, for our cli-ent who reported “anxiety,” a variety of antecedents may cue or occasion each aspect of the reported behavior—for example, fear of losing control (cognitive/affective), negative self-statements about autonomy and self-efficacy (cognitive), awareness of apprehension-related body sen-sations, fatigue, and hypoglycemic tendencies (somatic), staying up late and skipping meals (behavioral), being in public places (contextual), absence of significant oth-ers such as friends and siblings, and the demands of her elderly mother (relational). There also are antecedents that make components of the client's anxiety less likely to occur. These include feel-ing relaxed (affective), being rested (somatic), eating regu-larly (behavioral), decreased dependence on her friends (behavioral), decreased fear of separation from mother (affective), positive appraisal of self and others (cognitive), expectation of being able to handle situations (cognitive), absence of need to go to public places or functions (con-textual), and being accompanied to a public place by a significant other (relational). During the assessment phase of the helping process, it is important to identify those antecedent sources that prompt desirable behaviors and those that are related to inappropriate responses. The reason is that during the intervention (treatment) phase it is important to select strategies that not only aid the occurrence of desirable behavior but also decrease the presence of cues for un-wanted behavior. Consequences The consequences of a behavior are events that follow a behavior and exert some influence on the behavior, or are functionally related to the behavior. In other words, not everything that follows a behavior is automatically consid-ered a consequence. Suppose you are counseling a woman who occasion-ally embarks on drinking binges. She reports that after a binge she feels guilty, regards herself as a bad person, and tends to suffer from insomnia. Although these events are results of her binge behavior, they are not consequences unless in some way they directly influence her binges by maintaining, increasing, or decreasing them. In this case, other events that follow the drinking binges may be the real consequences. For instance, perhaps the cli-ent's binges are maintained by the feelings she gets from drinking; perhaps they are temporarily decreased when someone else, such as her partner, notices her behavior and reprimands her for it or refuses to go out with her. Like antecedents, the things that function as consequences will always vary with clients. By definition, rewarding or reinforcing events will maintain or increase the behavior. Such consequences often maintain or strengthen behavior through positive reinforcement, which involves the presen-tation of an overt or covert event following the behavior that increases the likelihood that the behavior will occur again in the future. People tend to repeat behaviors that result in pleasurable effects. Also, response contingencies can be more immediate or delayed. Those consequences that more immediately follow a problem behavior are more likely to exert a stronger effect. People also tend to engage in behaviors that have some payoffs, or value, even if the behavior is very dysfunc-tional (such payoffs are called secondary gains). For example, a client may abuse alcohol and continue to do so even after she loses her job or her family because she likes the feelings she gets while drinking and because the drinking helps her to avoid responsibility. Another client may continue to verbally abuse his wife despite the strain it causes in their relationship because the abusive behav-ior gives him a feeling of power and control. In these two examples, the behavior is often hard to change because the immediate consequences make the person feel bet-ter in some way. As a result, the behavior is reinforced, even if its delayed or long-term effects are unpleasant. In other words, in these examples, the client “values” the behavior that he or she is trying to eliminate. Often the secondary gain, the payoff derived from a manifest problem, is a cover for more severe issues that are not always readily presented by the client. For example, the husband who verbally abuses his wife may be lacking in self-esteem and may be feeling deeply depressed after the birth of their first child, feeling as if he has somehow “lost” his wife and is no longer the special person in her life. Clients may not always know why they engage in a behavior. Sometimes this knowledge is outside of the client's conscious awareness. Part of performing a good Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 191 assessment involves making reasons or secondary gains more explicit in the client's story. Consequences also can maintain behavior by negative reinforcement—removal of an unpleasant event fol-lowing the behavior, thereby increasing the likelihood that the behavior will occur again. People tend to repeat behaviors that bring an end to or get rid of annoying or painful events or effects. They also use negative rein-forcement to establish avoidance and escape behaviors. Avoidance behavior is maintained when an expected unpleasant event is removed. For example, avoidance of public places is maintained by removal of the expected anxiety associated with public places. Escape behavior is maintained when a negative (unpleasant) event al-ready occurring is removed or terminated. For example, punitive behavior toward a child temporarily stops the child's annoying or aversive behaviors. Termination of the unpleasant child behaviors maintains the parental escape behavior. Some consequences can weaken or eliminate the be-havior. A behavior is typically decreased or weakened (at least temporarily) if it is followed by an unpleasant stim-ulus or event (punishment), if a positive, or reinforcing, event is removed or terminated (response cost), or if the behavior is no longer followed by reinforcing events (operant extinction). For example, an overweight man may maintain his eating binges because of the feelings of pleasure he receives from eating (a positive reinforc-ing consequence) or because they allow him to escape from a boring work situation (negative reinforcing con-sequence). In contrast, his wife's reprimands or sarcasm or refusal to go out with him may, at least temporarily, reduce his binges (punishing consequence). Although using negative contingencies to modify behavior has many disadvantages, in real-life settings, such as home, work, and school, punishment is widely used to influ-ence the behavior of others. Helpers must be alert to the presence of negative consequences in a client's life and to the accompanying effects on the client. Helpers also must be careful to avoid the use of any verbal or nonver-bal behavior that may seem punitive to a client, because such behavior may contribute to unnecessary problems in the therapeutic relationship and to subsequent client termination of (escape from) therapy. Categories of Consequences Consequences also usually involve more than one source or type of event. Like antecedents, categories of consequences may be affec-tive, somatic, behavioral, cognitive, contextual, and/or rela-tional. For example, for our client who reports “anxiety,” the avoidance of public places results in a reduction of anxious feelings (affective), body tension (somatic), and worry about more autonomy (cognitive). Additional con-sequences that may help to maintain the problem include avoidance of being in public (behavioral) and increased attention from family and friends (relational). Contextual consequences may include reinforcement of cultural and gender values of being tied to her family of origin, being the family caregiver, and being able to “stay in the nest. ” It would be inaccurate to simply ask about whatever follows the specified behavior and to automatically classify it as a consequence without determining its particular effect on the behavior. As Cullen (1983, p. 137) notes, “If variables are supposed to be functionally related to behavior when, in fact, they are not, then manipulation of those variables by the client or therapist will, at best, have no effect on the presenting difficulties or, at worst, create even more difficulties. ” During the assessment phase of helping, it is important to identify those consequences that maintain, increase, or decrease both desirable and undesirable behaviors related to the client's concern. In the intervention (treatment) phase, this information will help you select change strate-gies that will maintain and increase desirable behaviors and weaken and decrease undesirable behaviors such as behavioral excesses and deficits. Information about con-sequences also is useful in planning treatment approaches that rely directly on the use of consequences to help with behavior change, such as self-reward. As Haynes et al. (2011) suggest, because interventions are selected that target the defined causes of client problems, identifying these causal variables and describing their relationship to the client's behavior problems is very important in the functional analysis. Ultimately, as these authors explain, the question for clinicians is: “What is it about the causal variable that is exerting the most important effects on the behavior problem for this particular client?” (p. 152). Iden-tification of specific antecedents and consequences helps to answer this question very concretely so that helpers can identify the contexts under which antecedents and conse-quences have the most direct and strongest effect on the client's problem behavior (Haynes et al., 2011, p. 153). It is important to reiterate that problem behaviors, antecedents, consequences, and components must be assessed and identified for each particular client. T wo clients might complain of anxiety or “nerves,” and the assessments might reveal very different components of the behavior and different antecedents and consequences. A multi-cultural focus also is important here: the behav-iors, antecedents, and consequences can be affected by the client's cultural affiliations and sociopolitical context. Also remember that there is often some overlap among ante-cedents, behavior, and consequences. For example, nega-tive self-statements or irrational beliefs might function in Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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192 Chapter 6 some instances as both antecedents and consequences for a given component of the identified concern. Consider a college student who reports depression after situations with less than desired outcomes, such as asking a girl out and being turned down, getting a test back with a B or C on it, and interviewing for a job and not receiv-ing a subsequent offer of employment. Irrational beliefs may function as an antecedent by cuing, or setting off, the resulting feelings of depression—for example, “Here is a situation that didn't turn out the way I wanted. It's awful; now I feel lousy. ” Irrational beliefs in the form of self-deprecatory thoughts may function as a consequence by maintaining the feelings of depression for some time even after the situation itself is over—for example, “When things don't turn out the way they should, I'm a failure. ” At the same time, keep in mind that this client has ratio-nal and coping beliefs as well as irrational ones and behav-ioral, environmental, and cultural strengths as well. These may be less obvious to him than the presenting issues, but part of your task is to help him uncover what they are. For additional information about the functional analysis assessment process, we urge you to consult the primer on this process developed by Yoman (2008). Chain Analysis It also is important to note that most issues presented by clients involve both multiple and complex chains of behavior sequences, so an ABC analysis is conducted on more than one factor. Neacsiu and Linehan (2014) refer to this as a chain analysis, defined as a “blow-by-blow description of the chain of events leading up to and fol-lowing the behavior. In a chain analysis the therapist constructs a general road map of how the client arrives at dysfunctional responses, including where the road actu-ally starts, and notes possible alternative adaptive path-ways or junctions along the way... The overall goal is to determine the function of the behavior or, from another perspective, the problem the behavior was instrumental in solving” (p. 435). As Haynes et al. (2011) suggest, chain analyses are important because “they can point to several possible intervention points” (p. 58). We list the specific steps involved in Linehan's (2015a. 2015b) chain analysis that she uses in assessment within her dialectical behavior therapy (DBT) integrated approach: Step One: Describe the specific problem behaviors. Be careful to operationalize the behaviors; that is, be specific and describe exactly what the client, did, said, or felt as well as the intensity of the behavior. Example: “I lost my temper when on the phone with my mom and gave her a lecture in a very stern voice. ”Step Two: Describe the specific prompting event that started the whole chain of behavior. This helps to determine the specific event that precipitated the start of the chain reaction. Begin with some event in the environ-ment that started the chain of behavior identified in step one. Example: “I felt mad that my mom told my stepdad about my problem at school without asking me first. ” Step Three: Describe vulnerability factors happening before the prompting event. These are factors that made the client more susceptible to the problematic chain, such as illness, injury, substance use, stressful environmental events, and intense emotions. Example: “I hadn't gone to the gym that day to release my tensions that had built up from school. ” Step Four: Describe in excruciating detail the chain of events that led up to the problem behavior. This step asks the cli-ent to imagine how the problem behavior is chained to the prompting event listed in step two. Questions such as, “How long is the chain?” “Where does the chain go next?” and “What are the links in the chain?” are useful for step four. The links can be overt behaviors, thoughts, emotions, somatic sensations, and so forth. The clinician can facilitate this step by continuing to ask the client, “What happened next?” and “What then?”. Linehan (2015a) suggests having the client actually write out all the links in the chain no matter how inconsequen-tial they seem, as if writing a script for a play (p. 22). Example: 1. I felt wired from not working out. 2. I felt hungry and short tempered from not eating enough during the day. 3. I heard my mom's voice on the phone telling me she told my stepdad about my school situation. 4. I thought “She had no right to do that without my permission. ” 5. I got mad and frustrated with her right away. 6. I wanted to teach her a lesson and so I lectured her like she was a child or student of mine. Step Five: Describe the consequences of the problem behavior. Here the client needs to identify very specifically the effect the behavior had on her or him, the client's environment, and how the client felt both immediately after the behav-ior and later on. Additionally, reactions of other people both immediately after and later are identified. As with precipitating events or antecedents, the helper assesses both environmental and behavioral consequences by ob-taining “detailed descriptions of the client's emotions, Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 193 somatic sensations, actions, thoughts, and assumptions” (Neacsiu & Linehan, 2014, p. 435). Example: Results in the environment: My mom had hurt feelings be-cause she was just trying to be helpful. Results for me: I felt immature. I missed an opportunity to have a great phone conversation with someone I love very much. We illustrate the functional assessment model later in the chapter in our sample case of Isabella. We also suggest that you work with the material presented in this sum-mary by consulting the visual summary in Figure 6. 1 and by working with Learning Activities 6. 2 and 6. 4. In conclusion, although we believe that functional analy-sis provides useful information to clinicians for subse-quent treatment planning, we also agree with the caveats observed by Haynes et al. (2011). Functional analysis can be time-consuming, imprecise, and not always com-prehensive enough to include all of the factors necessary for a useful treatment plan. As such, we discuss some additional factors necessary for treatment planning in Chapter 9. Diagnostic Classification of Client Issues Our emphasis throughout this chapter is on the need to conduct a thorough and precise assessment with each cli-ent to be able to define client issues in very concrete ways. In addition, helpers need to be aware that client behaviors Figure 6. 1 The ab C and Person-in-environment assessment Model Antecedents Behaviors Consequences Affecti ve Somatic Behavioral Cogniti ve Contextual Relational Informed by evidence-based measures Person (Individual) (What)Environment (Systemic) (Where-How) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
194 Chapter 6 can be organized in some form of diagnostic taxonomy (classification). While the assessment model we have de-scribed in this chapter is based on cognitive, learning, and emotion theories, it is also possible to assess clients, develop clinical hypotheses, and plan treatment based on a clinical disorder using a diagnostic anchoring system (Persons, 2008). As Hunsley and Mash (2010) point out, while there has been much debate about the strengths and weaknesses of such a diagnostic classification system, “the reality is that much of what we know about psychologi-cal conditions is dependent on these diagnostic systems” (p. 10). The diagnostic system most frequently used in the United States is found in the 5th edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013). Our interest in this chapter is simply to summarize the basic information found in the DSM-5 to help students understand how this system is used in assessing clients. With the Health Insurance Portability and Accountability Act (HIPAA) of 1996, providers in the United States are required to use diagnostic codes based on the ICD-CM, or the ninth revision of the International Classification of Diseases and Related Health Problems of the World Health Organization (WHO) for electronic billing and reimbursement. In 2015, diagnostic codes from the 10 th edition of the ICD-CM will be used and the ICD-CM 11 is already in process! The DSM-5 is more consistent with the ICD-CM than prior editions of this diagnostic manual and clinical disorders are described both by a ICD-9 numerical code in BOLD and an ICD-10 code in parentheses. The DSM-5 and Clinical Disorders DSM-5 consists largely of descriptions of various mental and psychological disorders broken down into 20 major diagnostic classes, with additional subcategories within these major categories. These 20 major diagnostic classes are listed in Table 6. 2. Specific diagnostic criteria are provided for each category. These criteria are intended to provide the practitioner with a way to evaluate and classify the client's concerns. The DSM-5 describes mental disor-ders as “syndromes characterized by clinically significant disturbance in an individual's cognition, emotion regula-tion, or behavior that reflects a dysfunction in the psycho-logical, biological, or developmental processes underlying mental functioning” (p. 20). In perusing this list perhaps you can note a couple of things. First, the placement of the disorders within this list is not accidental! The disorders have been placed in a system based on their relatedness to each other and to their similarities in characteristics as well. Also, the order of the disorders reflects a developmental focus across the lifespan, beginning with the neurodevelopmental disor-ders that represent conditions developing earlier in life and ending with neurocognitive disorders that represent conditions developing in later life. In between these two anchors are disorders that are more commonly first mani-fested in adolescence and young adulthood. Within the discussion of each of these 20 disorders, there is also a learning activity 6. 2 Functional assessment In this learning activity, refer back to the case of Mrs. Oliverio found in Learning Activity 6. 1 on page 187. Go through the case again. Then, complete as much of the grid in Figure 6. 1 as you can from the informa-tion you have about the client. You may wish to com-plete this in dyads or small groups to brainstorm possible responses. Table 6. 2 list of 20 Diagnostic Categories in the DSM-5 Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma and Stressor-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Medication-Induced Movement Disorders and Other Adverse Effects of Medication Other Conditions that May be a Focus of Clinical Attention Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 195 description of any criteria and specifiers relate to child-hood manifestations and onset. Also, in the DSM-5, dis-orders have been arranged and classified according to clusters of disorders based on the factor of an internalizing or an externalizing disorders. Internalizing disorders are those such as anxiety and depression, whereas externaliz-ing disorders involve conduct and impulse control issues and substance use. The classification system in the DSM-5 differs from prior editions of the DSM in that it is a nonaxial system. The clinician lists the principal diagnosis first and this diagnosis represents the focus of treatment. Secondary diagnoses that may also be present for a given client are listed underneath the principal one. Any other condi-tions that are not considered mental disorders but rather psychosocial and environmental problems that may im-pact the client's diagnosis and treatment are listed third. These include relational issues, abuse, educational and occupational problems, housing and economic issues, and so on. Case Example of a DSM-5 Diagnosis As an example, consider the case of a 64-year-old white male who presents with the issue of having difficulty maintaining erections with his partner. He also mentions that he is 2 years away from retirement but his company is downsizing and has been laying off people in his age bracket and he has some concerns this will happen to him in the near future. Assuming nothing else materialized in the assessment interviews, his DSM-5 diagnosis would look like this: 302. 72 (F52. 21) Erectile Disorder V62. 29 (Z56. 9) Other Problem Related to Employment In our example with the 64-year-old client, for erectile disorder there are no subtypes but there are three pos-sible specifiers: (1) whether the condition is lifelong or acquired; (2) whether the condition is generalized or situational; and (3) the current severity—if it is currently mild, moderate, or severe. Because he has indicated the is-sue began approximately 1 year ago and has not been life-long, we would add the specifier Acquired. And because he also has suggested that it is present under conditions of sexual intercourse but not under masturbation, we would add the specifier Situational. And we would also, based on his self-report, add the specifier Moderate for current severity. Thus, his final diagnosis would look like this: 307. 72, (F 52. 21), Erectile Disorder, Acquired, Situational, Moderate Severity V62. 29 (Z 59. 6) Problems related to Employment Dimensional Classification, Specifiers, and Subtypes One of the new features in the DSM-5 is the approach to diagnosis reflected in this new edition that is dimen-sional rather than categorical. In other words, instead of a diagnosis being viewed as the presence or absence of a symptom as in a categorical approach, the DSM-5 recog-nizes that separate disorders are often related conditions on a continuum, with some conditions being mild and other conditions being more severe; this is referred to as a dimensional diagnostic approach. Diagnostic categories such as bipolar disorders, autism, substance abuse, and schizophrenia are examples of disorders that are on a spectrum. As part of this dimensional approach to assessment, many of the clinical disorders listed have what are called specifiers—these represent additional information about the diagnostic criteria that help with treatment planning. The type of specifiers listed in the DSM-5 include the following: Course: (partial or full remission) Severity: (mild, moderate, severe) Frequency (such as four episodes per week)Duration (such as minimum duration of 6 months) Descriptive features (such as poor insight) Because these are not mutually exclusive, the prac-titioner may have more than one specifier listed in the diagnosis. For example, with delusional disorder, the practitioner might list if the delusions represent bizarre content as one specifier, and might also list whether this represents an initial episode or multiple episodes that are acute or are in partial or full remission. An additional specifier would be the severity of the delusions on a 5-point scale. In addition, for some clinical disorders there are also subtypes of the disorder listed. Subtypes represent mu-tually exclusive descriptions within a diagnosis so the practitioner chooses one. For example, delusional disor-ders lists six possible subtypes of the primary disorder a practitioner chooses from to further describe the prin-cipal diagnosis. Steps Involved in Making a Clinical Diagnosis with the DSM-5 A five-step process involved in making a clinical diagnosis using the DSM-5 to do so is presented: 1. Identify the disorder that meets criteria in the DSM-5 manual. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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196 Chapter 6 2. Specify the name of the disorder, such as Hoarding Disorder 3. Next, add any subtype or specifiers that fit with the cli-ent's presentation (for hoarding disorder the specifiers include “with excessive acquisition” and “with absent, poor, or good insight”) 4. Add the code number (located either at the top of the criteria set or within the subtypes or specifiers). In the DSM-5 there is a Bold code and a code in parentheses. Recall that the Bold code refers to the ICD-9 CM and the code in parentheses refers to the ICD-10 CM. In the event of multiple diagnoses, the focus of treat-ment or principal diagnosis is listed first, followed by other diagnoses in descending order of importance. For example, if hoarding is the primary disorder, and a sec-ondary disorder is dependent personality disorder, then this would be listed and coded as follows: 300. 3 (F42) Hoarding Disorder301. 6 (F60. 7) Dependent Personality Disorder 5. If, in addition to the clinical diagnoses, there are other conditions that are also a focus in the clinical ses-sions, or are impacting the clinical disorder, recall that these would also be included and listed as a V (ICD-9) code or Z (ICD-10) code. For example, if a contributing condition to the client with the hoarding disorder was related to living alone, then we could add: V60. 3 (Z60. 2) Problem related to living alone to this diagnosis. Also, while not required for a clinical diagnosis, if a particular client presented with a dis-ability or an impairment, the DSM-5 uses the World Health Organization Disability Assessment Schedule 2/0 (WHODAS 2. 0), Section III, to note a disability or an impairment. Despite apparent conceptual and practical limitations of diagnosis, the process can aid helpers in assessing tar-get behaviors and in selecting appropriate interventions for treatment. For instance, knowledge about selected features of various types of clinical pathology, such as the usual age of the patient at the onset of some disorder or whether the disorder is more common in men or in women, can aid in assessment. An addition to the DSM-5 is its routine inclusion of discussions of age, gender, and cultural implications of the various disor-ders. For example, it notes under panic attacks that fears about anxiety vary across cultures and it reports under agoraphobia that in some cultural or ethnic groups the participation of women in public life is restricted (APA, 2013). Limitations of Diagnosis: Categories, Labels, and Gender/Multicultural Biases Diagnostic classification presents certain limitations, and these are most apparent when a client is given a diagnos-tic classification without the benefit of a thorough and complete assessment. The most common criticisms of diagnosis are that it places labels on clients—often mean-ingless ones—and that the labels themselves are not well defined and do not describe what the clients do or don't do that makes them “delusional” or “a conduct disorder” and so on. Some proponents of the strengths perspective we discussed earlier in the chapter question whether for-mulating diagnoses is in a client's best interest because of potential stigmatization associated with such labels. In addition to these limitations, the process of making diagnoses using the current edition of the Diagnostic and Statistical Manual has come under sharp criticism from members of feminist therapy groups, from persons of color, and from those who are advocates for clients of color (Zalaquett et al., 2008, Paniagua & Yamada, 2013). For example, feminist therapists assert that the development of clinical disorders in women almost always involves a lack of both real and perceived power in their lives (Bal-lou & Brown, 2002). These therapists have noted that the concept of “distress,” which permeates the traditional diagnostic classification system, reflects a “highly individu-alized phenomenon” and overlooks distress as “a manifesta-tion of larger social and cultural forces” (Brown, 1992, p. 113). A feminist conception of diagnosis includes cultural relativity and ascertains what is normal for this individual at this particular time and place (Brown, 1992, p. 113). Thus, feminist practitioners would ask a client, “What has happened to you?” rather than, “What is wrong with you?” Similar concerns about bias in diagnosis have been raised by cross-cultural researchers and practitioners. White Kress and colleagues (2005) note that “research and literature on cross-cultural assessment, diagnosis, and treatment continue to expose the inaccuracy of the DSM system with underrepresented and marginalized groups” (p. 98). Clients from these groups tend to be overdiag-nosed, underdiagnosed, or misdiagnosed by clinicians. Misdiagnoses can easily occur when the languages be-tween clinician and client are different and when the services of translators are not available or utilized. Sue and Sue (2013) point out that the history of oppression (described earlier by Brown for women) also affects re-sulting diagnoses made for clients of color who, because of this history, may be reluctant to self-disclose and, as a Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 197 result, may be labeled paranoid. Sue and Sue (2013), like Brown, argue that diagnosis of clients of color must be understood from a larger social-political perspective. Oth-erwise, these clients may receive a diagnosis that overlooks the survival and protective value of their behaviors in a racist society. Further, the way in which disorders are ex-perienced by clients varies with things like ethnicity, race, and age. For example, in many parts of Chinese society the experience of depression is more physical than psy-chological, and Latino/Latina clients as well as refugees may report symptoms of depressive disorders very differ-ently than European Americans (Kleinman, 2004). Older clients may have more unique presentations of depression as well that impact clinical diagnoses (Gould, Edelstein, & Ciliberti, 2009). In the DSM-5, in addition to very brief discussions of age, gender, and cultural features of many of the clinical disorders, there is an appendix that includes a glossary of nine various cultural concepts of distress—that is, what the DSM-5 (APA, 2013) defines as “ways that cultural groups experience, understand, and communicate suf-fering, behavioral problems, or troubling thoughts and emotions” (p. 758). Paniagua (2013) has expanded this into a list of 19 culture-bound syndromes. In addition to this glossary, the DSM-5 appendix also includes an outline for a supplemental “cultural formula-tion interview” or CFI that, as they note, has been “field-tested for diagnostic usefulness among clinicians and for acceptability among patients” (p. 749). The CFI empha-sizes four domains of assessment: Cultural Definitions of the Problem, Cultural Perceptions of Cause, Context, and Support, Cultural Factors Affecting Self-Coping, and Past Help Seeking and Cultural Factors Affecting Current Help Seeking. The manual includes both an interview outline that can be used with clients and informants, that is, family members or caregivers of the client. According to the DSM-5, “the boundaries between normality and pathology vary across cultures for specific types of behav-iors” (p. 14). One of the supplemental assessment tools in a diagnos-tic assessment that is used with some (but not all) clients is known as a mental status examination. We discuss this assessment tool in the next section. Mental Status Examination After conducting an initial interview, you may wish to conduct (or refer the client for) a mental status examina-tion. A mental status examination is a model that allows the interviewer to assess current mental functioning of the client. It is not the same assessment tool as a diag-nostic interview, although information gathered from the mental status examination may be linked to particular clinical disorders. As Sommers-Flanagan and Sommers-Flanagan (2014) point out, a formal mental status evalu-ation is not used with all clients. Their recommendation is that this assessment tool is used as the client's suspected level of psychopathology increases (Sommers-Flanagan & Sommers-Flanagan, 2014). Moreover, some clinicians believe the mental status examination has skewed results with culturally diverse clients because of the possibil-ity of potentially invalid conclusions (Sommers-Flanagan & Sommers-Flanagan, 2014). Immigrant/refugee status, language differences, trust issues, cultural beliefs, cultural values, and norms can all affect the validity of the mental status examination with culturally diverse clients. The major categories covered in a mental status exam include general description and appearance of the client; mood and affect; perception; thought processes; level of con-sciousness; orientation to time, place, and people; memory; and impulse control. Additionally, the examiner may note the degree to which the client appeared to report the information accurately and reliably. Of these categories, disturbances in consciousness (which involves ability to perform mental tasks, degree of effort, and degree of fluency/hesitation in task performance) and orientation (whether or not clients know when, where, and who they are and who other people are) are usually indicative of brain impairment or cognitive disorders and require neu-rological assessment and follow-up as well. It is important for practitioners to know enough about the functions and content of a mental status exam to refer clients who might benefit from this additional assessment procedure. A summary of the content of a generic brief mental status exam is given in Table 6. 3. Although a mental status exam can provide a quick memory screening, it does not result in specific informa-tion about cognitive and memory impairments. To assess for dementia and cognitive impairment, an additional screening tool called the Mini-Mental Status exam (cur-rently the MMSE-2) is used. (Note, do not confuse the two assessment tools because they share some of the same language in their titles!). The MMSE-2 is considered quite sensitive at detecting deficits in cognitive impair-ment. Zuckerman (2010) believes that two newer mental status tools, the St. Louis University Mental Status exam (available at aging. slu. edu) and the Montreal Cognitive Assessment (available at www. mocatest. org), are even more sensitive for detecting mild cognitive impairment than the MMSE-2. Also, a very new brief mental status exam that is available for use as a rapid assessment of Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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198 Chapter 6 cognitive status in older adults is the Sweet 16 (Fong et al., 2011). This instrument is available as open access because it is not copyrighted. Mental status checklists suitable for child and adolescent clients can also be found at www4. parinc. com. For additional information about mental sta-tus examinations and neurophysiologic assessment, see Morrison (2014) and Zuckerman (2010). Diagnostic Interviewing In clinical settings, the interview(s) used to assess clinical disorders is known as the diagnostic interview (Segal & Hersen, 2009). Jones (2010) observes that once the task of only medically trained psychiatrists, now diagnostic interviewing is in the scope of practice of many mas-ter's level-trained practitioners. Accreditation standards in clinical kinds of programs such as counseling, social work, and psychology also require that trainees become familiar with diagnostic interviewing. Diagnostic interviews may be unstructured, semistruc-tured, or structured. As Jones (2010) notes, unstructured diagnostic interviews consist of “questions posed by the counselor with the client responses and counselor obser-vations recorded by the counselor. This type of interview is considered unstructured because there is no standard-ization of questioning or recording of client responses” (p. 220). Jones (2010) describes a comprehensive general interview outline that practitioners can use to engage in an unstructured diagnostic interview with adult clients. We have integrated some of her suggestions into our discussion of the components of intake and history interviews. Summerfeldt, Kloosterman, and Antony (2010) note that in the past three decades we have witnessed the de-velopment and use of a variety of both semistructured and structured diagnostic clinical interview protocols that are designed to minimize the sources of variability that make diagnosis unreliable (p. 95). Moreover, some new re-search has found that across inpatient, outpatient, and re-search settings, these kinds of more structured diagnostic interviews are rated positively by both consumers and helpers (Suppiger et al., 2009). Structured diagnostic interview schedules are avail-able that consist of a standardized list of questions, a stan-dardized sequence of questioning, including follow-up questions, as well as a systematic rating of client responses (Bagby, Wild, & T urner, 2003; Jones, 2010). The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) (Brown, Di Nardo, & Barlow, 1994), the ADIS-IV: C for children (Silverman & Albano, 1996), the Diagnos-tic Interview for Borderline Patients (DIB-R) (Zanarini, Frankenburg, & Vujanovic, 2002), and the Depression Interview and Structured Hamilton (DISH) (Freedland et al., 2002) are all examples of structured diagnostic interview schedules. Semistructured diagnostic interviews are still some-what structured in the use of specific questions but allow the clinician more flexibility in the use of follow-up ques-tions (Jones, 2010). A semistructured diagnostic inter-view compatible with the DSM-5 is the SCID-5, which is published by the American Psychiatric Publishing group and available at www. appi. org. For examples and informa-tion of additional structured and semistructured clinical interview protocols, consult Summerfeldt, Kloosterman, and Antony (2010). Generally, both structured and semistructured inter-views have better reliability than unstructured interviews, meaning that different interviewers would be more likely to arrive at the same diagnosis for a particular client. However, as Summerfeldt, Kloosterman, and Antony (2010) point out, the reliability of a diagnostic interview is determined by many factors, including the clarity and nature of the questions asked, the degree and consistency of training of interviewers, the conditions in which the interview is conducted, the type of reliability assessed, and so on. Sommers-Flanagan and Sommers-Flanagan (2014) summarize a number of issues about diagnostic inter-viewing from the research-based literature. They note that diagnostic interviews can produce more reliable results in Table 6. 3 Summary of brief Mental Status exam Note the client's physical appearance, including dress, posture, gestures, and facial expressions. Note the client's attitude and response to you, including alertness, motivation, passivity, distance, and warmth. Note whether there were any client sensory or perceptual behaviors that interfered with the interaction. Note the general level of information displayed by the client, including vocabulary, judgment, and abstraction abilities. Note whether the client's stream of thought and rate of talking were logical and connected. Note the client's orientation to four issues: people, place, time, and reason for being there (sometimes this is described as “orientation by four”). Note the client's ability to recall immediate, recent, and past information. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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Assessing and Conceptualizing Client Problems and Contexts 199 diagnosis if the practitioner sticks with the DSM diag-nostic criteria rather closely. They also note that training in diagnostic interviewing enhances the reliability of the process. Finally, they suggest that while structured diag-nostic interviews that deemphasize contextual factors are more likely to produce reliable diagnoses, they are also more likely to overlook individual difference (p. 341). As an example of the latter issue, consider that most of the screening and diagnostic tools were developed for use with younger rather than older adults (Edelstein et al., 2008). Sensitive Subjects and Risk Assessment in Diagnostic Interviewing Morrison (2014) has pointed out that some important subjects that come up in intake and assessment interviews can be sensitive for both helpers and clients. This poten-tial sensitivity does not mean that such subjects should be overlooked or discarded. However, it does mean that the helper should proceed with good judgment and seek con-sultation about when it is appropriate to assess these areas. On one hand, it may be seen as voyeuristic if a male coun-selor asks a young female presenting with an academic/career issue about her sexual practices and activity. On the other hand, if a client comes in and discusses problems in dating persons of the opposite sex and feelings of attrac-tion to same-sex people, not pursuing this subject would be an important omission. Specific subjects that may fall into the category of sensi-tive topics include questions about (1) suicidal thoughts and behavior; (2) homicidal ideas and violent behavior; (3) substance use, including alcohol, street drugs, and prescribed medications; (4) sexual issues, including sexual orientation, sexual practices, and sexual problems; and (5) physical, emotional, and sexual abuse, both past and current. Zuckerman (2010) has developed some struc-tured interview questions to utilize for sensitive subjects such as these topics. In general, we should point out that omitting questions about sensitive topics is not consid-ered optional! Each and every client should be asked about potential harm to self and others and substance use, and also should be screened for sexual, physical, and emotional abuse. Koven, Shreve-Neiger, and Edelstein (2007) recommend an interviewing strategy for handling sensitive subjects called the “plus minus approach. ” In this approach, the clinician balances difficult questions with those that are less threatening so that if a client reacts emotionally to a difficult question, the interviewer follows up with a question that is more benign. Risk Assessment: Violence or Harm to Others A particular category of sensitive subjects has to do with potential lethality or danger to self or others. Interest in this sensitive area has mushroomed with recent events such as suicide bombings and school shootings. Domes-tic violence is another area that may be very relevant for mental health inquiries and assessment. Although an in-depth discussion of the assessment of lethality and risk is beyond the scope of this book, we include some brief comments about this topic and recommend additional resources. The Mac Arthur study of high-risk clients for violence (excluding verbal threats for violence) identified more than 100 potential risk factors for violence but found no “magic bullet” predictor of future violence. The findings from this study suggest that a person's propensity for vio-lence is the accumulation and interaction of a number of risk factors, including criminological factors (such as history of violence and criminality), childhood experi-ences (such as physical abuse), environmental conditions (such as poverty and unemployment), and clinical risk factors (such as substance abuse, antisocial personality disorder, persistent violent thoughts and fantasies, and anger control issues). The findings of the Mac Arthur risk assessment study are summarized by Monahan and colleagues (2001). The American Psychiatric Associa-tion recently published a task force report on psychiatric violence risk assessment (Buchanan, Binder, Norko, & Swartz, 2012). They note that crimes of violence are often committed by younger males with prior offenses and abuse of substances. This report also summarizes a number of risk factors but, like the Mac Arthur study, notes no magic bullet predictors of future violence. This report also delineates between the important distinction between predicting violence and managing violence. Interview Leads/Questions for Harm to Others/Violence In the intake or history interview, questions about violence can be raised if the client discusses “arrests or time in con-finement” (Morrison, 2014, p. 101). If clients do not in-dicate any legal difficulties such as these, you can raise the topic by asking questions such as those recommended by Morrison (2014, p. 102) and Zuckerman (2010, p. 78): “Have you ever had any thoughts of harming others? If so, how far ahead have you planned it?”“Have you ever had any trouble controlling your impulses?” “Lost your temper?” “Threatened to harm someone else or an animal?” Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
