Transcript Work with Individuals

Work With Individuals
Step Five of the Decision Tree
Chapter 12
Direct Practice
Work with Individuals
• Direct practice with individuals encompasses:
Step one: Fiduciary responsibilities
Step two: Crisis Intervention
Step three: Case management
Step four: Individual or case advocacy
Step five: Therapy
• This chapter (12) guides the practitioner when
therapy is the course of action based on the facts
of the case.
Therapy
Method Choices
When the facts of the case at-hand indicate
that therapy is the intervention of choice,
social work clinicians must still decide which
method of therapy is the most appropriate:
(1) Step 5: Individual method- worker to one client
or dyad (parent/child; couple)
(2) Step 6: Family method – worker to one family
(3) Step 6: Group method – worker to one group
Therapy
Theory Choice
• Once a method is chosen, the clinician must
then choose a theory-based therapy to enact
a therapeutic process.
• The determination of best practices requires
that the clinician evaluate potential theorybased therapies and the evidence for or
against them when deciding upon a specific
treatment.
Key Assumptions
Best Practices
• Competent practice is tied to open assessment and
case-specific model building.
• Best practices may require the use of more than
one method and more than one theory.
• Best practices requires that interventions be
evidenced-based ( e.g. based on what works)
• See case example –Chapter 13
Beginnings
Point of Entry
• Point of entry refers to the intersect of help
seeking and help giving.
• A client’s point of entry with a help giver begins
with an interview by phone and/or in person.
• How a client enters service is pivotal in the
conceptualization of the profession and its planned
change processes.
• Practitioners are defined by their field of practice
(area of expertise), public or private auspice and
their setting. See chapter three.
The Interview
The interview is used for three purposes:
1. To establish rapport or a working relationship
with a client
2. To gather information (facts) relevant to the
request for service or need for therapy and to
arrive at a definition of the problem, its possible
causality & the course to be followed for
recovery
3. To enact a therapeutic process designed to
change feelings, cognitions, attitudes, beliefs,
personal or interpersonal functioning (behavior),
or some or all of the above.
Historical Perspective
The 5 W’s of Social Work
The parameters of who receives help for
what, where, when, and why (why is there a
problem) has driven the conceptualization
of direct social work practice since its
inception.
1W- Who is the Client?
1. The person (Richmond, Hollis, Perlman)
2. The environment (Robinson, Reynolds,
Smalley)
3. Person-in-the environment (Karls &Wandrei;
Germain and Gitterman)
4. The highly vulnerable and poverty stricken
individual and the traditional middle-upper
class client (Rothman)
5. Population age groups: children, adolescents,
adults and the elderly
2W- What is the Matter
1. Primary and persistent developmental, health,
and mental health conditions
2. Persistent problems in social functioning
secondary to primary conditions
3. Acute and temporary problems in living;
developmental or situational
4. Exposure to extraordinary circumstances
5. Inability to perform normative roles (welfare) or
conform to societal rules (criminal justice).
3W- Where
Practice Auspice
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Public Welfare Agencies
Not-for profit agencies
For-profit agencies
Managed care agencies
Faith-based agencies
Private Practice
4W-When
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When there is a need for concrete services
When the client feels subjective
discomfort and voluntarily seeks help
When the client is encouraged to seek help
by someone in authority; parent, teacher,
employer, spouse.
When the client is court-ordered or
mandated
5W- Why Is There a Problem?
Proximate and Distal Causality
• Proximate time causality: why is the client
seeking help now?
• Distal time causality: refers to identification
of the dynamic forces that created the
situation (there and then; past) or that
sustain and maintain it (here and now;
current).
5W Type and Number of
Problems to be Worked
• Nominal definitions refer to the type of
problem to be worked; “because of”..
truancy, eviction, suicidal ideation, school
failure, job loss, domestic violence, mental
illness, parenting problems etc
• Number of problems refers to whether the
focus of intervention is on a single
problem or on multiple problems.
5W Causality
Problem Source and Duration
• Problem exploration determines the source
of possible causality; social or individual
e.g what is the source of the problem?
• Problem duration determines whether
treatment should be directed at prevention,
early intervention, or tertiary (remedial)
intervention.
Historical Perspective
The Planned Change Process
• The profession, whether engaged in direct
or indirect social work practice, has used a
generic model of a planned change process
to describe what it does.
• The planned change process consists of five
major activities: (1) establishment of
rapport, (2) assessment, (3) contracting and
goal setting, (4) intervention, (5) evaluation.