200 Chapter 6 “Have you ever had feelings of uncontrollable rage?” “Have you ever broken things, raised your fist, gotten into someone's face, grabbed, pinched, kicked someone?” “Have you ever used a weapon of any kind such as a knife or something else?” Affirmative responses to these questions need to be explored with follow-up queries such as exploration of the circumstances of the violence, whether substance use was involved, and the consequences. While there are a number of structured risk assessment measures for assessing violence, a recent review and meta-analysis of these tools found low to moderate predictive values, depending primarily on how the instrument is used (Fazel, Singh, Doll, & Grann 2012). These authors conclude that “even after 30 years of development the view that violence, sexual, or criminal risk can be pre-dicted in most cases is not evidence-based” (p. 9). These authors also warn that using structured risk assessment tools on their own is not sufficient for the purposes of risk assessment of violence. If you are interviewing a client with the potential for or history of violence, it is crucial to become very aware of your own safety in the session. As Morrison (2014) notes, practically speaking, this means holding a session where others are nearby, seating yourself closer to the door than the client in case you should have to make an emergency exit, and having available some sort of easily triggered emergency alert system such as an alarm bell. Many practitioners have been stalked (either in person or in cyberspace), threatened, and/or physically attacked by at least one client. There is insufficient literature and training available to prepare practitioners to deal with potentially violent clients and to support helpers in the aftermath of attack. Consultation with colleagues and supervisors about this issue is very important, especially when dealing with a client who has a history of harass-ment, stalking, and aggression. Risk Assessment: Harm to Self Helping professionals are responsible for conducting sui-cide risk assessments or harm to self with all clients. In the United States, deaths from suicide now exceed those from vehicular crashes. There are a number of potential risk factors associated with suicidality in clients, although as Sommers-Flanagan and Sommers-Flanagan (2014) as-sert, “an absence of these factors in an individual client is no guarantee that he or she is safe from suicidal im-pulses” (p. 292). Among these factors, depression, partic-ularly hopelessness, perceived burdensomeness, substance abuse, history of trauma and victimization, and prior attempts are key risk factors. For older adults, risk factors include current mood disorders, psychiatric hospital ad-mission within the previous year, limited social network, and negatively perceived health status and sleep quality (Gould, Edelstein, & Ciliberti, 2009). Warning signs of suicide include suicidal thoughts (also known technically as “ideation”), having a plan and the means to carry it out, expressions of meaninglessness or lack of purpose, relationship losses, notable changes in behaviors, and giv-ing away of possessions (Sommers-Flanagan & Sommers-Flanagan, 2014). The top three warning signs include a threat to hurt or kill oneself, an attempt to find a means to hurt or kill oneself, and talking or writing about hurting or killing oneself. Stuctured Clinical Interview Guides for Harm to Self and Suicide Assessment In the area of suicide risk assessment, there are several useful structured clinical interview guides to assess potential danger to self. Chief among these are the Adolescent Suicide Assessment Protocol-20 (Fre-mouw, Strunk, Tyner, & Musick, 2005) and the Suicidal Adult Assessment Protocol (Fremouw, Tyner, Strunk, & Musick, 2008). These two protocols present a brief, user-friendly, structured clinical interview designed for practitioners to obtain an initial objective measure of adolescent and adult suicidal risk (Fremouw et al., 2005, p. 207). Both interview protocols include assessment of client demographic factors (such as gender, age, and marital status), historical factors (such as prior attempts and childhood abuse), clinical items (such as depression and hopelessness, impulsivity, and substance abuse), spe-cific suicidal risk questions (such as thoughts, plans, and intentions), contextual factors (such as firearm access, recent loss, stressors, and social isolation), and protective factors (such as family responsibilities, spiritual and/or religious beliefs, and social support). At the completion of the structured interview, each client is classified ac-cording to level of risk; depending on that level of risk, the interviewer will identify various forms of action and intervention such as consultation, increased monitor-ing, contracting, notification, referrals to other forms of treatment, and elimination of the method of suicide. A brief, structured suicide assessment interview protocol suitable for use as a basic screening tool across many kinds of settings has been developed by Bryan, Corso, Neil-Walden, and Rudd (2009). T wo specific suicide risk as-sessment instruments have been developed specifically for older adults (Edelstein, Woodhead, Segal, Heisel, Bower, Lowery, 2008). These interview protocols help practitioners use a more systematic approach to suicide risk assessment, underscoring the fact that suicide risk assessment is a must, not an option, in a history-taking or intake Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 201 interview, even if this subject is not raised by the client. Some clients may be at a serious risk for suicide but feel too embarrassed or despondent to share their concerns about it with the helper. Moreover, it is a myth that mentioning the topic could plant this idea in a client's mind! (Morrison, 2014). In fact, talking about suicide in appropriate ways actually seems to decrease the risk, because most suicidal individuals do not really want to die as much as they simply want to find a way to end their psychic pain (Shallcross, 2010). Interview Leads/Questions for Harm to Self and Suicide Risk Assessment At the most basic level, including the ques-tion, “Have you ever had any thoughts of hurting or killing yourself?” in any intake or history interview is essential. We like the way that Zuckerman (2010, p. 76) approaches this initial question in the interview: You have told me about some very painful experiences. They must have been hard to bear, and perhaps you sometimes thought of quitting the struggle-or harming yourself in some way-or perhaps ending your life. Is this true for you? Follow-up queries, depending on the client's response, include things such as whether there have been prior at-tempts, methods used for such attempts, whether the client has a plan in place for a future attempt, whether the client possesses firearms, current stressors in the client's life, influence of substances, current social sup-port or lack thereof in the client's life, reasons to live, things the client cares about (including animals, as well as people, values, projects, and so on), and the cli-ent's level of depression, hopelessness, and feelings of burdensomeness. Hunsley and Lee (2014) provide a list of empirically supported questions to use in conducing suicide risk as-sessments with clients: Have you had any thoughts of suicide recently? When you think about suicide, what exactly do you think about? Have you ever attempted suicide? Have you made any plans for taking your life, such as ob-taining the means to commit suicide? Do you think you could follow through on a suicide at-tempt? What are the reasons that you would consider suicide as an option? Have you ever hurt yourself intentionally, such as by cut-ting or burning yourself? Tell me about your family and friends. Do you feel sup-ported and are you able to talk to them about your problems?Do you think that anything can be done about your prob-lems? (p. 182). Cultural sensitivity is important in suicide risk assess-ment. When working with immigrants and refugees, some direct questions about suicidality may be met with silence or minimal responses. It is also important to realize that suicide risk can be both acute and chronic. Anyone who has two or more prior attempts is probably considered a chronic risk. As Pope and Vasquez (2011) note, remain-ing alert to the issue of suicide risk assessment throughout the therapeutic process is extremely important. In other words, suicide risk assessment is not just a “one shot” assessment. In the following section, we describe ways in which sensitive topics and risk assessments are integrated into intake/history interviews with clients. Intake Interviews and History Part of assessment involves eliciting information LO2 about the client's background, especially as it may relate to current concerns. Past, or historical, information is not sought as an end in itself or because the helper is necessarily interested in exploring or focusing on the cli-ent's past during treatment. Rather, it is used as a part of the overall assessment process that helps the practitioner fit the pieces of the puzzle together concerning the cli-ent's presenting issues and current life context. Often a client's current issues are precipitated by events found in the client's history. In no case is this more valid than with clients who have suffered trauma of one kind or another. For example, a 37-year-old woman came to a crisis center because of the sudden onset of extreme anxiety. The interviewer noticed that she was talking in a little girl voice and was using gestures that appeared to be very childlike. The clinician commented on this behavior and asked the client how old she felt right now. The client replied, “I'm 7 years old,” and went on to re-veal spontaneously an incident in which she had walked into a room in an aunt's house and found her uncle fondling her cousin. No one had seen her, and she had forgotten this event until the present time. In cases such as this one, history may serve as a retrospective baseline measure for the client and may help to identify cognitive or historical conditions that still exert influence on the current issue and might otherwise be overlooked. The process of gathering information about the client's background is called history taking. In many agency settings, history taking occurs during an initial inter-view called an intake interview. An intake interview is Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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202 Chapter 6 viewed as informational rather than therapeutic and, to underscore this point, is often conducted by someone other than the practitioner assigned to see the client. In these situations, someone else, such as an intake worker, sees the client for an interview, summarizes the informa-tion in writing, and passes the information along to the helper. Various kinds of information can be solicited dur-ing history taking, but the most important areas are the following: 1. Identifying information about the client. Jones (2010) notes that the diagnostic clues provided by this infor-mation include both gender, race, and referral source. 2. Presenting problems/symptoms, including history related to the presenting concerns. Jones (2010) suggests that helpers listen especially for psychological symptoms, behavioral patterns, stressors, and interpersonal con-flicts (p. 221). 3. Psychiatric and/or counseling history/treatment and previous diagnosis. Jones (2010) suggests that practitioners inquire not only about prior counseling but also about prior hospitalizations. 4. Educational and job history. Jones (2010) suggests that problems in academic achievement have been linked to substance abuse problems and the onset of early mental illness. Similarly, issues in work history may be indicative of disabling clinical disorders (p. 223). 5. Health and medical history. Some clients, such as indigent clients, older adults, and clients with dis-abling clinical disorders, may be at increased risk for medical conditions (Jones, 2010, p. 224). Jones (2010) lists a number of common medical condi-tions associated with psychological symptoms, including thyroid disorders, cardiac disorders, head trauma, neurological disorders, circulatory disor-ders, hepatitis, seizure disorder, lupus, electrolyte disturbances, and B-vitamin deficiencies (p. 224). Zuckerman (2010) describes the situation in which a client presents with psychological symptoms caused by a medical condition that is not immedi-ately (and often never) recognized as “psychiatric masquerade” (p. 359). In his clinical thesaurus, he describes a number of specific medical conditions that may masquerade as psychological symptoms. 6. Social/developmental history, including religious, spiritual, and cultural background and affiliations, predominant values, chronological/developmental events, military background, social/leisure activities, present social situation, legal problems, and sub-stance use history. Hunsley and Mash (2010) point out that awareness of what constitutes normative developmental tasks and age-related functioning throughout the lifespan is helpful in assessing history (p. 12). Knowledge of key developmental transitions is also useful (Ingram, 2006). Jones (2010) asserts that identifying known childhood and adolescent risk factors helps to establish information about clinical disorders in adulthood (p. 223). 7. Family, marital, relationship, sexual history, including any abuse history, partner status, and sexual orienta-tion information. Jones (2010) recognizes that clini-cal disorders are often associated with family history and the client's current or prior interactions with family members (p. 222). Relationship history is use-ful in determining if the client has demonstrated the ability to initiate and sustain intimate relationships (Jones, 2010, p. 222). Changes in relationship status as well as violence in relationship or marital history also provide important diagnostic clues. 8. Substance use and legal history. Screening for alcohol and drug use is considered important regardless of the client's presenting issues; this can begin with less threatening subjects such as caffeine and to-bacco use, followed by alcohol and other drug use. For some clients, substance abuse and legal history are connected. 9. Military history. In these times, it is not uncommon to encounter clients who are serving or have served in the military (often with multiple tours of duty), or who are members of a soldier's or veteran's family. Military history provides clues about possible post-traumatic stress. 10. Suicidal and/or homicidal ideation. Assess for ideation, plans, prior attempts, impulse control, reasons for living 11. Behavioral observations, including assessment of client communication patterns and appearance and de-meanor; mental status assessment would be included here if applicable. 12. Goals f or counseling and therapy/treatment. 13. Diagnostic (DSM) summary. 14. Person-in-environment (PIE) classification. Table 6. 4 presents specific questions or content areas to cover for each of these 14 areas. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 203 Table 6. 4 History-Taking Interview Content 1. Identifying information: Client's name, address, home and work telephone number; name of another person to contact in case of emergency Age Gender Disabilities Ethnicity and indigenous heritage Occupation Race Citizenship status Languages Referral source 2. Presenting concerns: Note the presenting concern (quote the client directly). Do this for each concern that the client presents. When did it start? What other events were occurring at that time? How often does it occur? What thoughts, feelings, and observable behaviors are associated with it? Where and when does it occur most? Least often? Are there any events or persons that precipitate it? Any specific stressors associated with it? Make it better? Make it worse? What chain of events led up to it? How much does it interfere with the client's daily functioning? What previous solutions/plans have been tried and with what result? What made the client decide to seek help at this time (or, if referred, what influenced the referring party to refer the client at this time)? 3. Psychiatric/counseling history: Previous counseling and/or psychological/psychiatric treatment Type of treatment Length of treatment Treatment place or person Presenting concern Outcome of treatment and reason for termination Previous hospitalization Prescription drugs for emotional and or psychological issues Nonprescription supplements used for emotional and psychological issues 4. Educational/job history: Trace academic progress (strengths and weaknesses) from grade school through last level of education completed Relationships with teachers and peers Types of jobs held by client and socioeconomic history, current employment, and socioeconomic status Length of jobs Reason for termination or change Relationships with coworkers Aspects of work that are most stressful or anxiety producing Aspects of work that are least stressful or most enjoyable Overall degree of current job satisfaction 5. Health/medical history: Childhood diseases, prior significant illnesses, previous surgeries Current health-related complaints or illnesses (e. g., headache, hypertension) Treatment received for current complaints: what type and by whom Date of last physical examination and results Significant health problems in client's family of origin (parents, grandparents, siblings) Significant health problems in client Client's sleep patterns Client's appetite level (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
204 Chapter 6 Table 6. 4 History-Taking Interview Content (continued) Current medications (e. g., aspirin, vitamins, birth control pills, recreational substance use, prescription medications) Drug and nondrug allergies Disability history Client's typical daily diet, including caffeine-containing beverages/food, alcoholic beverages, and use of nicotine or tobacco products Exercise patterns 6. Social/developmental/ history: Current life situation (typical day/week, living arrangements, occupation and economic situation, contact with other people) Social/leisure time activities, hobbies Religious affiliation, childhood and current Spiritual beliefs and concerns Contacts with people (support systems, family, and friends) and notations about whether such contacts are acquaintances or close, personal friends Community and cultural affiliations Significant events reported for the following developmental periods: (note especially behavior problems, school problems, child/ adolescent depression, ADHD symptoms, child abuse, traumas, losses as delineated by Jones (2010, p. 223) Preschool (0-6 years) Childhood (6-13 years) Adolescence (13-21 years) Young adulthood (21-30 years) Middle adulthood (30-65 years) Late adulthood (65 years and over) 7. Family, marital, relationship, sexual history: Presence of physical, sexual, and/or emotional abuse from parent, sibling, or someone else Composition of the family while client was living at home Identifying information of client's parents and siblings (age, occupation, education, birth order of siblings) How well parents got along with each other Which sibling appeared to be most favored by mother? By father? Least favored by mother? By father? Which sibling did client get along with best? Worst? History of previous psychiatric illness/hospitalization among members of client's family of origin Child abuse, domestic violence, other traumas in the family, including family history of suicide Use of substances in family of origin Dating history, prior relationships Engagement/marital history, reason for termination of relationship Current relationship with intimate partner (how well they get along, problems, stresses, enjoyment, satisfaction, and so on) Prior and/or current violence in relationships Number and ages of client's children Other people living with or visiting family frequently Description of previous sexual experience, including first one (note whether heterosexual, homosexual, or bisexual experiences are reported) Present sexual activity Any present concerns or complaints about sexual attitudes or behaviors Current sexual orientation 8. Substance use and legal history: Assess for tobacco use, including cigarettes, cigars, pipe, snuff Assess for caffeine use, including coffees, teas, soft drinks, caffeine tablets, chocolate, and energy drinks like Red Bull Assess for prescription and legal drug use, such as sedatives, hypnotics, anxiolytics, and central nervous system depressants. Note combinations of drugs and issues indicating intoxication and withdrawal. Assess for alcohol use. Assess for nonlegal drug use, including stimulants, opioids, hallucinogens, MDMA, dissociative anesthetics, inhalants, and cannabis. Zuckerman (2010) suggests beginning this assessment with the question: “What is/are your drugs of choice/preference?” (p. 71). Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 205 Detailed information also should be obtained in these categories about both history and consumption of the listed substances. Ask about whether substance use has ever resulted in any legal issues. Inquire about other legal issues such as tickets, detentions, warrants, convictions, probation, parole, evictions, bankruptcies, conflicts with others, abuse issues, protection from abuse orders (Zuckerman, 2010). 9. Military history: Assess for reserve or active duty Branch of service Duration of duty, number of tours of duty Combat or war zone duty Type of discharge Prior and current consequences of service for client and family 10. Suicidal and homicidal ideation: Presence or absence of suicidal thoughts; if present, explore onset, frequency, antecedent events, duration, and intensity of such thoughts—ranging from almost never, to occasional, weekly, and/or daily. Presence or absence of suicidal plan; if present, explore details of plan, including method, lethality, availability of method, and timeline of plan. Prior suicide threats and attempts by the client and also attempts/completions by family members Prior and/or current intentional self-harm or self-injurious behaviors such as cutting, burning Overall suicidal intent—nonexistent, low, moderate, severe Presence or absence of homicidal ideation; client attitudes that support or contribute to violence Presence or absence of homicidal plan; if present, explore details of plan, including method, means, availability of means, timeline of means, intended victim(s) Prior homicidal threats and acts—instances and patterns Overall homicidal intent—nonexistent, low, moderate, severe 11. Behavioral observations (also include mental status results if administered): General appearance and demeanor Client communication patterns 12. Goals for counseling and therapy: Client's desired results for treatment Client's motivation for getting help at this time 13. Diagnostic summary (if applicable) and DSM-5/ICD codes: 14. PIE classification (Karls & Wandrei, 1994): Factor I: Social Role Problem Identification: severity, duration, coping and strength indices, type of social role problem, type of interactional difficulty Factor II: Environmental Problem Identification: severity, duration, and strength indices, type of environmental problem area and associated discrimination code The sequence of obtaining this information in a history or an intake interview is important. Generally, the inter-viewer begins with the least threatening topics and saves more sensitive topics until near the end of the session, when a greater degree of rapport has been established and the client feels more at ease about revealing personal infor-mation to a total stranger. Not all of this information may be required for all clients. Obviously, this guide will have to be adapted for use with different clients—especially those of varying ages, such as children, adolescents, and the elderly, who may need a simpler way to provide such information and in a shorter amount of time. Cultural Issues in Intake and Assessment Interviews It is important to note and account for sources of cul-tural bias within a traditional intake interview and within assessment interviews in general. Canino and Spurlock (2000) point out that “in some cultures disturbed be-havior may be viewed as related to a physical disorder or willfulness”; therefore, talking about the behavior is not expected to help (p. 75). In some cultural groups, there is a sanction against revealing personal information to Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
206 Chapter 6 someone outside the family or extended family circle. Also, clients' perceptions of what is socially desirable and undesirable behavior as well as their perceptions of psy-chological distress may reflect values different from the ones held by the practitioner: “Certain cultural factors must be considered in determining the normalcy or pa-thology of a response. For example, 'hearing the Lord speak' may be a culture-specific impression and therefore nonpathological for some religious groups. An inner-city African American adolescent's statement 'All whites are out to get us' may actually represent the thinking of the community in which he lives rather than qualify as a sign of paranoia” (Canino & Spurlock, 2000, p. 80). In interpreting the information received from an in-take interview and mental status exam, remember that some information can have cultural meanings that are unknown to you. For example, some cultures view the child as 1 year old at the time of birth; other cultures may favor the use of culturally sanctioned healing remedies instead of traditional Western medical or psychological treatment. Also, cultures have different practices regard-ing discipline of children and adolescents, so what you may view as either indulgent or harsh may not be seen that way by the client and the client's collective com-munity. What constitutes a “family” also varies among cultures; in assessing for family history, it is important to ask about extended family members who may live outside the household as well as about a parent's significant other. Clients might also report religious and spiritual beliefs that are unfamiliar to the helper, and these can affect the client's help-seeking behavior and perceptions of distress. Microaggressions in Intake and Assessment Interviews Another issue pertaining to cultural dimensions of clients in intake and assessment interviews has to do with micro-aggressions—verbal comments or queries that communi-cate a derogatory slight or insult to the client (Sue, 2010). For example, a culturally insensitive interviewer may actu-ally demonstrate some form of racial or ethnic profiling in an intake interview by assuming something pejorative about the client based solely on the client's race or ethnic-ity. An example of this would be a practitioner posing more questions about substance use with Native American clients than with other clients and viewing their reports of a non-existent history with substances as “suspicious” (Sue, 2010). Another example provided by Sue and colleagues (2007) of a microaggressive act in an intake interview would be acting on the assumption that Asian Americans and Latino Americans are “foreign born. ” As Sue and his colleagues (2007) explain, “A female Asian American client arrives for her first therapy session. Her therapist asks her where she is from, and when told 'Philadelphia,' the therapist further probes by asking where she was born. In this case, the therapist has assumed that the Asian American client is not from the United States and has imposed through the use of the second question the idea that she must be a foreigner” (p. 281). Microaggressions in interviews also can occur with clients who are older and/or have some kind of disabil-ity. For example, a practitioner may assume that an older adult cannot hear well and consequently the practitioner speaks to the client in a very loud voice. Or a clinician may assume that because a client has a visible disability that the client is not smart enough to process something that the clinician would assess with a nondisabled client. (See Learning Activity 6. 3. ) Another challenge faced by practitioners in conduct-ing intake and assessment interviews involves clients who do not speak English as their primary language. In these instances, when alternative helpers are not available, translators and interpreters may be brought in. The use of ancillary persons, while a culturally sensitive option, presents new issues in terms of confidentiality and privacy (Hunsley & Lee, 2010). Additional guidelines for conducting cross-cultural clinical interviews have been provided by Martinez (2013). He observes that with clients from marginalized cultural groups that there may be “other layers of com-plexity” in ascertaining the client's presenting issues as some clients may describe presenting symptoms in words and phrases that are not understood to the practitioner. There are several examples of culturally sensitive in-terview protocols. One such protocol, developed by Tanaka-Matsumi, Seiden, and Lam (1996), is the Cultur-ally Informed Functional Assessment (CIFA) Interview. Designed to define client issues in a culturally sensitive manner, this interview protocol includes a variety of steps such as assessing the cultural identity and acculturation status of the client, assessing the client's presenting issues with reference to the client's cultural norms, probing explanations of the client's issue and possible solutions to avoid pathologizing seemingly unusual but yet cultur-ally normative responses, conducting a functional assess-ment of the client's problem behaviors, and determining learning activity 6. 3 Cultural Issues in assessment In a dyad or a small group, identify examples of both potential and actual microaggressions that could easily occur in intake and history-taking sessions with clients. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 207 whether the client's reactions to controlling variables are similar to or different from customary reactions of one's cultural referent group(s). History taking (and mental status exams, if applicable) usually occur near the very beginning of the helping pro-cess. After obtaining this sort of preliminary information about the client as well as an idea of the range of present-ing complaints, you are ready to do some direct assess-ment interviewing with the client to define the parameters of concerns more specifically. Direct assessment inter-viewing is the focus of our following chapter. Putting it all Together: Evidence-Based Assessment and Conceptualization At the beginning of our chapter, we stated that assessment is about helping our clients tell and develop their story. As helpers, we facilitate this process through many of the interviewing skills we have described in earlier chapters. We also use the lens of the assessment models and tools described in this chapter to help clients develop the nar-rative. Then, we have the task of integrating all the parts of the story into a cohesive whole, into a narrative that helps to answer questions and to make sense of varying parts. This includes a descriptive account of the client's prior and current life situation, the clinical disorders and potential diagnoses, the client's overall level of function-ing including strengths and adaptive functioning, cultural factors, problem behaviors, and maintaining conditions. In short, conceptualization requires synthesis of a wide range of information and data obtained during assessment for the purpose of generating answers to questions about how the client can best be helped. The conceptualiza-tion process helps us figure out possible explanations for the development and maintenance of the client's problems and concerns. Helpers of almost all theoretical orientations engage in this sort of conceptualization pro-cess, although varying theoretical orientations are likely to develop different kinds of hunches and hypotheses about clients. As Hunsley and Mash (2008) observe, “the assessment process is inherently a decision-making task” in which practitioners formulate and test hypotheses by integrating data that are incomplete or inconsistent (p. 7). Ingram (2012) asserts that developing and applying hypotheses about client cases is one of the most com-plex tasks facing practitioners. As she notes, it involves a number of processes including a search for the best-fit hypotheses that are compatible with the assessment data for the individual client, testing the fit of the hypothesis by gathering data to rule it in or out and combining hy-potheses that are efficient and accurate enough to lead to a good treatment plan (p. 12). Unfortunately, therapeutic bias can lead to errors in clinical decision-making; aware-ness of bias may help to minimize the impact of clinical decision-making errors in our conceptualization process (Hunsley & Lee, 2010). We can also enhance our clinical decision-making with practice of assessment and concep-tualization processes as illustrated in the following model case and learning activities. Model Case: Conceptualizing To assist you in conceptualizing client concerns with the models from this chapter, we provide a case illustration fol-lowed by two practice cases for you to analyze in Learning Activity 6. 4. The conceptual understanding you should acquire from this chapter will help you actually define and conceptualize client issues with a clinical interview assess-ment, which is the focus of our next chapter! The Case Isabella is a 15-year-old student completing her sopho-more year of high school and presently taking a college preparatory curriculum. Her initial statement in the first counseling session is that she is “unhappy” and anxious at school, except when she is socializing with her friends. On further clarification, Isabella reveals that she is unhappy and worried because she doesn't think she is measuring up to her classmates and that she dislikes being with these “top” kids in her classes, who are very competitive. She reports feeling “on edge” at school, having difficulty focusing or concentrating, and trouble falling asleep due to staying awake at night and worrying about school the following day, particularly her “performance” in school. Her teachers have noticed her lapses in concentration and suggested she speak with you, the school counselor. She reports particular concern in one math class, which she says is composed largely of “guys” who are much smarter than she is. She states that she thinks about the fact that “girls are so dumb in math” rather frequently during the class and she feels intimidated. She reports that as soon as she is in this class, she gets anxious and “withdraws. ” She states that she sometimes gets anxious just thinking about the class, and she says that when this happens she gets “butterflies” in her stomach, her palms get sweaty and cold, and her heart beats faster. When asked what she means by “withdrawing,” she says she sits by herself, doesn't talk to her classmates, and doesn't Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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208 Chapter 6 learning activity 6. 4 assessment Models To help you in conceptualizing a client's issue, we provide two cases. We suggest that you work through the first case completely before going on to the second. After reading each case, respond to the questions following the case by yourself or with a partner. Then, compare your responses with the feedback on page 211. The Case of Ms. Weare and Freddie Ms. Weare and her 9-year-old son, Freddie, have come to Family Services after Ms. Weare said she had reached her limit with her son and needed to talk to another adult about it. Their initial complaint is that they don't get along with each other. Ms. Weare complains that Freddie doesn't get himself ready in the morning, and this makes her mad. Freddie complains that his mother yells and screams at him frequently. Ms. Weare agrees that she does, especially when it is time for Freddie to leave for school and he isn't ready yet. Freddie agrees that he doesn't get himself ready and points out that he does this just to “get Mom mad. ” Ms. Weare says this has been going on as long as she can remember. She states that Freddie gets up and usu-ally comes down to breakfast not dressed. After breakfast, Ms. Weare always reminds him to get ready and threatens that she'll yell or hit him if he doesn't. Freddie usually goes back to his room, where, he reports, he just sits around until his mother comes up. Ms. Weare waits until 5 min-utes before the bus comes and then calls Freddie. After he doesn't come down, she goes upstairs and sees that he's not ready. She reports that she gets very mad and yells, “You're dumb! Why do you just sit there? Why can't you dress yourself? You're going to be late for school! Your teacher will blame me because I'm your mother. ” She also helps Freddie get ready. So far, he has not been late, but Ms. Weare says she “knows” he will be if she doesn't “nag” him and help him get ready. When asked about the option of removing her help and letting Freddie get ready on his own, she says that he is a smart kid who is doing well in school and that she doesn't want this factor to change. She never finished high school herself, and she doesn't want that to happen to Freddie. She also says that if he didn't have her help, he would probably just stay at home that day and she wouldn't get any of her own work done. On further questioning, Ms. Weare says this behavior does not occur on weekends, only on school days. She states that as a result of this situation, although she's never punished him physically, she feels very nervous and edgy after Freddie leaves for school, often not doing some neces-sary work because of this feeling. Asked what she means by “nervous” and “edgy, ” she reports that her body feels tense and jittery all over. She indicates that this reaction does not help her high blood pressure. She reports that Freddie's father is not currently living at home because they recently separated, so all the child rearing is on her shoulders. Ms. Weare also states that she doesn't spend much time with Freddie after school; she does extra work at home at night because she and Freddie “don't have much money. ” DSM-5 Diagnosis for Ms. Weare V61. 20 (Z62. 820) Parent-child relational problem V60. 2 (Z59. 6) Low Income Respond to these questions. 1. What behaviors does Freddie demonstrate in this situation? 2. Is each behavior you have listed overt or covert?3. What individual and environmental strengths and re-sources do you see for Freddie? 4. What behaviors does Ms. Weare exhibit in this situation? 5. Is each behavior you have listed overt or covert?6. What individual and environmental strengths and re-sources do you see for Ms. Weare? 7. List one or more antecedent conditions that seem to bring about each of Freddie's behaviors. 8. List one or more antecedent conditions that seem to bring about each of Ms. Weare's behaviors. 9. List one or more consequences (including any second-ary gains) that influence each of Freddie's behaviors. After each consequence listed, identify how the conse-quence seems to influence Freddie's behavior. 10. List one or more consequences that seem to influence each of Ms. Weare's behaviors. After each consequence listed, identify how the consequence seems to influ-ence her behavior. 11. Identify aspects of the developmental context of the case that impact Freddie and Ms. Weare's situation. 12. Identify aspects of the sociopolitical/cultural context that appear to affect Ms. Weare's behavior. The Case of Mrs. Rodriguez Mrs. Rodriguez is a 34-year-old Mexican American woman who was a legal immigrant to the United States when she was 10 years old. She was brought to the emergency room by the police after her bizarre behavior in a local supermar-ket. According to the police report, Mrs. Rodriguez became very aggressive toward another shopper, accusing the man of “following me around and spying on me. ” When con-fronted by employees of the store about her charges, she stated, “God speaks to me. I can hear his voice guiding me in my mission. ” On mental status examination, the coun-selor initially notes Mrs. Rodriguez's unkempt appearance. She appears unclean. Her clothing is somewhat dishev-eled. She seems underweight and looks older than her stated age. Her tense posture seems indicative of her anx-ious state, and she smiles inappropriately throughout the interview. Her speech is loud and fast, often incoherent, Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 209 and she constantly glances suspiciously around the room. Her affect is labile, fluctuating from anger to euphoria. On occasion, she looks at the ceiling and spontaneously starts talking. When the helper asks to whom she is speaking, she replies, “Can't you hear him? He's come to save me!” Mrs. Rodriguez is alert and appears to be of average gen-eral intelligence. Her attention span is short. She reports no suicidal ideation and denies any past attempts. However, she does express some homicidal feelings for those who “continue to secretly follow me around. ” When the family members arrive, the helper is able to ascertain that Mrs. Rodriguez has been in psychiatric treatment on and off for the past 10 years. She has been hospitalized several times in the past 10 years during similar episodes of unusual behavior. In addition, she has been treated with several antipsychotic medicines. There is no evidence of any physi-cal disorder or any indication of alcohol or drug abuse. Her husband indicates that she recently stopped taking her medicine after the death of her sister and up until then had been functioning adequately during the past year without a great deal of impairment, although she was not capable of holding regular paid employment outside of the home. DSM-5 Diagnosis for Mrs. Rodriguez295. 90 (F20. 9) Schizophrenia, Multiple episodes, cur-rently in acute episode; Severity: 4 (present and severe) V15. 81 (Z91. 19) Nonadherence to medical treatment Respond to these questions. See page 211 for feedback. 1. List several of the behaviors that Mrs. Rodriguez demonstrates. 2. Is each behavior you have listed overt or covert?3. List any individual and environmental strengths and resources you observe. 4. List one or more antecedents that seem to elicit Mrs. Rodriguez's behaviors. 5. List one or more consequences that appear to influ-ence the behaviors, including any secondary gains. Describe how each consequence seems to influence the behavior. 6. Identify aspects of the developmental context of the case that affect her behavior. 7. Identify aspects of the sociopolitical and cultural context that affect her behavior. volunteer answers or go to the board. Often, when called on, she says nothing. As a result, she reports, her grades are dropping. She also states that her math teacher has spoken to her several times about her behavior and has tried to help her do better. However, Isabella's nervousness in the class has resulted in her cutting the class whenever she can find any reason to do so, and also faking illness or oversleeping to stay home from school whenever she can. As a result, she has almost used up her number of excused absences from school. She states that her fear of competitive academic situations has been there since she started high school a year ago, when her parents started to compare her with other students and put “pressure” on her to do well in school so she could go to college. When asked how they pressure her, she says they constantly talk to her about getting good grades and how success is tied to a college degree. Isabella reports a strong network of girlfriends with whom she “hangs out a lot. ” She reports that during this year, since the classes are tougher and more competitive, school is more of a problem to her and she feels increas-ingly anxious. Isabella reports that all this has made her dissatisfied with school, and she has questioned whether she wants to stay in a college prep curriculum. She has toyed with the idea of going to culinary school instead of going to college. However, she says she is a very inde-cisive person and does not know what she should do. In addition, she is afraid to decide this because if she changed her curriculum, her parents' response would be very nega-tive. Isabella states that she cannot recall ever having made a decision without her parents' assistance. She feels they often have made decisions for her. She says her parents have never encouraged her to make decisions on her own because they say she might not make the right decision without their help. Isabella is an only child. She indicates that she is constantly anxious about making a bad or wrong choice so that when she is confronted with deci-sions she feels worried and lacks confidence in her choices. Analysis of the Case There are two related problems for Isabella and these are reflected in our DSM-5 diagnosis. The first is anxiety. Be-cause she reports anxiety about school and about decision-making issues, and because she reports being on edge, lapses in concentration, and sleep disturbances, occurring on more days than not in the last 6 months, as well as other indicators, she shows evidence of a generalized anxiety dis-order. In addition, there is clearly an academic/educational problem that is a focus of attention and in fact the setting where she is seeking help. (Note how these are coded below on the DSM-5 diagnostic classification system). Next, we use the functional assessment/ABC model (Figure 6. 1) presented earlier in the chapter to analyze these two issues. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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210 Chapter 6 Analysis of the Anxiety Issue Relevant Behaviors 1. Feeling “on edge” 2. Lapses in concentration3. T rouble falling asleep Isabella's feelings of edginess are a covert behavior, whereas the lapses in concentration and trouble falling asleep are overt behaviors. Individual and Environmental Strengths These include Isa-bella's help-seeking behavior and teacher and peer support. Context of Issue Antecedent Conditions Isabella's anxiety (feeling on edge, lapses in concentration) regarding school is cued by being in a competitive, college prep curriculum as well as her self-deprecating beliefs about her performance compared to her peers. Her trouble falling asleep is also cued by internal worry and beliefs about her school performance, that is, her “not measuring up. ” Consequences Isabella's anxiety (feeling edgy, lapses in concentration, trouble falling asleep) is maintained by increased teacher attention and avoidance of the school situation (faking illness and oversleeping to stay home). Analysis of the School Issue Relevant Behaviors Isabella's behaviors at school include: 1. Self-defeating labeling of her math class as “competi-tive” and of herself as “not as smart as the guys. ” 2. Sitting alone, not volunteering answers in math class, not answering the teacher's questions or going to the board, and cutting class. Isabella's self-defeating labels are a covert behavior; her sitting alone, not volunteering answers, and cutting class are overt behaviors. Individual and Environmental Strengths These include Isa-bella's help-seeking behavior and the support of her math teacher. Context of Issue Antecedent Conditions Isabella's behaviors at school are cued by certain “competitive” classes, particularly math. Previous antecedent conditions include verbal compari-sons about Isabella and her peers made by her parents and verbal pressure for good grades and withholding of privileges for bad grades by her parents. Notice that these antecedent conditions do not occur at the same time. The antecedent of the anxiety in the competitive class occurs in proximity to Isabella's problem behaviors and is a stimulus event. However, the verbal comparisons and parental pressure began approximately 1 year ago and probably function as a setting event. Consequences Isabella's behaviors at school are maintained by: 1. An increased level of attention to her by her math teacher. 2. Feeling relieved of anxiety through avoidance of the situation that elicits anxiety. By not participating in class and by cutting class, Isabella can avoid putting herself in an anxiety-provoking situation. 3. Her poorer grades, possibly because of two payoffs, or secondary gains. First, if her grades get too low, then she may not qualify to continue in the college prep curriculum. This would be the ultimate way to avoid putting herself in competitive academic situations that elicit anxiety. Developmental Context This part of the assessment ad-dresses the developmental context of the case. In this case, Isabella is 15 and a teenager. Developmentally speaking, teenagers are in the business of identifying with their peer group and separating from the influence of their family, parents, and other caregivers to establish an increased sense of independence. In Isabella's case, you also can see the effects of her being an only child and the parenting style, which appears to be overprotective and authoritarian. Social-Political /Cultural Context This part of the as-sessment addresses the question of how Isabella's pre-senting issues are a manifestation of the social-political context and cultural structure in which she lives. Isabella's concerns appear to be shaped by a context in which she has been reinforced (and punished) for what she does (or doesn't do). This pattern has led to a devalu-ing and uncertainty of who she is and what she wants and needs. She appears to feel powerless in her current environment—partly, we suspect, because of the power her parents have exerted over her, partly because of the power exerted by a school system and academic culture that emphasizes college prep values, and partly because of lessons she has learned from her cultural groups about men, women, and achievement. In her math classroom, the gender context plays a big role. She is literally in the gender minority. She compares herself negatively to the boys in the classroom, who hold the power, and she is shut down by her negative comparison. The relevant Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 211 6. 4 Feedback assessment Models The Case of Ms. Weare and Freddie 1. Freddie's behavior is sitting in his room and not getting ready for school. 2. This is an overt behavior because it is visible to some-one else. 3. Strengths and resources for Freddie include his being smart, doing well in school, and having a mom who be-lieves in him and wants to see him do well academically. 4. Ms. Weare's behaviors are (a) feeling mad and (b) yell-ing at Freddie. 5. Feeling mad is a covert behavior, as feelings can only be inferred. Yelling is an overt behavior that is visible to someone else. 6. Strengths and resources for Ms. Weare include her de-cision to seek help and her decision not to try to cope with this situation alone anymore. 7. Receiving a verbal reminder and threat from his mother at breakfast elicits Freddie's behavior. 8. Ms. Weare's behavior seems to be cued by a 5-minute period before the bus arrives on school days. 9. Two consequences seem to influence Freddie's behav-ior of not getting ready for school: (a) he gets help in dressing himself, and this interaction influences his behavior by providing special benefits; and (b) he gets some satisfaction from seeing that his mother is up-set and is attending to him. These consequences seem to maintain his behavior because of the attention he gets from his mother in these instances. A possible secondary gain is the control he exerts over his mother at these times. According to the case description, he doesn't feel that he gets much attention at other times from his mother. 10. The major consequence that influences Ms. Weare's be-havior is that she gets Freddie ready on time and he is not late. This result appears to influence her behavior by helping her avoid being considered a poor mother by herself or by someone else and by helping him suc-ceed in school. 11. The developmental context impacting this parent-child relational issue involves the recent separation between Ms. Weare and Freddie's father, Ms. Weare's apparent stress about single parenting, and her par-enting style. 12. This parent-child relational issue is undoubtedly af-fected by the fact that Ms. Weare is raising her son alone and appears to be living in a fairly isolated social climate with little social support. She also is the sole economic provider for Freddie, and her behavior and her child rear-ing are affected by her lack of financial resources. Overall, she appears to feel disempowered in her ability to han-dle her parental and financial responsibilities. The Case of Mrs. Rodriguez 1. There are various behaviors for Mrs. Rodriguez: (a) di-sheveled appearance; (b) inappropriate affect; (c) delu-sional beliefs; (d) auditory hallucinations; (e) homicidal ideation; and (f) noncompliance with treatment (medi-cine). 2. Disheveled appearance, inappropriate affect, and non-compliance with treatment are overt behaviors—they are observable by others. Delusions, hallucinations, and homicidal ideation are covert behaviors as long as they are not expressed by the client and therefore not visible to someone else. However, when expressed or demon-strated by the client, they become overt behaviors as well. 3. Strengths and resources include a lack of reported sui-cide ideation and support and care from her extended family. 4. In this case, Mrs. Rodriguez's behaviors appear to be elicited by the cessation of her medication, which is the major antecedent. Apparently, when she stops taking her medicine, an acute psychotic episode results. 5. This periodic discontinuation of her medicine and the subsequent psychotic reaction may be influenced by the attention she receives from the mental health pro-fession, from her family, and even from strangers when she behaves in a psychotic, helpless fashion. Additional possible secondary gains include avoidance of responsi-bility and of being in control. 6. The developmental context of the case that affects her behavior includes the fact that she was an immigrant to the United States when she was 10 years old, her diag-nosis and subsequent psychiatric treatment that began when she was in her early 20s, and the developmental transition of the recent death of her sister. 7. With respect to the sociopolitical/cultural context of the issue, it is important in this case to note the potential influence of the cultural/ethnic affiliations of Mrs. Rod-riguez. Ideas that may seem delusional in one culture may represent a common belief held by many persons in another culture. Delusions with a religious thread may be considered a more typical part of religious experience in a particular culture, such as a sign of “divine favor. ” The skilled helper would take this into consideration in the assessment before settling on a final diagnosis. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
212 Chapter 6 overt and the covert behaviors that we describe appear to be tools Isabella is using to cope with this loss and sense of powerlessness as well as ways to attempt to increase the power she has and decrease the power held by other sources of authority. The DSM-5 diagnoses for Isabella follow: DSM-5 Diagnosis for Isabella 300. 02 (F41. 1) Generalized Anxiety Disorder V62. 3 (Z55. 9) Academic or Educational Problem CHAPTER Su MMARy Assessment is the basis for development of the en-tire helping program. Assessment has important in-formational, educational, and motivational functions in therapy. Although the major part of assessment occurs early in the helping process, to some extent as-sessment, or identification of client concerns, goes on constantly throughout the process. As the assessment unfolds, the client's story unfolds as well. An impor-tant part of assessment is the helper's ability to concep-tualize client concerns. Conceptualization models help the practitioner think clearly about the complexity of client issues. The assessment model described in this chapter is based on several assumptions, including these: 1. Most behavior is learned, although some psychological issues may have biological causes. 2. Neurobiology is an increasingly important consider-ation in clinical assessment. 3. Client issues need to be viewed within a develop-mental context that includes things such as life stage, developmental transitions, family history, parenting style, and attachment. 4. Issues occur in a social and cultural context and in-clude levels or systems and cultural variables impacting individuals' lives. This ecological perspective of clinical assessment, also known as the person-in-environment model, uses an assessment tool known as the PIE clas-sification system. 5. In addition to assessment of client issues, a focus on clients' individual and environmental resources and strengths is also important. 6. Increasingly, clinical assessment is informed by evi-dence and the use of evidence-based assessment tools that have good reliability, validity, and norms or cutoff scores. Such measures also need to be valid for diverse clients. 7. The functional assessment, based on the ABC model, has a considerable amount of empirical support. It involves an analysis of the antecedents, behaviors, and consequences of a client's presenting issue and the func-tional relationships among these three components. Another part of assessment may involve a clinical diagnosis of the client. Current diagnosis is based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, and involves classifying clinical disorders using a dimensional process that reflects the International Clas-sification of Diseases or ICD numerical codes. Diagnosis can be a useful part of assessment. For example, knowl-edge about selected features of various types of clinical syndromes can add to the understanding of a client's con-cern. However, diagnosis is not an adequate substitute for other assessment approaches and is not an effective basis for specifying goals and selecting intervention strategies unless it is part of a comprehensive treatment approach in which issues are identified in a concrete, or operational, manner for each client. Additional diagnostic assessment tools include the mental status exam and structured and semistructured diagnostic interviews. An important part of assessment and diagnosis also in-volves risk assessment of clients, particularly risk or danger to self and others as well as obtaining information about the client's history. Research has shown that both assessment and diagnosis are subject to gender and cultural bias. The skilled practitioner conducts a multidimensional assess-ment process that includes an awareness of the current and historical sociopolitical context in which the client lives and also the client's gender and cultural referent groups. Visit Cengage Brain. com for a variety of study tools and useful resources such as video exam-ples, case studies, interactive exercises, flash-cards, and quizzes. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Assessing and Conceptualizing Client Problems and Contexts 213 6 Knowledge and Skill Builder Assessing and Conceptualizing Client Problems and Contexts 213 Part One For Learning Outcome 1, read the case descriptions of Mr. Huang and then answer the following questions: 1. What are the client's behaviors? 2. are the behaviors overt or covert? 3. What are the client's individual and environmental strengths and resources? 4. What are the antecedent conditions of the client's concern? 5. What are the consequences of the behaviors? Second-ary gains? 6. In what way do the consequences influence the behaviors? 7. How does the developmental context of the issue impact the client's behaviors? 8. In what ways are the behaviors manifestations of the social-political and cultural context? Answers to these questions are provided in the Feedback section on page 214. The Case of Mr. Huang A 69-year-old Asian American man, Mr. Huang, came to coun-seling because he felt his performance on the job was “slip-ping. ” Mr. Huang had a job in a large automobile company. He was responsible for producing new car designs. Mr. Huang re-vealed that he noticed he had started having trouble approx-imately 6 months previously, when the personnel director came in to ask him to fill out retirement papers. Mr. Huang, at the time he sought help, was due to retire in 9 months. (The company's policy made it mandatory to retire at age 70. ) Until this incident with the personnel director and the completion of the papers, Mr. Huang reported, everything seemed to be “okay. ” He also reported that nothing seemed to be changed in his relationship with his family. However, on some days at work, he reported, he had a great deal of trouble completing any work on his car designs. When asked what he did instead of working on designs, he said, “Worry-ing. ” The “worrying” turned out to mean that he was engaging in constant repetitive thoughts about his approaching retire-ment, such as, “I won't be here when this car comes out” and “What will I be without having this job?” Mr. Huang stated that there were times when he spent almost an entire morning or afternoon “dwelling” on these things and that this seemed to occur mostly when he was alone in his office actually working on a car design. As a result, he was not turning in his designs by the specified deadlines. Not meeting his deadlines made him feel more worried. He was especially concerned that he would “bring shame both to his company and to his family who had al-ways been proud of his work record. ” He was afraid that his present behavior would jeopardize the opinion others had of him, although he didn't report any other possible “costs” to himself. In fact, Mr. Huang said that it was his immediate boss who had suggested, after several talks and lunches, that he use the employee assistance program. Mr. Huang said that his boss had not had any noticeable reactions to his missing deadlines, other than reminding him and being solicitous, as evidenced in the talks and lunches. Mr. Huang reported that he enjoyed this interaction with his boss and often wished he could ask his boss to go out to lunch with him. However, he stated that these meetings had all been at his boss's request. Mr. Huang felt somewhat hesitant about making the request himself. In the past 6 months, Mr. Huang had never received any sort of reprimand for missing deadlines on his drawings. Still, he was concerned with maintaining his own sense of pride about his work, which he felt might be jeopardized since he'd been having this trouble. DSM-5 Diagnosis for Mr. Huang309. 24 (F43. 22) Adjustment disorder with anxiety V62. 89 (Z60. 0) Phase of life problem (impending retirement) Part Two Learning Outcome 2 asks you to conduct a role-play history-taking interview with a client. We suggest you complete this part of the knowledge and skill builder by forming triads in your class, with one person being the helper, one being the role-play client, and a third being the observer. Conduct a 30-minute session with one person serving as the helper and the other taking the client's role; the observer should use the outline in Table 6. 4 to provide feedback to the helper at the end of the interview. Switch roles two times so that each person functions as the helper, client, and observer one time each. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
214 Chapter 6 6 Knowledge and Skill Builder Feedback Part One Learning Outcome 1 asks you to identify a series of responses for a designated client case. See if your responses are similar to those provided in the following feedback section. The Case of Mr. Huang 1. Mr. Huang's self-reported behaviors include worry about retirement and not doing work on his automo-bile designs. 2. Worrying about retirement is a covert behavior. Not do-ing work on designs is an overt behavior. 3. Individual and environmental strengths and resources include Mr. Huang's prior job success and the support of his boss and family. 4. One antecedent condition occurred 6 months ago, when the personnel director conferred with Mr. Huang about retirement and papers were filled out. This is an overt antecedent in the form of a setting event. The personnel director's visit seemed to elicit Mr. Huang's worry about retirement and his not doing his designs. a covert antecedent is Mr. Huang's repetitive thoughts about retirement, getting older, and so on. This is a stimulus event. 5. The consequences include Mr. Huang's being excused from meeting his deadlines and receiving extra atten-tion from his boss. 6. Mr. Huang's behaviors appear to be maintained by the consequence of being excused from not meeting his deadlines with only a “reminder. ” He is receiving some extra attention and concern from his boss, whom he values highly. He may also be missing deadlines and therefore not completing required car designs as a way to avoid or postpone retirement—that is, he may expect that if his designs aren't done, he'll be asked to stay longer until they are completed. 7. The anxiety that Mr. Huang is experiencing surround-ing the transition from full-time employment to re-tirement is a fairly universal reaction to a major life change and developmental transition and is an im-portant developmental factor impacting Mr. Huang's behavior. 8. Mr. Huang is also affected by his cultural/ethnic affili-ation in that he is concerned about maintaining pride and honor and not losing face or shaming the two groups he belongs to—his family and his company. Part Two Learning Outcome 2 asked you to conduct a role-play his-tory-taking interview with a client. Your observer used Table 6. 4 to provide feedback to your on your role play. What can you conclude about your skills in conducting history-taking interviews? What are your strong suits? What parts were more challenging for you? What parts did you avoid? Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
215 Conducting an Interview Assessment with Clients Assessment is a way of identifying and defining a client's concerns to make decisions about therapeutic treatment. Various methods are available to help the practitioner identify and define the range and parameters of client issues. These methods include standardized tests, such as interest and personality inventories; psychophysiologi-cal assessment, such as monitoring of muscle tension with chronic headaches with an electromyograph (EMG) machine; self-report checklists, such as assertiveness scales and anxiety inventories; observation by others, including observation by the helper or by a significant person in the client's environment; self-observation, in which the client observes and records some aspect of the issue; imagery, in which the client uses fantasy and directed imagery to vicariously experience some aspect of the issue; role play-ing, in which the client may demonstrate some part of the issue in an in vivo yet simulated enactment; and direct interviewing, in which the client and helper identify con-cerns through verbal and nonverbal exchanges. All these methods are also used to evaluate client progress during the helping process in addition to their use in assessment for the purpose of collecting information about clients. In this chapter we concentrate on direct interview-ing, not only because it is the focus of the book but also because it is the one method readily available to all helpers without additional cost in time or money. It is also a method of assessment that allows the practitioner to observe the client(s) (Hunsley & Lee, 2014). For ex-ample, in interviewing a client you can note things like demeanor, grooming (or lack thereof), activity level, attention span, speech, and other nonverbal behaviors (Gould, Edelstein, & Ciliberti, 2009). In actual practice, it is important not to rely solely on the interview for as-sessment data but rather to use several methods of obtain-ing information about clients. Recall from Chapter 6 that evidence-based assessment involves a decision-making process that targets data from multiple measures with sound psychometric properties (Hunsley & Mash, 2008). Assessment Interviewing According to cognitive-behavioral literature, the interview is the first step in a comprehensive assessment of client is-sues (Sayers & Tomcho, 2006). As Sayers and Tomcho point out, although there are many assessment tools now available to practitioners, the assessment interview is the first step in identifying client problems. They note that guided by the client's concerns, the assessment interview “attempts to discover the relationship between the per-son's environment and his/her individual responses to it” (p. 63). Despite the overwhelming evidence confirming the popularity of the interview as an assessment tool, some persons believe it is the most difficult assessment approach for the helper to enact. Successful assessment Learning Outcomes After completing this chapter, you will be able to 1. When given a written description of a selected client, outline in writing at least two interview leads for each of the 11 assess-ment categories that you would explore during an assessment interview with this person. 2. In a 30-minute role-play interview, demonstrate leads and responses associated with nine out of 11 categories for assessing the client. chapter 7 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
216 Chapter 7 interviews require specific guidelines and training to obtain accurate and valid information from clients that will make a difference in treatment planning (Koven, Shreve Neiger, & Edelstein, 2007; Sayers & Tomcho, 2006). In this chapter we describe a structure and provide some guidelines to apply in assessment interviews to identify and define client issues. This chapter describes interview leads that in applied settings are likely to elicit certain kinds of client information. However, as Sayers and Tom-cho (2006) observe, little research on the effects of inter-view procedures has been conducted. The leads that we suggest are supported more by practical and conceptual considerations than by empirical data. As a result, you will need to be attentive to the effects of using them with each client. Remember, too, that because the clinical assessment interview relies on client self-report, its ac-curacy and reliability are very much dependent on the ac-curacy and veracity of what the client says to the clinician. Eleven Categories for Assessing Clients To help you acquire the skills associated with assessment interviews, we describe 11 categories of information you need to seek from each client. These 11 categories are illustrated and defined in the following list and subsections. These categories are based on the con-ceptual models of assessment we described in Chapter 6. LO2 LO1They reflect the influences of learning, neurobiology, hu-man development, social context and culture, strengths, and evidence. We have interwoven these influences on assessment into our assessment interviewing approach, which is conceptually based on the functional assess-ment and person-in-environment models of assessment we discussed in Chapter 6. These 11 categories are also summarized in the Interview Checklist at the end of the chapter (page 243) and in Box 7. 1. The first three categories—explanation of the purpose of assessment, identification of the range of concerns, and prioritization and selection of issues—are a logical start-ing place. First, it is helpful to give the client a rationale, a reason for conducting an assessment interview, before gathering information. Next, some time must be spent in helping the client explore all the relevant issues and prioritize issues to work on in order of importance, an-noyance, and so on. The other eight categories follow prioritization and selec-tion. After the helper and client have identified and selected the issues to work on, these eight categories of interviewing leads are used to define and analyze parameters of the issue. The helper will find that the order of the assessment leads varies among clients. A natural sequence will evolve in each interview, and the helper will want to use the leads associ-ated with these content categories in a pattern that fits the flow of the interview and follows the lead of the client. It is important in assessment interviews not to impose your structure at the expense of the client. The amount of time and number of sessions required to obtain this information 1. Explanation of purpose of assessment—presenting rationale for assessment interview to the client 2. Identification of range of concerns—using leads to help the client identify all the relevant primary and secondary issues to get the big picture 3. Prioritization and selection of issues—using leads to help the client prioritize issues and select the initial area of focus 4. Identification of present behaviors—using leads to help the client identify the six components of current behavior(s): affective, somatic, behavioral, cognitive, contextual, and relational 5. Identification of antecedents—using leads to help the client identify categories of antecedents and their ef-fect on the current issue 6. Identification of consequences—using leads to help the client identify categories of consequences and their influence on the current issue7. Identification of secondary gains—using leads to help the client identify underlying controlling variables that serve as payoffs to maintain the issue 8. Identification of previous solutions—using leads to help the client identify previous solutions or attempts to solve the issue and their subsequent effect on the issue 9. Identification of client individual and environmental strengths and coping skills—using leads to help the cli-ent identify past and present coping or adaptive be-havior and how such skills might be used in working with the present issue 10. Identification of the client's perceptions of the concern— using leads to help the client describe her or his under-standing of the concern 11. Identification of intensity—using leads and/or client self-monitoring to identify the impact of the concern on the client's life, including (a) degree of severity and (b) frequency and/or duration of current behaviors BOX 7. 1 11 Categories of Assessing Clients Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 217 will vary with the concerns and with clients. It is possible to complete the assessment in one session, but with some clients an additional interview may be necessary. Although the practitioner may devote several interviews to assess-ment, the information gathering and hypothesis testing that go on do not automatically stop after these few ses-sions. Some degree of assessment continues throughout the entire helping process just as the importance of the helping relationship continues throughout this time as well. Category 1. Explaining the Purpose of Assessment In explaining the purpose of assessment, the helper gives the client a rationale for conducting an assessment inter-view. The intent of this first category of assessment is to give the client a set, or an expectation, of what will occur during the interview and why assessment is important to both client and helper. Explaining the purpose of the interview assessment is especially important in cross-cultural helping because culturally based attitudes weigh heavily in a person's expectations about assessment. Here is one way the helper can communicate the pur-pose of the assessment interview: “Today I'd like to focus on some concerns that are bothering you most. To find out exactly what you're concerned about, I'll be asking you for some specific kinds of information. This information will help both of us identify what you'd like to work on. How does this sound [or appear] to you?” After presenting the rationale, the helper looks for some confirmation or indication that the client understands the importance of assessing issues. Also, depending on whether or not this is the initial helping interview (in some places the intake or history interview occurs initially and specific assessment inter-views follow that), the practitioner must obtain informed consent and provide the client with information about privacy and confidentiality and the limits to confiden-tiality. Informed consent is usually accompanied by a written document given to the client at the outset of the helping process and provides information about you, your training, the kinds of services provided, the likely benefits and risks associated with therapy, the Privacy Act and implications for clients, and confidentiality and limits to it. However, the provision of a written informed consent document is not complete without addressing this issue directly with the client in the interview setting. The prac-titioner might say something like the following: Juanita, I know that you read the agreement that we provided to you when you came in today and I wanted to take a few minutes to talk about that before we go further in the session. I wanted to see if you have any questions and I wanted to make sure to emphasize several things in the agreement about confidentiality. Generally speaking, the commitment to maintaining confidentiality means that I do not share what you tell me with anyone outside of the session. However, there are a couple of exceptions to this. If you told me that a child or an elder was being abused, I would need to break confidentiality and report this to the proper authorities. Similarly, if you indicated you were in danger of hurting yourself or hurting someone else, I would also need to break confidentiality and take steps to protect you and/or the other person, which would mean not being able to keep this information between us. Also, if there was ever some kind of a court case, a judge could order me to give testimony or to provide my records. Finally, if you would want me to give information to someone else about yourself, such as another provider, I can do that, but you would need to sign a written authorization form. I know this is a lot to absorb at once, so take a minute to reflect on what I said and what you read and let's make sure you feel clear about this. Here is a sample of what a practicum student could say in the initial interview with a first-time client. This sample was provided by Barry Edelstein, Ph. D. and Wil-liam Fremouw, Ph. D., who are affiliated with the Quin Curtis T raining Center in the Department of Psychology at West Virginia University, Hi (name of client). My name is ______. I am a student who is being supervised by Dr. ______, who is a licensed health care provider. Before we begin discussing your reasons for coming here today, I need to go over a few important points. First, everything you say during our sessions will be held in confidence. However, there are a few exceptions. If I have reason to believe that you are abusing a child, vulnerable adult, or older adult, I am mandated to report that to the Office of Child Protective Services or the Office of Adult Protective Services, respectively. If I have reason to believe that you are at risk for taking your life, I have a duty to protect you. If I have reason to believe that you intend to harm someone else, I have a duty to warn that individual or to ensure that the person is not harmed. My clinical records for you can be subpoenaed by a court to discuss the content of our meetings. This would be rare, but it is important for you to know that it is a possibility. For example, if you were involved in a custody dispute and your fitness as a parent were questioned, then a court could subpoena your records or me. I am also required to submit information about you and your progress to your insurance company if your sessions are being paid for by your insurance company. My supervisor will be informed of your progress and have input into my work with you. If necessary, I may need to solicit a professional consultation to assist in your treatment, but I would discuss this with you. I know this is a lot of information to take in at once, so I am wondering if you have any questions or concerns I can address before we move on. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
218 Chapter 7 Category 2. Identifying the Range of Concerns In this range of concerns category, the practitioner uses open-ended leads to help clients identify all the major issues and concerns in their life now. Often clients will initially describe only one concern, and on further in-quiry and discussion the helper discovers a host of other ones, some of which may be more severe or stressful or have greater significance than the one the client originally described. If the helper does not try to get the big pic-ture, then the client may reveal additional concerns either much later in the helping process or not at all. Here are examples of range-of-concerns leads: “What are your concerns in your life now?” “Please describe some of the things that seem to be bothering you. ” “What are some present stresses in your life?”“What situations are not going well for you?”“Tell me about anything else that concerns you now. ” After using range-of-concerns leads, the practitioner should look for the client's indication of some general areas of concern or things that are troublesome. An occa-sional client may not respond affirmatively to these leads. Some clients may be uncertain about what information to share, or clients may be from a cultural group in which it is considered inappropriate to reveal personal informa-tion to a stranger. In such cases, the helper may need to use an approach different from verbal questioning. For example, Lazarus (1989) has recommended the use of an Inner Circle strategy to help a client disclose concerns. The client is given a picture like this: ABCDE The helper points out that topics in circle A are very per-sonal, whereas topics in circle E are more or less public infor-mation. The helper can provide examples of types of topics likely to be in the A circle, such as sexual concerns, feelings of hostility, intimacy problems, and dishonesty. These ex-amples may encourage the client to disclose personal con-cerns more readily. The helper also emphasizes that progress takes place in the A and B circles and may say things like, “I feel we are staying in circle C,” or, “Do you think you've let me into circle A or B yet?” Sometimes the helper may be able to obtain more specific descriptions from a client by having the client role-play a typical situation. Exploring the range of concerns is also a way to establish who the appropriate client is. A client may attribute the concern to an event or to another person. For instance, a student may say, “That teacher always picks on me. I can never do anything right in her class. ” Because most clients seem to have trouble initially owning their role in the issue or tend to describe it in a way that minimizes their own contribution, the helper will need to determine who is most invested in having it resolved and who is the real person requesting assistance. Often it is helpful to ask clients who feels that it is most important for the concern to be resolved—the client or someone else. It is important for practitioners not to assume that the person who arrives at their office is always the client. The client is the person who wants a change and who seeks assistance for it. In this example, if the student had desired a change and had requested assistance, then the student would be the client; if it were the teacher who wanted a change and requested assistance, then the teacher would be the client. Sometimes, however, the helper gets stuck in a situation in which a family or a client wants a change and the per-son whose behavior is to be changed is sent as the client. Determining who the appropriate client is can be very important in working with these mandated clients, who are required to see a helper but have little investment in being helped! One strategy that can be useful with clients in these situations is to establish a win-win contract where they agree to talk about what you want to discuss for half the session in exchange for talking (or not talking) about what they want to for the other half of the session. The question of who is the appropriate client is also tricky when the issue involves two or more persons, such as a relationship, partnership, or family issue. In reha-bilitation counseling, for example, the client may be not only the individual with a disability but also the client's employer. Many family therapists view family issues as devices for maintaining the status quo of the family and recommend that either the couple or the entire family be involved, rather than one individual. Category 3. Prioritizing and Selecting Issues Rarely do clients or the results of assessment suggest only one area or issue that needs modification or resolution. Typically, a presenting concern turns out to be one of several unresolved issues in the client's life. For example, the assessment of a client who reports depression may also Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 219 reveal that the client is troubled by her relationship with her teenage daughter. History may reveal that this adult woman was also physically abused as a child. After a client describes all of her or his concerns, the practitioner and client will need to select the issues that best represent the client's purpose for seeking help. The primary question to be answered by these leads is, “What is the specific situa-tion the client chooses to start working on?” Prioritizing issues is an important part of assessment and goal-setting. If clients try to tackle too many issues simultaneously, then they are likely to soon feel over-whelmed and anxious and may not experience enough success to stay in therapy. Selection of the issue(s) to ad-dress in the current helping context is the client's respon-sibility, although the helper may help with formulating the client's choice. The following guidelines form a framework to help clients select and prioritize issues to work on: 1. Start with the presenting issue, the one that best repre-sents the reason the client sought help. Leads to use to help determine the initial or presenting issue include, “Which issue best represents the reason you are here?” and, “Out of all these concerns you've mentioned, iden-tify the one that best reflects your need for assistance. ” 2. Start with the issue that is primary or most important to the client to resolve. Often this is the one that causes the client the most pain or discomfort or annoyance or is most interfering to the client. Modifying the more important issues seems to lead to lasting change in that area, which may then generalize to other areas. Here are some responses to use to determine the client's most important priority: “How much happiness or relief would you experience if this issue were resolved?” “Of these concerns, which is the most stressful or painful for you?” “Rank order these concerns, starting with the one that is most important for you to resolve to the one least important. ” “How much distress or loss would you experience if you were unable to resolve this issue?” 3. Start with the concern or behavior that has the best chance of being resolved successfully and with the least effort. Some issues/behaviors are more resistant to change than others and require more time and energy to modify. Initially, it is important for the client to be reinforced for seeking help. One significant way to do this is to help the client resolve something that makes a difference without much cost to the client. Responses to determine what issues might be resolved most suc-cessfully include, “Do you believe there would be any unhappiness or discomfort if you were successful at resolving this concern?” or “How likely do you think we are to succeed in resolving this issue or that one?” or “Tell me which of these situations you believe you could learn to manage most easily with the greatest success. ” 4. Start with the issue that needs resolution before other issues can be resolved or mastered. Sometimes the presence of one issue sets off a chain of other ones; when this issue is resolved or eliminated, the other ones either improve or at least move into a position to be explored and modified. Often this concern is one that is central or prominent in the range of elicited ones. 5. Giving mandated clients the responsibility for pri-oritization of concerns is particularly important. This choice allows them to set the agenda and may foster greater cooperation than clinician-directed prioritiza-tion of concerns. Category 4. Understanding the Present Behaviors After selecting the initial area of focus, it is important to determine the components of the present behavior. For example, if the identified behavior is “not getting along very well with people at work,” with an expected outcome of “improving my relationships with people at work,” we would want to identify the client's feelings (affect), body sensations ( somatic phenomena), actions (overt behavior), and thoughts and beliefs ( cognitions) that occur during the situations at work. We would also explore whether these feelings, sensations, actions, and thoughts occurred with all people at work or only with some people (relationships) and whether they occurred only at work or in other settings, at what times, and under what conditions or with what concurrent events (context). Without this sort of exploration, it is impos-sible to define the behavior operationally (concretely). Furthermore, it is difficult to know whether the client's work concerns result from the client's actions or observ-able behaviors, from covert emotional responses such as feelings of anger or jealousy, from cognitions and beliefs such as, “When I make a mistake at work, it's terrible,” from the client's transactions with significant others that suggest an “I'm not okay—they're okay” position, from particular events that occur in certain times or situations during work, as during a team meeting or when working under a supervisor, or from toxic people or environmental conditions in the workplace. Recall from Haynes et al. (2011) that problem behaviors have multiple response modes and that these modes or com-ponents may shift over the course of therapy. This un-derscores the fact that assessment is an ongoing rather than a one-shot process! Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
220 Chapter 7 The advantage of viewing the problem this way is that vague phenomena are translated into specific and observable experiences. When this occurs, we not only get a better idea of what is happening with the client but also have made the issue potentially measurable, allowing us to define potential outcomes and monitor treatment progress toward the outcomes. The end result of this kind of specificity is that the behavior is defined or stated in terms such that two or more persons can agree on when it exists. We next describe specific things to explore for each of these six components, and we suggest some leads and responses to further this exploration with clients. a. Affect and Mood States Affective components of be-havior include self-reported feelings or mood states, such as “depression,” “anxiety,” and “happiness. ” Feelings are generally the result of complex interactions among be-havioral, physiological, and cognitive systems rather than unitary experiential processes. Clients often seek help be-cause of this component—that is, they feel bad, uptight, sad, angry, confused, and so on, and they want to get rid of such unpleasant feelings. One category of things to ask the client about to get a handle on feelings or mood states is feelings about the present behavior. After eliciting feelings, note the content (pleasant/unpleasant) and level of intensity. Remember that positive feelings are as important to identify as nega-tive ones, because they build resources, enhance creative problem-solving, increase coping skills, and enhance health (Lopez, Pedrotti, & Snyder, 2014). Although there are many ways to assess for content and level of intensity of affect, one simple way is to use a rating scale, such as the Subjective Units of Distress Scale (SUDS; Wolpe, 1990), with a 1-10 or a 0-100 range to assess intensity. The SUDS asks clients to provide a numerical rating ranging from no distress (1 or 0) to the most distress pos-sible (10 or 100). Example interview leads to assess positive and negative effects include the following: “How do you feel about this?” “What kinds of feelings do you have when you do this or when this happens?” “Describe the kinds of feelings you are aware of when this happens. ” “Describe the positive feelings you have associated with this. Also, describe the negative ones. ” “On a 10-point scale, with 1 being low and 10 being high, how intense is this feeling?” “If the number 0 represented no distress, and the number 100 represented severe distress, how would you rate the feeling on this scale of 0 to 100 in terms of intensity?”A second category is concealed or distorted feelings— that is, feelings that the client seems to be hiding from, such as anger, or a feeling like anger that has been dis-torted into hurt. The following are example responses: “You seem to get headaches every time your husband criti-cizes you. Describe what feelings these headaches may be masking. ” “When you talk about your son, you raise your voice and get a very serious look on your face. What feelings do you have—deep down—about him?” “You've said you feel hurt and you cry whenever you think about your family. T une in to any other feelings you have besides hurt. ” “You've indicated you feel a little guilty whenever your friends ask you to do something and you don't agree to do it. T ry on resentment instead of guilt. T ry to get in touch with those feelings now. ” The practitioner can always be on the lookout for con-cealed anger, which is the one emotion that tends to get shoved under the rug more easily than most. In exploring concealed feelings, the clinician needs to pay attention to any discrepancies between the client's verbal and non-verbal expressions of affect. Distorted feelings that are common include reporting the feeling of hurt or anxiety for anger, guilt for resentment, and sometimes anxiety for depression, or vice versa. Remember that clients from some cultures may be reluctant to share feelings, especially vulnerable ones, with someone they don't yet know well or trust. b. Somatic Sensations Closely tied to feelings are body sensations. Some clients are very aware of “internal ex-periencing”; others are not. Some persons are so tuned in to every body sensation that they become somatizers, whereas others seem to be switched off below the head (Lazarus, 1989). Neither extreme is desirable. Some per-sons may describe complaints in terms of body sensations rather than as feelings or thoughts—that is, as headaches, dizzy spells, back pain, and so on. Older adults with anxiety issues, for example, may present with more so-matic symptoms than younger adults (Gould, Edelstein, & Ciliberti, 2009). Behavior can also be affected by other physiological processes, such as nutrition and diet, ex-ercise and lifestyle, substance use, hormone levels, and physical illness. The helper will want to elicit informa-tion about physiological complaints, about lifestyle and nutrition, exercise, substance use, and so on, and about other body sensations relating to the behavior. Some of this information is gathered routinely during the health history portion of the intake interview, but bear in mind Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 221 that the information obtained from a health history may vary depending on the client's cultural affiliation. Helpers can ask clients who have trouble reporting somatic sensa-tions to focus on their nonverbal behavior or to engage in a period of slow, deep breathing and then to conduct a body scan, that is, a visualization from head to toe of where they may be experiencing sensations or discomfort in the body. Useful leads to elicit this component of the present behavior include: “What goes on inside you when you do this or when this happens?” “What are you aware of when this occurs?” “Notice any sensations you experience in your body when this happens. ” “When this happens, describe anything that feels bad or uncomfortable inside you—aches, pains, dizziness, and so on. ” c. Overt Behaviors or Motoric Responses Clients often de-scribe a behavior in very nonbehavioral terms. In other words, they describe a situation or a process without describing their actions or specific behaviors within that event or process. For example, clients may say, “I'm not getting along with my partner” or “I feel lousy” or “I have a hard time relating to authority figures,” without specify-ing what they do to get along or not get along or to relate or not relate. When inquiring about the behavioral domain, the helper will want to elicit descriptions of both the presence and the absence of concrete overt behaviors connected to the issue—that is, what the client does and doesn't do. The helper also needs to be alert to the presence of behavioral excesses and deficits. Excesses are things that the person does too much or too often or that are too extreme, such as binge eating, excessive crying, or assaultive behavior. Deficits are responses that occur too infrequently or are not in the client's repertory or do not occur in the expected context or conditions, such as fail-ure to initiate requests on one's behalf, inability to talk to one's partner about sexual concerns and desires, or lack of physical exercise and body conditioning programs. Again, it is important to keep a cultural context in mind here: what might be considered a behavioral excess or deficit in one culture may be different in another. The helper may also wish to inquire about “behavioral opposites” (Lazarus, 1989) by asking about times when the person does not behave that way. This is important because you are balancing the assessment interview by focusing on what the client does well, not just on the problematic behaviors. Prosocial behaviors are as important to assess as nonsocial ones. Here are examples of leads to elicit in-formation about overt behaviors and actions: “Describe what happens in this situation. ” “What do you mean when you say you're 'having trouble at work'?” “What are you doing when this occurs?”“What do you do when this happens?”“What effect does this situation have on your behavior?”“Describe what you did the past few times this occurred. ”“If I was recording this scene, what actions and dialogue would the camera pick up?” Occasionally the practitioner may want to supplement the information gleaned about behavior from the client's oral self-report with more objective assessment approaches, such as role plays and behavioral observations. These ad-ditional assessment devices will help practitioners improve their knowledge of how the client does and doesn't act in the situation and in the environmental setting. d. Cognitions, Beliefs, and Internal Dialogue In the past few years, helpers of almost all orientations have empha-sized the relative importance of cognitions or symbolic processes in contributing to, exacerbating, or improving situations that clients report. Unrealistic expectations of oneself and of others are often related to presenting issues, as are disturbing images, self-labeling and self-statements, and cognitive distortions. When the cognitive component is a very strong element of the concern, part of the result-ing treatment is usually directed toward this component and involves altering unrealistic ideas and beliefs, cogni-tive distortions and misconceptions, and dichotomous thinking. Assessment of the cognitive component is accordingly directed toward exploring the presence of both irrational and rational beliefs and images related to the identified issue. Irrational beliefs will need to be altered later. Ratio-nal beliefs are also useful during intervention. Remember, though, that cognitions and belief systems may be quite culturally specific. Irrational beliefs take many forms, and the most dam-aging ones seem to be related to automatic thoughts or self-statements and maladaptive assumptions such as “shoulds” about oneself, others, relationships, work, and so on, “awfulizing” or “catastrophizing” about things that don't turn out as we expect, “perfectionistic standards” about ourselves that often are projected onto others, and “externalization,” the tendency to think that out-side events are responsible for our feelings and problems. The practitioner will also want to be alert for the pres-ence of cognitive distortions and misperceptions, such Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
222 Chapter 7 as overgeneralization, exaggeration, and drawing conclu-sions without supporting data. Underlying these auto-matic thoughts and assumptions are cognitive schemas. A schema is a deep-seated belief about oneself, others, and the world that takes shape in the client's early develop-mental history and confirms the client's core beliefs about himself or herself, others, and the world. For example, depressed or anxious clients often focus selectively on cog-nitive schemas that reinforce their vulnerabilities (Leahy, Holland, & Mc Ginn, 2011). Although clients may have difficulty verbalizing spe-cific cognitions and beliefs, their nonverbal cues may be important indicators that core beliefs and schemas are being activated in the assessment process. Linscott and Di Giuseppe (1998) note that when the therapist has touched on a core-disturbed belief system, the client will frequently exhibit emotional and behavioral reactions. The client who was previously actively engaged in the conversation with the therapist may abruptly begin to avoid the therapist's questions, make little eye contact, evidence disturbed facial expressions, and work to change the subject. Or the client may become enlivened, as if a light bulb has been illuminated by the therapist's inquiries... In addition, the client's sudden anger and confrontational arguments with the therapist may also signal that a core belief has been elicited. (p. 117) Leads to use to assess the cognitive component include the following: “What beliefs [or images] do you hold that contribute to this concern? Make it worse? Make it better?” “When something doesn't turn out the way you want or expect, how do you usually feel?” “What data do you have to support these beliefs or assumptions?” “What are you thinking about or dwelling on when this [issue] happens?” “Please describe what kinds of thoughts or images go through your mind when this occurs. ” “Notice what you say to yourself when this happens. ” “What do you say to yourself when it doesn't happen [or when you feel better, and so on]?” “Let's set up a scene. You imagine that you're starting to feel a little upset with yourself. Now run through the scene and relate the images or pictures that come through your mind. Tell me how the scene changes [or relate the thoughts or dialogue—what you say to yourself as the scene ensues]. ” “What are your mental commentaries on this situation?”“What's going through your mind when ______ occurs? Can you recall what you were thinking then?”e. Context: Time, Place, Concurrent Events, and Environment Behaviors occur in a social context, not in a vacuum. What often makes a behavior a “problem” is the context surrounding it or the way it is linked to various situations, places, and events. This is at the heart of the person- in-context or person-in-environment assessment ap-proach. For example, it is not a problem to undress in your home, but the same behavior on a public street in many countries would be called “exhibition-ism. ” In some other cultures, this same behavior might be more commonplace and would not be considered abnormal or maladaptive. Looking at the context sur-rounding the issue has implications not only for assess-ment but also for intervention, because a client's cultural background, lifestyle, and values can affect how the cli-ent views the issue and also the treatment approach to resolve it. Assessing the context surrounding the issue is also important because most issues are situation-specific—that is, they are linked to certain events and situa-tions, and they occur at certain times and places. For example, clients who say, “I'm uptight” or “I'm not assertive” usually do not mean they are always uptight or nonassertive, but rather in particular situations or at particular times. It is important that the helper does not reinforce the notion or belief in the client that the feeling, cognition, or behavior is pervasive. Otherwise, clients are even more likely to adopt the identity of the “problem” and begin to regard themselves as possessing a particular trait such as “nervousness,” “social anxi-ety,” or “nonassertiveness. ” They are also more likely to incorporate this trait into their lifestyles and daily functioning. In assessing contextual factors associated with the issue, you are interested in discovering: 1. Situations or places in which the issue usually occurs and situations in which it does not occur (where the issue occurs and where it does not). 2. Times during which the issue usually occurs and times during which it does not occur (when the issue occurs and when it does not). 3. Concurrent events—events that typically occur at or near the same time as the issue. This information is important because sometimes it suggests a pattern or a significant chain of events related to the issue that clients might not be aware of or may not report on their own. 4. Any cultural, ethnic, and racial affiliations, any par-ticular values associated with these affiliations, and how Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 223 these values affect the client's perception of the issue, the client's worldview, and the client's view of change. 5. Sociopolitical factors—that is, the overall zeitgeist of the society in which the client lives, the predominant social and political structures of this society, the major values of these structures, who holds power in these structures, and how all this affects the client. Here are example responses to elicit information about contextual components of the issue—time, place, and concurrent events: “Describe some recent situations in which this issue oc-curred. What are the similarities in these situations? In what situations does this usually occur? Where does this usually occur?” “Describe some situations when this issue does not occur. ”“Can you identify certain times of the day [week, month, and year] when this is more likely to happen? Less likely?” “Does the same thing happen at other times or in other places?” “What else is going on when this problem occurs?”“Describe a typical day for me when you feel 'uptight. '”“Are you aware of any other events that normally occur at the same time as this issue?” Assessing the context surrounding the client's problems includes exploring not only the client's immediate psy-chosocial environment but also wider environmental con-texts such as cultural affiliation and community (Ungar, 2011). Part of your intervention approach often involves helping clients to feel more empowered to act on their own behalf in their environment. Typically, the kinds of environmental systems you assess for during the inter-view include ones such as neighborhood and community, institutions and organizations, socio-cultural-political systems, and person-family support networks. The last one—social networks—is discussed in the next section on relational aspects of the issue. Within each system, it is important to assess the extent to which the system adds to the client's concerns—as well as the availability of resources within the system to help the client resolve the concerns. Remember that environments can be for better and for worse. A frequently used tool for assessing context and en-vironment is the ecomap (see Figure 7. 1). The ecomap was originally developed by Hartman as a paper-and-pencil assessment tool to map the ecological system of an individual client or a family (Hartman, 1979; 1994). Preliminary data on the ecomap as an evidence-based assessment tool are provided by Calix (2004). An ecomap is a useful visual tool used to supplement the interview leads in a way that helps assess and define the interrelationships between individual clients and their families and other systems (Hepworth et al., 2013). An advantage of the ecomap is that it can be used with individuals, families, groups, and even organizations (Seabury, Seabury, & Garvin, 2011). To complete an ecomap, the client writes his or her name or “me” in a circle in the center of a piece of pa-per. Then, the client identifies and encircles the people, groups, and organizations that are part of his or her current environment—work, day care, family, friends, community groups, religion, school, cultural groups, and so on. These circles can be drawn in any size, and the size may indicate the influence or lack of influence of that environmental system in the client's life. Next, the client draws a series of lines to connect his or her personal circle to the other circles. The type of line that the client draws indicates the client's view of the quality of the relationship with each system. Typically a client is instructed to use solid lines to link his or her own circle to the circles that represent something positive or a strong connection, and to use broken lines to link to circles that represent some-thing negative or a stressful connection. Finally, the client draws wavy lines to the circles that represent something that he or she needs but is not available. After completing the ecomap, the practitioner can use interview leads like the following ones to complete the Figure 7. 1 Sample Ecomap Source: From Hepworth, Rooney, Rooney, & Strom-Gottfried, Brooks/Cole Empowerment Series: Direct Social Work Practice, 9 ed. Copyright 2013 by Cengage Learning. Reproduced by permission. www. cengage. com/permissions Client Family Extended family School Work Recreation Culture and religion Community Friends Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