Historical Perspective
Direct Practice Overtime
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As individual casework
As crisis intervention
As case management
As case advocacy
As individual therapy
As family and child welfare services
As family therapy
As clinical group work
As generalist practice
Historical Perspective
Conceptualization of Therapy Overtime
The therapeutic process has been viewed and
conceptualized as:
(1) pharmacological
(2) crisis intervention
(3) psychodynamic; analytic
(4) psychodynamic; interpersonal
(5) behavioral-learning
(6) cognitive-behavioral
Conceptualizations of Therapies
Continued
(7) solution-focused
(8) strengths-based
(9) empowerment
(10) post modern
(11) socialization – conformity to norms
This list is not exhaustive.
Conceptualizations of Indirect
Practice Overtime
• As policy practice
• As administrative or management practice; work
with organizations
• As community practice; inter-group relations
• As class advocacy; rights advocacy, organizing
• As political social work
• As grant writing, fund raising and program
evaluation
• As generalist practice
Value Base of Clinical Social
Work: Core Values
• Biestek identified the following as core social
work values in direct clinical practice:
(1) Confidentiality
(2) Self-determination
(3) Non-judgmental attitude
(4) Acceptance
• These were discussed in full in chapter two (the
fiduciary model and legal context of direct
practice).
Knowledge Of Human Behavior
Therapy
• Therapists need knowledge of human behavior to
enact a therapeutic process.
• Each theory of human behavior contains
assumptive premises of cause-effect.
• Common biological, psychological, and
sociological theories of human behavior are
described and differentiated in exhibit 12.1
• Taught and learned knowledge is referred to as
declarative knowledge.
Declarative Knowledge
Definition
• Declarative knowledge begins with a cognitive
map of learned (taught) concepts
• The declarative knowledge needed to enact a
therapeutic process depends on causal knowledge
of individual resilience (normality) and
vulnerability (abnormality).
• Knowing what interferes with the unfolding of
resilience leads to practice theories (procedural
knowing) about how to prevent or correct missteps
Procedural Knowledge
Fresh Client Data
• Learned (taught) theoretical concepts are stored in
memory as schemas.
• When faced with fresh client data, the novice tries
to match the facts of the client’s case with the
stored knowledge s/he has learned; this is referred
to as procedural knowing.
• The novice has beginning competency when s/he
applies learned concepts to client data e.g. the
thinking column in a process recording.
Procedural Knowing
Supervision/Mentorship
• Reflection on action (thinking) is facilitated
by the use of process recordings.
• Supervised by a master clinician, the novice
(student) advances her/his expertise by
using process recordings in supervision.
• In contrast, the master clinician engages in
tacit knowing.
Tacit Knowing
Definition
• Tacit knowing relies on highly disciplined and
automatic procedural knowledge and on a highly
refined self-regulated ability to allow for reflection
and adjustment of performance in the therapeutic
moment.
• Tacit knowing is reflection in action in the
therapeutic moment.
• Tacit knowing distinguishes the master clinician
from the novice.
Tacit Knowing
Improvisation-Creativity
• The master clinician can reshape understanding of
the situation and depart from established
procedures to respond to novel and unexpected
conditions.
• The master clinician uses tacit knowing to readjust
her/his definition of the problem and adjust
strategies and tactics accordingly.
• Tacit knowing reflects mastery of the art of
therapy.
6 Common Factors
Procedural Knowing
According to Binder (2004) every theory-based
therapy has the following 6 factors in common.
Each theory-based therapy possesses:
(1) some view of personality & interpersonal
functioning (though not necessarily the same
view).
(2) some theory about cognitive, affective, and
behavioral processes that are activated (or not)
during the process of therapy
.
6 Common Factors
Continued
(3) specific guidance on how to formulate the
problem to be worked
(4) knowledge of salient maladaptive patterns of
behavior and a theory of how change occurs and
problems are solved e.g. explanation and change
(5) criteria (goals) to track the course of therapy and
measure its outcome success
(6) strategies for managing therapeutic missteps &
the therapeutic relationship
Therapeutic Alliance
Generic or Common Factors
• At a minimum, a therapeutic alliance
begins with belief in the helping
relationship e.g. belief bonding ( see
chapters 4 and 6).
• Empathy is a common factor in establishing
belief bonding or rapport.
Therapeutic Alliance
Theory-Specific
• Beyond common factors, the therapeutic process
of relationship is theory-bound.