224 Chapter 7 picture about the environmental events surrounding the client's concerns: “Describe the relationship between yourself and all these systems and structures in your current environment. ” “How do you experience your current environment? How has this experience been affected by your gender, race, ethnicity, income status, and so on?” “What is the relationship between you and these larger systems in your ecomap? What has this relationship been like so far in your life? How has this affected your current concerns?” “Do you feel that you need stronger or closer relation-ships with any of these larger systems in your ecomap? If so, what has made it difficult for these relationships to develop?” “How would you describe the sociopolitical and socio-economic environment you are in? How has it affected your concerns?” “How much has your concern been affected by oppression, prejudice, and discrimination in your environment?” “How has your environment fostered empowerment? Or disempowerment? How has this affected the concerns you are bringing to me?” “Does your environment have a primary story associated with it? If so, could you give this story a title, and what would it be?”* To familiarize yourself with assessing an individual in relationship to her or his environment, complete Learning Activity 7. 1. f. Relationships, Significant Others, and Social Support Just as issues are often linked to particular times, places, events, and environmental conditions, they are also often connected to the presence or absence of other people. *Adapted from Kemp, Whittaker, & T racy, 1997, pp. 103-106 and Ungar, 2011, p. 206. People around the client can bring about or exacerbate a concern. Someone temporarily or permanently absent from the client's life can have the same effect. Assessing the client's relationships with others is a significant part of many theoretical orientations to counseling, including dynamic theories, Adlerian theory, family systems theory, and behavioral theory. Interpersonal issues may occur because of a lack of significant others in the client's life, because of the way the client relates to others, or because of the way sig-nificant others respond to the client. Consider the role of other people in the development of Mario's school phobia: Mario, a 9-year-old new arrival from Central America, had moved with his family to a homogeneous neighborhood in which they were the first Spanish-speaking family. Consequently, Mario was one of the few Latino children in his classroom. He soon developed symptoms of school phobia and was referred to an outpatient mental health clinic. A clinician sensitive to cultural issues chose to work very closely with the school, a decision that facilitated access for Mario to a bicultural, bilingual program. The clinician also realized that Mario was a target of racial slurs and physical attacks by other children on his way to and from school. The school responded to the clinician's request to address these issues at the next parent-teacher conference. With the ongoing support of a dedicated principal, Mario's symptoms abated, and he was able to adjust to his new environment (Canino & Spurlock, 2000, p. 74). Other persons involved in the issue often tend to dis-count their role in it. It is helpful if the practitioner can get a handle on what other persons are involved in the issue, how they perceive the issue, and what they might have to Learning Activity 7. 1 Ecomaps 1. Using the ecomap format in Figure 7. 1, draw a circle representing yourself in the middle of a piece of paper, and around that circle list the systems that are part of your current environment—for example, work, school, family, friends, religion and cultural groups, community groups, recreation, and ex-tended family. 2. Around each system draw circles of varying sizes to indicate the degree of influence of that environmental system in your life. 3. Draw a solid line from your circle to any circles that represent systems with which your connection is posi-tive or strong. 4. Draw a broken line from your circle to any circles that represent systems with which your relationship is stressful or negative. 5. Draw a wavy line from your circle to any circles that represent systems that you need but are not available to you. 6. Look over your ecomap. What conclusions can you draw? You may wish to share your conclusions with a classmate. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 225 gain or lose from a change in the issue or the client. As Gambrill (2012) observes, such persons may anticipate negative effects of improvement in an issue and covertly try to sabotage the client's best efforts. For example, a hus-band may preach “equal pay and opportunity” yet secretly sabotage his wife's efforts to move up the career ladder for fear that she will make more money than he does or that she will find her new job opportunities more interesting and rewarding than her relationship with him. Other people can also influence a client's behavior by serving as role models. People whom clients view as significant to them can often have a great motivational effect on clients in this respect. An important aspect of the relational context of the client's concern has to do with availability and access to re-sources in the client's social and interpersonal environment, including support from immediate and extended family, friends, neighbors, and people affiliated with the client in work, school, and community organizations. Remember that purposeful, positive relationships are just as important to identify as problematic ones (Lopez, Pedrotti, & Snyder, 2014). As Hepworth and colleagues (2013) point out, social support systems are being recognized increasingly as having a critical role in a client's level of functioning by meeting a variety of client needs such as attachment, belonging, nurturing, physical care, validation, and so on. These authors contend that certain kinds of clients are in particular need of social and relational support: the elderly, abused or neglected children, teenage parents, persons with AIDS, widows and widowers, persons and families with severe mental illness, the terminally ill and their caregiv-ers, persons with disabilities, and persons who experience dislocation as refugees and immigrants (p. 239). One specific tool that can supplement the interview leads to understanding about a client's social support system is the genogram. Similar to the ecomap tool, the genogram is a useful visual tool to use in the assessment of interactional patterns with clients and those in their environments. The genogram originated with Bowen's (1961) family therapy approach and has been further de-veloped by Mc Goldrick (2011) and Mc Goldrick, Gerson, and colleagues (Mc Goldrick, Gerson, & Shellenberger, 1999; Gerson, Mc Goldrick, & Petry, 2008). The geno-gram shows in a visual way the kinds of relationships and patterns of relationships within a client's family sys-tem. It is a tool to help clients obtain better information about the relationships and interactional patterns in their families across generations (usually three generations), especially repetitive patterns that are emotional in nature. The point of the genogram, however, is not to draw a work of art that necessarily follows a standardized format but to obtain and assess information about interactional patterns within the client's family history that will shed light on assessing relational aspects of the client's current issues. (Specialized genograms that focus on additional areas of interest such as attachment, spirituality, and cul-ture are also available). In typical genogram diagramming, symbols for males are drawn with squares and symbols for females are drawn with circles. Computer software for both genograms and ecomaps is available at www. genogramanalytics. com. We present a sample genogram with basic instructions in Figure 7. 2. (For more detailed information about genograms, consult the sources we list and see also Learning Activity 7. 2). Example leads for assessing the relational component of the issue include the following: “Tell me about the effects this issue has on your relation-ships with significant others in your life. ” “What effects do these significant others have on this concern?” “Who else is involved in this issue besides you? How are these persons involved? What would their reaction be if you resolved this issue?” “From whom do you think you learned to act or think in this way?” “Describe the persons present in your life now who have the greatest positive impact on you. Negative impact?” “Describe the persons absent from your life who have the greatest positive impact on you. Negative impact?” “What types of social support do you have available in your life right now—too much support or too little?” “Who do you think you need in your life right now that isn't available to you?” “Who are the main people in this social support system?”“Which of these people are there for you? Which of these people are critical of you?” “What people and social support systems in your life em-power you? Disempower you?” “What things get in your way of using these social support systems and the effective people in them?” “What people in your life are nourishing to you? Toxic or depleting to you?” “What people in your life do you look up to? What quali-ties do they have that help you in your current situation?” Category 5. Identifying Antecedents Antecedents are certain events that happen before and con-tribute to an issue. Much of the assessment process consists of exploring contributing variables that precede and cue the issue (antecedents) and things that happen after the issue (consequences) that in some way influence or maintain it. Recall that antecedents have to be identified for each behav-ioral issue the client presents (Haynes et al., 2011). Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
226 Chapter 7 Kenneth 1933-(Teacher, known as isolatedfrom others. Jewish,2nd-generation in U. S. )Marcia 1935-(Housewife, raisedin poverty. Jewish,1st-generationin U. S. )George 1927-(Electrician, quiet, sought to “get along,” 2nd-generation German American, Catholic)Fay 1930-1980(Housewife,alternately warmand cold, died ofalcoholism,6th-generation British American,Presbyterian) Jane 1955-(Divorced twice, suspected of having drinking problems)Harold 1952-(Carpenter, perfectionist held his family of origin together, demanding of others)Anne 1955-(Teacher, manyclose friends,breast cancerat age 30)Norman, 1957-(Accountant, isolated from others) Example of family genogram Nathan, 1983-(Quiet, doing exceptionally well in school)Joan 1985-(Withdrawn, angry, few friends, doing poorly in school)Married 1983Married 1955 Married 1955 Male Female Close Enmeshed Estranged Distant Con/f_lictual Separated Basic relationship symbols Figure 7. 2 Sample Genogram Adapted from Intentional Interviewing and Counseling: Facilitating Client Development in a Multicultural Society, 7 ed., by A. E. Ivey, M. B. Ivey, & C. P. Zalaquett, p. 276. Copy-right 2010 by Cengage Learning. Reprinted by permission. 1. List the names of the client's family members for at least three generations with dates of birth and death (if applicable), cause of death, occupations, significant illness, and any substance abuse issues. 2. List important cultural/environment/contextual issues including ethnic identity, race, religion, economic, and social class factors. List significant developmental transitions and roles and life events such as divorce, trauma, loss, and so on. 3. Basic relationship symbols are shown as well as a sample genogram diagram. Remember that, like behaviors, antecedents (and consequences) are varied and may be affective, somatic, behavioral, cognitive, contextual, or relational. Further, antecedents (and consequences) are likely to differ for each client. Antecedents are both external and internal events that occasion or cue the behaviors and make them more or less likely to occur. Some antecedents occur immediately before (stimulus events); other antecedents (setting events) may have taken place a long time ago, but it is identification of the contiguous antecedents that is most useful because these are more likely to exert impor-tant triggering effects on the client's problem behaviors (Haynes et al., 2011). In helping clients explore antecedents, you are par-ticularly interested in discovering: (1) what current condi-tions (covert and overt) exist before the issue that make it more likely to occur; (2) what current conditions (covert and overt) exist that occur before the issue that make it less likely to occur; and (3) what previous conditions, or setting events, exist that still influence the issue. Example leads for identifying antecedents follow and are grouped by category: Affective “What are you usually feeling before this happens?”“When do you recall the first time you felt this way?”“Describe the feelings that occur before the issue and make it stronger or more constant. ” “Identify the feelings that occur before the issue that make it weaker or less intense. ” “Tell me about any holdover feelings or unfinished feelings from past events in your life that still affect this issue. For Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 227 example, can you recall events in your childhood associ-ated with this particular feeling?” Somatic “Notice what goes on inside you just before this happens. ”“Are you aware of any particular sensations in your body before this happens?” “Describe any body sensations that occur right before this issue that make it weaker or less intense. Stronger or more intense?” “Is there anything going on with you physically—an illness or physical condition—or anything about the way you eat, smoke, exercise, and so on, that affects or leads to this issue?” Behavioral “If I were recording this, describe the actions and dialogue the camera would see before this happens. ” “Identify any particular behavior patterns that occur right before this happens. ” “What do you typically do before this happens?”“Can you think of anything you do that makes this more likely to occur? Less likely to occur?” “What was the very first specific thing that happened that started this whole chain of events for you?” Cognitive “What kinds of pictures or images do you have before this happens?” “What are your thoughts before this happens?”“What are you telling yourself before this happens?”“Identify any particular beliefs that seem to set the issue off. Now recall the events in your childhood associated with that particular belief. ”“Describe what you think about [see or tell yourself] before the issue occurs that makes it stronger or more likely to occur. Weaker or less likely to occur?” Contextual “Has this ever occurred at any other time in your life? If so, describe that. ” “How long ago did this happen?”“Where and when did this occur the first time?”“Describe how you see those events related to your concern. ”“Tell me about anything that happened that seemed to lead up to this. ” “When did the issue start—what else was going on in your life at that time?” “What were the circumstances under which the issue first occurred?” “What was happening in your life when you first noticed this?” “Are you aware of any events that occurred before this issue that in some way still influence it or set it off?” Relational “Can you identify any particular people who seem to bring on this issue?” “Who are you usually with right before or when this occurs?” “Are there any people or relationships from the past that still influence or set off or lead to this issue in some way?” Category 6. Identifying Consequences Consequences are external or internal events that influence the current problem by maintaining it, strengthening or increasing it, or weakening or decreasing it. Consequences occur after the problem and are distinguished from results Learning Activity 7. 2 Genograms 1. Using the genogram format found in Figure 7. 2, list the names of your family members for three generations. Include ages, dates of birth, and dates of death. List cause of death if known. List occupa-tions, notable illnesses, and any substance abuse issues. 2. List important relational and contextual issues as well as significant life events. 3. Using the symbols displayed in Figure 7. 2, draw the genogram to reflect males and females and the kinds of relationships among the family members ranging from close to separated. 4. Examine your genogram and, perhaps with a partner or in a small group, explore the following questions: What behavioral patterns have occurred and recurred in your family system that have persisted throughout several generations? For example, do you see recurring patterns of victimization, domestic violence, suicide, substance abuse, discrimination? What are the predominant cultural and spiritual beliefs that have persisted in your family system throughout generations? Can you determine any patterns of coping used in vari-ous generations to deal with tragedies, developmental transitions, and stressful life events? Adapted from Ivey, Ivey, and Zalaquett (2014) and Seabury, Seabury, and Garvin (2011). Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
228 Chapter 7 or effects by the fact that they have direct influence by either maintaining or decreasing the problem behaviors in some way. As Haynes et al. (2011) remind us, it is the contigu-ous consequences that are more likely to exert maintaining effects on the client's problem behaviors. Remember, too, that consequences need to be identified for each behavioral issue the client presents (Haynes et al., 2011). In helping clients explore consequences, you are inter-ested in discovering both internal and external events that maintain and strengthen the undesired behavior and also events that weaken or decrease it. Example leads for iden-tifying consequences follow and are grouped by category: Affective “How do you feel after ______?”“How does this feeling affect the issue (for example, keep it going, stop it)?” “Describe any particular feelings or emotions that you have after it that strengthen or weaken it. ” Somatic “What are you aware of inside you just after this happens? How does this affect you?” “Note any body sensations that seem to occur after the issue that strengthen or weaken it. ” “Is there anything you can think of about yourself physi-cally—illnesses, diet, exercise, and so on—that seems to occur after this? How does this affect it?” Behavioral “What do you do after this happens, and how does this make the issue worse? Better?” “How do you usually react after this is over? In what ways does your reaction keep the issue going? Weaken it or stop it?” “Identify any particular behavior patterns that occur af-ter this. How do these patterns keep the issue going? Stop it?” What happens afterward that helps you avoid or escape from the problem?” Cognitive “What do you usually think about afterward? How does this affect the issue?” “What do you picture after this happens?”“What do you tell yourself after this occurs?”“Identify any particular thoughts [or beliefs or self-talk] during or after the issue that make it better. Worse?” “Tell me about any certain thoughts or images you have afterward that either strengthen or weaken the issue. ”Contextual “What happened after this?”“When does the issue usually stop or go away? Get worse? Get better?” “Where are you when the issue stops? Gets worse? Gets better?” “Identify any particular times, places, or events that seem to keep the issue going. Make it worse or better?” Relational “Can you identify any particular people who can make the issue worse? Better? Stop it? Keep it going?” “Can you identify any particular reactions from other people that occur after the issue? In what ways do these reactions affect the issue?” Category 7. Identifying Secondary Gains: A Special Case of Consequences Occasionally clients have a vested interest in maintaining the status quo of the concern because of the payoffs that the issue produces. For example, a client who is overweight may find it difficult to lose weight, not because of unalterable eating and exercise habits but because the extra weight has allowed him to avoid or escape such things as new social situations or sexual relationships and has produced a safe and secure life-style that he is reluctant to give up. A child who is constantly disrupting her school classroom may be similarly reluctant to give up such disruptive behavior even though it results in loss of privileges because it has given her the status of “class clown,” resulting in a great deal of peer attention and support. It is always extremely important to explore with clients the payoffs, or secondary gains, they may be getting from having the issue, because often during the interven-tion phase such clients seem resistant. In these cases, the resistance is a sign the payoffs are being threatened. The most common payoffs include money, attention from sig-nificant others, immediate gratification of needs, security, control, and avoidance of responsibility. Questions you can use to help clients identify possible secondary gains include these: “The good thing about ______ is... ” “What happened afterward that was pleasant?”“What was unpleasant about what happened?”“Has your concern ever produced any special advantages or considerations for you?” “As a consequence of your concern, have you gotten out of or avoided things or events?” “Please describe the reactions of others when you do this. ”“How does this issue help you?” Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 229 “What do you get out of this situation that you don't get out of other situations?” “Do you notice anything that happens afterward that you try to prolong or to produce?” “Do you notice anything that occurs afterward that you try to stop or avoid?” Category 8. Exploring Previous Solutions Another important part of the assessment interview is to explore previous solutions, or what things the client has already attempted to resolve the concern and with what ef-fect. This information is important for two reasons. First, it helps you to avoid recommendations for resolutions that amount to more of the same. Second, in many instances, solutions attempted by the client either create new con-cerns or make the existing concern worse. Leads to hep the client identify previous solutions include the following: “How have you dealt with this or other concerns before? What was the effect? What made it work or not work?” “Tell me about how you have tried to resolve this concern. ” “What kinds of things have you done to improve this situ-ation?” “Describe what you have done that has made the concern better. Worse? Kept it the same?” “What have others done to help you with this?”“What has kept the issue from getting worse?” Category 9. Identifying the Client's Coping Skills, Individual and Environmental Strengths, and Resources When clients come to helpers, they usually are in touch with their pain and often only with their pain. Conse-quently, they are short-sighted and find it hard to be-lieve that they have any internal or external coping skills, strengths, and resources that can help them deal with the pain more effectively. In the assessment interview, it is useful to focus not only on the issues and pains but also on the person's positive assets and resources that the pain may mask (Sayers & Tomcho, 2006). This sort of focus is the primary one used by the strengths-based assessment ap-proach we described in Chapter 6. Recent cognitive thera-pists have also placed increasing emphasis on the client's self-efficacy—the sense of personal agency and the degree of confidence the client has that she or he can do something (see also Chapter 15). Positive cognitive processes such as self-efficacy, learned optimism, and hope reflect ways of thinking that can impact therapeutic outcomes (Lopez, Pedrotti, & Snyder, 2014). Additionally, helpers should remember that, like many variables, coping skills are cul-ture-and gender-specific; some men and women may not report using the same coping strategies, just as “effective coping” defined in one cultural system may be different in another one. Coping styles that you consider maladaptive may be adaptive for the client as a way to survive his or her environment (Canino & Spurlock, 2000, p. 66). Focusing on the client's positive assets achieves several purposes. First, it helps convey to clients that despite the psy-chological pain, they do have internal resources available that they can muster to produce a different outcome. Second, it emphasizes wholeness—the client is more than just his or her “problem. ” Third, it gives you information on potential problems that may crop up during an intervention. Finally, information about the client's past success stories may be ap-plicable to current concerns. Such information is extremely useful in planning intervention strategies that are geared to using the kind of problem-solving and coping skills already available in the client's repertoire. As Neacsiu and Linehan (2014) point out, clients can learn to prevent future issues by identifying coping strategies they could implement to prevent the problem from occurring another time or with the same intensity. Narratives with particular sources of adversity can be revised with the practitioner's help. For example, clients who have experienced trauma can help to heal them-selves by telling or drawing the story of the trauma and its key events. It is also important for these clients to put an ending on the story. Clients with trauma histories usually feel help-less in the face of the trauma. As these clients co-construct their stories, they can also narrate strengths and resources they used to help cope with the trauma. Images of strength are especially important in healing stories of adult survivors. Information to be assessed in this area includes: 1. Protective factors associated with the client's history and development. What about the client's background and history is associated with particular protective factors for the client? 2. Behavioral assets and problem-solving skills. When does the client display adaptive behavior instead of prob-lematic behavior? Often this information can be ob-tained by inquiring about opposites—for example, “When don't you act that way?” 3. Cognitive coping skills, such as rational appraisal of a situa-tion, ability to discriminate between rational and irrational thinking, selective attention and feedback from distrac-tions, and the presence of coping or calming self-talk. 4. Self-control and self-management skills, including the client's overall ability to withstand frustration, to as-sume responsibility for self, to be self-directed, to con-trol undesired behavior by either self-reinforcing or self-punishing consequences, and to perceive the self as Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
230 Chapter 7 being in control rather than being a victim of external circumstances. 5. Environmental strengths and resources. In addition to the three individual client strengths described, it is increas-ingly important to assess the strengths and resources available within the client's environment. These include not only the support network we mentioned earlier but also things such as availability of adequate employment, housing, transportation, and health care. Environmen-tal strengths also include cultural strengths of belonging to a collective community, such as community cohe-siveness, community racial identity, and community resources, groups, and organizations (Jones-Smith, 2014; Ungar, 2011). Cultural affiliations can give cli-ents certain protective factors that serve as sources of strength when clients experience adversity. Factors such as racial and ethnic pride, spirituality and religion, and interconnectedness of mind, body, and spirit are other examples of culturally protective factors for clients from marginalized groups (Sue, 2010). To assess these kinds of individual and environmen-tal strengths and resources, Saleebey (2013) has devel-oped some assessment questions that recognize and build on strengths in eight specific domains. (Note that these strength-building assessment questions are quite compat-ible with a solution-focused behavior therapy (SFBT) ap-proach, which we discuss in great detail in Chapter 10. ). Examples of these strength-based queries identified by Saleebey (2013, pp. 107-108) are shown in Box 7. 2. Other useful leads to identify these kinds of individual and environmental strengths and resources include the following: “When you think about where you are in your life now and where you started from, what kinds of things in your background and development have been protective and helpful for you?”“What strengths do you have as a member of your particu-lar ethnic or cultural group?” “What skills or things do you have going for you that might help you with this concern?” “Describe your strengths or assets that you can use to help resolve this concern. ” “What tools have you used in the past to help you overcome adversity?” “When don't you act this way?” “What kinds of thoughts or self-talk help you handle this better?” “Notice when you don't think in self-defeating ways. ”“What do you say to yourself to cope with a difficult situ-ation?” “Identify the steps you take in a situation you handle well. What do you think about and what do you do? How could these steps be applied to the present issue?” “In what situations is it fairly easy for you to manage or control this reaction or behavior?” “What kinds of coping strategies could you use the next time this happens to either prevent the problem or make it less intense?” “Rate the degree of confidence you have in your capabilities when you are immersed in this situation. ” (self-efficacy query) “When you think about this situation, is your expectancy that it will go well or go poorly?” (optimism query) “Tell me about what kind of resources in any aspect of your community or environment you are currently using. ” “What aspects of your community and overall environ-ment do you find helpful?” “What kinds of things in your community and environ-ment would you describe as strengths or assets?” “Describe what strengths and resources in your community and environment are available that you need to use more often. ” Survival questions: “How have you managed to get this far, given all the challenges you have described to me—what and who has helped you?” Support questions: “Where have you found support in meet-ing these challenges? What people, groups, associations, organizations have helped you?” Exception questions: “Recall times in your life when you be-lieve things were going very well for you and tell me what was different then from now?” Possibility questions: “What do you hope for now in this situ-ation? What possibilities do you see arising for you from these challenging circumstances?”Esteem questions: “In thinking about your life in general, and about these issues specifically, what gives you pride? What do you and can you feel good about?” Perspective questions: “How are you making sense of these current struggles?” Change questions: “What are your ideas about how things might change—about the potential for things being dif-ferent for you?” Meaning questions: “What does the current challenging situation you find yourself in mean to you?”BOX 7. 2 Examples of Strength Questions Adapted from Saleebey, 2013. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 231 Category 10. Exploring the Client's Perception of the Concern: Patient Position Most clients have their own perceptions of and explana-tions for their concerns. It is important to elicit this infor-mation during an assessment session for several reasons. First, it adds to your understanding of the concern. The helper can note which aspects of the concern are stressed and which are ignored during the client's assessment of the issue. Second, this process gives you valuable infor-mation about patient position, the client's strongly held beliefs and values—in this case, about the nature of the issue. Clients usually allude to such positions in the course of presenting their perceptions of concerns. Ignoring the client's position may cause the practitioner to develop a counseling strategy that the client resists because it is incompatible with this position. You can get a client to describe his or her view of the concern very concisely simply by asking the client to give the concern a one-line title as if it were a movie, play, or book. Another way to elicit the client's perception of the concern is to describe the concern in only one word and then to use the selected word in a sentence. For example, a client may say, “Guilt,” and then, “I have a lot of guilt about having an affair. ” The same client might title the concern “Caught between T wo Lovers. ” This technique works extremely well with children, who typically are quick to think of titles and words without a lot of deliberation. It is also important to recognize the impact of culture, ethnicity, and race on clients' perceptions and reports of concerns. For example, clients from some cultural groups may report the cause of concerns in terms of external factors, supernatural forces, or both. Helpers must not minimize or ridicule such explanations; also, they should incorporate such explana-tions into the assessment and treatment process. In the change phase of helping, successful interventions often depend on recognizing and validating the client's “perception of the problem. ” This emphasis on the client's perspective has made a dramatic impact on the care of older adult clients, but the principle extends to all clients. When clients speak out about their perspectives, there is more collaboration and shared investment in the change process. Leads to help clients identify and describe their views of concerns include: “What is your understanding of this issue?” “Tell me how you explain this concern to yourself. ”“What does the issue mean to you?”“What is your interpretation [analysis] of this concern?”“What else is important to you about the concern that we haven't mentioned?” “Give the issue a title. ”“Describe the issue with just one word. ”Category 11. Ascertaining the Intensity of the Concern It is useful to determine the intensity of the concern. You want to check out how much the concern is affecting the cli-ent and the client's daily functioning. If, for example, a client says, “I feel anxious,” does the client mean a little anxious or very anxious? Is this person anxious all the time or only some of the time? And does this anxiety affect any of the person's daily activities, such as eating, sleeping, or working? There are two kinds of intensity to assess: the degree or severity and the frequency (how often) and/or duration (how long) of it. a. Degree of Intensity Often it is useful to obtain a client's subjective rating of the degree of discomfort, stress, or in-tensity of the concern. The helper can use this information to determine how much the concern affects the client and whether the client seems to be incapacitated or immobi-lized by it. To assess the degree of intensity, the helper can use leads similar to these: “You say you feel anxious. On a scale from 1 to 10, with 1 being very calm and 10 being extremely anxious, where would you be now?” “How strong is your feeling when this happens?”“How has this interfered with your daily activities?”“How would your life be affected if this issue were not resolved in a year?” “On a scale from 0 to 100, with 0 being no distress and 100 being extreme distress, where would you place your distress now?” In assessing degree of intensity, you are looking for a client response that indicates how strong, interfering, or pervasive the concern seems to be. b. Frequency and/or Duration In asking about frequency and duration, your purpose is to have the client identify how often (frequency) and/or how long (duration) the current behaviors occur. Data about how often or how long they occur before a change strategy is applied are called baseline data. Baseline data provide information about the present extent of the problem. They can be used later to compare the extent of the problem before and af-ter a treatment strategy has been used. Leads to assess the frequency and duration of the current behavior include the following: “How often does this happen?” “How many times does this occur?”“How long does this feeling usually stay with you?”“How much does this go on, say, in an average day?” Some clients can discuss the severity, frequency, or duration of the behavior during the interview rather Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
232 Chapter 7 easily. However, many clients may be unaware of the number of times the behavior occurs, how much time it occupies, or how intense it is. As we described in Chapter 6, most clients can give the helper more ac-curate information about frequency and duration by engaging in self-monitoring of the behaviors with a writ-ten log. Use of logs to supplement the interview data is illustrated later in the model dialogue. Another useful supplement to obtain information about the intensity of the problem is the TLFB or Timeline Follow-Back Assessment (Sayers & Tomcho, 2006). This method is described as follows. The key aspects of the TLFB method include the use of a calendar as well as a systematic review of each time period on the calendar, working backward to stimulate recall. First, the interviewer establishes the time period, such as 1 month, 6 months, and so on, depending on the predicted frequency and the clinical consideration regarding the type of behavior involved. The therapist then asks about key events in the patient's life during this period or holidays as marked on the calendar to relate these events to the behavior in question. Then, starting with the most current time period, the interviewer asks about the frequency of behavior for that period... Working backward, 1 week (or 1 month, depending on the context) at a time, the interviewer asks for the patient's estimate of the behavior for that period. If the patient has a calendar or appointment book of his or her own, then the patient is asked to use this as a cue for better recall (p. 73). Box 7. 3 provides a review of the 11 categories of client assessment. This table may help you conceptualize and summarize the types of information you will seek during assessment interviews. Limitations of Interview Leads in Assessment The leads we present in this chapter are simply tools that the helper can use to elicit certain kinds of client informa-tion. They are designed to be used as a road map to pro-vide some direction for assessment interviews. However, the leads alone are an insufficient basis for assessment because they represent only approximately half of the pro-cess at most—the helper responses. The other part of the process is reflected by the responses these leads generate from the client. A complete interview assessment includes not only asking the right questions but also synthesizing and integrating the client responses. Think of it this way: In an assessment interview, you are simply supplementing your basic skills with some spe-cific leads designed to obtain certain kinds of information. While many of your leads will consist of open-ended ques-tions, even assessment interviews should not disintegrate into a question-and-answer or interrogation session. You can obtain information and give the information some mean-ing through other verbal responses, such as summarization, clarification, confrontation, and reflection. Demonstrating sensitivity is especially important because sometimes during assessment, a client may reveal or even re-experience very traumatic events and memories. The quality of the help-ing relationship remains very important during assessment interviews. Handling the assessment interview in an under-standing and empathic way becomes critical. It is also ex-tremely important to clarify and reflect the information the client gives you before jumping ahead to another question. The model dialogue that follows after Learning Activity 7. 3 illustrates this process. (See also Learning Activity 7. 3. )1. Purpose of assessment 2. Range of concerns3. Prioritization of issues4. Identification of behaviors5. Identification of antecedents6. Identification of consequences7. Identification of secondary gains (payoffs)8. Previous solutions9. Coping skills and individual and environmental strengths 10. Client perceptions of issue11. Severity, frequency, and duration of issue BOX 7. 3 Review of 11 assessment categories (4) Behaviors (5) Antecedents (6) Consequences and (7) Secondary gains (payoffs) Affective Affective Affective Somatic Somatic Somatic Behavioral Behavioral Behavioral Cognitive Cognitive Cognitive Contextual Contextual Contextual Relational Relational Relational Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 233 Learning Activity 7. 3 Interview Assessment Part One This activity is designed to assist you in identifying assess-ment leads in an interview. You are given a helper/client dialogue that consists of an interview with a mother, Ms. Weare, about her relationship with her son Freddie (Chap-ter 6). For each helper response, your task is to identify and write down the type of assessment lead used by the helper. You may find it helpful to use the Interview Checklist at the end of this chapter as a guide for this activity. There may be more than one example of any given type of lead. Also, identify the listening and influ-encing responses used by the helper. Feedback follows on page 236. Dialogue between Ms. Weare and the Helper 1. Helper: Hello, Ms. Weare. Could you tell me about some things going on now that are concerning you? Client: Not too much. Family Services sent me here. 2. Helper: So you're here just because they sent you—or is there something bothering you? Client: Well, they don't think my kid and I get along too well. My kid is Freddie. 3. Helper: What do you think about the way you and Freddie get along? Client: Well, I yell at him a lot. I don't like to do that, but sometimes he gets me so mad. I don't like to, but he needs to learn. 4. Helper: So there are times when you get real mad at Freddie and then you yell at him. You don't like to do this, but you see it as a way to help him learn right and wrong. Client: That's it. I don't like to, but there are times when he needs to know something. Like yesterday, I bought him new pants, and he came home from school with a big hole in them. Now, I just don't have money to keep buying him new pants. 5. Helper: You just mentioned the incident with Freddie's pants. What are some other times that you get mad at Freddie? Client: Every morning. Freddie's in third grade now. But he still doesn't dress himself in the morning. I want to be a good mother and get him to school on time, and he tries to be late. He waits around not getting dressed. 6. Helper: Any other times you can remember getting mad? Client: Well, not too long ago he was playing outside and broke a window. I got mad then. But that doesn't happen every day like his not getting dressed does. 7. Helper: So one thing that really bothers you is what goes on in the mornings. Tell me exactly what does happen each morning at your house. Client: Well, I call Freddie to get up and tell him to dress before he comes down for breakfast. He comes down all right—in his pajamas. I warn him after breakfast to get ready. Usually about 5 minutes before the bus comes, I'll go up. He'll just be sitting in his room! He's still not dressed. I'll yell at him and then dress him so he's not late. 8. Helper: And your main feeling at this point is that you're mad. Anything else you feel? Client: No, just very mad. 9. Helper: And what exactly do you do when you go upstairs and he's not dressed? Client: I yell at him. Then I help dress him. 10. Helper: What kinds of things do you usually say to him? Client: I tell him he's dumb and he's going to be late for school, and that I have to make sure he won't be. 11. Helper: You mentioned this happens in the morning. Does this situation go on every morning or only some mornings? Client: Just about every morning except weekends. 12. Helper: When did these incidents seem to begin? Client: Ever since Freddie started going to school. 13. Helper: So it appears that this has been going on for about 3 years, then? Client: Yes, I guess so. 14. Helper: Okay, now let's go back over this situation. You told me you remind Freddie every morning to get dressed. He never dresses by breakfast. You re-mind him again. Then, about 5 minutes before the bus comes, you go upstairs to check on him. When do you notice that you start to feel mad? Client: I think about it as soon as I realize it's almost time for the bus to come and Freddie isn't down yet. Then I feel mad. 15. Helper: And what exactly do you think about right then? Client: Well, that he's probably not dressed and that if I don't go up and help him, he'll be late. Then I'll look like a bad mother if I can't get my son to school on time. 16. Helper: So in a sense you actually go help him out so he won't be late. How many times has Freddie ever been late? Client: Never. 17. Helper: You believe that helping Freddie may prevent him from being late. However, your help also excuses Freddie from having to help himself. What do you think would happen if you stopped going upstairs to check on Freddie in the morning? Client: Well, I don't know, but I'm his only parent now. Freddie's father and I are separated now. It's up to me, all by myself, to keep Freddie in line. If I didn't go up and if Freddie was late all the time, his teachers might blame me. I wouldn't be a good mother. (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
234 Chapter 7 Learning Activity 7. 3 (continued) 18. Helper: Of course, we don't really know what would happen if you didn't go up and yell at him or help him dress. It might be so different for Freddie after the first day or two he would dress himself. It could be that he thinks it's easier to wait and get your help than to dress himself. He might think that by sitting up there and waiting for you to help, he's getting a special advan-tage or attention from you. Client: You mean like he's getting a favor from me? 19. Helper: Sure. And when we find a way to get a favor from someone, we usually do as much as we can to keep getting the favor. Ms. Weare, I'd like to ask you about something else. Do you think maybe that you see helping Freddie out as a way to avoid having Freddie be late and then not having someone blame you for this? Client: Sure. I'd rather help him than get myself in hot water. 20. Helper: Okay, so you're concerned about what you think might happen to you if he's late. You see getting him ready on time as a way to prevent you from getting the heat for him. Client: Yes. 21. Helper: How do you usually feel after these incidents in the morning are over? Client: Well, it upsets me. 22. Helper: Okay, you feel upset. Do these feelings seem to make you want to continue or to stop helping Freddie? Client: Probably to stop. I get worn out. Also, some-times I don't get my work done then. 23. Helper: So helping Freddie so he won't be late and you won't be blamed sort of makes you want to keep on helping him. Yet when you feel upset and worn out af-terward, you're tempted to stop helping. Have I heard you accurately? Client: I guess that could be true. 24. Helper: Gee, I imagine that all the responsibility for a 9-year-old boy would start to feel like a pretty heavy burden after a while. Client: Yeah. I guess a lot of the time it does. 25. Helper: Those may be feelings we'll want to talk about more. I'm also wondering whether there are any other things in your life causing you any concern now? Client: No, this is about it. 26. Helper: Ms. Weare, we've been talking a lot about some problem situations you've had with Freddie. De-scribe some times when the two of you get along okay. Client: Well, on weekends we do. Freddie dresses him-self whenever he gets up. I sleep later. 27. Helper: What happens on weekends when the two of you get along better? Client: Sometimes I'll take him to a movie or a game. And we eat all our meals together. Usually, weekends are pleasant. He can be a good boy, and I don't scream all the time at him. 28. Helper: So you realize it is possible for the two of you to get along. How do you feel about my talking with Freddie and then with both of you together? Client: That's okay. Part Two To incorporate the interview leads into your verbal reper-tory, we suggest that you try a role-play interview of the case of Ms. Weare (Chapter 6) or the case of Mr. Huang (Chapter 6) with a triad. One person can take the role of the client (Ms. Weare or Mr. Huang); another can be the helper. Your task is to assess the client's concerns using the inter-view leads described in this chapter. The third person can be the observer, providing feedback to the helper during or following the role play, using the Interview Checklist at the end of this chapter as a guide. Model Dialogue: Interview Assessment To see how these assessment leads are used in an inter-view, read the following dialogue in the case of Isabella. An explanation of the helper's response and the helper's rationale for using it appears before the responses. Note the variety of responses used by the helper. Helper response 1 is a rationale to explain to the client, Isabella, the purpose of the assessment interview. 1. Helper: Isabella, last week you dropped by to schedule today's appointment, and you mentioned you were feeling unhappy and anxious at school. It might be helpful today to take some time just to explore exactly what is going on with you and school and anything else that concerns you. I'm sure there are ways we can work with this, but first I think it would be helpful to both of us to get a better idea of what all the issues are for you now. Also, I know I gave you an explana-tion and consent form to take home and review with your parents. I wanted to go over that as well and also highlight what we mean about the word in it called confidentiality. It basically means that what you tell me I keep to myself except in a few situations like if I find out about child abuse that has happened or is happening, or if you were planning to hurt yourself or someone else—I would have to tell someone else in these situations. Does this make sense to you? Client: Yeah. I don't really have any questions about that or the form I took home (hands it to the counselor). Cause one time when my grandpa died and my grandma Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 235 came to stay with us for a while we went to see a counselor for a couple times and she talked about this stuff, too. The main thing I want to talk to you about today is with school. It's really bugging me. Helper response 2 is a lead to help Isabella identify the range of her concerns. 2. Helper: Okay, you just said school is the main con-cern. From the way you said that and the way you look right now, I have the feeling school isn't the only thing you're concerned about in your life. Client: Well, you're right about that. I'm also kind of not getting along too well with my parents. But that's kind of related to this school thing, too. In the next response, the helper simply listens to Isabella and synthesizes what she's saying by using a paraphrase response. 3. Helper: So from your point of view, the school thing and the issue with your parents are connected. Client: Yeah, because I'm having trouble in some of my classes. There's too much competition. I feel the other kids are better than I am. I've thought about changing from this college prep program to the work-study pro-gram, but I don't know what to do. I don't like to make decisions anyway. At the same time, my parents put a lot of pressure on me to perform well, to make top grades. They have a lot of influence with me. I used to want to do well, but now I'm kind of tired of it all. In the next response, the helper continues to listen to Isabella and reflect her feelings. 4. Helper: It seems like you're feeling pretty overwhelmed and discouraged right now. Client (lowers head, eyes, and voice tone): Yeah, I am. I've started to have trouble sleeping at night cause I worry about all this stuff now when I try to sleep. Helper senses Isabella has strong feelings about these issues and doesn't want to cut them off initially. Helper instructs Isabella to continue focusing on the feelings. 5. Helper (Pause): Let's stay with these feelings for a few minutes and see where they take you. 6. Client (Pause—eyes fill with tears): I guess I just feel like all this stuff is coming down on me at once. I feel edgy at school and worried about how I am doing there. I've been having more trouble concentrating, which just makes things worse for me. And honestly cause school is difficult for me now except when I'm hanging out with my friend like at lunch, sometimes I oversleep or fake illness so I can stay home. Helper continues to attend, to listen, and to reflect the client's current experience. 7. Helper: It seems like you feel you're carrying a big load on your shoulders— Client: Yeah. In response 8, the helper summarizes Isabella's concerns and then uses a lead to determine whether Isabella has prioritized her concerns. 8. Helper: I think before we're finished I'd like to come back to these feelings, which seem pretty strong for you now. Before we do, it might help you to think about not having to tackle everything all at once. You know you mentioned several things that are bothering you—feeling unhappy and anxious at school, having trouble making decisions, having trouble sleeping and concentrating, and not getting along with your par-ents. Which of these bothers you most? Client: I'm not really sure. I'm concerned right now about having trouble in my classes. But sometimes I think if I were in another type of curriculum, I wouldn't be so tense about these classes. But I'm sort of worried about decid-ing to do this. Helper response 9 is a clarification. The helper wants to see whether the client's interest in work-study is real or is a way to avoid the present issue. 9. Helper: Do you see getting in the work-study program as a way to get out of your present problem classes, or is it a program that really interests you? Client: It's a program that interests me. I think sometimes I'd like to get a job after high school instead of going to college, or maybe just go to culinary school. But I've been thinking about this for a year, and I can't decide what to do. I'm not very good at making decisions on my own. Helper response 10 is a summarization and instruction. The helper goes back to the areas of concern. Note that the helper does not draw explicit attention to the client's last self-deprecating statement. 10. Helper: Well, your concerns about your present class problems and about making this and other decisions are somewhat related. Your parents tie into this, too. Maybe you could explore all concerns and then decide later about what you want to work on first. Client: That's fine with me. Helper response 11 is a lead to identify some present behaviors related to Isabella's concern about competitive classes. Asking the client for examples can elicit specificity about what does or does not occur during the situation of concern. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
236 Chapter 7 11. Helper: Okay, give me an example of some trouble you've been having in your most competitive class. Client: Well, I guess I shut down in these classes. Also, I've been cutting my math classes. It's the worst. My grades are dropping, especially in math class. It's hardest for me to focus in that class in particular. Helper response 12 is a behavior lead regarding the context of the concern to see whether the client's concern occurs at other times or other places. 12. Helper: Where else do you have trouble—in any other classes, or at other times or places outside school?Client: Well, to some degree, I always feel anxious in any class because of the pressures my parents put on me to get good grades. But my math class is really the worst. And then it bothers me at night when I try to go to sleep, too. Helper response 13 is a lead to help the client identify overt behaviors in math class (behavioral component of concern). 13. Helper: Describe what happens in your math class that makes it troublesome for you. [The helper could also use imagery assessment at this point. ] Client: Well, to start with, it's a harder class for me. I have to work harder to do okay. In this class I get nervous whenever I go in it. So I withdraw. Client's statement “I withdraw” is vague. So helper re-sponse 14 is another overt behavior lead to help the client specify what she means by “withdrawing. ” Note that since the helper did not get a complete answer to this, the same type of lead is used again. 14. Helper: What do you do when you withdraw? [This is also an ideal place for a role-play assessment. ] Client: Well, I sit by myself; I don't talk or volunteer an-swers. Sometimes I don't go to the board or answer when the teacher calls on me. Now that the client has identified certain overt be-haviors associated with the concern, the helper will use a covert behavior lead to find out whether there are any predominant thoughts the client has during the math class (cognitive component of issue). 15. Helper: What are you generally thinking about in this class? Client: What do you mean—am I thinking about math? The client's response indicated some confusion. The helper will have to use a more specific covert behavior lead to assess cognition, along with some self-disclosure, to help the client respond more specifically. 16. Helper: Well, sometimes when I'm in a situation like a class, there are times when my mind is on the class and other times I'm thinking about myself or about something else I'm going to do. So I'm wondering what you've noticed you're thinking about during the class. Client: Well, some of the time I'm thinking about the math problems. Other times I'm thinking about the fact that I'd rather not be in the class and that I'm not as good as the other kids, especially all the guys in it. 7. 3 Feedback Interview Assessment Part One Identification of the responses in the dialogue between Ms. Weare and the helper are as follows: 1. Open-ended question 2. Clarification response 3. Open-ended question 4. Summarization response 5. Paraphrase response and behavior lead: exploration of context 6. Behavior lead: exploration of context 7. Paraphrase response and behavior lead: exploration of overt behavior 8. Reflection-of-feelings response and behavior lead: exploration of affect 9. Behavior lead: exploration of overt behavior10. Behavior lead: exploration of overt behavior11. Paraphrase and behavior lead: exploration of context12. Antecedent lead: context13. Clarification response14. Summarization response and antecedent lead: affect15. Behavior lead: exploration of cognitions16. Paraphrase and open question responses17. Consequences: overt behavior18. Consequences: secondary gains for Freddie19. Consequences: secondary gains for Ms. Weare20. Summarization response and exploration of secondary gains for Ms. Weare 21. Consequences: affect22. Consequences: affect23. Summarization (of consequences)24. Reflection-of-feelings response25. Range-of-concerns lead26. Coping skills27. Coping skills28. Paraphrase and open-ended question Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 237 The client has started to be more specific, and the helper thinks perhaps there are still other thoughts going on. To explore this possibility, the helper uses another covert behavior lead in response 17 to assess cognition. 17. Helper: What else do you recall that you tell yourself when you're thinking you're not as good as other people? Client: Well, I think that I don't get grades that are as good as some other students'. My parents have been pointing this out to me since junior high. And in the math class I'm one of four girls. The guys in there are really smart. I just keep thinking how can a girl ever be as smart as a guy in math class? No way. It just doesn't happen. The client identifies more specific thoughts and also suggests two possible antecedents—parental comparison of her grades and cultural stereotyping (girls shouldn't be as good in math as boys). The helper's records show that the client's test scores and previous grades indicate that she is definitely not “dumb” in math. The helper will summarize this and then, in the next few responses, will focus on these and on other possible antecedents, such as the nervousness the client mentioned earlier. 18. Helper: So what you're telling me is that you believe most of what you've heard from others about yourself and about the fact that girls automatically are not supposed to do too well in math. Client: Yeah, I guess so, now that you put it like that. I've never given it much thought. 19. Helper: Yes. It doesn't sound like you've ever thought about whether you, Isabella, really feel this way or whether these feelings are just adopted from things you've heard others tell you. Client: No, I never have. 20. Helper: That's something we'll also probably want to come back to later. Client: Okay. 21. Helper: You know, Isabella, earlier you mentioned that you get anxious about this class. When do you notice that you feel this way—before the class, during the class, or at other times? Client: Well, right before the class is the worst. About 10 minutes before my English class ends—it's right before math—I start thinking about the math class. Then, I get nervous and feel like I wish I didn't have to go. Recently, I've tried to find ways to cut math class. The helper still needs more information about how and when the nervousness affects the client, so response 22 is another antecedent lead. 22. Helper: Tell me more about when you feel most nervous and when you don't feel nervous about this class. Client: Well, I feel worst when I'm actually walking to the class and the class is starting. Once the class starts, I feel better. I don't feel nervous about it when I cut it or at other times. However, once in a while, if someone talks about it or I think about it, I feel a little nervous. And recently I've started feeling anxious and nervous at night when I try to go to sleep cause I find myself worrying about school the next day. The helper realizes at this point that the words nervous/ anxious have not been defined and goes back in the next response to a covert behavior lead to find out what Isabella means by nervous (affective component). 23. Helper: Tell me what you mean by the word nervous and anxious—what goes on with you when you're feeling like this? Client: Well, I get sort of a sick feeling in my stomach, and my hands get all sweaty. My heart starts to pound. I feel on edge. And I have trouble concentrating at school now a lot of the time. And when this happens to me at night, I have trouble going to sleep. In the next response, the helper continues to listen and paraphrase to clarify whether the nervousness is experi-enced somatically. 24. Helper: So your nervousness really consists of things you feel going on inside you like a pit in your stom-ach, sweaty hands, heart pounding, and so on. Client: Yeah. Next, the helper will use an intensity lead to determine the severity of nervousness. 25. Helper: How strong is this feeling—a little or very? Can you rate it on a 1 to 10 scale with 1 being low and 10 being extremely strong? Client: Before class, very strong—like a 7 especially be-fore math class. At other times, just a little, maybe a 3, but some nights it goes back up to maybe a 6. The client has established that the nervousness seems mainly to be exhibited in somatic forms and is more in-tense before class. The helper will use an antecedent lead is used next. 26. Helper: Which seems to come first—feeling ner-vous, not speaking up in class, or thinking about other people being smarter than you? Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
238 Chapter 7 Client: Well, thinking about the other kids and that I don't measure up to them cause they are so much smarter than I am. Because that starts before I get in the class and even sometimes starts the night before. The helper has a clue from the client's previous com-ments that there are other antecedents that have to do with the client's concern—such as the role of her parents. The helper will pursue this in the next response, using an antecedent lead. 27. Helper: Isabella, you mentioned earlier that you have been thinking about not being as smart as some of your friends ever since you started high school. When do you recall you really started to dwell on this? Client: Well, that's right, when I started high school a year ago. The helper didn't get sufficient information about what happened to the client then, so another antecedent lead will be used to identify this possible setting event. 28. Helper: What do you recall happened then? Client: Well, my parents said when you start high school, your grades become really important in order to go to college. So, for the last year they have been telling me some of my grades aren't as good as other students'. Also, if I get a B, they will take something away, like going out with my friends. The helper has no evidence of actual parental reac-tion but will work with the client's report at this time, because this is how the client perceives parental input. If possible, a parent conference could be arranged later with the client's permission. The parents seem to be using negative rather than positive consequences with Isabella to influence her behavior. The helper wants to pursue the relationship between the parents' input and the client's present behavior to determine whether parental reaction is eliciting part of Isabella's present concerns. The helper will use a lead to identify this as a possible antecedent. 29. Helper: How do you think this reaction of your par-ents relates to your present problems? Client: Well, since I started high school, they have talked more about needing to get better grades for college. And I have to work harder in school and especially in math class to do this. I guess I feel a lot of pressure to perform—which makes me withdraw and just want to hang it up. Now, of course, my grades are getting worse, not better. The helper, in the next lead, will paraphrase Isabella's previous comment. 30. Helper: So, the expectations you feel from your par-ents seem to draw out pressure in you. Client: Yes, that happens. In response 31, the helper will explore another possible antecedent that Isabella mentioned before—thinking that girls aren't as good as boys in math. 31. Helper: Isabella, I'd like to ask you about something else you mentioned earlier that I said we would come back to. You said one thing that you think about in your math class is that you're only one of four girls and that, as a girl, you're not as smart in math as a boy. Do you know what makes you think this way? Client: I'm not sure. Everyone knows or says that girls have more trouble in math than boys. Even my teacher. He's gone out of his way to try to help me because he knows it's tough for me. The client has identified a possible consequence of her behavior as teacher attention. The helper will return to this later. First, the helper is going to respond to the cli-ent's response that “everyone” has told her this thought. Helpers have a responsibility to point out things that clients have learned from stereotypes or irrational beliefs rather than actual data, as is evident in this case from Isabella's academic record. The helper will use confrontation/ challenge in the next response. 32. Helper: You know, studies have shown that when young women drop out of math, science, and en-gineering programs, they do so not because they're doing poorly but because they don't believe they can do well. * It is evident to me from your records that you have a lot of potential for math. Client: Really? Helper response 33 is an interpretation to help the client see the relation between overt and covert behaviors. 33. Helper: I don't see why not. But lots of times the way someone acts or performs in a situation is affected by how the person thinks about the situation. I think some of the reason you're having more trouble in your math class is that your performance is hindered a little by your nervousness and anxiety and by the way you put yourself down and compare yourself constantly to your peers. In the next response, the helper checks out and clarifies the client's reaction to the previous interpretation. 34. Helper: I'm wondering now from the way you're look-ing at me whether this makes any sense or whether what I just said muddies the waters more for you? *From studies conducted at Wellesley College's Center for Re-search on Women. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 239 Client: No, I guess I was just thinking about things. But I guess it's not just that my parents expect too much of me. I guess in a way I expect too little of myself. I've never really thought of that before. 35. Helper: That's a great observation. In a way the two sets of expectations are probably connected. These are some of the kinds of issues we may want to work on if this track we're on seems to fit for you. Client: Yeah. Okay, it's a problem. The helper is going to go back now to pursue possible consequences that are influencing the client's behavior. The next response is a lead to identify consequences. 36. Helper: Isabella, I'd like to go back to some things you mentioned earlier. For one thing, you said your teacher has gone out of his way to help you. Would you say that your behavior in his class has got you any extra attention or special consideration from him? Client: Certainly extra attention. He talks to me more frequently. And he doesn't get upset when I don't go to the board. Helper response 37 will continue to explore the teach-er's behavior as a possible consequence. 37. Helper: Do you mean he may excuse you from board work? Client: For sure, and I think he, too, almost expects me not to come up with the answer. Just like I don't expect myself to. The teacher's behavior may be maintaining the client's overt behaviors in class by giving extra attention to her and by excusing her from some kinds of work. A teacher conference may be necessary at some later point. The helper, in the next two responses, will continue to use other leads to identify possible consequences. 38. Helper: What do you see you're doing right now that helps you get out of putting yourself through the stress of going to math class? Client: Do you mean something like cutting class? 39. Helper: I think that's perhaps one thing you do to get out of the class. What else? Client: Well, let's see—I guess staying home from school cause then I don't even have to be in class! The client has identified cutting class and staying home as ways to avoid the math class. The helper, in the next response, will suggest another consequence that the client mentioned earlier, though not as a way to get out of the stress associated with the class. The helper will suggest that this consequence functions as a secondary gain, or payoff, in a tentative interpretation that is checked out with the client in the next three responses: 40. Helper: Also, Isabella, you told me earlier that your grades were dropping in math class. Is it possible that if these grades—and others—drop too much, you'll au-tomatically be dropped from these college prep classes? Client: That's right. 41. Helper: I'm wondering whether one possible reason for letting your grades slide is that it is almost an automatic way for you to get out of these competi-tive classes. Client: How so? 42. Helper: Well, if you became ineligible for these classes because of your grades, you'd automatically be out of this class and others that you consider com-petitive and feel nervous about. What do you think about that? Client: I guess that's true. Since I can't decide if I want to stay in these college prep classes or switch to the work-study program. In the next response, the helper uses summarization and ties together the effects of “dropping grades” to math class and to the previously expressed concern of a curriculum-change decision. 43. Helper: Right. And letting your grades get too bad will automatically mean that decision is made for you, so you can take yourself off the hook for mak-ing that choice. In other words, it's sort of a way that part of you has rather creatively come up with to get yourself out of the hassle of having to decide something you don't really want to be responsible for deciding about. Client: Wow! Gosh, I guess that might be happening. 44. Helper: That's something you can think about. We didn't really spend that much time today exploring the other things you were concerned about, so that will probably be something to discuss the next time we get together. I know you have a class coming up in about 10 minutes, so there are just a couple more things we might look at. Client: Okay—what next? In the next several responses (45-51), the helper contin-ues to demonstrate listening responses and to help Isabella Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
240 Chapter 7 explore solutions she's tried already to resolve the issue. They look together at the effects of the use of the solutions Isabella identifies. 45. Helper: Okay, starting with the nervousness and pres-sure you feel in math class—is there anything you've attempted to do to get a handle on this concern? Client: Not really—other than talking to you about it and, of course, cutting class and playing hooky. 46. Helper: How do you think these solutions have helped you? Client: Well, like I said before—it helps mainly because on the days I don't go, I don't feel uptight. 47. Helper: So you see it as a way to get rid of these feel-ings you don't like. Client: Yeah, I guess that's it. 48. Helper: Can you think of any ways in which these solutions have not helped? Client: Gee, I don't know. Maybe I'm not sure what you're asking. 49. Helper: Okay, good point! Sometimes when I try to do something to resolve a concern, it can make the issue better or worse. So I guess what I'm really ask-ing is whether you've noticed that your “solutions” of cutting class and playing hooky have in any way made the problem worse or in any way have even contributed to the whole issue? Client (Pause): I suppose maybe in a way. (Pause) In that, by cutting class or staying home, I miss out on the work, and then I don't have all the input I need for tests and homework, and that doesn't help my poor grades. 50. Helper: Okay. That's an interesting idea. You're say-ing that when you look deeper, your solution also has had some negative effects on one of the issues you're trying to deal with and eliminate. Client: Yeah. But I guess I'm not sure what else I could do. 51. Helper: At this point, you probably are feeling a little bit stuck, like you don't know which other direction or road to take. Client: Yeah. At this point, the helper shifts the focus a little to explo-ration of Isabella's assets, strengths, and resources. 52. Helper: Well, one thing I sense is that your feelings of being anxious are sort of covering up the resources and assets you have within you to handle the issue and work it out. For example, can you identify any particular skills or things you have going for you that might help you deal with this issue? Client: Well, I am pretty responsible. I'm usually fairly loyal and dependable. It's hard to make decisions for my-self, but when I say I'm going to do something, I usually do it. 53. Helper: Okay, great. So what you're telling me is you're good on follow-through once you decide something is important to you. Client: That sounds hopeful! Isabella and the helper have been talking about indi-vidual strengths. Next (in responses 54-57), the helper will explore any environmental and cultural strengths and resources that can help Isabella in this situation. 54. Helper: So far we've been talking about your own individual assets. Can you think of any assets or resources—including people—in your immediate environment that could be useful to you in dealing with these concerns? Client: Well, I mentioned my math teacher. He does go out of his way to help me. He even has given all of us his e-mail address to use if we get stuck on a homework problem, and he has a tutoring session after school every Thursday, too. But I haven't used his help too much out-side of class. 55. Helper: So you rely on him more during class? Client: Yup. 56. Helper: Are there any other people or resources avail-able to you that you may or may not be using? Client: Hmm. Not really sure about this one. 57. Helper: Earlier you mentioned your friends. Do you ever do homework with them or have study groups with them? Client: No—we mainly just go out on weekends to do things. But I think that might be a good idea, and I think my parents would be in favor of that one, too. In the next few responses, the helper tries to elicit Isabella's perception and assessment of the main issue. 58. Helper: Just a couple more things. Changing the focus a little now, think about the issues that you came in with today—and describe the main issue in one word. Client: Ooh—that's a hard question! Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 241 59. Helper: I guess it could be. Take your time. You don't have to rush. Client (Pause): Well, how about can't? 60. Helper: Okay, now, to help me get an idea of what that word means to you, use it in a sentence. Client: Any sentence? 61. Helper: Yeah. Make one up. Maybe the first thing that comes in your head. Client: Well, “I can't do a lot of things I think I want to or should be able to do. ” Next, the helper uses a confrontation to depict the in-congruity revealed in the sentence Isabella made up about her concern. 62. Helper: Okay, that's interesting too, because on one hand you're saying there are some things you want to do that aren't happening and, on the other hand you're also saying there are some things that aren't happening that you think you should be doing. Now, these are two pretty different things mixed together in the same sentence. Client: Yeah. [Clarifies. ] I think the wanting stuff to hap-pen is from me and the should things are from my parents and my teachers. 63. Helper: Okay, so you're identifying part of the whole issue as wanting to please yourself and others at the same time. Client: Mm-hmm. In the next two responses, the helper explores the con-text related to these issues and sets up some self-monitoring homework to obtain additional information. Note that this is a task likely to appeal to the client's dependability, which she revealed during exploration of coping skills. 64. Helper: That's something we'll be coming back to, I'm sure. One last thing before you have to go to your next class. Earlier we talked about some spe-cific times and places connected to some of these issues—like where and when you feel anxious and also where and when you put yourself down and think you're not as smart as other people. What I'd like to do is give you sort of a diary to write in this week to collect some more information about these kinds of problems. Sometimes writing these kinds of things down can help you start making changes and sorting out the issues. You've said that you're pretty dependable. Would doing this appeal to your dependability? Client: Sure. That's something that wouldn't be too hard for me to do. 65. Helper: Okay, let me tell you specifically what to keep track of, and then I'll see you next week—bring this back with you. (Goes over instructions for self-monitoring homework. ) (See Isabella's behavior log in Figure 7. 3. ) For Isabella Week of Nov. 6-13 Behavior Date Time Place Frequency/duration or Severity Thinking of self as not as smart as other students Mon., Nov. 610:00 a. m. Math class: taking test IIII Tues., Nov. 7 10:15 a. m. Math class: got B on test IIII IIII Tues., Nov. 7 5:30 p. m. Home: parents didn't like test grade IIII II Thurs., Nov. 9 9:30 a. m. English class: thinking math is next II Sun., Nov. 12 9:30 p. m. Home: dread about school tomorrow III Feeling anxious and nervous Mon., Nov. 610:00 a. m. Math class: test 8 (on 1 to 10 SUDS Scale) Tues., Nov. 7 10:15 p. m. Thinking about poor test grade7 (on 1 to 10 SUDS Scale) Figure 7. 3 Example of a Behavior Log Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
242 Chapter 7 At this time, the helper also has the option of giving Isabella a history questionnaire to complete and/or a brief self-report inventory to complete, such as an anxiety in-ventory or checklist. Ch Apt Er Su MMAry This chapter focuses on the use of interviewing to assess client concerns. The interview is one of the primary ways that practitioners assess clients, supplemented by other measures that are valid and reliable for clients, such as self-assessment and monitoring, observation, self-report measures, and so on. The assessment interview approach presented in this chapter has been developed by incorporating aspects of both functional assessment and ecological assessment. The functional assessment is based on principles of learning while the ecological assessment is based on the person-in-environment approach. In the interview approach de-scribed in this chapter, practitioners focus on defining six components of behavior: affective, somatic, behavioral, cognitive, contextual, and relational. They also seek to identify antecedent events that occur before the issue and cue it and consequent events that follow the issue and in some way influence it or maintain it. Consequences may include payoffs, or secondary gains, that give value to the dysfunctional behavior and thus keep the issue go-ing. Antecedents and consequences may also be affective, somatic, behavioral, cognitive, contextual, and relational. Contextual and relational ABCs form the basis of an en-vironmental assessment to determine the ways in which clients' social network (or lack thereof) and environmental barriers and resources affect the issue. Other important components of assessment interviewing include identify-ing previous solutions the client has tried for resolving the issue, exploring individual and environmental strengths, exploring the client's perceptions of the issue, and identi-fying the frequency, duration, or severity of the concern. The assessment interview approach described in this chapter yields important information to helpers about the etiology and maintenance of client issues and concerns. Such information forms the basis of outcome goals and treatment planning. Visit Cengage Brain. com for a variety of study tools and useful resources such as video exam-ples, case studies, interactive exercises, flash-cards, and quizzes. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
7 Knowledge and Skill Builder Conducting an Interview Assessment with Clients 243 Part One A client is referred to you with a presenting concern of free-floating, or generalized (pervasive), anxiety. Outline the spe-cific interview leads you would ask during an assessment interview with this client that pertain directly to her present-ing component. Your objective (Learning Outcome 1) is to identify at least two interview leads for each of the 11 assess-ment categories described in this chapter and summarized in Box 7. 3. Feedback follows on page 250. Part Two Using the description of the client in Part One, conduct a 30-minute role-play assessment interview in which your objective is to demonstrate leads and responses associated with at least nine out of the 11 categories described for as-sessment (Learning Outcome 2). You can do this activity in a triad in which one person assumes the role of helper, another is an anxious client, and the third person plays the role of observer; trade roles two times. If groups are not available, audiotape or videotape to record your interview. Use the Interview Checklist below as a guide to assess your performance and to obtain feedback. After completing your interview, develop some hypoth-eses, or hunches, about the client. In particular, try to develop guesses about: 1. Antecedents that cue or set off the anxiety, making its occurrence more likely 2. Consequences that maintain the anxiety, keep it going, or make it worse 3. Consequences that diminish or weaken the anxiety 4. Secondary gains, or payoffs, attached to the anxiety 5. Ways in which the client's previous solutions may con-tribute to the anxiety or make it worse 6. Particular individual and environmental strengths, re-sources, and coping skills of the client and how these might be best used during treatment/intervention 7. How the client's gender, culture, and environment affect the problem You may wish to continue this part of the activity in a triad or do it by yourself, jotting down ideas as you proceed. At some point, it may be helpful to share your ideas with your group or your instructor. Interview Checklist for Assessing Clients Scoring Category of information Examples of helper leads or responses Client response Yes No ___ ___ 1. Explain purpose of assessment interview; obtain informed consent; explain limits to confidentiality“I am going to be asking you more questions than usual so that we can get an idea of what is going on. Getting an accurate picture about your concern will help us to decide what we can do about it. Your input is important. Also, I want to go over the consent document you read. I want to make sure you understand about what confidentiality means and the exceptions to confidentiality, too. ”______ (check if client confirmed understanding of purpose) ___ ___ 2. Identify range of concerns (if you don't have this information from history) “What would you like to talk about today?”“What specifically led you to come to see someone now?”“Describe any other issues you haven't mentioned. ”______ (check if client described additional concerns) ___ ___ 3. Prioritize and select primary or most immediate issue to work on“What issue best represents the reason you are here?”“Of all these concerns, which one is most stressful (or painful) for you?”“Rank order these concerns, starting with the one that is most important for you to resolve to the one least important. ”“Tell me which of these issues you believe you could learn to deal with most easily and with the most success. ”______ (check if client selected issue to focus on) (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
244 Chapter 7 7 Knowledge and Skill Builder (continued) “Which one of the things we discussed do you see as having the best chance of being solved?” “Out of all the things we've discussed, describe the one that, when resolved, would have the greatest impact on the rest of the issues. ” ___ ___ 4. 0. Present behavior ______ (check if client identified the following components) ___ ___ a. Affective aspects: feelings, emotions, mood states“What are your feeling when this happens?”“How does this make you feel when this occurs?”“What other feelings do you have when this occurs?”“What feelings is this issue hiding or covering up?”“What positive feelings do you have surrounding this issue?”“Negative ones?” ______ (check if client identified positive and negative feelings) ___ ___ b. Somatic aspects: body sensations, physiological responses, organic dysfunction and illness, medications“What goes on inside you then?”“What do you notice in your body when this happens?”“ When this happens, are you aware of anything that goes on in your body that feels bad or uncomfortable—aches, pains, and so on?” ______ (check if client identified body sensations) ___ ___ c. Behavioral aspects: overt behaviors/actions“In recording this scene, what actions and dialogue would the camera pick up?”“What are you doing when this occurs?”“What do you mean by 'not communicating'?”“Describe what you did the last few times this occurred. ”______ (check if client identified overt behaviors) ___ ___ d. Cognitive aspects: automatic, helpful, unhelpful, rational, irrational thoughts and beliefs; internal dialogue; perceptions and misperceptions“What do you say to yourself when this happens?”“What are you usually thinking about during this problem?”“What was going through your mind then?”“What kinds of thoughts can make you feel ______?”“ What beliefs [or images] do you hold that affect this issue?” Sentence completions: I should ______, people should ______, it would be awful if ______, ______ makes me feel bad. ______ (check if client identified thoughts, beliefs) ___ ___ e. Contextual aspects: time, place, or setting events“Describe some recent situations in which the issue occurred. Where were you? When was it?”“Does this go on all the time or only sometimes?”“Does the same thing happen at other times or places?”“At what time does this not occur? Places? Situations?”“What effect does your cultural/ethnic background have on this issue?”“What effects do the sociopolitical structures of the society in which you live have on this issue?”______ (check if client identified time, places, other events) “Describe the relationship between yourself, your concerns, and your current environment. We could draw this relationship if you want to see it [using an ecomap]. ”Scoring Category of information Examples of helper leads or responses Client response Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 245 ___ ____ f. Relational aspects: other people“What effects does this concern have on significant others in your life?”“What effects do significant others have on this concern?”“Who else is involved in the concern? How?”“What persons present in your life now have the greatest positive impact on this concern? Negative impact?”“What about persons absent from your life?”“Who in your life empowers you? Disempowers you? Nourishes you? Feels toxic to you?”______ (check if client identified people) ___ ____ 5. 0. Antecedents—past or current conditions that cue, or set off, the behavior______ (check if client identified following antecedent categories) ___ ____ a. Affective antecedents “What are you usually feeling before this?” “When do you recall the first time you felt this way?”“What are the feelings that occur before the issue and make it more likely to happen? Less likely?”“Describe any holdover or unfinished feelings from past events in your life that still affect this issue. How?”______ (feelings, mood states) ___ ____ b. Somatic antecedents “What goes on inside you just before this happens?” “Are you aware of any particular sensations or discomfort just before the issue occurs or gets worse?”“Are there any body sensations that seem to occur before the issue or when it starts that make it more likely to occur? Less likely?”“Is there anything going on with you physically—like illness or a physical condition or in the way you eat or drink—that leads up to this issue?”______ (body sensations, physiological responses) ___ ____ c. Behavioral antecedents “If I were recording this, what actions and dialogue would I pick up before this happens?”“Identify any particular behavior patterns that occur right before this happens. ”“What do you typically do before this happens?”“What seems to start this entire chain of events?”______ (overt behavior) ___ ____ d. Cognitive antecedents “What are your thoughts before this happens?” “What are you telling yourself before this happens?”“Can you identify any particular beliefs that seem to set the issue off?”“What do you think about [or tell yourself] before the issue occurs that makes it more likely to happen? Less likely?”______ (thoughts, beliefs, internal dialogue, cognitive schemas)“To what extent is your concern affected by oppression and discrimination that you experience in your environment?”“To what extent does your environment give or deny you access to power, privilege, and resources?”“What opportunities do you have in your environment for sharing spiritual and cultural values and activities?” (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
246 Chapter 7 7 Knowledge and Skill Builder (continued) ___ ____ e. Contextual antecedents “How long ago did this happen?” “Has this ever occurred at any other time in your life? If so, describe that. ”“Where and when did this occur the first time?”“What things happened that seemed to lead up to this?”“What was happening in your life when you first noticed the issue?”______ (time, places, other events) “How were things different before you had this concern?”“What do you mean, this started 'recently'?” ___ ____ f. Relational antecedents “Are there any people or relationships from past events in your life that still affect this concern? How?”“Identify any particular people that seem to bring on this concern. ”“Are you usually with certain people right before or when this issue starts?”“Are there any people or relationships from the past that trigger this issue in some way? Who? How?”“How do the people who hold power in your life trigger this issue?”______ (other people) ___ ____ 6. 0. Identify consequences that maintain and strengthen issue or weaken or diminish it______ (check if client identified following sources of consequences) ___ ____ a. Affective consequences “How do you feel after this happens?” “When did you stop feeling this way?”“Are you aware of any particular feelings or reactions you have after the issue that strengthen it? Weaken it?”______ (feelings, mood states) ___ ____ b. Somatic consequences “What are you aware of inside you—sensations in your body—just after this happens?”“How does this affect the issue?”“Are there any sensations inside you that seem to occur after the issue that strengthen or weaken it?”“Is there any physical condition, illness, and so on about yourself that seems to occur after the issue? If so, how does it affect the issue?”______ (body or internal sensations) ___ ____ c. Behavioral consequences“What do you do after this happens, and how does this make the issue better? Worse?”“How do you usually react after this is over?”“In what ways does your reaction keep the issue going? Weaken it or stop it?”______ (overt responses)Scoring Category of information Examples of helper leads or responses Client response Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 247 “Identify any particular behavior patterns that occur after this. ”“How do these patterns keep the problem going? Stop it?” ___ ____ d. Cognitive consequences“What do you usually think about afterward?”“How does this affect the issue?”“What do you picture after this happens?”“What do you tell yourself after this occurs?”“Identify any particular thoughts [beliefs, self-talk] that make the issue better. Worse?”“Are there certain thoughts or images you have afterward that either strengthen or weaken the issue?”______ (thoughts, beliefs, internal dialogue) ____ ___ e. Contextual consequences“When does this issue usually stop or go away? Get worse? Get better?”“Where are you when the issue stops? Get worse? Get better?”“Identify any particular times, places, or events that seem to keep the issue going. Make it worse or better?”______ (time, places, other events) ____ ___ f. Relational consequences“Can you identify any particular reactions from other people that occur following the issue?” “In what ways do their reactions affect the issue?” “Identify any particular people who can make the issue worse. Better? Stop it? Keep it going?”“How do the people who have power in your life situation perpetuate this concern?”______ (other people) ___ ___ 7. Identify possible secondary gains“Has your concern ever produced any special advantages or considerations for you?”“As a consequence of your concern, have you gotten out of or avoided things or events?”“What do you get out of this situation that you don't get out of other situations?”“Do you notice anything that happens afterward that you try to prolong or to produce?”“Do you notice anything that occurs after the problem that you try to stop or avoid?”“Are there certain feelings or thoughts that go on after the issue that you try to prolong?”“Are there certain feelings or thoughts that go on after the issue that you try to stop or avoid?”“The good thing about ______ [issue] is... ”______ (check if client identified gains from issue) ____ ___ 8. Identify solutions already tried to solve the issue“How have you dealt with this or other issues before? What was the effect? What made it work or not work?”“How have you tried to resolve this concern?”“What have you done that has made the issue better? Worse? Kept it the same?”“What have others done to help you with this?”______ (check if client identified prior solutions) ____ ___ 9. Identify client coping skills, strengths, resources“What skills or things do you have going for you that might help you with this concern?”“Describe a situation when this concern is not interfering. ”______ (check if client identified assets, coping skills, (continued) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
248 Chapter 7 7 Knowledge and Skill Builder (continued) “What strengths or assets can you use to help resolve this?”“When don't you act this way?”“What kinds of thoughts or self-talk help you handle this better?”“When don't you think in self-defeating ways?”“What do you say to yourself to cope with a difficult situation?”“Identify the steps you take in a situation you handle well—what do you think about and what do you do? How could these steps be applied to the present issue? How could these prevent the issue from recurring in the future?”“What resources are available to you from your community and your environment?”individual and environmental strengths, resources) “What kinds of things in your community and environment do you consider to be strengths and assets?”“What sorts of positive, purposeful relationships do you have now that help you with this issue?”“What do you find meaning in from particular aspects of your culture?” ____ ___ 10. Identify client's description/assessment of the issue (note which aspects of issue are stressed and which are ignored)“What is your understanding of this issue?”“How do you explain this concern to yourself?”“Tell me about what the issue means to you. ”“What is your interpretation [analysis] of the concern?”“Sum up the issue in just one word. ”“Give the concern a title. ”_____ (check if client explained issue) ____ ___ 11. Estimate intensity of behavior/symptoms (assign self-monitoring homework, if useful) a. Degree of Intensity b. Frequency/Duration“On a scale of 1 to 10, with 1 being very calm and 10 being very anxious, rate the intensity of the anxiety you feel. ” “How often do you feel this way?”How long does this persist when it occurs?” ______ (check if client estimated intensity) Yes No Other skills ____ ___ 12. The helper listened at-tentively and recalled accurately the informa-tion given by the client. 13. The helper used basic listening responses to clarify and synthesize the information shared by the client. Scoring Category of information Examples of helper leads or responses Client response Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Conducting an Interview Assessment with Clients 249 14. The helper followed the client's lead in deter-mining the sequence or order of the information obtained. Observer comments: Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
7 Knowledge and Skill Builder Feedback250 Chapter 7 Part One See whether the interview leads that you generated are simi-lar to the following ones: “Is this the only issue you're concerned about now in your life, or are there other issues you haven't mentioned yet?” (Range of concerns) “When you say you feel anxious, what exactly do you mean?” (Behavior-affective component) “When you feel anxious, what do you experience inside your body?” (Behavior-somatic component) “When you feel anxious, what exactly are you usually doing?” (Behavior-behavioral component) “When you feel anxious, what are you typically thinking about [or saying to yourself]?” (Behavior-cognitive component) “Try to pinpoint exactly what times the anxiety occurs or when it is worse. ” (Behavior-contextual component) “Describe where you are or in what situations you find yourself when you get anxious. ” (Behavior-contextual component) “Describe what other things are usually going on when you have these feelings. ” (Behavior—contextual component) “How would you describe the relationship between yourself and these concerns and your current environment?” (Behavior-contextual component) “Can you tell me what persons are usually around when you feel this way?” (Behavior-relational component) “How would you describe your support in your life right now?” (Behavior-relational component) “Who in your life now empowers you? Disempowers you?” (Behavior-relational component) “Are there any feelings that lead up to this?” (Antecedent-affective) “What about body sensations that might occur right before these feelings?” (Antecedent-somatic) “Have you noticed any particular behavioral reactions or patterns that seem to occur right before these feelings?” (Antecedent-behavioral) “Are there any kinds of thoughts—things you're dwelling on—that seem to lead up to these feelings?” (Antecedent-cognitive) “When was the first time you noticed these feelings? Where were you?” (Antecedent-contextual) “Can you recall any other events or times that seem to be related to these feelings?” (Antecedent-contextual) “Does the presence of any particular people in any way set these feelings off?” (Antecedent-relational)“Are you aware of any particular other feelings that make the anxiety better or worse?” (Consequence-affective) “Are you aware of any body sensations or physiological responses that make these feelings better or worse?” (Consequence-somatic) “Is there anything you can do specifically to make these feelings stronger or weaker?” (Consequence-behavioral) “Can you identify anything you can think about or focus on that seems to make these feelings better or worse?” (Consequence-cognitive) “At what times do these feelings diminish or go away? Get worse? In what places? In what situations?” (Consequence-contextual) “Do certain people you know seem to react in ways that keep these feelings going or make them less intense? If so, how?” (Consequence-relational) “As a result of this anxiety, have you ever gotten out of or avoided things you dislike?” (Consequence-secondary gain) “Has this problem with your nerves ever resulted in any special advantages or considerations for you?” (Consequence-secondary gain) “What have you tried to do to resolve this issue? How have your attempted solutions worked out?” (Previous solutions) “Describe some times and situations when you don't have these feelings or you feel calm and relaxed. What goes on that is different in these instances?” (Coping skills) “How have you typically coped with other difficult situations or feelings in your life before?” (Coping skills) “What resources are available to you from your culture and community that you can use to help with this problem?” (Individual and environmental strengths-coping) “What kinds of things in your community and environment do you feel are strengths and assets?” (Individual and environmental strengths-coping) “If you could give this problem a title—as if it were a movie or a book—what would that title be?” (Client perceptions of issue) “How do you explain these feelings to yourself?” (Client perceptions of issue) “How many times do these feelings crop up during a given day?” (Frequency of issue) “How long do these feelings stay with you?” (Duration of issue) “On a scale from 1 to 10, with 1 being not intense and 10 being very intense, how strong would you say these feelings usually are?” (Severity of issue) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
251 Constructing, Contextualizing, and Evaluating Treatment Goals Personal Reflection Activity Pause for a few minutes to answer the following LO1 questions by yourself or with someone else: 1. What is one thing you would like to change about yourself? 2. Suppose you succeeded in accomplishing this change. How would things be different for you? What would you be doing, thinking, or feeling as a result of this change?3. What would be the payoffs or benefits to you if you made this change? 4. What would be some of the risks—to you or others—if you made this change? 5. Looking at where you are now and where you'd like to be, what are the steps along the way to get from here to there? 6. Identify anticipated interferences or obstacles (people, feelings, ideas, situations) that might interfere with the attainment of your goal. 7. Identify resources (skills, people, knowledge) that you would need to use or acquire to attain your goal. 8. How would you evaluate progress toward this outcome? These questions reflect the process of constructing and evaluating goals for counseling. Goals represent desired outcomes and they function as benchmarks of client prog-ress. In this chapter we describe and model concrete guidelines to help you and your clients construct, define, and evaluate goals for counseling. Where Are We Headed? Imagine a recent adventure in unfamiliar territory. LO1 Because the place was new to you, you may have felt disoriented and lost. You may remember asking yourself, “Where am I?” and then asking your companion, “Where is it we want to go?” More than likely you consulted a map—one mounted on a wall or a post nearby, or a map on your mobile device. Whichever type of map you Learning Outcomes After completing this chapter, you will be able to 1. Identify a situation about you or your life that you would like to change. Construct, contextualize, and evaluate one desired outcome for this issue, using the Goal-Setting Worksheet in the Knowledge and Skill Builder section as a guide. 2. Apply at least 10 of the 13 categories reviewed in this chapter and listed in the Interview Checklist in the Knowledge and Skill Builder section to a written client case. In doing so, you will be able to describe the steps you would use with this client to con-struct, contextualize, and evaluate desired outcome goals. 3. Demonstrate during a role play with two colleagues at least 10 of the 13 categories reviewed in this chapter and listed in the Interview Checklist in the Knowledge and Skill Builder section. These are categories associated with constructing, contextual-izing, and evaluating outcome goals. 4. With yourself or another person or client, conduct an outcome evaluation of a real or a hypothetical counseling goal, specifying when, what, and how you would measure the outcome. chapter 8 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