• The use of self in therapeutic alliance depends on
one’s theory of therapy.
• Models of talk therapy are based on different
theories of how change (the therapeutic process)
occurs.
• Not all theories of change require the same level
of relationship intensity.
Middles
Therapeutic Enactment
• Intervention is the middle phase of the social work
change process. It follows assessment (a theory of
what is the matter) and contracting.
• Contracting involves worker-client agreement on
what is the matter and agreement on the change
process (a theory of change).
• Therapy involves theory choice and appraisal of
the evidence for or against treatment options.
• Such options must be evaluated for their cultural
relevance.
Theory-Based Therapy
Example: Learning Theory
• According to this theory, all behavior is learned
and can therefore be unlearned. What has not been
learned can be taught.
• Learning can occur incrementally (shaping) or in
large chunks. One can learn through trial and error
or vicariously through observation.
• There are five schools of thought within learning
theory: (1) classical conditioning, (2) operant
conditioning, (3) cognitive-behavioral, (4) social
learning and (5) stress management e.g relaxation
techniques, guided imagery etc.
Example
Behavior Modification
ABC assessment:
A Antecedant events; S=Stimulus cues (Classical
conditioning); what triggers the behavior
B The behavior, affect, or thought that has been
defined as problematic; its frequency; baseline
C Consequence- R= responses that increase,
decrease or extinguish the behavior; (Operant
conditioning; reinforcement).
Behavior-Modification
Techniques
• Social Learning Theory. The worker models
appropriate behavior; client rehearses worker
coaches.
• Classical conditioning. The worker “unpairs” the
S-R. Desensitization. The stimulus cues are
changed or the client is taught an incompatible
response to the cue i.e. running rather than eating
when upset.
• Operant conditioning. The worker changes the
consequent conditions; uses positive or negative
reinforcement. Punishment may be used to
extinguish behavior.
Behavior Modification
Relationship
• Client as his/her own therapist; client can be
taught to manage his/her own behavior.
Biofeedback, guided imagery & relaxation skills
help the client manage the physiology of tension.
• Others as therapists; the worker teaches others in
the client’s environment how to act as antecedent
and consequent events in the client’s life ( parents,
teachers, guardians).
• See process recording on Kyle in chapter 13.
Theory-Based Therapy
Cognitive-Behavioral
• In contrast to the time sequence of behavior
modification (S-R) cognitive behavioral therapy
is perceptual and mediational.
• The attributions made about an event are held to
explain dysfunctional emotions (anxiety, anger,
depression) or behavior.
• An individual’s attributions (world views) are
learned and can be unlearned
• See process recording of Lily in chapter 13.
Cognitive-Behavioral
Assessment
The ABC paradigm in this model refers to:
A Activating event (stimulus)
B Belief – an activating event is
interpreted by learned core beliefs or by
learned distorted cognitions
C The affect or behavior that results
(consequence) is mediated by the meaning the
individual attributes to the event or his/her
belief about the event.
Cognitive-Behavioral
Techniques
• Intervention targets the core beliefs (perceptions)
or distorted cognitions of the individual.
• Techniques include:
(1) keeping an automatic thought record
(2) Socratic questioning
(3) challenging distorted cognitions by asking for
evidence e.g. how do you know that?
(4) substituting functional thought patterns for
dysfunctional patterns.
Example: Psychodynamic Theory
Major Premises
• According to this theory all behavior has a
purpose but one is not always aware of the
purpose of his/her behavior.
• Behavior is a product of nature and nurture
• Behavior is a product of past & current
experiential history.
• Behavior is both developmental and interpersonal
(self-other).
• There are four major psychodynamic schools of
thought briefly discussed in this chapter.
4 Psychodynamic Schools of
Thought
1. Analytic- Traditional Freudian- Drive Theory
2. Ego Supportive – Problem Solving
3. Relational
-Object relations psychology (Mahler)
-Interpersonal psychoanalysis (Sullivan)
-Self psychology (Kohut)
4. Narrative therapy
Psychodynamic Theory
Example: Analytic Therapy
Assessment:
• Typographical model: Mental activities are
conscious, preconscious, and sub or unconscious
• Structural model: Personality is composed of the
Id, Ego, and Superego.
• Drive or Dynamic model: energy is finite and
affects development and functioning
• Energy is encumbered by impulses (drives).
Internal conflict (personality structures) makes
energy unavailable for other uses.