252 Chapter 8 consulted, you more than likely saw the words, “You are here” accompanied by an arrow pointing to your current location or a blue circle or a pin drop on your mobile device. Simply figuring out your current location and orienting yourself geographically can be an accomplish-ment, especially when you feel lost. Isn't this the function of a global positioning system or GPS? In the helping professions, this is the purpose of client assessment—to determine where the client is at the start of therapy and to help orient the client to his or her current situation. “You are here” allows the adventure of therapy to begin in a meaningful and purposeful way. The next task, as in any voyage, is to determine where to go. In the helping professions, this is the task of goal formulation. Beginning With The End in Mind In general, treatment goals represent the destination LO1 or the end point of therapy described by clients. This is the telic or purposeful nature of therapy. Goals are the direct response to one or more of the following questions: “Where do I hope to be?” “Where do I need to be?” “Where do I want to be?” Goals serve to facilitate client movement from the client's current circumstance to a destination the cli-ent values, an envisioned end point that is worth it. In this way, treatment goals represent a vision of client improvement—first and foremost, improvement envi-sioned by the client, and, secondarily, improvement en-dorsed or supported by the helper. Think about it: you are much more likely to move from here to there if you are clear about and can understand where “there” is. Not be-ing able to see the desired end point on your GPS makes it much more difficult to invest the time, energy, and money needed to travel from your current location. And move-ment is much more likely when the traveler can see for himself or herself the destination in the distance or view the end point on the map rather than taking someone else's word for it. Purposes of Treatment Goals Goals have been defined as “cognitive representations that serve a directional function for behavior by focusing the individual on more specific possibilities” (Elliot, Mc-Gregor, & Thrash, 2002, p. 373). This definition captures the features of visualization and movement described thus far, and it also highlights important purposes of treatment goals. We highlight six. 1. Provide Direction The first purpose of treatment goals is to provide direction for helping. T reatment goals are the signposts or the mile markers that serve to keep the work of therapy on track or on target. Without them, therapy would be analogous to “wandering in the wilderness” and would likely dimin-ish into a futile and frustrating exercise. Just as in any journey, once the destination has been established, the direction (e. g., north, south) for travel—as well as the actual route and map—can be determined. Goals there-fore serve as the structure or the framework for helping, identifying when the work of client and helper has been accomplished. Although each theoretical orientation and evidence-based practice (EBP) has its own direction, constructing goals that are tailored to the person who is the client helps to ensure that helping is structured specifically to meet the needs of that person. This is what is referred to as an individualized or idiographic approach to goal for-mulation, an approach that focuses on the client's unique needs and preferences. It differs from a nomothetic ap-proach to goal formulation, which follows general laws or guidelines and pertains to all individuals or groups of individuals (e. g., cultural groups, persons who share a pri-mary diagnosis). A general or nomothetic treatment goal for a female college student who is experiencing depres-sion and is meeting with a therapist trained in the EBP of acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012) might be engaging in the standard practice of cognitive defusion so that she is able to decrease the believability of, or the attachment to, her long-held thought that she is worthless and subsequently experience behavioral flexibility. An idiographic goal for this same female client would be shaped by the particu-larities of her case (e. g., recent events in her life, familial history of depression, sexual orientation, ethnic identity) and would require further contextualization. Persons and Tompkins (2007) explain that “evidence-based nomothetic formulations [are] the foundation for the development of idiographic formulations” (p. 292). This means that both approaches are needed, that both must work in concert in service of the client. Once the foundation of care has been established, we believe that clients are much more likely to launch on a journey of change and travel to a specified destination if the plan or map that has been developed has been tailored or customized to them—their very own personalized itinerary. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 253 a particular outcome. Given the client's choice of goals and the helper's areas of competence, the helper decides whether to continue working with the client or to consult with a supervisor or colleague about possibly referring the client to someone else who may be in a better position to render services. There are at least three caveats about the practice of referral. First, the decision to refer is never that of the practitioner in training or someone who continues to receive training and clinical supervision. That decision belongs to the supervisor. Second, often helpers do not have the luxury of selecting the clients they want to work with or of simply opting out of helping based on the helper's personal values or preferences, or even skill level or expertise. For example, helpers providing services in a public school located in a large metropolitan area will need to be prepared to work with students, their families, and also school personnel who are affiliated with dif-ferent religions and practice a range of customs. Third, hand-picking clients based on the helper's comfort level or how well the client's values match those of the helper's personal values is simply unethical (American Counseling Association's ACA Code of Ethics, 2014). As discussed in Chapter 2, client referrals are to be based on helper skill level, not personal values. Because of this, referring a cli-ent to another helper is as an action of last resort (Kaplan, 2014). A client whose presenting concerns may warrant specialized services may be unable to travel to or afford the recommended services of a specialty clinic. In this latter case, the helper may need to continue to provide routine services while pursuing specialized training and enlist the assistance of a qualified supervisor. 5. Justify Recommended Services T reatment goals are a basis for the helper's recommenda-tion to use particular change strategies and interventions. The changes that the client desires will, to some degree, determine the kinds of action plans and treatment strate-gies that can be used with some likelihood of success. Without clarifying what the client needs and wants, it is almost impossible to explain and defend one's choice to move in a certain direction or to use one or more change strategies. Without goals, the helper may use a particular approach without any justifiable basis. Whether the ap-proach will be helpful is left to chance rather than choice. 6. Evaluate Outcomes The sixth and final purpose of treatment goals is to deter-mine whether or the extent to which services have been effective. If clients have not made progress toward an 2. Provide Focus T reatment goals also provide a focus for helper and client activities, which is consistent with goal-setting theory in organizational psychology (Locke & Latham, 2002). According to this theory, goals serve to focus attention on goal-relevant activities and away from goal-irrelevant activities. This is quite evident in the performance of successful athletes, who set goals for themselves and then use the goals not only as motivating devices but also as standards against which they rehearse their performance over and over, often cognitively or with imagery. For example, running backs in football constantly see them-selves getting the ball and running downfield and into the end zone. Champion snow skiers are often seen closing their eyes and bobbing their heads in the direction of the course before the race. Gymnasts and divers are known to engage in similar behaviors prior to competition. Goals therefore help with successful performance and problem resolution because they are usually rehearsed in our work-ing memory and because they direct our attention to the resources and components in our environment that are most likely to help with devising a solution. In the case of treatment goals, clients must be able to picture or “taste” or somehow experience first-hand the target behaviors or end results reflected in their goals. 3. Foster Expectation and Hope for Improvement Goals are intended to foster in clients an expectation and hope for improvement. As Lee, Uken, and Sebold (2007) noted, “The use of goals shifts the focus of attention from what cannot be done to what can be accomplished; it moves clients away from blaming others or themselves and holds them accountable for developing a better, dif-ferent future” (p. 30). Clients who are able to envision a relief or a lifting of their current level of distress are likely to invest in the helping process, and informing clients that being able to resolve or at least to manage a long-held dilemma not only is possible but also is probably likely to engender hope. Hope is a major component of a strengths-based helping perspective (Lopez, Pedrotti, & Snyder, 2015) and, along with expectations of positive outcomes, has been identified as a significant factor in client change (Anderson, Lunnen, & Ogles, 2010; Wampold, 2007). 4. Determine Helper Qualifications T reatment goals also make it possible for helpers to deter-mine whether they have the necessary skills, competen-cies, and interests to work with a particular client toward Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
254 Chapter 8 identified endpoint or goal after a certain time in counsel-ing, it might be said that services have not been helpful. In this sense, treatment goals signify the consequence of treatment and its interventions. Keeping the ultimate goal in mind, the helper and client can monitor progress toward the goal and measure the effectiveness of a change intervention. These data provide continuous feedback to both helper and client. One method for systematically collecting and using real-time outcome data from clients over the course of therapy has proven to enhance overall client outcomes in five large randomized controlled studies. Conceived by Michael J. Lambert (2010a, 2010b), this method entails alerting therapists to immediate client feedback about things such as symptom management and the therapeutic relationship, so that therapists can then make alterations in their plan for therapy, including the focus of the next session and specific interventions. Client feedback is ob-tained from brief standardized measures, such as versions of the Outcome Questionnaire (OQ) developed by Lam-bert and colleagues (available at www. oqmeasures. com), and then reported immediately to therapists on a mobile device. This client feedback can be used to assess the feasibility of the established outcome goals and also the effectiveness of interventions already applied. This type of system illustrates the interrelatedness of the processes of constructing and evaluating outcome goals. Characteristics of Well-Constructed Treatment Goals Think of the process of determining an LO1 LO2 LO3 outcome goal with a client as similar to helping the cli-ent paint a picture of the life he or she wants to be living and the type of person he or she wants to be as a result of participating in counseling. The painting takes shape as the visual depiction meets certain criteria and develops certain characteristics. We discuss eight characteristics of well-constructed treatment goals in this section. They are listed in Box. 8. 1. 1. Salutary, Not Remedial If goals represent a vision of client improvement, then a primary characteristic of well-constructed treatment goals is that they represent the presence of something positive, not the absence of something negative. This feature is promi-nent in solution-focused therapy (Berg & Miller, 1992; De Jong & Berg, 2013; Macdonald, 2007; Walter & Peller, 2000) and other forms of strengths-based helping, such as person-centered care (Adams & Grieder, 2014), as well as in cognitive-behavior therapies (Persons, 2008). This means, in part, that treatment goals identify and describe what the client will be doing rather than what the client will not be doing. Consider this: What comes to mind when you are asked to describe not being angry or a decrease in anxiety? Can you picture an absence of anger or a decrease in anxiety? More than likely what is envisioned is what is in place of this absence and this de-crease, that is, behavior associated with the alternative or the opposite of anger and anxiety, such as speaking calmly or remaining quiet, smiling faintly, engaging in deep breathing exercises, or counting down slowly from 10 to 1 or from 10 to 0. These are behaviors that can be seen and described and are therefore present. Envisioning the ab-sence, decrease, or loss of something is really not possible because we cannot see what is no longer there! What is possible is seeing the replacement or the alternative to this absence or void—what is referred to as instead behaviors. For the client who responds to the question, “What do you want to have happen as a result of being in counsel-ing?” with, “I don't want to be all stressed out and feel panicky all the time,” the helper can then ask, “What do you want to be feeling instead of stressed out and panicky?” The client's response to this question will then represent the goal for therapy, the alternative to “not stressed out” and “not panicky. ” If the client is not able to picture this right away—which is very common—then the helper can 1. Salutary, not remedial: Describe the presence of some-thing positive, not the absence of something negative 2. New and different 3. Process-oriented, not static: Describe a regular and an ongoing process, not a once-and-for-all accomplish-ment4. Realistic and achievable: Within the client's control 5. Specific and comprehensible6. Compelling and useful: Personally meaningful 7. Interpersonally related: Noticed by and benefitting others 8. Involve hard work: Challenging for the client Source: Berg & Miller, 1992; De Jong & Berg, 2013; Lee, Sebold, & Uken, 2003; Persons, 2008; Walter & Peller, 1992, 2000. BOX 8. 1 Eight Characteristics of Well-Constructed Treatment Goals Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 255 inquire further about preferred alternatives that the client can envision and identify with, such as “confident” and “self-assured. ” This process may take some time because the person who is steeped in anxiety and other stressors may not be able to see outside of or beyond the confines of this difficulty, especially if the symptoms have been present for a long time. With patience, skillful questioning, and coach-ing on the helper's part, specific behaviors associated with the preferred alternative, the “instead” (e. g., confidence and self-assurance), can be identified little by little, things for the client to do now, even in small measure, to achieve the goal and arrive at the preferred destination. It is worth repeating that well-constructed treatment goals are preferred end points that can be seen, not descrip-tions of what cannot be seen. They represent the increase of desired behaviors, rather than the mere decrease or ab-sence of undesired behaviors. As Persons (2008) explained, clients can limit their involvement in unwanted behaviors (e. g., avoiding a particular bully at school), but this does not automatically translate to an increase in desired behav-iors (e. g., sleeping soundly through the night). One can do less of something undesirable, but this does not mean that what is desirable will increase as a result. In dialectical behavior therapy (DBT), the overarching goal is to help cli-ents establish a life worth living, not just to prevent clients from killing themselves. In the words of DBT developer Marsha Linehan, DBT is “a life worth living program, not a suicide prevention program” (personal communication, October 1, 2009). Because treatment goals represent the vision of client improvement, helpers must be persistent in assisting clients to envision the instead, the presence of what they want and what is worth it to them, not simply describing what they hope will diminish or vanish. Goals that describe the presence of something positive are what we refer to as salutary goals, whereas goals that men-tion the absence of something negative are remedial goals. As their name suggests, salutary goals are health-promoting, they provide sustenance, and they signify the addition or promotion of something good and beneficial. By contrast, remedial goals are corrections; they are the result of interven-tions designed to correct or calibrate a deficiency. The dis-tinction between salutary goals and remedial goals is similar to the distinction made between approach goals and avoid-ance goals. Whereas approach goals focus on a positive end state and thus imply movement toward a desired outcome, avoidance goals focus on negative end states and therefore suggest moving or staying away from them. Although Persons (2008) described good treatment goals as those that focus on increasing desired behaviors and also focus on reducing symptoms and problems (i. e., salutary and remedial, as well as approach and avoidance), we contend that helpers must prioritize salutary and ap-proach goals in their work with clients—particularly as therapy progresses—if therapy is to be effective. Research supports this strategy. Clients in a university counseling center who identified more avoidance goals at the begin-ning of counseling were less likely to report overall life sat-isfaction at the end of counseling compared to clients who identified fewer avoidance goals (Elliot & Church, 2002). In addition, Wollburg and Braukhaus (2010) found that patients participating in a cognitive behavioral therapy program for depression who developed only approach goals at the beginning of treatment reported significantly lower scores on the Beck Depression Inventory at the end of treatment than those patients in the same program who had developed at least one avoidance goal. It is difficult for us to imagine therapy ending suc-cessfully when only remedial or avoidance goals and not salutary or approach goals have been met. This would be the equivalent in medicine of discharging patients from the hospital once they have been medically stabilized or terminating psychiatric services without a referral to talk therapy once the patient has responded well to a medica-tion regimen. For persons assessed with severe alcohol use disorder, detoxification may be necessary (i. e., medically managed withdrawal), but it is not considered a specific form of treatment by itself; rather, it is a prelude to treat-ment and the recovery process (Doweiko, 2015). In the addictions field, persons who have been detoxed but who have yet to begin a plan of recovery are sometimes referred to as “dry drunks. ” For them, the remedial or avoidance goal would have been met (i. e., stopped drinking), but the salutary or approach goal (i. e., active and ongoing recovery) is unmet. Intervening to avert and contain crises such as suicidal intent and drug overdose is certainly necessary, but we do not consider crisis intervention in itself to be sufficient for effective mental health care. In many ways, remedial treatment goals can be likened to intermediate goals or subgoals that we discuss later in the chapter—they are intended to be met along the way, fulfilled during active treatment; but they are not considered the end point of therapy or the equivalent of outcome goals. Again, reduc-ing symptoms of anxiety denotes progress but does not justify terminating treatment if the client is not able to institute positive, instead behaviors. 2. New and Different Goals that represent the presence of something positive, not just the absence of something negative, imply that new and different behaviors are intended. In their work Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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256 Chapter 8 with domestic violence offenders, Lee and colleagues (Lee, Sebold, & Uken, 2003; Lee, Uken, & Sebold, 2007, 2012) stipulated that treatment goals must describe be-haviors that clients have not generally engaged in before. The expectation that clients develop new and different behaviors is understandable given that most persons seek counseling because their typical or routine behaviors are not working. Goals therefore must be geared to break the repetitive and failed attempts at coping and usher in more functional patterns. 3. Process Oriented, Not Static Goals that are process-oriented reflect the continuity or maintenance of preferred outcomes, rather than a once-and-for-all achievement. Egan (2014) refers to these as sustainable goals. This characteristic exempli-fies the assumption in systems theory and solution-fo-cused therapy that change is constant (Lee et al., 2003). Examples of process-oriented goals include remaining gainfully employed rather than simply getting a job, consistently implementing specific parenting skills learned in treatment rather than enforcing appropri-ate discipline for the first time, continuing to excel in school rather than making the dean's list one semester, and managing symptoms of anxiety rather than becom-ing symptom-free. There are two aspects of treatment goals that we hope are evident in these examples. First, well-constructed goals depict a destination that is ever present, that is nonend-ing, suggesting that the benefits of therapy are meant to be enduring, extending beyond the completion of a treatment program. This is similar to how graduation and commencement are understood at various academic institutions. Whereas graduation signifies the successful completion and ending of a degree program, commence-ment signifies the beginning of a new venture. Earning the degree is not necessarily an ultimate outcome or end-all, be-all goal; it is actually the stepping stone or the intermediate goal to another destination. Second, process-oriented treatment goals also make evi-dent that the purpose of therapy is to help clients manage and cope with ongoing challenges, not to eliminate chal-lenges entirely. An expectation and misconception that many clients may have when they enter counseling is that something can be done to take away or wipe out their concern and dilemma. “Fix my child,” they may say, or “I want to be cured. ” This is understandable when clients are experiencing acute emotional distress and perhaps even physical pain. Medication may be targeted as the answer, but even medication cannot eliminate unwelcome and debilitating symptoms altogether. As helpers in behavioral health who are not medical professionals and whose expertise is in the process of talk therapy, we would do well to not use static, fixed, or permanent language when constructing treatment goals. Process language is recommended. “Recovery” can be used instead of “recovered,” “taking medication as pre-scribed” can be used instead of “medication adherent” or “medication compliant,” and “detaching from emotional pain” or “grounding” can be used instead of “avoid trig-gers. ” (The practice of “grounding” is used in the treat-ment of women struggling with problematic substance use and post-traumatic stress disorder or PTSD to focus on, remain grounded in, and maintain connection with the external world. It is part of the evidence-based prac-tice called Seeking Safety developed by Najavits, 2002. ) Again, if change is constant, then our role as helpers is to help clients continue to manage difficulties by routinely practicing skills intended to promote and sustain well-being, not eradicate problems altogether. 4. Realistic and Achievable It is not uncommon for clients to speak of preferred des-tinations that are too ambitious and therefore too distant and far off. This is particularly true at the beginning of therapy for all age groups and suggests limited understand-ing of, or investment in, the process of change. Goals may also be proposed that are simply impossible. Clients expe-riencing a great deal of distress, for example, are prone to grandiose thinking and may demand miraculous interven-tion. When this happens, it is important for helpers not to squelch the client's wishful thinking or to immediately and brusquely correct irrational or illogical proposals. Rather, helpers are advised to validate the client's need and then re-direct the client's energies. This means bringing into focus what it is the client wants to be, have happen, or accom-plish. Again, well-formulated goals are those destinations that can be seen by the client and therefore they must be in view and in focus, and thus attainable. Well-constructed treatment goals that are realistic and achievable are also within the client's control. This means that goals must be fashioned according to what the client can accomplish rather than what can be accomplished for the client. According to self-determination theory (Deci & Ryan, 2012), this defines autonomy, one of three basic and universal psychological needs essential for human growth and well-being (the other two are competence and relat-edness). Autonomy refers to self-governance or the need to view oneself as the source of decision-making. Behav-ing in an autonomous fashion means acting according to self-endorsed and integrated values and beliefs (i. e., what I believe is what I do, and vice versa) rather than being Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 257 extrinsically motivated or coerced by others or acting in a certain way only to avoid shame and embarrassment. There is a volitional quality to autonomous behavior, which distinguishes it from independence. One can be forced by others to become independent, but one cannot be forced to become autonomous. Autonomous behavior also is closely aligned with au-thenticity. This means that someone who is behaving autonomously is one whose behaviors are congruent with his or her values. This type of behavior is more likely to be maintained because it is intrinsically motivated and personally endorsed as valuable. Clients involved in outpatient therapy who identified personal goals for autonomous rather than extrinsically motivated or co-erced reasons demonstrated lower levels of depression and anxiety, demoralization, and interpersonal problems, and higher levels of sense of coherence or meaning in life (Michalek, Klappheck, & Kosfelder, 2004). This suggests that treatment goals endorsed by clients as realistic and achievable are more likely to be enacted and maintained. Garvin (2009) noted that helpers should not support clients in their efforts to attain illegal or immoral goals. 5. Specific and Comprehensible Goal specificity refers to clarity. Without a clear focus, forward movement cannot be expected. Constructing specific goals also means that forward movement can be traced and measured, allowing the client, helper, and oth-ers in the client's life to determine progress. Goals that are specific are often behaviorally defined, describing what the client will be doing when therapy has been successful. When treatment goals are described with specificity, they are thus detailed and clear, and the behaviors that com-prise or fulfill each goal are evident. When treatment goals are specific, they are also much more likely to be understood and endorsed by the client, thus supporting client autonomy. The practice of construct-ing goals in a way the client can comprehend is referred to in solution-focused therapy as “language matching. ” This means that the helper is deliberate in using words the client can relate to, words that are part of the client's lexicon, and, as recommended by Adams and Grieder (2014), written in the client's primary language. Clinical verbiage is relin-quished for the sake of client discernment. These skills are particularly important in cross-cultural counseling. 6. Compelling and Useful Although our formal training as helpers does not include sales and marketing, our work with clients may often feel like we are “selling” a new perspective and “marketing” a more functional and rewarding way of living. This is the product of our care, concern, and empathy for clients. We didn't enter the profession to watch clients persist in destructive behaviors, stumble, and fail. Nonetheless, it is imperative that we not impose our recommendations onto clients. As much as we believe a particular goal will benefit a client, buying into that goal is not our deci-sion—it is the client's. It is the goal that he or she will be living, not us. And for clients to fully endorse a treatment outcome, it must be worth it to them—it must be what Persons (2008) describes as emotionally compelling, and it also must be seen by clients as useful. Implied in this characteristic of compelling and useful treatment goals is that clients not only have choices but also have preferences, and these are paramount. Elicit-ing and incorporating client preferences have become essential features of evidence-based practice (Tompkins, Swift, & Callahan, 2013), and research indicates that clients who receive their preferred treatment are signifi-cantly less likely to end treatment prematurely and more likely to benefit from treatment than clients who receive nonpreferred treatments or whose preferences are ignored (Swift, Callahan, & Vollmer, 2011). Goal construction must therefore attend to what the client values, regards as important, and deems worthy of investment—again, supporting the client's autonomy. And for this to occur, the client must be able to see himself or herself as a full partner in the process of therapy, someone whose views are recognized, validated, and respected. As Lee and col-leagues (2003) state, “People who set their own goals, in their own terms, are more likely to work on them and maintain investment in them” (p. 152). 7. Interpersonally Related Well-constructed treatment goals also describe client be-haviors that will be noticed by and will benefit others. Another way to say this is that client improvement should not be sequestered or hidden from view. Rather, it should be on full display for others to see and appreciate. The client should not be the only one to reap the benefits of effective therapy. Many persons enter therapy at the behest of someone else, because their behavior has nega-tively affected others or at least has been a concern for others. It is therefore logical to devise treatment goals that, when achieved, will have a positive impact on persons in the client's life. This is particularly true for clients from more collectivistic than individualistic cultures who view improvement as the betterment of their primary cultural group, be it family, neighborhood, or community. Al-though the client must be the primary beneficiary of treat-ment goals, client improvement must also have a positive side effect on others, or provide second-hand benefits. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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258 Chapter 8 One helpful way to construct treatment goals that are interpersonally related is to query, with the client's per-mission, the client's referral source or a family member or friend. Informed by solution-focused therapy, the ques-tions posed might be: “What does [client] need to do differently for you to know that therapy was helpful?” “What will be some of the small signs to you that [client] is trying?” “What will convince you that [client's] change is legitimate and lasting and not just a fluke?”Responses would then be shared with the client and used to construct a treatment goal that will be beneficial not only to the client but also to others. Further questions to query the client directly about goals that would benefit others might be: “How will others know that coming to counseling has been helpful for you?” “What will you be doing that will convince [family mem-ber, friend, referral source] that you have changed for the better?” “What do you hope others will notice first that will tell them that your hard work in counseling has paid off?” “In what ways will your hard work make a positive and last-ing difference for your family (or team, neighborhood, community)?” 8. Involve Hard Work If change were easy, then therapy would not be nec-essary. T reatment goals must therefore be a challenge to clients and reflect the investment and hard work needed from clients for positive change to be realized. Of course, these should remain realistic accomplishments, with outcomes that are within the client's control and possible with support from the helper and other persons in the client's life, such as family members. But treat-ment goals should not simply describe what the client is already doing or what the client can easily accomplish. Constructing such goals would make a mockery of the treatment process and render therapy inconsequential. When persons are able to remain invested in a project that yields early and lasting benefits, their own self-efficacy is strengthened—the collective efficacy of their cultural group may also be strengthened—and this por-tends further and ongoing exertion toward subsequent goals. It is the client, however, who must be able to see the direct connection between his or her efforts and a positive outcome. Support for Goal Characteristics Lee and colleagues (2007) found that treatment goal characteristics predicted lower recidivism among domes-tic violence offenders. Specifically, clients who devel-oped treatment goals that were behaviorally described, positively stated, stated as a small step, and stated in process form had lower recidivism rates after they com-pleted treatment. In another study of adults with diabetes (Miller, Headings, Peyrot, & Nagarja, 2012), greater goal specificity was associated with attaining the goal of an improved diet. These and other studies (e. g., Wollburg & Braukhaus, 2010) highlight the importance of well-con-structed treatment goals to mobilize client change. Before reading further, we encourage you to review the eight characteristics of well-constructed treatment goals and then participate in Learning Activity 8. 1. This activity is intended to test your ability to recognize well-constructed goals when you witness them in action. Cultural Considerations Clients from different cultural groups may require differ-ent counseling processes and goals. To gain an apprecia-tion for another's cultural identity and values, Okun and Suyemoto (2013) recommend assessing sociocultural and sociostructural factors, such as age, ethnic and racial back-ground, gender, sexual orientation, socioeconomic status, and violence history. As discussed in Chapters 2 and 6, Hays (2008, 2013) uses an expanded list of cultural influ-ences that include developmental disabilities, disabilities acquired later in life, and indigenous heritage. These are organized according to the acronym ADDRESSING, which captures only a few of the vast elements that com-prise the complexities of identity and the human experi-ence and therefore influences the content and process of developing appropriate treatment goals. It is worth repeating that treatment goals represent the vision of client improvement and that it is the client—more so than the helper—who must envision improve-ment for progress to be made. This means that helpers must privilege the experience and ideas of their clients (Bo-hart & Tallman, 2010), including their cultural identity and practices. T reatment goal formulation should there-fore take into consideration the specific values, customs, and traditions of the client's culture (Bernal & Sáez-Santi-ago, 2006), even if these do not match those of the helper. Take, for example, the white Protestant clinician who thought her Arab Muslim college student would be able Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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Constructing, Contextualizing, and Evaluating Treatment Goals 259 to resolve her depression and anxiety by further “distanc-ing” herself from her “overly protective” and “demanding” family back in the Middle East. The client, however, has made the decision to forgo a full scholarship for graduate studies in the United States so that she can return home and fulfill her “duty” to her family as the caretaker to her ailing grandmother. For her, this means a return to tradi-tional dress and the inevitability of an arranged marriage. This one example highlights the importance of as-sessing clients' collectivist and individualist orientation and, for ethnic minority clients, acculturation (extent of adopting values and practices of the majority culture) and enculturation (extent of identifying with one's own ethnic minority culture; Blume & García de la Cruz, 2005). T reatment goals for certain clients might also hinge on their experiences of being on the receiving end of microag-gressions, what Sue (2010) defined as brief, common, and daily verbal, behavioral, and environmental indignities (whether or not intentional) that communicate hostile, derogatory, or negative racial, gender, sexual orientation, and religious slights and insults to a target person or group. The helper's failure to consider a client's experi-ence of microaggressions and how these have impacted the client over time might affect the client's decision not to return to counseling or the client's lack of improvement during counseling. In using cultural awareness to develop goals, the impor-tant point for helpers is to be aware of their own values and biases, to remain perpetual learners of cultures of which they are not a member (Hays, 2008, 2013), and to avoid deliberately or inadvertently steering the client toward goals that may reflect their own cultural norms rather than the client's expressed wishes. The emphasis is on adapting therapy and customizing treatment goals Learning Activity 8. 1 Goal Characteristics in Action The centerpiece of Lee and colleagues' (2003) solution-focused group treatment for domestic violence offenders is the construction of treatment goals. Clients are the ones to identify their own treatment goal, a goal that, for them, represents a present and future behavior they are inter-ested in. This goal-setting focus of treatment is intended to convey to clients that they are accountable for changing their behavior. Although Lee and colleagues' (2003) goal-setting task (p. 56) incorporates most of the eight characteristics of well-constructed treatment goals listed in Box 8. 1 and discussed thus far in the chapter, we have modified their goal-setting task in this Learning Activity so that all eight characteristics are represented. Can you spot them? We invite you to read through the following task that could be presented to clients in group therapy (consistent with Lee et al. 's treatment program) or to individual clients (and therefore the helper would use “I” language instead). Once you have read through the task, refer back to Box 8. 1, and then respond to the following questions: How many characteristics of well-constructed goals can you identify in the goal-setting task? On a separate sheet of paper, write down each of the characteristics that you identified and, for each one, write down how it was illustrated in the goal-setting task. That is, what is the example provided in the task? Write down the specific words in the example that illustrate each character-istic. Also, develop an alternative or an additional example, one that is your own creation. For each characteristic that you identified in the goal-setting task, explain to a classmate how the example in the task reflects the characteristic of well-constructed goals that you selected. Also share with your classmate your own example and explain how it reflects the specific character-istic of well-constructed goals. Compare your responses. Feedback to Learning Activity 8. 1 is provided on page 260. Goal-Setting Task* We want you to create a goal for yourself that will be use-ful to you in improving your life. Picture something that you will be doing rather than what you won't be doing. It's actually impossible to picture a behavior that's not in motion, something that's not being done! The goal should be interpersonal in nature, that is to say, that when you work on the goal, another person will be able to notice the changes you've made, and potentially that person could be affected by the change in how you behave. Another way to think about this is that if you brought us a videotape of yourself working on your goal, you would be able to point out the different things you were doing and maybe even note how these changes affected the other people on the tape. The goal needs to be something different, a behavior that you have not generally done before. This means it will reflect your diligence and hard work. It will also represent something positive and beneficial, something you're work-ing toward instead of avoiding. Keep in mind that because you will be expected to report on your goal work every time we meet, it is important that your goal be a behavior you can do at least a few times per week. *Adapted from Lee, Sebold, and Uken, 2003, p. 56. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
260 Chapter 8 8. 1 Feedback Goal Characteristics in Action Goal Characteristic Example in Goal-Setting Task Explanation Salutary, not remedial What you will be doing rather than what you won't be doing Something positive and beneficial, some-thing you're working toward instead of avoiding A behavior that can be visualized rather than one that can't be seen Focus on encouraging purposeful behav-ior that for the client is rewarding and worth the effort Emphasis on advancing, or forward move-ment, rather than on retreat; approaching the goal rather than avoiding the problem New and different Something different, a behavior not gen-erally done before What good is therapy if the client con-tinues as before, doing the “same-old, same-old”? Doing something new and different can serve as the evidence that participating in therapy made a positive difference Process-oriented, not static What you will be doing Something you're working toward Verbs are stated in process form (i. e., do-ing, working) rather than in static or end-state form (e. g., would have done or accomplished) Realistic and achievable A behavior you can do at least a few times per week Something that with practice is not too difficult and can become routine or cus-tomary Something the client can take credit for en-acting because it originated from the cli-ent, not from someone else (demonstrates the client's autonomy and self-regulation) Specific and comprehensible On a video segment, you can point out the different things you were doing Client can detect specific behaviors that he or she has demonstrated Client can explain the purpose of these be-haviors to another person Compelling and useful Meaningful and useful to you in improving your life Something that convinces the client that the effort was worth it A behavior that makes a positive differ-ence in the client's daily life Interpersonally related Another person will be able to notice the changes you've made Point out how these changes affected other people on a video segment A new behavior that makes a positive dif-ference for others, not just for the client Secondhand benefit of client's treatment gains May be viewed as a form of restitution or making amends so that client's good standing is reinstated by others Involve hard work Reflect your diligence and hard work “You earned it!” or “You earned it!” Something done with effort, with purpose, is likely to have a lasting benefit than something done easily or casually Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 261 to the needs and preferences of each individual client be-cause effective treatments are those that are culturally fo-cused and adapted to the needs and circumstances of the client (Hays, 2014; Smith, Rodriguez, & Bernal, 2011). The Process of Change T reatment goals identify the content of change: what needs to change or what will be different when positive change has occurred. The process of change is concerned with the how of change: how change can and does occur for clients. In nonclinical and clinical samples, there are accounts of quantum change, or the experience of sudden, sur-prising, and permanent personal transformation (Miller, 2004; Miller & C'de Baca, 2001). Most change, how-ever, experienced in and outside of therapy, is gradual and ongoing and cannot be achieved instantaneously. As Bien (2004) remarked, “Deep and lasting change in psychotherapy occurs through [a] process—a process of sustained attention to a fundamental life dilemma” (p. 497). And dilemmas, by definition, are not simple to understand, much less work through. This explains our recommendation that helpers eliminate from their clini-cal vocabulary and from conversations with clients words that imply that change is automatic or even permanent, words such as “fix” or “cure” or even “recovered. ” Alter-native or instead language to use would include “working on,” “managing,” or “recovering. ” Remember that one of the characteristics of well-formulated goals is that goals are stated in process form, meaning that they describe behaviors that are regular and ongoing. Determining what these ongoing behaviors will be is aided by the use of stage models. We discuss three, one prominently. Transtheoretical Model and Stages of Change Prochaska and colleagues (Prochaska & Di Clemente, 1982; Prochaska, Di Clemente, & Norcross, 1992) de-veloped the transtheoretical model of change. The trans-theoretical model (TTM) depicts a temporal sequence of change and suggests common activities that propel behavior change from one time period to another. It is transtheoretical because it “cuts across” and transcends or rises above existing theories of psychotherapy by offering something new. That something new is a theory of when and how people change. In this way, the TTM is an in-tegrative model—integrating theories and practices and offering a new perspective. The TTM has three dimensions: processes, levels, and stages of change. Processes of change in the TTM are defined as 10 common activities or tasks that correspond to and mobilize change. Among these are consciousness-or awareness-raising (promoted by education and feedback), self-re-evaluation, dramatic relief or emotional arousal, stimulus control or regulating exposure to certain places or people, and counterconditioning or response substitu-tion. This latter process is similar to the practice of oppo-site action in DBT (Linehan, 2015), whereby persons are coached to express an emotion in a manner inconsistent with a felt emotion, such as smiling in a relaxed man-ner when thinking of someone you argued with recently and still feel angry toward. Levels of change in TTM are the prioritization of five distinct but related problems addressed in psychotherapy: symptom/situational problems, maladaptive cognitions, current interpersonal conflicts, family/systems conflicts, and intrapersonal conflicts. The TTM is best known for its third dimension: the outline of five time periods or stages in the change pro-cess, referred to as the stages of change. They are de-picted in Figure 8. 1. Each stage represents a step toward a particular outcome goal, and certain characteristics are prominent in each stage. Taken together, the stages signify different attitudes, intentions, and behaviors regarding changing a target behavior (Connors, Di Clemente, Velas-quez, & Donovan, 2013). The five stages of change and their corresponding characteristics are: 1. Precontemplation: Persons in precontemplation are unaware of or are oblivious to a need to change their behavior, are underaware or do not fully comprehend the need to change, or simply do not intend to change their behavior in the near future. They may be resigned to continuing as is or are adamant about not sacrific-ing something that is just too important to them at this point. When they enter treatment, it is because they have been mandated or otherwise coerced to do so by someone else because their behavior has become problematic for others. 2. Contemplation: Persons in contemplation are aware that a change in their behavior is needed, but they are not able to do so (e. g., they lack certain skills or confidence) or they do not want to make the change just yet. They know that change would offer benefits, but they also are well aware of the costs involved. Cli-ents in this stage of change are torn between changing and remaining the same; they feel stuck and confused and are ambivalent about change. Because of this, contemplation may be considered the behavioral pro-crastination stage of change, and persons—whether or not they are in treatment—can remain in this stage of change for months or even years. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
262 Chapter 8 3. Preparation: Persons in preparation have made a deci-sion to change their behavior in the near future (e. g., next month) because the negative consequences of change are not as great as before. They have resolved their ambivalence about changing a target behavior by convincing themselves that change is needed and will be beneficial. This may be considered the dress rehearsal stage of change in that clients are practicing their new behavior in baby steps, but they have yet to break out and engage fully in the new behavior. They are still planning, strategizing, and getting ready for their behavioral debut. 4. Action: Persons in the action stage of change are actively and deliberately engaged in changing their overt behavior. Their commitment to making a change is clear and firm and their efforts are noticeable to others. They have debuted their new behavior and are investing considerable time and energy into making this behavioral change routine and permanent; they intend to make this new behavior stick. 5. Maintenance: Persons who have continued to engage in the new behavior for more than 6 months and have realized the early benefits of change are considered to be in the maintenance stage of change. Because of their success, they are sold on this new behavior and want the benefits to keep on coming. They are intent on consolidating the gains made and preventing relapse. Box 8. 2 on page 263 provides a case example of the stages of change process applied to Corinne. We recommend that you read through her case now while inspecting Figure 8. 1 more closely. As you do so, notice the sequence of stages in Figure 8. 1. Four of them form a circle, and relapse and recycling are a part of this process. Notice that the precon-templation stage is not actually part of the cycle of change. It precedes the start of the cycle. This means that persons such as Corinne enter the change process when they move into the contemplation stage of change. It also means that no one can relapse to precontemplation; this would be the equivalent of going back to ignorance, which actually is impossible to do. The relapse and recycling component of the stages of change model reinforces the cyclical and recursive aspect of change, that change is not linear. It also means that change is difficult, that change is a back-and-forth process and therefore requires trial and error over time, and that back steps in the process of change (e. g., back to contemplation) represent opportunities for enhanced learning and the practice of different skills. Corinne, featured in Box 8. 2, likely did not make changes easily or smoothly. Her doubts about breaking up with Logan are not uncommon and signify a relapse to contemplation once she had moved into preparation. Clients and their family members should be alerted to the not uncommon phenomenon of relapse and recycling (but not back to precontemplation), and helpers should be ready to select effective interventions—appropriate for or matched to the lapsed stage of change—when this occurs. The three dimensions of the TTM work together when the helper selects one process or a specific intervention Precontemplation Contemplation Preparation Maintenance Action Figure 8. 1 Stages of Change Model Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 263 treat ment method and promoting therapy progress” (p. 151). This is true for several reasons. First, as practitio-ners, we need to have an understanding of what it means to change if we are to promote change in clients. Second, SOC assessment allows the helper to start where the cli-ent is. This “client-first” mentality exemplifies the client's defining role in therapy that research over many years has identified as one of the most important— if not the most important—variable to explain client change in therapy (Bohart & Tallman, 2010). Third, SOC assessment allows practitioners to formulate relevant treatment goals and to select appropriate interventions. These are presented in Table 8. 1 and a few examples are used to explain. Clients in the precontemplation stage of change come to counseling at someone else's request or under some sort of pressure. This is actually quite common and may be based on its appropriate match with a particular client's stage of change or readiness to change so that it addresses one of the levels or problems of change. In this way, the TTM helps clinicians assist their clients in how (pro-cesses), when (stages), and what (levels) to intentionally change (Prochaska & Norcross, 2010). Given this method of integrating the three TTM dimensions, it is evident that the client's stage of change (SOC) is assessed first to determine an intervention that targets a specific level or presenting problem. Perhaps this explains the popularity of the SOC dimension of the TTM. Stage of Change Assessment Norcross, Krebs, and Prochaska (2011) emphasized that SOC assessment “has vital implications for guiding To conceptualize the stages of change dimension of the TTM, consider Corinne, a young woman in a controlling re-lationship with her male partner, Logan. It is Corinne's sister and one of Corinne's long-time friends who have expressed their concern about Logan's seemingly tight control over Corinne's life, such as calling and texting her frequently during the day, recommending what she should wear, and expecting her to spend almost every evening and all week-end with him and no one else. During their nearly 1-year relationship, Corinne has obliged his requests, describing Logan as a “romantic” who really cares about her. In the precontemplation stage of change, Corinne doesn't understand the concern about Logan expressed by her sis-ter and friend, explaining to them that Logan is just “needy” and that she's glad to be able to care for him. She believes their concern is unfounded and she says she's happy in their relationship, even though she doesn't get to see her family or some of her friends as much as she used to. She doesn't see a need to change anything about her relation-ship with Logan. However, as Corinne learns more about the concern that her sister and friend have about Logan, and as she ponders further what her life is like now with Logan versus what it used to be like before she met him, she realizes why others might be concerned. Awareness of some of the downsides of being with him signifies a move into the contemplation stage of change. It is during this stage that Corinne struggles with wanting to please and care for Logan while at the same time wanting some of her old freedom back. “He does so much for me, ” she explains, “but I really do want to make more decisions for myself once again. ” The “but” is a tip-off that ambivalence has sur-faced, representing a tension between these two polarities. She now asks herself: “Do I keep going as is or do I begin to make some changes for myself?”Only after considerable time weighing the pros and cons of making changes in her relationship with Logan does Corinne realize the need to make a change. She be-comes convinced that staying as is will not be in her best interest and, in fact, will become debilitating for her. She also realizes that there will actually be more advantages to changing her relationship with Logan than staying as is, and that the costs of changing won't be as considerable as earlier thought. This realization is the tipping point into the preparation stage of change. Time is now spent devising ways to change her behavior, including practic-ing new behaviors in small ways, such as not returning all of his calls right away, doing things with her sister, and using new communication skills, such as not apologizing to Logan unnecessarily. As Corinne gains confidence and increased skill in her interactions with Logan (as well as time spent with her sister and friend), she “goes public” with her new behavior, thereby moving into the action stage of change. This entails breaking up with Logan, staying at her sister's place tempo-rarily, getting a new phone, and enrolling in a self-defense class. This takes considerable effort because these alterna-tive behaviors are still new for her and there is occasional doubt about ending things with Logan. After a period of time of experiencing an increasing number of benefits of being on her own and not being under his control, Corinne gains further confidence in her own decision-making and lifestyle. She remains committed to improving her own self. The focus now shifts to protecting and building on these benefits and not sliding back to her old ways of thinking that she needs to care for Logan or that she needs to be in a relationship right now. This is the maintenance stage of change wherein the new self and the new behaviors have been integrated into daily living. BOX 8. 2 Case Example of Stages of Change Process Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
264 Chapter 8 the norm. Indeed, research suggests that approximately 40 percent of clients enter treatment in the precontempla-tion stage of change (Norcross et al., 2011). Clients in this stage can be difficult to engage, and therefore the helper's role is described as that of a nurturing parent. This role entails acknowledging the client's experience of feeling co-erced, building a relationship, and increasing the client's awareness of the consequences of his or her behavior. One of the principles of change outlined by Prochaska (1999) is that for clients to move out of precontemplation and into effective action, the benefits of change must out-weigh the shortcomings of change by 100 percent. That is, “therapists should place twice as much emphasis on the benefits of changing than on the costs” (p. 241). Clients in the contemplation stage of change are aware of a concern but not able to see themselves as part of the solution, at least initially. Approximately 40 percent of clients enter treatment in the contemplation stage of change. It is important to recognize the experience of vacillation in these clients and to remember that am-bivalence about change is common. All of us experience what Jungians refer to as “tension of the opposites”—the need to hold on to what is familiar while testing out what is new. During the contemplation stage of change, the helper's role is that of a Socratic teacher and appropriate interventions include validating the client's ambivalence, exploring the client's concerns or reasons for not changing (or disadvantages of changing), and helping to raise the client's awareness of the potential benefits or advantages of changing, which might become apparent as the costs of change decrease. Indeed, Prochaska (1999) proposed that for persons to move out of contemplation into effective action, the costs of changing must decrease. Clients in the preparation and action stages of change acknowledge that there is a problem, see themselves as part of the solution, and are committed to working toward specific outcomes. Only 20 percent of clients enter treat-ment in the preparation stage of change. Clients in this stage intend to take some action soon, may have already tried something, and may have a plan. The helper's role is that of an experienced coach and his or her primary task is to develop a plan of action with the client and to enhance the client's commitment to the change plan. It is an error to think that simply because the client has made a commitment to change, action will follow automatically. The helper as coach must craft a very specific plan of ac-tion with the client, remain vigilant in guiding the client through the process of testing the waters, and provide the client with detailed feedback. Strategies for helpers to use during the preparation stage of change include identifying specific behaviors to implement on a trial basis, teach-ing and demonstrating specific skills associated with the target behavior, rehearsing or role-playing those skills, correcting skill deficits, tracking progress, and remaining TABLE 8. 1 Stages of Change and Corresponding Interventions Stage of Change Interventions Role of Helper Precontemplation Remain optimistic Provide rationale for interventions and change Convey respect and use active listening skills Increase the pros of change Nurturing parent Contemplation Validate client's ambivalence about change Explore both sides of client's ambivalence: advantages and disadvantages of change Educate client about change process Decrease the disadvantages or costs of change while helping to increase the client's perception of the advantages of change Socratic teacher Preparation Define, work toward, and evaluate selected outcomes Present all alternatives Encourage brief experiments with change Experienced coach Action Develop cognitions and skills to prevent relapse/setbacks prior to termination Review action plan Consultant Maintenance Provide emotional support Consultant Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 265 supportive and helpful for the client. These same helper strategies are then used when the client has moved into the action stage. In both the preparation and action stages of change, continuous evaluation of client progress is essential. This makes it possible to modify the plan, iden-tify and replicate effective skills, and maintain momen-tum for change. Clients in the maintenance stage of change often face difficulties holding on to the gains made in prior stages. It is often easier to prepare for and initiate new behaviors than it is to maintain new behaviors. Think of this stage as the period after the honeymoon, when the focus shifts from the wedding and being newly married to maintain-ing a healthy marriage. What was once new is now part of the person's daily routine and, as a result, the person's self-identity likely has changed. To continue to benefit from the newly acquired self-image and lifestyle, ongoing focus and deliberate action are needed. Maintenance can there-fore be understood as a time of perpetual adjustment and is not an occasion for clients to sit back and hit the cruise control. Doing so would reflect a laissez faire attitude and a devaluing of the change process, and it could signal a person's propensity to relapse and cycle back into earlier stages of change. Maintenance goals and skills are espe-cially important in the areas of problematic substance use, mood disorders such as depression, and chronic mental health problems such as schizophrenia. For clients in the maintenance stage of change, the helper is in the role of a consultant (Norcross et al., 2011). An approach that seems particularly useful in working with clients in the maintenance stage of change is the relapse prevention model developed by Marlatt (see Marlatt & Donovan, 2005). This model is frequently used for relapse prevention in addictive behaviors and recently has expanded to highlight the importance of mindfulness practice in recovery (Bowen, Chawla, & Marlatt, 2011). Because relapse is a dynamic process involving intrapersonal and interpersonal determinants (Marlatt & Witkiewitz, 2005; Witkiewitz & Marlatt, 2004), relapse prevention is an ongoing process designed to help persons (1) identify high-risk situations for relapse, (2) acquire behavioral and cognitive coping skills (e. g., mindfulness), and (3) attend to issues of balance in lifestyle. Recent research suggests that mindfulness-based relapse prevention helps to lessen substance use and craving among culturally diverse per-sons experiencing substance use problems and symptoms of depression (Bowen et al., 2009; Witkiewitz & Bowen, 2010). Mindfulness skills also have been found to facilitate client movement toward treatment outcome goals, specifi-cally approach or salutary goals (Crane, Barnhofer, Hargus, Amarasinghe, & Winder, 2010). Stage of change assessment is invaluable, specifically in determining treatment goals. For a treatment goal to be realistic and achievable, it should clearly represent the next stage of change. T wo examples may help explain. For a young client who is in the precontemplation stage of change about his participation in the vandalism of school property following his high school football team's loss in the division championship game, an appropriate treat-ment goal for him would be acknowledging that his be-havior was wrong and realizing that he will likely have to change the group of friends he's been hanging out with if he wants to remain out of trouble, graduate on time, and be eligible for a college athletic scholarship. “Yeah, maybe I'll just do the tutoring after school instead,” he says, “but I don't know what I'll tell them [his old friends] or if I can really stick with it [the tutoring]. ” Even though he voices uncertainty about being able to make a behavioral change, his use of the word “maybe” signals his movement out of precontemplation and into contemplation. In this case, a new perspective or heightened awareness that brings with it ambivalence actually represents improvement. And improvement is measured as transitioning into the next stage of change, not necessarily the action stage of change. West and Brown (2013) criticize the stages of change model for its “arbitrary” differentiation between stages, its failure to predict behavior change, and its focus on conscious decision-making and planning processes. We believe, however, that because of its focus on decision-making and planning, it is a useful tool in treatment planning. Practitioners who are familiar with the stages of change can actively use it by first identifying the stage a client is in with respect to a target or change behavior, and then applying the appropriate interventions to facilitate the client's movement to the next stage. Referring back to Table 8. 1 may be helpful at this point. Two Other Stage Models Other stage models exist to help assess client needs and determine the direction and sequencing of treatment. As opposed to the stages of change dimension of the TTM that conceptualizes a person's stage of change, these other models depict stages of treatment for persons presenting with specific disorders. These are discussed in the follow-ing two stage models. For persons with co-occurring disorders (e. g., mental illness and substance use disorder), Osher and Kofoed (1989) identified four stages of treatment that continue to be promoted today in the provision of integrated treat-ment for co-occurring disorders (Mueser, Noordsy, Drake, & Fox, 2003). These stages are engagement, persuasion, Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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266 Chapter 8 active treatment, and relapse prevention. The focus of the engagement stage is to establish a therapeutic alliance by maintaining regular contact with the client, offering sup-port, practical assistance (e. g., food, clothing), and crisis intervention. Once a connection has been made and the client has become engaged in treatment, the focus of treatment shifts to increasing the client's awareness about his or her substance use and facilitating motivation to change. It is in this persuasion stage of treatment that in-formation is provided to the client (e. g., education about the effects of substances on mood, skills training) in the style of motivational interviewing (Miller & Rollnick, 2013) so that the client becomes empowered to make a decision about change. When the client has significantly reduced his or her substance use for more than 1 month and is actively seeking to maintain those reductions, he or she is considered to be in the stage of active treatment. The focus now is on more structured counseling and skills training. Similar to the maintenance stage of change in the TTM, the relapse prevention stage of treatment for persons with co-occurring disorders is concerned with helping the client develop a meaningful recovery process. The focus shifts from giving up substances to working toward a healthy life. Table 8. 2 illustrates the goals of treatment at each stage, along with sample interventions. Overlap with the stages of change in the TTM is also presented. Dialectical behavior therapy (DBT; Linehan, 2015) structures treatment according to five stages or, more pre-cisely, pretreatment and four stages of treatment. Each stage addresses a specific target or treatment need. Pre-treatment orients and prepares a client for treatment. The target is for the client and therapist to agree to treatment goals and to commit to work together. T reatment cannot proceed unless and until both client and therapist com-mit to treatment and DBT requires voluntary rather than coerced treatment. This pretreatment stage underscores the importance of client-helper collaboration. Stage 1 of treat-ment targets life-threatening behaviors, therapy-interfering behaviors, behaviors that interfere with living a quality life, and behavioral skills needed to achieve these ends. Stage 2 targets post-traumatic stress responses and emotion dys-regulation or duration of emotions, such as shame, anger, and emptiness. Stage 3 targets problems in living, such as employment difficulties, relationship/ marital distress, and difficulties with problem-solving. Stage 4 of treatment tar-gets a client's sense of incompleteness, such as the desire for spiritual fulfilment and managing boredom. It is in this TABLE 8. 2 Stages of Treatment and Corresponding Goals and Interventions for Persons with Co-occurring Disorders Stage of Treatment Goal Interventions Corresponding Stage of Change Engagement Establish working alliance Outreach Practical assistance Crisis intervention Help in avoiding legal penalties Precontemplation Persuasion Enhance client awareness of problematic nature of substance use and increase motivation to change Individual and family education Motivational interviewing Social skills training Use of medications to treat mental illness Contemplation Preparation Active treatment Help client further reduce substance use and, if possible, attain abstinence Individual and family problem-solving Self-help groups Individual cognitive behavioral counseling Action Relapse prevention Maintain awareness that relapses can happen and to extend recovery to other areas (e. g., social relationships)Independent housing Involvement in supported or independent living Becoming role model for others Maintenance Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 267 final stage of treatment that clients focus on achieving a sense of freedom and feeling joy. Using a Stage Model Use of any of the three stage models presented in this sec-tion helps clinicians and clients know how to determine what's next—how to identify suitable and realistic treat-ment goals based on the client's current functioning and preferences. Rather than thinking too ambitiously and thereby priming for potential failure or at least disap-pointment, stage models serve to keep both client and helper in check so that the process of change in therapy remains somewhat predictable and manageable. Collaborative Construction of Treatment Goals Kuyken, Padesky, and Dudley (2009) maintain that LO3 LO4 case conceptualization is a collaborative process, and that “the client must be integrally and explicitly involved at every stage of the conceptualization process” (p. 28). We believe this is also true during the construction of treat-ment goals. They and others (e. g., Persons, Beckner, & Tompkins, 2013) describe the principle of collaborative empiricism, which refers to the client and helper's shared commitment to therapy and their active style of partner-ship wherein each checks with the other about informa-tion collected from formal and informal assessments, such as the client's own observations and ideas. This pragmatic focus and systematic method suggests that the helper does not have the answer; rather, both client and helper serve as detectives, formulating hypotheses, and then testing out strategies that may be helpful to the client. Each is expected to provide evidence for what works. Although client-helper collaboration in the con-struction of treatment goals is not a new concept, it has garnered explicit focus in most evidence-based practices (EBPs), specifically EBPs that incorporate principles of cognitive-behavior therapy (CBT). These include DBT and ACT, which make use of highly ex-periential strategies such as mindfulness activities and exposure-based acceptance exercises. T reatment goals thus are derived from client-helper transactions, spe-cifically from the helper's focus on ensuring mutual understanding about what would be most useful for the client. In DBT, a lack of collaboration or progress is considered first a failure in dialectical assessment; that is to say, the therapist missed something in con-ceptualizing the client case and the focus of treatment (Koerner, 2007, p. 337). The helper thus bears the responsibility for developing and maintaining client-helper collaboration in most EBPs. Collaboration implies a joint effort. We therefore de-scribe the helper's task of learning from and connecting with the client, and also leading the way. Returning to our earlier travel analogy, we think of this as the helper's dual role as fellow traveler and tour guide. This means that for collaboration to be taking place, the helper must learn from the client's previous travels, understand where the client wants to travel next, and then guide the way toward that preferred destination. Situated in Relationship Persons (2008) described the therapeutic relationship as a collaboration, or working together, that makes the enact-ment of treatment interventions possible, and also as an intervention in itself. She proposed a synthesis of these two perspectives that we believe applies to the process of goal formulation. Collaborating to construct treatment goals cannot be done prior to or in lieu of a therapeutic relationship. Col-laboration presumes that a relational connection has been established. As discussed in Chapter 3, Bordin (1979) defined the therapeutic alliance, a component of the ther-apeutic relationship, as the extent to which the therapist and helper agree on treatment goals and tasks, and also as the strength of the emotional bond between them. Defining the quality of the therapeutic connection in large part according to the client and helper's agreement on goals and tasks reinforces for us the prominence of the goal construction process. It also means that the two are inextricably linked: agreement on treatment goals cannot be accomplished outside the boundaries of an established and trusting partnership, and such a therapeutic partner-ship cannot be sustained if both partners do not agree on goals. Without investing time in deliberating goals that are mutually acceptable—and constantly staying in step with clients about the intent and direction of therapy—the bond between client and helper is likely to weaken or even rupture. Collaborative goal construction itself is an interven-tion. This means that it is the helper's responsibility to be deliberate in using specific skills. It also means that client-helper agreement on the goal itself is a goal of treatment and that goal construction indeed is a process. Further-more, goal construction as an intervention situates it—as with other interventions—in a therapeutic relationship. Prominent pronouns used are we and us, signifying a partnership and a team effort. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
268 Chapter 8 Mutual Cooperation Having established a safe and trusting relationship—an emotional bond—with clients does not mean that col-laborative goal construction is smooth sailing. The client-helper partnership simply means that the vehicle is in place for the work of counseling to continue. This work requires mutual cooperation, which we define as each partner consulting the expertise of the other in a dynamic and recursive way. In medicine, this practice is referred to as shared decision-making (Drake, Deegan, & Rapp, 2010) and is situated in between clinician paternalism (one who knows best) and client informed choice (I alone will decide). The partner or team shares with the other as much information at his or her disposal (e. g., client de-scribes symptoms in detail, clinician explains all available treatment options) in an open manner so that treatment decisions result from mutual influence and not clinician unilateralism, or winning over the client on predeter-mined recommendations. The constant back-and-forth between client (or client and family members) and helper (or team of professional helpers) includes an ongoing as-sessment of the advantages and disadvantages of proposed goals, similar to exploring both sides of client ambivalence about change for clients in the contemplation stage of change. Shared decision-making and mutual cooperation may require more effort on the helper's part than on the client's. In a professional helping relationship, clinicians hold more of the power than clients and, therefore, for the sake of expediency or prestige or both, may revert to a more persuasive and prescriptive approach when making decisions on treatment goals. Research with physicians has found that shared decision-making remains more a philosophy or value than actual practice (Karnieli-Miller & Eisikovits, 2009). Challenges of implementing shared decision-making include finding time, improving com-munication, and increasing access to relevant and ev-idence-based information so that good choices can be made (Torrey & Drake, 2010). To address these chal-lenges, helpers are encouraged to become proficient in the use of electronic medical records so that information is readily accessible during a counseling session. It also is recommended that helpers are prepared to offer clients a menu of options, routinely solicit feedback from clients, and constantly check for clarity (see Osborn, West, Kinds-vatter, & Paez, 2008). During treatment goal formula-tion, the helper cooperates with the client's ideas about goals rather than the other way around, a practice that can have an empowering effect on clients. In their solution-focused group treatment for domestic violence offenders, Lee and colleagues (2007) found that when there was greater agreement between clients and helpers about the usefulness of clients' self-generated goals. At the end of the 3-month treatment clients had greater confidence in their ability to continue working toward their goals, and this (along with goal specificity) predicted a lower rate of recidivism. In an earlier description of this practice, Lee and colleagues (2003) stated that “the focus of treatment is not so much on determining the goal con-tent but on facilitating the process of goal development and goal accomplishment in participants” (p. 33). Referral and Collateral Consultation Collaborative construction of treatment goals is aided by consulting persons external to the client-helper re-lationship, specifically persons who have an interest in the client's outcome. These persons are referred to as collaterals. Of course this consultation can only occur with the client's permission and therefore implies that it is the client-helper team—and not simply the helper— conducting the consultation. Persons to consult include the client's referral source and collaterals or family mem-bers and friends. Questions to pose include those listed earlier in this chapter in the discussion of the interperson-ally related characteristic of treatment goals. Not only can the referral source and collaterals help in the process of treatment goal construction, they can also provide feedback on progress made toward goals. This im-plies that the helper will periodically check in with a client's family member, for example, over the course of therapy. From a solution-focused approach, this might include coaching family members to be on the lookout for posi-tive change behaviors. From a DBT approach, this might include the helper “commissioning” the client to consult key informants about their observations of change and then reporting back to the helper the client's findings. This would be a variant of the consultation-to-the-client strategy in DBT (Linehan, 2015) wherein the client is viewed as the key informant on his or her condition, not anyone else. Commitment to Treatment Goals Constructing treatment goals that the client and helper agree on does not necessarily mean that the client is com-mitted to work toward those goals. The stages of change and the stages of treatment discussed earlier in this chap-ter remind us that change is a process and that it is, for the most part, a gradual process. Helpers must therefore engage in the constant process of assessing their clients' investment in working toward identified goals. In motivational interviewing (MI; Miller & Rollnick, 2013), commitment talk is a form of change talk that Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 269 signifies the client's intention to put his or her plans into action. Words that declare commitment are the same ones used when taking an oath of office or declaring one's vow to a beloved, words such as “I am” and “I will. ” In ACT (Hayes et al., 2012), commitment is understood specifi-cally as committed action, engaging in overt behaviors to sustain a valued direction. Helpers operating from an integration of MI and ACT would therefore listen for and promote client change talk with respect to an identified treatment goal and then assist the client to “walk the talk” by acting on his or her commitment to that treatment goal. This involves mobilizing the client's self-efficacy, the belief in one's capacity to enact persistent yet flexible change. In DBT, commitment is understood as both an agree-ment and a behavior and is not confined to the pre-treatment stage. Recommitment to treatment goals is a constant goal of therapy and in DBT it is explicitly a shared enterprise. Helpers must therefore continually reassess their responsiveness to clients, adjusting their style and therapeutic commitment to accommodate client needs. A shared commitment to treatment goals might be likened to Bandura's (1997) concept of collective efficacy, defined as “a group's shared belief in its conjoint capabili-ties to organize and execute the courses of action required to produce given levels of attainments” (p. 477). The collective efficacy of certain communities (e. g., African American neighborhoods) has been found to mobilize community engagement to address depression in their community (Chung et al., 2009), reduce suicide attempts among adolescents in Chicago neighborhoods (Maimon, Browning, & Brooks-Gunn, 2010), and promote post-disaster mental health and general well-being following the damaging effects of a hurricane (Lowe, Joshi, Pietrzak, Galea, & Cerdá, 2015). Applied to the client-helper col-laboration, collective efficacy may facilitate the realization of treatment goals. Model Dialogue: Goal Formulation To illustrate the process of goal formulation LO2 LO3 LO4 in treatment, the case of Isabella is continued here as a dia-logue in an interviewing session directed toward goal construction. Helper responses are prefaced by an expla-nation. Note the italicized words that illustrate key prin-ciples and practices of goal formulation discussed thus far in this chapter. In response 1, the helper starts out with a review of the last session. 1. Helper: Isabella, last week we talked about some of the things that are going on with you right now that you're concerned about. What do you remember about what we talked about? Client: Well, we talked a lot about my problems in school—like my trouble in math class. Also about the fact that I can't decide whether or not to switch over to a vocational curriculum—and if I did, my parents would be upset. 2. Helper: That all fits with my memory, too. You summed it up well. We also talked about the pressure and anxiety you feel in competitive situations like your math class and your difficulty in making decisions. I believe we also mentioned that you tend to go out of your way to please others, like your parents, or to avoid making a decision they might not like. Client: Mm-hmm. I tend to not want to create a hassle. I also just have never made many decisions by myself. In the helper's next response, response 3, the helper moves from problem definition to goal selection. Re-sponse 3 consists of an explanation about goals and their purpose. Notice the helper's use of first-person plural pro-nouns that reinforce goal formulation as a collaborative effort, fueled perhaps by collective efficacy. 3. Helper: Yes, I remember you said that last week. I've been thinking that since we've kind of got a handle on the main issues you're concerned about, today it might be helpful to talk about things you might want to happen—or how you'd like things to be different. This way, we know exactly what we can be talking about and working on that's most helpful to you. How does that sound? Client: That's okay. I mean, do you really think there are some things I can do about these problems? The client has indicated some uncertainty about pos-sible change. The helper will pursue this in response 4 and indicate more about the purpose of goals and possible effects of counseling for Isabella. Again, notice the helper's reference to a therapeutic partnership. Also notice that ar-riving at Isabella's preferred goal will take some hard work on her part. 4. Helper: You seem a little uncertain about whether things can be different. To the extent that you have some control over a situation, it is possible to make some changes. Depending on what kind of changes you want to make, there are some ways we can work together on this. It will take some work on your part, too. How do you feel about this? Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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270 Chapter 8 Client: Okay. I'd like to get out of the rut I'm in. In the helper's next response, the helper explores the ways in which the client would like to change. Because “get out of the rut I'm in” is a goal that cannot be visualized—a remedial goal rather than a salutary goal—the helper probes for behaviorally specific descriptors. This will allow Isabella to begin to paint the picture of her desired destination, a preferred outcome that she can actually see. 5. Helper: So you're saying that you don't want to con-tinue to feel stuck. Exactly how would you like things to be different—say, in 3 months from now—from the way things are now? Client: I'd like to feel less pressured in school, especially in my math class. The client has identified one possible goal, although it is a remedial goal, stated in negative terms. In the helper's next response, the helper helps the client identify a salutary goal. This also means helping Isabella approach a desired alterna-tive rather than avoid a problem. 6. Helper: Okay, that's something you don't want to do. Can you think of another way to say it that would describe what you do want to do? Client: I guess I'd like to feel confident about my ability to handle tough situations like math class. In the next response, the helper paraphrases Isabella's goal and solicits feedback to clarify whether she restated it accurately. 7. Helper: So you're saying you'd like to feel more posi-tively about yourself in different situations—is that it? Client: Yeah, I don't know if that is possible, but that's what I would like to have happen. In responses 8-14, the helper continues to help Isabella explore and identify desired outcomes. Again, notice her consistent use of first-person plural pronouns. 8. Helper: In a little while we'll take some time to explore just how feasible that might be. Before we do that, let's make sure we don't overlook anything else you'd like to work on. In what other areas is it important to you to make a change or to turn things around for yourself? Client: I'd like to start making some decisions for myself for a change, but I don't know exactly how to start. 9. Helper: Okay, that's part of what we'll do together. We'll look at how you can get started on some of these things. So far, then, you've mentioned two things you'd like to work toward—increasing your confidence in your ability to handle tough situations like math and starting to make some decisions by yourself without relying on help from someone else. Is that about it, or can you think of any other things you'd like to work on? Client: I guess it's related to making my own decisions, but I'd like to decide whether to stay in this program or switch to the vocational one. 10. Helper: So you're concerned also about making a spe-cial type of decision about school that affects you now. Client: Yeah. But I'm sort of afraid to, because I know if I switch, my parents would have a terrible reaction when they found out. 11. Helper: You've mentioned another situation we might need to try to get a different handle on. As you told me last week, in certain situations, like math class or with your parents, you tend to back off and let other people take over for you. Client: Yeah, I do, and I guess this school thing, math class, is an example. I mean a lot of times I do know what I want to do or say but I just don't follow through. Like not telling my parents about what I think about this whole college prep curriculum. Or not telling them how their harping on me about grades makes me feel. Or even in math class, just sitting there and sort of letting the teacher do a lot of the work for me when I really do probably know the answer or could go to the board. 12. Helper: So in certain situations, with your parents or in math class, you may have an idea or an opinion or a feeling, but you usually don't express it. Client: Mm-hmm. Usually I don't because sometimes I'm afraid it might be wrong or I'm afraid my parents would get upset. 13. Helper: So anticipating that you might make a mis-take or that your parents might not like it keeps you from expressing yourself in these situations. Client: Yeah, I guess so. I hadn't thought of it that way before, really. 14. Helper: Then is this another thing that you'd like to work on? I mean, changing your expectations about how other people will respond? Client: Sure. I can't keep on not doing things, running away from things, or withdrawing into my own little world forever. Because Isabella has again stated the outcome in negative terms, in the next four responses (15-18) the helper helps Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 271 Isabella restate the goal in positive terms to make it a salutary goal rather than a remedial goal. Notice how the helper en-courages this restatement by describing a goal as something that can be visualized, and also using the word instead. 15. Helper: Okay, now again you're sort of suggesting a way that you don't want to handle the situation. You don't want to withdraw. Can you describe something you do want to do in these situations in a way that you could see, hear, or grasp yourself doing it each time the situation occurs? Client: I don't know exactly what you mean. 16. Helper: Well, for instance, suppose I need to lose weight to improve my health. I could say, “I don't want to eat so much, and I don't want to be fat. ” But that just describes not doing certain things and I can't really visualize a “not. ” So it would be more helpful to describe something I'm going to do instead, some-thing I can picture or visualize doing, like “Instead of eating between meals, I'm going to go out for a walk, or talk on the phone, or create a picture of myself in my head as a healthier person. ” Client: Okay, I see what you mean now. So I guess in-stead of withdrawing, I—well, what is the opposite of that? I guess I think it would be better if I volunteered the answers or gave my ideas or opinions—things like that. 17. Helper: Okay, so you're saying that you want to express yourself instead of holding back. Things like expressing opinions and feelings. Client: Yeah. 18. Helper: Okay, so there are three things you want to work on. Anything else? Client: No, I can't think of anything. In the next response, the helper asks Isabella to select one of the goals to work on initially. This is also part of specifying the goal and making sure Isabella understands it. Tackling all three outcomes simultaneously could be overwhelming to a client. 19. Helper: Okay, as time goes on and we start working on some of these things, you may think of something else—or something we've talked about today may change. What might be helpful now is to decide which of these three things you'd like to work on first. Client: Gee, that's a hard decision. In the previous response, Isabella demonstrated one of her problems: difficulty in making decisions. In the next response, the helper provides guidelines to help Isabella make a choice but is careful not to make the decision for her. She honors Isabella's autonomy and indicates her willingness to cooperate with Isabella. 20. Helper: Well, it's not a decision I can make for you. I'd encourage you to start with the area you think is most important to you now—and also maybe one that you feel you could work with successfully. Client (Long pause): Can this change too? 21. Helper: Sure—we'll start with one thing, and if later on it doesn't feel right, we'll move on. Client: Okay. Well, I guess it would be the last thing we talked about—starting to express myself in situations where I usually don't. In the next response, the helper discusses the degree to which Isabella believes the change represents something she will do rather than something someone else will do. 22. Helper: Okay, sticking with this one area, it seems like these are things that you could make happen without the help of anyone else or without requiring anyone else to change too. Think about that for a minute and see whether that's the way it feels to you. Client (Pause): I guess so. You're saying that I don't need to depend on someone else; it's something I can start doing. In the next response, the helper shifts to exploring pos-sible advantages of goal achievement as part of the process of mutual cooperation. This is similar to exploring both sides of client ambivalence about change for clients in the contemplation stage of change. Notice that the helper asks Isabella first to express her opinion about advantages, a strengths-based approach; the helper also is giving her in vivo practice in one of the skills related to her goal. 23. Helper: One thing I'm wondering about—and this will probably sound silly because in a way it's obvi-ous—but exactly how will making this change help you or benefit you? Client: Hmm. (Pause) I'm thinking. Well, what do you think? In the previous response, the client shifted responsibil-ity to the helper and “withdrew,” as she does in other anxiety-producing situations such as math class and inter-actions with her parents. In the next response, the helper summarizes this behavior pattern. The helper also provides feedback to Isabella to raise awareness of her behavior that for Isabella has become a concern, a practice appropriate for clients in either the precontemplation stage of change or the contemplation stage of change. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
272 Chapter 8 24. Helper: You know, it's interesting; I just asked you for your opinion about something, and instead of sharing it, you asked me to sort of handle it instead. Are you aware of this? Client: Now that you mention it, yeah, I can see that. But I guess that's what I do so often that it's sort of automatic. In the next three responses (25-27), the helper assesses Isabella's problems, which results in information that can be used later for planning of subgoals and action steps. 25. Helper: Can you run through exactly what you were thinking and feeling just then? Client: Just that I had a couple of ideas, but then I didn't think they were important enough to mention. 26. Helper: I'm wondering if you also may have felt a little concerned about what I would think of your ideas. Client (Face flushes): Well, yeah. I guess it's silly, but yeah. 27. Helper: So is this sort of the same thing that happens to you in math class or around your parents? Client: Yeah—only in those two situations I feel much more uptight than I do here. In the next four responses, the helper continues to explore potential advantages for Isabella of attaining this goal. This exploration exemplifies mutual cooperation and collaborative empiricism in treatment goal construction and resembles the exploration of both sides of client am-bivalence for clients in the contemplation stage of change. 28. Helper: Okay, that's really helpful because that infor-mation gives us some clues on what we'll need to do first to help you reach this result. Before we explore that, let's go back and see whether you can think of any ways in which making this change will help you. Client: I think sometimes I'm like a doormat. I just sit there and let people impose on me. Sometimes I get taken advantage of. 29. Helper: So you're saying that at times you feel used as a result. Client: Yeah. That's a good way to put it. Like with my girlfriends I told you about. Usually we do what they want to do on weekends, not necessarily what I want to do, be-cause even with them I withdraw and don't express myself. 30. Helper: So you are noticing some patterns here. Okay, other advantages or benefits to you? Client: I'd become less dependent and more self-reliant. More sure of myself. 31. Helper: Okay, that's a good thought. Any other ways that this change would be worthwhile for you, Isabella? Client: Hmm... I can't think of any. That's honest. But if I do, I'll mention them. In the next responses (32-35), the helper initiates ex-ploration of possible disadvantages of this goal. This bal-ances the exploration of possible advantages of this goal and is a strategy used for clients in either the precontempla-tion or the contemplation stage of change. 32. Helper: Okay, great! And the ones you've mentioned I think are really important ones. Now, I'd like you to flip the coin, so to speak, and see whether you can think of any disadvantages that could result from moving in this direction. Client: I can't think of any in math. Well, in a way I can. I guess it's sort of the thing to do there. If I start express-ing myself more, people might wonder what's going on. 33. Helper: So you're concerned about the reaction from other students. Client: Yeah, in a way. But there are a couple of girls in there who are pretty popular... but they did make the honor roll, too. So I guess I wouldn't be like a geek or anything. And actually, with my girlfriends, I don't think they'd mind that I spoke up; it just hasn't been how I've acted with them. They might be surprised, but I think they'd be okay with that. 34. Helper: It sounds, then, like you believe that is one disadvantage you could live with. Any other ways in which doing this could affect your life in a less good way—or could create another problem for you? Client: I think a real issue there is how my parents would react if I started to do some of these things. I don't know. Maybe they'd welcome it. But I sort of think they'd con-sider it a revolt or something on my part and would want to squelch it right away. 35. Helper: Are you saying you believe your parents have a stake in keeping you somewhat dependent on them? Client: Yeah, I do. This is a difficult issue. Without observing her family, it would be impossible to say whether this is Isabella's per-ception (and an unhelpful one) or whether the parents do play a role in this problem. Goal formulation at this point reflects the interpersonal nature of treatment goals and en-hancing the collective efficacy of the family. The helper thus reflects both possibilities (similar to weighing advan-tages and disadvantages as part of heightening awareness Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 273 for persons in the precontemplation stage of change) in the next response and also suggests collateral consultation. 36. Helper: That may or may not be true. It could be that you see the situation that way and an outsider like me might not see it the same way. However, it's possible your parents might subtly wish to keep you from growing up too quickly. This could potentially be a serious enough disadvantage that the four of us may need to sit down and talk together. Client: Do you think that would help? In the next two responses, the helper and Isabella continue to discuss potential disadvantages related to this goal. Notice that in the next response, instead of answering the client's previous question directly, the helper shifts the responsibility to Isabella and solicits her opinion (similar to DBT's consultation-to-the-client strategy), again giving her in vivo opportunities to dem-onstrate one skill related to the goal. 37. Helper: What do you think? Client: I'm not sure. They are sometimes hard to talk to. 38. Helper: How would you feel about having them meet with us one time? Client: Right now it seems okay. How could it help exactly? In the following response, the helper changes from an individual focus to an interpersonal or systemic focus, because the parents may have an investment in keeping Isabella dependent on them or may have given Isabella an injunction: “Don't grow up. ” The systemic focus avoids blaming any one person. 39. Helper: I think you mentioned it earlier. Sometimes when one person in a family changes the way she or he reacts to the rest of the family, it has a boomerang effect, causing ripples throughout the rest of the family. If that's going to happen in your case, it might be helpful to sit down and talk about it and anticipate the effects, rather than letting you get in the middle of a situation that starts to feel too hard to handle. It could be helpful to your parents, too, to explore their role in this whole issue. Client: I see. Well, where do we go from here? 40. Helper: Because our time is about up for today, that's what we will focus on first when we meet next week, okay? We'll map out a plan of action then. (Note: The same process of goal formulation would also be carried out in subsequent sessions for the other two out-come goals that Isabella identified earlier in this session. )Contextualizing Treatment Goals T reatment with most clients involves LO2 LO3 LO4 working toward more than one goal. This is particularly true for complex client cases, such as persons with co-occurring substance use and mental health disorders. It is useful to have the client specify one or more desired goals for each separate concern, but to tackle several outcome goals at one time would be unrealistic. The helper should ask the client to choose and specify one of the outcome goals to pursue first. Once this is done, the helper and client can then determine intermediate goals or subgoals and action steps. In this section we present several methods for contex-tualizing treatment goals. By contextualizing we mean the helper's initiative to further define treatment goals for and with the client so that each goal can be understood in the context of corresponding behaviors, under certain conditions (settings, circumstances), and at particular levels (frequency, duration, and intensity). This process includes identifying intermediate goals or subgoals that correspond to each outcome goal, and then prioritizing or sequencing goals. We also discuss obstacles or interfer-ences to goal attainment and resources to facilitate the achievement of goals. Contextualizing treatment goals can be likened to preparations made for a long-awaited trip. Based on the location of the targeted destination, decisions are made about apparel and other belongings to pack, luggage to take, means of transportation, travel itinerary, and travel-ing companions. These decisions help to clarify the action plan; with greater texture or detail, the vision of client improvement is more apparent and realistic, and the map constructed is much more likely to help the client reach his or her final destination successfully. Behaviors Related to Goals Contextualizing goals involves specifying in operational or behavioral terms what the client (whether an indi-vidual, group member, or organization) is to do as a result of counseling. This part of an outcome goal de-fines the particular behavior the client is to perform and answers the question “What will the client do, think, or feel differently?” Examples of behavior outcome goals include exercising more frequently, asking for help from a teacher, verbal sharing of positive feelings about oneself, and thinking about oneself in positive ways. As you can see, both overt and covert behaviors, including thoughts and feelings, can be included in this part of the outcome goal as long as the behavior is defined by what it means for Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