Psychodynamic Theory
Analytic Therapy: Techniques
• Relies on free association, dream analysis,
and interpretation of defense mechanism in
a therapeutic environment that is capable of
keeping the individual safe as the
unconscious is made conscious
• When the unconscious is made conscious,
energy is freed to solve problems, to
increase resilience, and to enjoy life.
Psychodynamic Thought
Example: Ego Supportive
• Assessment focus is on painful or maladaptive
behavior caused by:
(1) emotional trauma
(2) developmental crises
(3) situational crises
(4) difficulties in social functioning; role
performance
(5) difficulties in interpersonal relationships
• See Process recording on Mrs. Jones in chapter 13.
Psychodynamic
Ego Supportive: Techniques
• Through empathic responding the worker becomes
a powerful significant other to the client in
therapy.
• Worker acts as a holding environment; the worker
acts as an emotional bridge that prevents the client
from harming self or others until the client is able
to reassert emotional control for him/herself.
• Worker lends ego support to help client problem
solve until client regains capacity for autonomous
problem solving.
Ego Supportive Techniques Continued
• Skills training is a major technique of this model;
skills increase competency and mastery of self and
one’s environment.
• The model builds on and strengthens the coping
capacities thereby increasing client resilience and
decreasing client vulnerability.
• The model is reality focused; interventions target
inside and outside realities. It is reflective and
action-oriented.
Psychodynamic Thought
Example: Relational Paradigms
• According to Bordon (2000), the relational
paradigm has replaced drive psychology as
the central paradigm in contemporary
psychodynamic thought.
• There are three schools of thought within
the relational paradigm: (1) object relations
theory, (2) interpersonal psychoanalysis,
and (3) self-psychology.
Example: Objects Relations
Major Premises
• An alternative to drive theory, this theory is based
on internalization of interpersonal experience.
• Personality is viewed as an outcome of a series of
chronologically ordered phases: autistic, symbiotic
separation-individuation, and object constancy.
• The personality consists of core representations of
self, others (objects), and modes of relating (self in
relation to other).
• Attachment, early care giving, and connection to
others are foci of assessment.
Object Relations
Major Premises -Continued
• The model holds that previous relational
conflicts play out in current relationships
through repetition compulsion.
• Current maladaptive interpersonal
functioning is related to earlier emotionally
traumatizing relationships.
Object Relations
Techniques
• Within the therapeutic alliance, a triangle forms
between the client , an other (a person in the
client’s past or current life) and the clinician.
• The social work clinician works with transference
to correct past failures in relationship in the here
and now interactive moment (corrective emotional
experience)
• Clients experience new ways of being related to
and new ways of relating to others in the safety of
the therapeutic alliance.
Psychodynamic Thought
Example: Self Psychology
• This model accepts that personality develops
because of a primary need for connection.
• The model assumes that there has been a failure in
empathic response by the client’s primary figures.
• Disorders of self are characterized by difficulties
in negotiating need, regulating emotion,
maintaining self esteem and pursuing meaningful
goals
• The personality is perceived as living on the
border between anxiety and psychoses.
Self Psychology
Techniques
• Therapeutic actions are based in a
“responsive self-object milieu”e.g.
therapeutic atunement to the client’s
subjective state.
• Managing the therapeutic relationship is
critical in this model; transference and
counter-transference
Psychodynamic Thought
Example: Interpersonal Therapy
• This model holds that personality develops
as a consequence of interactive experience
in relational fields throughout life.
• The motivation to interact is based in the
need for satisfaction and security.
• Assessment focus is on the problematic
aspects of interactions with others.
Example: Interpersonal Therapy
Techniques
• The clinician is a participant observer in the
interactive field of the client; both subject and
object.
• The clinician uses the interactive moment in
session to experience (assess) what is wrong and
based on corrective attunement to respond
(intervention) in a healing manner.
• The clinician is a tool of corrective interpersonal
learning and healing.
Psychodynamic Thought
Example: Narrative Therapy
• According to this model, one’s social context
influences how one processes interpersonal
interactions; the personal is political.
• Unlike other models, this theory allows the worker
and client to take into account political, economic,
and cultural factors that impact interpersonal
interactions.
• It is held that the telling of ones’ story reviews
experiential history in an attempt to make sense of
it.
Example: Narrative Therapy
Techniques
• The therapeutic alliance is used to facilitate the
telling of the client’s story(narrative)
• The clinician acts as a co-participant in the client’s
effort to review experience, consider alternative
views of his/her life, reconstruct meaning and
elaborate adaptive life stories.
• Therapy challenges the social constructions of
others about the client’s story.
• New meanings are co-constructed within the
therapeutic alliance.
Errors and Missteps in The
Therapeutic Alliance
• According to Binder, errors in therapist technique
include: (1) misunderstanding of the meaning of
client communication or intention, (2) vague
communication by the therapist to the client, (3)
mistimed interventions, (4) failure to recognize the
implications of client communication, (5)
awkward use of transference interpretation (6)
sending mixed messages with implicit hostile
meanings,
Errors and Missteps
Continued
• (7) not being able to identify salient
interpersonal themes that should be the
focus of work, (8) failure to recognize
disguised allusions, and (9) failure to track a
central issue consistently and (10) failure to
manage transference and countertransference
Transference and Counter-Transference
Psychodynamic Theory
• From a psychodynamic perspective, relationship is
created and recreated by the behaviors engaged in
by participants in interactive dialog.
• Because the worker-client relationship is grounded
in interaction, it is subject to transference.
• Managing potential ruptures and missteps in the
therapeutic alliance due to transference and
counter-transference requires that the clinician
monitor her/his use of self during the therapeutic
process.
Managing Transference and
Counter- Transference
• The clinician monitors her/his use of self through
supervision, consultation, and one’s own therapy if
warranted. Students monitor their use of self in
supervision through the third column of process
recordings.
• Premise: it is important that the client replay
earlier relationships (transference) through the
therapeutic alliance however, the worker must not
replay his/her earlier relationships (countertransference) as to do so would interfere with the
helping process.
Therapeutic Missteps
Hepworth, Rooney, and Larsen (2002) offer the
following list of 14 therapeutic missteps:
(1) failing to sense important feelings experienced
by the client
(2) being inattentive or “tuning out” clients
(3) sending messages that clients interpret as
criticisms or put-downs
(4) failing to acknowledge incremental successes
achieved by clients
Therapeutic Missteps-Continued
(5) employing inept or poorly timed interpretations
or confrontations
(6) exhibiting lapses of memory about important
information
(7) being tardy or canceling appointments
(8) appearing fidgety or drowsy
(9) disagreeing, arguing, or giving excessive advice
(10) taking sides against the client
Therapeutic Missteps-Continued
(11) not allowing a client to be an active participant
in planning his/her own treatment
(12) dominating discussion or frequently interrupting
clients
(13) failing to recognize client limitations by giving
assignments that they cannot carry out.
(14) Using power beyond the range of legal
mandates
Indicators That The Therapeutic
Process is Not Going Well
Hepworth, Rooney, and Larsen (2002) identify the
following 17 client behaviors:
(1) mental blocking
(2) lengthy periods of silence
(3) inattention or mind wandering
(4) rambling at length; dwelling on
unimportant details
(5) restlessness or fidgeting
(6) discussing superficialities or irrelevant matters
Indicators-Continued
(7) lying or misrepresenting the facts
(8) avoiding feelings and problems by
focusing on abstract ideas
(9) changing the subject
(10) forgetting details of a distressing event
(11) being tardy, forgetting, changing or canceling
appointments
(12) minimizing problems or claiming miraculous
improvement
Indicators-Continued
(13) bringing up important material at the
end of the session
(14) not paying fees
(15) not applying skills or insight gained to
daily life
(16) assuming a stance of helplessness
(17) using verbal ploys to justify not taking
corrective actions
Counseling vs. Therapy
Is There a Difference?
• The terms “counseling” and “therapy” are
frequently used to distinguish the BSW from the
MSW clinical practitioner.
• The BSW graduate and the MSW foundation year
student are educational and experiential novices in
the art of therapy.
• Second year MSW students may(or may not)
choose an educational or practice trajectory that
will advance their clinical skills.
Counseling vs. Therapy
Continued
• Clinical social work practitioners continue to be
supervised while employed, leading to mastery of
the art of therapy.
• This is reflected in the type and level of licensing
they earn.
• Some social work clinicians get advanced clinical
training as doctoral students in clinical social work
programs or as students in clinical programs
staffed by psychologists and psychiatrists.
• Accreditation as a skilled Analytic psychotherapist
requires additional training.
Examples
• See exhibit 12. “Guidelines for Selecting a
Theory-based Talk Therapy at the end of the
chapter.
• See chapter 13 for an explication of a case
focused on work with an individual.
• See decision schemas 12. “direct practice”
and decision schema 12. Therapeutic
Process at the the end of the chapter.