274 Chapter 8 each client. Defining goals behaviorally makes the goal-setting process specific, and specifically defined goals are more likely than vaguely stated intentions to create incen-tives and guide performance. When goals are behaviorally or operationally defined, it is easier to evaluate the effects of your intervention strategy. Specific methods the helper can use to identify the ac-tion part of a goal include: “When you say you want to, what do you see yourself doing?” “What could I see you doing, thinking, or feeling as a result of this change?” “You say you want to be more self-confident. Describe the things you would be thinking and doing as a self-confident person. ” “Describe for me an example of this goal. ”“When you are no longer ___, what will you be doing instead?” “What will it look like when you are doing this?” It is important for the helper to use methods such as these until the client can picture and describe in detail the overt and covert behaviors associated with the goal. This is not an easy task because many clients, especially those in the early stages of change (e. g., contemplation), can only describe change in vague or abstract terms. If the client has trouble specifying behaviors, then the practitioner can provide further instructions, information, or examples. The practitioner can also encourage the client to use ac-tion verbs to describe what will be happening when the goal is attained. As we mentioned earlier, it is important for clients to specify what they want to do (salutary goal), not what they don't want to do or what they want to stop (remedial goal). This is also the difference between describing approach behavior rather than avoidance be-havior. The goal is usually defined sufficiently when both client and helper can visualize and describe in detail the vision of client improvement. Conditions of Treatment Goals The second part of contextualizing an outcome goal is to determine certain conditions of the realized goal, namely the setting and the accompanying circumstances. These conditions include where, when, and with whom the be-haviors associated with the goal will occur. Specifying the conditions of a behavior establishes boundaries and helps ensure that the behavior will occur only in desired settings or with desired people and will not generalize to undesired settings. For example, a woman may wish to increase the number of positive verbal and nonverbal responses she makes toward her partner. In this case, time spent with her partner would be the condition or circumstances in which the behavior occurs. However, if this behavior generalized to all persons with whom she interacts, then it might have negative effects on the very relationship that she is trying to improve. Methods used to determine the conditions of the out-come goal include: “Where would you like to do this?” “In what situations do you want to be able to do this?”“When do you want to do this?”“Who would you be with when you do this?” The helper is looking for a response that indicates where or with whom the client will make the change or perform the desired behavior. If the client gives a non-committal response, then the helper may suggest client self-monitoring to obtain these data, such as completing a diary card consistent with dialectical behavior therapy. The helper also can use self-disclosure and personal ex-amples to demonstrate that a desired behavior may not be appropriate in all situations or with all people. Levels of Change The third part of contextualizing an outcome goal is de-termining the level or amount of the behavioral change. In other words, this part answers the question “How much is the client to do or to complete to reach the desired goal?” The level of an outcome goal serves as a barometer that measures the extent to which the client will be able to perform the desired behavior. For example, a man may state that he wants to improve his overall health (a salu-tary goal) by decreasing his cigarette smoking (a remedial goal). The following week, he may report that he did a pretty good job of cutting down on cigarettes. However, unless he can specify how much he actually decreased smoking, both he and the helper will have difficulty in de-termining how much the client really completed toward the goal. In this case, the client's level of performance is ambiguous. In contrast, if he had reported that he reduced cigarette smoking by two cigarettes per day in 1 week, his level of performance could be determined easily. If his goal were to decrease cigarette smoking by eight cigarettes per day, then this information would help to determine progress toward the goal. Setting the level of amount of behavior change reflected in the outcome goal is the part of the goal that enables both the client and the practitio-ner to determine when the action has been accomplished or the behavior has been changed. As with the behavior and condition parts of an out-come goal, the level of change should always be estab-lished individually for each client, whether the client is an Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). 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Constructing, Contextualizing, and Evaluating Treatment Goals 275 individual, couple, group, or organization. The amount of satisfaction derived from goal attainment often de-pends on the level of performance established. A suitable level of change will depend on factors such as the present level of the undesired behavior, the present level of the desired behavior, the resources available for change, the client's readiness to change, and the degree to which other conditions or people are maintaining the present level of undesired behavior. One way to set the level of a goal that is manageable is to use a scale that identifies a series of increasingly desired outcomes for each given area. This practice, known as goal attainment scaling, was introduced by Kiresuk and Sherman (1968) and has been used by a wide range of professionals (Kiresuk, Smith, & Cardillo, 1994) who work with diverse client and patient populations, includ-ing sex offenders (Hogue, 1994), violent offenders in in-patient treatment (Izycky, Braham, Williams, & Hogue, 2010), and patients in geriatric day hospitals (Stolee et al., 2012). Goal attainment scaling enhances client-helper collaboration, exemplifies individualized or idiographic treatment planning, and is appropriate when there are multiple goals to consider. In goal attainment scaling, the helper and client devise five outcomes for a given issue and arrange these outcomes by level or extent of change on a scale in the following numerical order: much less than expected or most unfavorable outcome (2); less than expected outcome (1); expected outcome (0); more or better than expected outcome (1); and much more than or best possible expected outcome (2). Table 8. 3 shows an example of a goal attainment scale (GAS). This example reflects T urner-Stokes' (2010) rec-ommended alternative rating wherein a 0. 5 is added to indicate partial achievement of the expected level. Us-ing these numerical scores, you can quantify levels of change in outcome goals by transforming the scores to standardized T scores (see T urner-Stokes, 2010). What is important is to ensure that both client and helper under-stand and agree on the meaning of each of the five levels on the GAS they construct. The primary purpose of goal attainment scaling is to assess the amount of client change on an identified target behavior, but because of its versa-tility it can also function as a therapeutic tool (Marson, Wei, & Wasserman, 2009). We introduce goal attainment scaling at this point to help make outcome goals more explicit; we return to this model later in the chapter when discussing various outcome measures. The purpose of establishing a targeted level of change in the treatment goal is to determine present and future levels of the desired behavior. The level of an outcome goal can be expressed by the number of times, or fre-quency, the client wants to be able to do something. Occasionally, the frequency of an appropriate level may be only one, as when a client's outcome goal is to make one decision about a job change. In this instance, the occurrence or lack thereof is the level of change. In other instances, the level of an outcome goal is expressed by the amount of time, or duration, the client wants to be able to do something. And in other instances, particu-larly when the goal behavior reflects a change in emo-tions, the level is expressed as a rating or scaling, referred to as intensity. Here are some ways to establish the level of change: “How much would you like to be able to do this compared with how much you're doing it now?” (duration) “How often do you want to do this?” (frequency)“From the information you obtained during self-monitoring, you seem to be studying only approximately 1 hour per week now. What is a reasonable amount for you to increase this without getting bogged down?” (duration) “If your feelings are very distressing, say about a 10 on a 0-to-10 scale, where would you like them to be after our work together using this 0-to-10 rating?” (intensity) The practitioner can help the client establish an appro-priate level of change by referring to the self-monitoring data collected during assessment. If the client has not engaged in self-monitoring, then it is almost imperative to have the client observe and record present amounts of the undesired behavior and the goal behavior. This informa-tion will give some idea of the present level of behavior—that is, the base rate or baseline level. This information is important because the desired level should be contrasted with the present level of the overt or covert behaviors. A client's data-gathering is very useful for defining is-sues and goals and for monitoring progress toward the goals. This is another example of the way in which goal TABLE 8. 3 Alternative Goal Attainment Scale Verbal Description of Achievement Corresponding Weight/Score A lot more 2 A little more 1 As expected 0 Partially achieved 0. 5 Same as baseline 1 Worse 2 Source: Turner-Stokes, 2010. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
276 Chapter 8 definition and goal evaluation occur simultaneously in actual practice. First Things First: Prioritizing and Sequencing Goals In the tradition of cognitive behavioral therapies, LO2 LO3 Nezu and his colleagues (Nezu & Nezu, 2010; Nezu, Nezu, & Cos, 2007; Nezu, Nezu, & Lombardo, 2004) differentiate between ultimate outcome goals and inter-mediate or instrumental outcome goals in treatment. Ultimate outcome goals describe the end point of therapy, are directly related to the reason therapy was initiated, and reflect the overall purpose or point of therapy. They con-stitute the conditions for determining when treatment can be terminated and considered a success. They are the final destination of therapy. Instrumental or intermediate outcome goals, however, are goals that are achieved along the way, goals that lead to and are instrumental in eventu-ally arriving at the ultimate goal. They are the stepping stones or stair-steps leading to the intended end point. In many ways they represent the preconditions or the prereq-uisites for fulfilling the ultimate outcome and arriving at the final destination. Although Nezu and colleagues refer to both types of goals as outcome goals, for our purposes we refer to outcome goals and intermediate goals or subgoals. One way to explain the relationship between outcome goals and intermediate goals or subgoals is to entertain once again our travel or voyage analogy. To arrive at the final destination (the outcome goal) on one's itinerary, several stops along the way (the intermediate or subgoals) must be made. Destinations that are quite distant or are very difficult to reach will require several intermedi-ate stops. And depending on certain conditions (e. g., weather, time changes, traveler's health, traffic, road con-ditions, or water conditions), changes may need to be made along the way, necessitating alternative stops or extra way stations, intermediate or subgoals that weren't in the original plan but are instrumental in arriving at the final destination. To begin the journey and launch the process of change, the final destination or outcome goal must be broken down into a series of smaller and more manageable goals. These are the intermediate or instrumental goals or subgoals that are action steps. The subgoals are usually arranged in a hierarchy, and the client tackles the subgoals at the bot-tom of the ranked list before attempting the ones near the top. Although an outcome goal can serve as a compass or general directive for change, the specific subgoals may determine a person's immediate activities and degree of effort in making changes. It may be helpful to think of subgoals as activities the client can do now, whereas the outcome goal remains a distant not-yet reality. Once a primary outcome goal has been identified, the client and helper work together to identify several subgoals. The subgoals are then ordered as a series of tasks according to their complexity and degree of difficulty and immediacy. Because some clients are put off by the word hierarchy, we refer to stair steps that can be drawn on a piece of paper, similar to the stair steps depicted in Figure 8. 2. The first criterion for ranking subgoals is the complexity and degree of difficulty of the task. A series of tasks may represent either increasing requirements of the same (overt or covert) behavior or demonstrations of different behav-iors, with simpler and easier responses sequenced before more complex and difficult ones. Although one of the char-acteristics of well-formulated treatment goals is that they involve hard work (see Box 8. 1), clients need to experience success early on as an incentive for further change. As Lee and colleagues (2003) reason, “keeping the goal simple in the beginning allows for early success and room to expand it later on in the process” (p. 66). The second criterion for ranking is immediacy. For this criterion, the client ranks subgoals according to prerequisite tasks—that is, the tasks that must be done before others can be achieved. The sequencing of subgoals in order of complexity is based on learning principles called shaping and successive approximations. Shaping helps someone learn a small amount at a time, with reinforcement or encouragement for each task completed successfully. Gradually, the per-son learns the entire amount or achieves the overall result through these day-to-day learning experiences that suc-cessively approximate the overall outcome. After all the steps have been identified and sequenced, the client begins to carry out or mobilize the actions rep-resented by the subgoals, beginning with the initial step and moving on. Usually, it is wise not to attempt a new subgoal until the client successfully completes the task at hand. Progress made on initial and subsequent steps pro-vides useful information about whether the gaps between steps are too large or just right and whether the sequenc-ing of steps is appropriate. As the subgoals are met, they become part of the client's current repertoire that can be used in additional change efforts toward the outcome goals. The ultimate outcome goal for one client is stated at the top of Figure 8. 2. The stair steps in Figure 8. 2 il-lustrate how she intends to arrive at the destination of being healthy in 12 months. Think of each stair step as Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 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Constructing, Contextualizing, and Evaluating Treatment Goals 277 Figure 8. 2 Goal Stair Steps Increase time spent in eating fi rst helpings at dinner by engaging in mindful eating (chewing food slowl y, noticing texture and taste of food) for fi rst 10 mins. 3. Increase heightened aw areness of present moment by engaging in one 20-min. mindfulness activity daily. 2. Increase amount of daily exe rcise by walking at least 1 mile/day at a fast pace. 1. Decrease second helpings at dinner by drinking one full glass of wa ter immediately af ter first helping and then getting up fr om ta ble. 4. Increase positive thoughts about self as a healthy person by engaging in three positive visualizations per da y. 5. Acquire verbal and nonverbal conversational skills and use them to become acquainted with at least one new personweekl y. 6. Maintain previoussix subgoals over12 month s. 7. Outcome Goal: To think, feel, and look like a healthy person by losing 40 pounds ov er the next 12 months. an intermediate goal or a subgoal toward the ultimate outcome goal. This client's rationale is that if she increases exercise and relaxation first (stair steps 1 and 2), it will be easier for her to alter her eating habits (stair steps 3 and 4). For her, more difficult and also less immediate subgoals include restructuring her thoughts about herself as a healthier person (stair step 5) and developing social skills necessary to initiate new relationships (stair step 6). For her, stair step 6 will be the most difficult one because her weight serves partly to protect her from social dis-tress situations. Once she arrives at stair step 6, the final subgoal, stair step 7, is to keep these actions going for at least 12 months. At the top of a client's stair steps, it is important for the helper to discuss with the client ways for her to maintain the subgoals for a longer period of time. This is the equivalent of working with clients in the maintenance stage of change. Notice in this example that the outcome goal is stated in positive terms and therefore reflects a salutary goal—not “I don't want to be overweight and unhealthy,” but “I do want to feel, think, and look like a healthy person. ” The subgoals represent actions the client will take to support this desired outcome. Also notice that all the subgoals point to and are stated in the same way as the outcome goal—with the definition of the behaviors to be changed, the level of change, and the conditions or circumstances Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
278 Chapter 8 of change so that the client knows what to do, where, when, with whom, and how much or how often. To help the client identify appropriate intermediate goals or subgoals and action steps, the helper can use the following strategies: “How will you go about doing [or thinking, feeling] this?” “What exactly do you need to do to make this happen?”“Let's brainstorm some actions you'll need to take to make your goal work for you. ” “What have you done in the past to work toward this goal? How did it help?” “Let's think of the steps you need to take to get from where you are now to where you want to be. ” The helper is always trying to encourage and support cli-ent participation and responsibility in goal formulation, re-membering that clients are more likely to carry out changes that they themselves originate. This explains Lee and col-leagues' (2003) policy that clients create their own goals in their group treatment program. Because it is the client who is the primary agent of change (Bohart & Tallman, 2010), Lee and colleagues “steadfastly refuse to give in to [their] urges to offer examples of goals” to clients (p. 58), believing that such “interference” would distract clients from discov-ering their own goals that work for them. Furthermore, they state their contention that “filling any uncomfortable silences only displays a lack of confidence in the [client's] abilities to begin the process” (p. 58). Their belief is that some clients have difficulty determining goals because they want to use their time wisely, wanting to be sure the eventual goals will benefit them. When this happens, they applaud the client's commitment to finding a goal that is meaning-ful for them, saying, “Even when it seems impossible right now, you are determined to find a goal that really fits for you. ” To help clients select their own goals and tasks, Lee and colleagues describe their style as patient, supportive, and persistent, encouraging clients to consult other members of the treatment group as well as family members and friends. Questions they pose to clients include “What do you think someone who knows you well might advise you to work on?” “What is the smallest thing that you could do that would help with that?” “On a scale from 1 to 10, with 1 being 'not important at all' and 10 being 'extremely important,' how important is it to you that you accomplish this goal?” “When you start working on this goal, what would you actually be doing that someone else would notice?” Throughout the goal task exercise, Lee and colleagues recommend that helpers capitalize on their clients' previous successes, clarify the purposes and characteristics of well-formulated treatment goals, notice the client's ef-fort to cooperate, compliment all efforts made to develop a goal, and restate the goal when it is well defined. Running Interference by Addressing Obstacles To ensure that the client can complete each LO1 intermediate goal or subgoal successfully, it is helpful to identify obstacles that could interfere. Obstacles may in-clude overt and/or covert behaviors, and in dialectical behavior therapy (DBT) these are referred to as therapy-interfering behaviors. Potential obstacles or interferences to check out with the client include the presence or ab-sence of certain feelings or mood states, thoughts, beliefs and perceptions, other people, and situations or events. Another obstacle could be lack of knowledge or skill. For example, a 72-year old client experiencing sleep difficulty may not have an understanding of circadian rhythms or the changes in sleep patterns with natural aging, and may not be aware of specific sleep hygiene practices (e. g., re-duce alcohol use, sleep only in the bedroom, avoid view-ing a computer or other LCD screen 1 hour prior to bedtime, return to bed only when sleepy; Milner & Belicki, 2010). Identifying lack of knowledge or skill is important if the client needs information or training be-fore the subgoal action can be attempted. After such ob-stacles are identified, the client and practitioner can develop a plan that addresses the obstacles so they do not linger as stumbling blocks to change. Clients often are not very aware of any factors that might interfere with completing a subgoal, and they may need prompts from the helper, such as the following, to identify obstacles: “Describe some obstacles or stumbling blocks you might encounter when working toward this goal. ” “What people [or feelings, ideas, situations] might get in the way of arriving at this destination?” “What or who might prevent you from working on this activity?” “In what ways might you have difficulty completing this task successfully?” “Identify information or skills you need to complete this action effectively. ”Occasionally, the helper may need to point out appar-ent obstacles that the client overlooks, such as long-held beliefs and routines. If significant obstacles are identified, then a plan to deal with or counteract the effects of these Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 279 factors needs to be developed. Often this plan resembles an anti-sabotage plan in which helper and client try to predict ways in which the client might not do the desired activity and then work around the possible barriers. Sup-pose you explore obstacles with the client who is experi-encing sleep difficulty and wants to obtain restful sleep. While you explore subgoals with him, he acknowledges his recent increased alcohol consumption, his belief that he must get the same number of hours of time sleep at night at age 72 as he did when he was in his 40s, and that he should not need to nap during the day. In developing an antisabotage plan, you would need to target specific behaviors (e. g., alcohol use) and belief systems (e. g., he is not immune to aging) to work through these obstacles. Doing so might include training in mindfulness skills to accept certain things as they are in the present moment rather than forcing change. Identifying Resources to Facilitate Goal Achievement The next step is to identify resources—factors that LO1 will help the client complete intermediate goal or subgoal tasks effectively. Like obstacles, resources include overt and covert behaviors as well as environmental sources. Potential resources to explore include feelings, thoughts and belief systems, people, situations, informa-tion, and skills. The practitioner helps clients identify al-ready present or developed resources that, if used, can make completion of the subgoal tasks more likely and more successful. A specific resource involved in attaining desired out-comes is referred to by Bandura (1997) and others as self-efficacy. Self-efficacy involves two types of personal expectations that affect goal achievement: (1) an outcome expectation and (2) an efficacy expectation. The outcome expectation has to do with whether and how much a cli-ent believes that engaging in particular behaviors will in fact produce the desired results. For a female client with diabetes, the outcome expectation would be the extent to which she believes that the actions represented by the subgoals will help her become a healthier person. The ef-ficacy expectation involves the client's level of confidence regarding how well she can complete the behaviors neces-sary to reach the desired results. People in the client's environment, especially those who observe and lend support to the client's goals, are po-tent resources; they also contribute to collective efficacy discussed earlier. Resources may also be found in the client's cultural community—people, situations, events, and so on. Skills of the client or of others in the client's environment—skills such as resilience, persistence, flex-ibility, and optimism—can also be used as resources. Strategies to help the client identify and make use of resources include: “Identify resources you have available to help you as you go through this activity [or action]. ” “What specific feelings [or thoughts] are you aware of that might make it easier for you to ___?” “Tell me about the support system you have from others that you can use to make it easier to ___. ” “What skills [or information] do you possess that will help you do ___ more successfully?” “How much confidence do you have that you can do ___?” “To what extent do you believe that these actions will help you do ___?” “Describe what resources are available to you in your envi-ronment and cultures that can help you take this action. ” It is an important reminder that goal formulation is a joint enterprise between client and helper, and that change is more often than not a process. This means that identify-ing goals and intermediate goals or subgoals and action steps should not be done hastily, nor should the helper prescribe or unilaterally assign goals. Even when the client demands or expects the helper to “fix” or somehow instan-taneously remedy the presenting concern, the helper is advised to assume a collaborative stance, enlist the client's expertise, and engage in shared decision-making. Evaluating Treatment Process and Outcomes Good ethical practice calls for helpers to evaluate LO2 LO3 client progress toward outcome goals. Professional codes of ethics specify that practitioners have a responsibility to provide the best and most effective treatments to their clients. The purpose of evaluation is not merely descrip-tive; it also is to improve services to clients. A large body of research suggests that tracking client progress—a prac-tice known as treatment monitoring—can improve cli-ent outcomes (Lambert, 2010a, 2010b). As Haynes, Smith, and Hunsley (2011) stated: “Accurate and mean-ingful measurements are crucial for determining whether real changes are occurring and understanding the vari-ables that might be hindering or facilitating that change” (p. 97). Evaluating therapy process and outcome also guides treatment planning. Process evaluation refers to the assess-ment of ongoing aspects of care, such as the therapeutic Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. 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280 Chapter 8 alliance and client status from one session to the next. Outcome evaluation generally is specific to the measure-ment of client status or client response to treatment dur-ing the course of therapy or at discharge. Both types of evaluation have been instrumental in research conducted over 50 years that has demonstrated the overall effective-ness of psychotherapy, a claim the American Psychological Association (APA) made official in 2012 (see www. apa. org /about/policy/resolution-psychotherapy). Several tools are available for helpers to conduct routine process and outcome evaluation in either print (completed by hand) or digital/online format. T wo of these are the Outcome Questionnaire (OQ®-45. 2), developed by Mi-chael J. Lambert and designed to measure patient progress in therapy, and the OQ®-ASC, a clinical assessment tool used in conjunction with the OQ®-45. 2 to help clini-cians know how to respond to client change in therapy. A Youth Outcome Questionnaire (Y-OQ®-2. 0) also is avail-able in the self-report version and a version completed by a parent/guardian. All OQ versions are available at www . oqmeasures. com. T wo other measures are the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS), both developed by Scott D. Miller and Barry C. Duncan, and available at www. centerforclinicalexcellence. com. A majority (61%) of clients participating in couples therapy found the use of the ORS and SRS in each session to be useful/helpful (Anker, Sparks, Duncan, Owen, & Stapnes, 2011). The OQ measures, as well as the ORS and SRS, are listed on the Substance Abuse and Mental Health Services Administration's (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP; www . nrepp. samsha. gov). They also are relatively easy to use and are not time-consuming. Despite ethical mandates to evaluate process and out-come goals, the availability of measures to do so, and client improvement and positive ratings as a result of par-ticipating in treatment monitoring, many practitioners resist evaluating client outcomes (Bufka & Camp, 2010; Lambert, 2010a, 2010b). Reasons include believing: (1) it is time-consuming; (2) the tools for measuring outcome are not appropriate for the type of treatment they pro-vide; or (3) the benefits of outcome evaluation will not be immediately apparent to themselves or their clients. Furthermore, many therapists tend to overestimate their skills, as well as client improvement, while overlooking and therefore not responding to client deterioration (Hat-field, Mc Cullough, Frantz, & Krieger, 2010; Walfish, Mc Calister, O'Donnell, & Lambert, 2012). Because of these concerns, we describe in the following section what we believe are pragmatic and cost-effective ways to evaluate outcome goals. As Brown and Min-ami (2010) indicated, reimbursement from third-party providers rests on the helper's ability to provide evidence of treatment outcomes. There are similar expectations for clinical mental health practice in the school setting (Bohnenkamp, Glascoe, Gracey, Epstein, & Benningfield, 2015). Regardless of funding source, routine evaluation of client progress is one component of clinical expertise, and clinical expertise is integral to evidence-based practice (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 276). What to Evaluate Goal behaviors are evaluated by measuring the LO3 amount or level of the defined behaviors. Three dimen-sions commonly used to measure the direction and level of change in goal behaviors are frequency, duration, and intensity. You may recall that these three dimensions are reflected by the level of the client's outcome goal. Whether one or a combination of these response dimensions is measured depends on the nature of the goal, the method of assessment, and the feasibility of obtaining particular data. It is important to measure the targets of treatment, that is, what have been identified as the needs, problem areas, or dilemmas of treatment—essentially the focus of intervention or change strategies—so that the measures represent valid indicators of the effectiveness of the inter-vention (Bloom, Fischer, & Orme, 2009). The response dimensions should be individualized, particularly because they vary in the time and effort that they cost the client. Dimension 1: Frequency Frequency reflects the number (how many, how often) of overt or covert behaviors and is determined by obtaining measures of each occurrence of the goal behavior. Fre-quency counts are typically used when the goal behavior is discrete and of short duration. Panic episodes and headaches are examples of behaviors that can be moni-tored with frequency counts. Frequency data are typically collected during or immediately after the occurrence of specified behaviors and therefore in the client's natural en-vironment. This practice of collecting repeated real-time data in vivo is known as ecological momentary assess-ment (Shiffman, Stone, & Huffard, 2008), and it allows clinicians and clients to collect and monitor a specified range of client information (e. g., mood, attitude, behav-ior) outside of therapy. Data can be captured in writing, such as completing the diary card that is standard practice in DBT, and also by using a computer, smartphone, or other mobile device. For example, clients can be “beeped” to respond at certain times of the day to yes or no questions Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 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Constructing, Contextualizing, and Evaluating Treatment Goals 281 such as, “Did you experience a binge episode?” or “Have you completed your exercise task?” Programs have been developed to monitor behaviors such as binge eating and substance use on devices the client already owns or on a device issued to the client. Clients can also enter fre-quency counts of specified behaviors, such as the number of positive (or negative) self-statements before and after a bingeing episode. Occasionally, frequency is simply the presence or absence of a particular behavior, and in this case the level of the goal is referred to as occurrence. Occurrence refers to the presence or absence of target behaviors. Checklists can be used to rate the occurrence of behaviors. For example, an older client who has trouble with self-care could use a checklist to rate occurrence of self-care behaviors such as brushing teeth, flossing teeth, taking medicine, washing oneself, and combing hair. Sometimes, frequency counts should be converted to percentage data. For example, knowing the number of times a behavior occurred may not be meaningful unless data are also available on the number of possible occur-rences of the behavior. For example, data about the num-ber of times an overweight client consumes snacks might be more informative if converted to a percentage. In this example, the client would self-monitor both the number of opportunities to eat snacks and the number of times he or she actually did snack. After these data are collected, they would then be converted to a percentage. The ad-vantage of percentage scores is that they indicate whether the change is a function of an actual increase or decrease in the number of times the response occurs or is merely a function of an increase or decrease in the number of op-portunities to perform the behavior. Thus, a percentage score may give more accurate and more complete infor-mation than a simple frequency count. However, when it is hard to detect the available opportunities or when it is difficult for the client to collect data, percentage scores may not be useful. Dimension 2: Duration Duration reflects the length of time a particular response or collection of responses occurs. The measurement of duration is appropriate whenever the goal behavior is not discrete and lasts for varying periods. Time spent thinking about one's strengths, the amount of time spent on a task or with another person, the period of time consumed by depressive thoughts, and the amount of time that anxious feelings lasted, for example, can be measured with dura-tion counts. Duration may also involve time between an urge and an undesired response, such as the time one holds off before lighting up a cigarette or before eating an unhealthy snack. It also can involve elapsed time between a covert behavior such as a thought or intention and an actual response, such as the amount of time before a shy person speaks up in a discussion (sometimes elapsed time is referred to as latency). Measures of both frequency and duration can be ob-tained in one of two ways: continuous recording or time sampling. Both fulfill the purpose of ecological momen-tary assessment discussed earlier. If the client obtains data each time he or she engages in the goal behavior, then the client is collecting data continuously. Continuous record-ing, however, is sometimes impossible, particularly when the goal behavior occurs very often or when its onset and termination are hard to detect. In these cases, a time-sampling procedure may be more practical. In time sampling, a day is divided into equal time intervals, for example, 90 minutes, 2 hours, or 3 hours. The client keeps track of the frequency or duration of the goal behavior only during randomly selected intervals. When time sampling is used, data should be collected during at least three time intervals every day and during different time intervals every day so that representative and unbiased data are recorded. One variation of time sampling is to divide time into intervals and indicate the presence or absence of the target behavior in each interval. If the behavior occurs during the interval, a yes is recorded; if it does not occur, a no is noted. Time sampling is less precise than continuous recordings of frequency or dura-tion of a behavior, yet it does provide an estimate of the behavior and may be a useful substitute in monitoring high-frequency or nondiscrete target responses. Dimension 3: Intensity Clients can report the intensity of a behavior or a feeling with some kind of numerical rating. These are generally referred to as individualized rating scales and are tailor-made for each client and situation to measure treatment tar-gets (Bloom et al., 2009). Solution-focused therapists obtain client ratings of intensity by using scaling questions— for example, “On a 10-point scale, with 1 being low and 10 be-ing high, rank the degree of anxiety you are experiencing. ” Another example of an intensity rating is called the SUDS scale, or the Subjective Units of Disturbance Scale. On this scale, zero represents no distress and 100 represents severe distress. These kinds of scales can be used in a helping session or assigned to clients for self-monitoring between sessions. In addition, practitioners can develop more formalized rat-ing scales for clients to rate intensity. For example, intensity of anxious feelings can be measured with ratings from 0 (not anxious) to 5 (panic) on a self-anchored scale. Cronbach (1990) suggested three ways to decrease sources of error frequently associated with rating scales. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
282 Chapter 8 First, the helper should be certain that what is to be rated is well defined and specified in the client's language. For example, if a client is to rate depressed thoughts, then helper and client need to specify, with examples, what constitutes depressed thoughts (such as, “Nothing is go-ing right for me,” “I can't do anything right”). These defi-nitions should be customized to each client on the basis of an analysis of the client's target behavior and contributing conditions. Second, rating scales should include a descrip-tion for each point on the scale. For example, episodes of anxious feelings in a particular setting can be rated on a 5-point scale on which 1 represents no anxiety or little anxiety, 2 equals some anxiety, 3 means moderately anxious, 4 refers to strong anxious feelings, and 5 indicates very intense anxiety. Third, rating scales should be unidirec-tional, starting with 0 or 1. Negative points (points below 0) should not be included—a key difference with goal attainment scaling. In using self-anchored unidirectional rating scales, it is also important to tell clients that the in-tervals on the scale are equal—that the difference between 1 and 2, for example, is the same as the difference between 3 and 4 or between 5 and 6 (Fischer & Corcoran, 2007, p. 25). One advantage of these sorts of individualized or self-anchored scales is that they can be used at multiple times during a day and the results can be averaged to get a daily single score that can then be plotted on a chart or graph for a visual sign of progress (Bloom et al., 2009). How to Evaluate Hopwood and Bornstein (2014) recommend a LO1 multi-method approach to initial assessment as well as treatment monitoring. This means collecting information from a variety of sources, not just one. Doing so is intended to provide a more comprehensive impression of client concerns, needs, and resources so that planning care can proceed with greater clarity and perhaps precision. Relying solely on client self-report—even when a variety of measures are used—provides limited and perhaps skewed information when compared to obtaining infor-mation from other sources as well. These include consult-ing family and friends (known as collateral contacts), other professionals (e. g., teachers, school counselor), and records from any previous therapy involvement. Although more expensive, the use of biomarkers has become more popular in the assessment and treatment planning of per-sons with certain conditions, such as schizophrenia, dementia, and depression. Biomarkers are the biochemi-cal, genetic, or molecular indicators of a particular bio-logical condition or process (Mihura & Graceffo, 2014) and are generally obtained using electro-mechanical mea-sures, such as positron emission tomography (PET), func-tional magnetic resonance imaging (f MRI), and other neuroimaging tests used for persons with degenerative conditions such as dementia. In addictions treatment, routine or periodic urinalysis tests are conducted to verify or refute a client report of substance use, as well as to track decreases in substance over time. Selecting any type of outcome measure is not an easy decision for most practitioners. It involves consideration of measures that are: (1) psychometrically sound (ac-curate, reliable, and valid); (2) pragmatic and easy to use; (3) relevant to the client's stated goals; (4) relevant to the client's level of functioning; (5) related to the client's resources and constraints; (6) relevant to the cli-ent's cultural influences (e. g., gender, age, race/ethnicity, language); and (7) sensitive to treatment effects, or what Haynes et al. (2011) refer to as a measure's clinical utility. Leibert (2006) identified additional issues involved in the selection of outcome measures in an attempt to improve measurement validity. His recommendations include: 1. Norms for both client and nonclient populations2. Clear administrative and scoring procedures for before, during, and after treatment 3. Clear operational definition of what is being measured to allow for replication by others 4. Brief enough measures that allow for repeated mea-surements during the counseling process In the rest of this section, we discuss ways practitioners can use goal-related outcome measures to facilitate the evaluation process. We highlight methods that obtain information directly from clients because of their ease of use. There are three general categories of goal-related outcome measures: (1) individualized outcome assess-ment such as goal attainment scaling discussed earlier in the chapter; (2) specific measures of outcome, which typically involve the use of a rapid assessment instrument (RAI) to assess a given problem area; and (3) global mea-sures of outcome that tap into broad problem areas across populations. Practitioners can use any or all of them. It is important to remember that the accuracy of the evalua-tion process is enhanced when multiple measures of the same goal behavior are used. Individualized Outcome Assessment Individualized outcome assessment is the process of measuring outcomes that are specifically defined for the client. The best known individualized outcome Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
Constructing, Contextualizing, and Evaluating Treatment Goals 283 assessment measure is the goal attainment scale (GAS; Kiresuk & Sherman, 1968) described earlier in this chapter. The GAS is constructed while the helper and client are developing outcome goals and prior to the beginning of any treatment protocol or change interven-tion. A particular advantage of this method is that the GAS can be constructed during rather than outside the helping situation and with the client's participation and assistance. Therefore, the GAS requires almost no extra time from the helper, reinforces the client's role in the change process, and provides a quantifiable method of assessing outcome. Multidisciplinary care providers who used the GAS with patients in a geriatric day hospital rated its usefulness as good and noted that its primary strength was that it gave patients a voice in their care (Stolee et al., 2012). The GAS for Isabella found in Table 8. 4 on p. 283 uses frequency as the measure of change, but you can also con-struct scales using duration and intensity as indicators of change, as is true for the GAS in Table 8. 3 on page 275. A GAS can also be constructed to measure the intensity or severity of a client's panic attacks on a 100-point SUDS scale. Goal-attainment scaling is useful because each point on the rating scale is described in a quantifiable way, eliminating ambiguity. Another advantage of this system is its applicability to assessing change in couples, families, and organizations, as well as in individual clients (Marson et al., 2009). Although scoring the GAS may be more difficult than a standardized assessment tool, and there-fore more difficult to interpret, assistance with scoring (and additional GAS examples for use with children and families) is available on the GAS website: www. marson-and-associates. com/GAS/GAS_index. html. Another way that outcomes specific to individual clients are measured is self-monitoring by clients. Self- monitoring entails observing and recording aspects of one's own covert or overt behavior as close in time as possible to the occurrence of the behavior. In evaluating goal behaviors, a client uses self-monitoring to collect data about the number, amount, and severity (frequency, dura-tion, intensity) of the goal behaviors. Self-monitoring is an excellent way to obtain a daily within-person measure of the behavior over days or weeks. This can be done by using ecological momentary assessment (Shiffman et al., 2008) mentioned earlier, whereby clients track and record their behaviors at specified intervals, often prompted by a handheld device, such as a smartphone, that emits a signal at certain times so that the client can record their activity and/or response. This method has been used with per-sons with schizophrenia to record their social interaction behaviors and corresponding affective response at four different times during the day and then evaluating behav-iors (Granholm, Ben-Zeev, Fulford, & Swendsen, 2013). Self-monitoring provides a picture of a client's every-day behaviors or feelings that might be considered triv-ial and therefore easily forgotten; because monitoring is taking place in the client's natural environment, data have ecological validity. Self-monitoring helps determine environmental and social influences or the contribut-ing conditions to target behaviors and involves not only noticing occurrences of the goal behavior but also record-ing data using paper-based diaries, mechanical counters, or smartphones or other electronic devices. Self-monitoring has many advantages, although some-times the accuracy or reliability of it is doubtful. The ac-curacy of self-monitoring can be improved when clients are instructed to self-monitor in vivo when the behavior occurs, rather than self-recording at the end of the day, when they must rely on recall. Using hand-held mobile devices to prompt the client to self-record also may en-hance the accuracy of self-monitored data, including re-cord of the day and actual time of reporting. TABLE 8. 4 Goal Attainment Scale for Isabella's First Outcome Goal Levels of Predicted Attainment of Verbal Initiating Skills Frequency of Verbal Initiating Skills (-2) Most unfavorable outcome 0 per week (-1) Less than expected success 1 per week—either with parents or in math class (0) Expected level 2 per week—at least one with parents and at least one in math class (+1) More than expected success 4 per week—at least two with parents and two in math class (+2) Best expected success 8 or more per week—at least four with parents and four in math class Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
284 Chapter 8 Specific Measures of Outcome In addition to the individualized outcome assessment measures such as the GAS and client self-monitoring, the helper should consider giving clients paper-based rapid assessment instruments (RAIs) that can provide self-report data about symptom reduction and level of im-provement. These instruments focus on specific areas of concern such as anxiety or depression. For a comprehen-sive listing of such measures, see Fischer and Corcoran's (2013) compendiums that describe measures appropriate for couples, families, and children (volume 1), as well as with adults (volume 2). These include measures that obtain information about a client from another source (i. e., collateral), such as the Behavior Rating Index for Chil-dren (BRIC; Stiffman, Orme, Evans, Feldman, & Keeney, 1984) that measures the degree of a child's behavior prob-lems and is completed by parents, teachers, other caretak-ers, as well as children themselves. Another source of RAIs specific to children and youth mental health is the Center for School Mental Health at the University of Maryland's School of Medicine that maintains a list and description of (and links to) free clinical assessments that measure global outcomes (e. g., response to treatment), specific outcomes (e. g., trauma, disordered eating), and academic outcomes. This source can be accessed at http://csmh. umaryland. edu /Resources/Clinician Tools/index. html. It is important to choose a rapid-assessment instru-ment that has good psychometric properties, is easy to read, use, and score, and relates directly to the client's identified problems and symptoms at intake and to the stated outcome goals of counseling. For example, the Beck Depression Inventory II (BDI-II; Beck, Steer, & Brown, 1996) is frequently used with clients who are depressed at intake and want to become less depressed, but it would not be suitable for someone who presents with a different problem such as anxiety, anger control, or relationship dissatisfaction. Also, because many of the psychometric properties of RAIs have been normed in Caucasian clients—often middle-class college students—caution must be applied when some of these instruments are used with culturally diverse clients. If you cannot find a culturally relevant RAI, perhaps you should use goal at-tainment scaling instead. Most RAIs can be used to assess outcomes at the begin-ning, midpoint, termination, and follow-up of treatment. Fischer and Corcoran (2013) noted that RAIs can be over-used because they are easy to use and score; therefore, they recommend that sufficient time should elapse between RAI completions, such as once per week or minimally twice per week. They further advise that RAI scores not be accepted uncritically as truth but rather as estimates of some attribute. Clients are more likely to submit honest rather than socially desirable responses when they under-stand how the information will be used for their benefit. RAIs also make it possible for clients to disclose sensitive information (particularly at the beginning of therapy) that might otherwise be difficult to verbalize. Generally speaking, RAIs are efficient and allow access to informa-tion about the client that would be difficult to observe. They are but one means of assessment and therefore should be used in conjunction with other methods, such as supervision and global measures of outcome. Global Measures of Outcome In addition to RAIs such as the Beck Depression Inven-tory II (Beck et al., 1996) and the Beck Anxiety Inventory (Beck, 1993), there are RAIs that tap into general levels of client functioning and a range of symptoms. These mea-sures are called global outcome measures because they are “designed to be used across client diagnoses” (Leibert, 2006, p. 111). RAIs that cover a wide range of symp-toms and are thus applicable as global outcome measures include the Symptom Checklist (SCL-90-R; Derogatis, 1983), the Brief Symptom Inventory (BSI; Derogatis, 1993), and the Behavior and Symptom Identification Scale (BASIS-32 and BASIS-24; Eisen & Grob, 2008; Eisen, Grob, & Klein, 1986). The SCL-90-R and the BSI both have nine subscales and a primary global severity index as well as extensive normative data across a variety of client populations and age groups. The BASIS-32 has five subscales and the BASIS-24 has six subscales (including a self-harm subscale), and both scales compute an overall average score. Because the BASIS-32 has been used most extensively in inpatient rather than in outpatient settings, the BASIS-24 was designed to be used with more diverse populations (see the BASIS website for more information: www. basissurvey. org). An outcome measure suitable for evaluating the goals of child and adolescent clients is the Child and Adolescent Functional Assessment Scale (CA-FAS; Hodges, 1997). A limitation of global measures of outcome is that they do not directly measure the behaviors specified in the client's outcome goals. However, an advantage of these broader and multifaceted RAIs has to do with clinical significance. In the past 25 years, there has been a major movement in the evaluation of mental health services toward criteria that reflect clinically significant outcomes (Lambert 2010a, 2010b). Clinical significance refers to the effect of a treatment intervention on a single client, and it denotes improve-ment in client symptoms and functioning at a level com-parable to that of the client's healthy peers. For change Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the e Book and/or e Chapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. | Interviewing and Change Strategies for Helpers -- Sherry Cormier Paula S_ Nurius and Cynthia J_ Osborn -- 8th 2017 -- Cengage Learning Inc -- 7ad765f70d931446a1a204fea013935b -- Annas Archive.pdf |
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