Thursday, September 11, 2014

Person Centered Therapy

Person Centered Therapy




The Therapy Process
■ Six conditions necessary and sufficient for personality changes to occur:
o Two persons are in physiological contact
o The first, the client is experiencing incongruence
o The second, the therapist, is congruent or integrated in the relationship
o The therapist experiences unconditional positive regard or real caring for the client
o The therapist experiences empathy for the client’s internal frame of reference and endeavors to communicate this to the client
o The communication to the client is, to a minimal degree, achieved.


■ Three Requirements for Therapy

o Genuineness
■ Accurate empathic understanding
■ Genuineness or realness in relations between therapist and client
■ Being oneself in the therapeutic relationship with the client

o Unconditional positive regard
■ Acceptance and caring
■ NOT approval of all behavior

o Congruence
■ Understanding of client’s frame of references
■ Ability to deeply grasp the client’s subjective world and communicate this to the client


Role of the Therapist

o Focuses on the quality of the therapeutic relationship
o Serves as a model of a human being struggling towards greater realness
o Is genuine, integrated, and authentic, without a false front
o Can openly express feelings and attitudes that are present in the relationship with the client




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Tuesday, September 9, 2014

Biopsychosocial History and Collateral Data

Biopsychosocial History and Collateral Data

The Biopsychosocial (BPS) History is a hallmark of social work, recognizing the link between physical health, physical functioning and the individual's social environment. A comprehensive BPS history can provide extensive information to inform where additional assessment is needed and where the focus of treatment is required. However, if the client is the only reporter, the information can be limited, incongruent or falsified. Collateral data can provide verification of accurate information, complete gaps in accurate reporting, provide areas for additional investigation or correct bad information.

The BPS goes beyond the mind/body connection in vogue for much of the 20th century in the United States and recognizes the link between the physical/body, mental/mind, and emotional/social/spiritual aspects of the individual. Without such inclusion, vital aspects of the client will be missed, leaving crucial diagnostic information out of the clinical picture. Unless assessment is complete, treatment will be incomplete. Even if a professional could adequately argue he can complete an accurate diagnostic assessment without all three components, arriving at the same DSM-IV diagnosis as a clinician who completes a BPS, the clinician who does not complete a BPS will not be informed enough to do a complete treatment plan and may miss vital contributing factors. How then can treatment be complete if factors that impact the problem are not identified?

The BPS will include cursory identifying information, presenting problem/issue, summary impression, goals, discharge/transition plan and a diagnostic impression. The bulk of the instrument consists of three sections: the biological/medical (including substance related issues, medical conditions, medications, disability restrictions), psychological (including symptom/problems, mental status, family history of psychiatric issues, risk assessment), and social (including spirituality, cultural issues, educational background, developmental history, legal history, marital/relationship status and history, employment history/aspirations and needs/abilities/preferences).

The biological section of the BPS assesses the client's medical history, developmental history, current medications, substance abuse history and family history of medical illnesses. The clinician is interested in exploring issues related to diabetes, thyroid disease, cancer, high blood pressure, cardiac history, chronic pain and other health issues because health issues can mask as mental health symptoms or exacerbate them. A referral should be made to address medical concerns that are not being treated. Clients who are on medications can have care coordinated with the treating provider, and more should be known about the medication, as side effects can also mask as or exacerbate psychiatric symptoms or illnesses. Collateral data is helpful when abuse of substances is suspected, such as abuse of pain medication, or with medical information because it is outside the scope of social work practice.

The psychological issues in the BPS assess the client's present psychiatric illness or symptoms, history of the current psychiatric illness or symptoms, past/current psychosocial stressors and mental status. Exploration of how the problem has been treated in the past, past/present psychiatric medications and the family history of psychiatric and substance-related issues is also included. Substance-related illnesses and issues with the client or family may be categorized in various ways within the BPS. Some forms link it with the medical portion of the report, while others the psychological, and still others the social, perhaps with legal issues. Theoretical orientation, program focus or other more practical issues may drive where this and other elements are placed. The importance of psychological issues is self-evident, driving diagnostic criteria and primary treatment focus. While self-report may be reliable, having an additional source of information is useful, such as a family member, spouse or friend, to provide an additional perspective on the symptoms presented. Clients may, for example, have issues of shame or distorted thinking that prevent them from sharing accurate details about symptoms.

The social aspects of the BPS focus on the client systems, both proximal and distal, unique client context and may identify strengths and/or resources available for treatment planning. Included in this portion of the BPS are components such as spirituality, cultural factors, sexual identity issues/concerns, personal history, family of origin history, support system, abuse history, education, legal history, marital/relationship, work history, and risk assessment (suicidality, homocidality, impulse control, risk history).





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Assessment of Client System Strengths and Weaknesses

Assessment of Client System Strengths and Weaknesses

A variety of approaches exist to the identification of strengths and weaknesses or problems within the client or client system. Depending on the social workers training and theoretical perspective, the approach to assessment will have a distinct tone, even if the components and conclusions of assessment have essentially the same content information. The difference in the approach, however, can set a specific course for treatment. As research has shown, different approaches have more or less efficacy for different populations and different target problems.

A traditional assessment format seeks to develop rapport and a working relationship that will be underscored with trust, respect, dignity and integrity. Depending on the theoretical approach, more or less focus will be placed on the relationship itself. The assessment identifies problems and issues that cause difficulties, and the treatment plan may be written in terms of what issues need to be resolved. The components of the assessment will be a history, a psychosocial study, mental status, level of functioning, clinical assessment, recommendations and goals for treatment.

In a strengths-based approach, the assessment process has the same components, but the approach is markedly different. The entire focus of the process is to reframe the client’s attitude, perceptions and behaviors into a strengths-based perspective and orientation. Specific efficacy has been found in the literature for this approach, for example Multi-systemic Therapy (MST) has been used with success in youth populations and is a strength-based model.

The strength-based model assesses the inherent strengths within a client or client system and seeks to build upon those strengths. This requires the worker to reframe and shift the client or family perceptions toward the positive, thereby instilling hope. For example, a couple may seek marital counseling and report they constantly argue, reporting daily arguing, only relenting when they cease to speak with one another. In response to this negative issue or problem, the social worker with a strength-based perspective might pose to the couple their dedication to continue communicating, seek support under the current stress and note the marriage is intact (even if situation is tenuous at best and seems overwhelming to all present in the session).

The reason to use a strength-based approach is the empowerment that underscores the process of assessment and treatment, as opposed to describing the client in terms of a diagnosis or experiencing other deficits. The approach removes stigmatizing terms that clients use and internalize that create helplessness about change. Removing stigmatizing terms moves clients further from the victim perspective reinforced by mainstream society. Identifying and reviewing the positive attributes the client has fosters hopefulness within the client or family, beginning the process for recovery and success. It may be the first time a client has heard, identified or focused on strengths, providing a positive environment for change. The process elevates the client, helping the client see their own power and expertise in their own life, identifying what has and has not worked in the past and providing a platform to work from to identify what might work for them in the future. Clients become more invested when they can see how they have control of their own recovery and power in their lives.

Changes from the social worker’s perspective involve a shift in how the client is viewed. Stigmatizing terms and phrases such as resistant, poor insight, dysfunctional, non-compliant, not motivated for treatment, or difficult. Additionally, the importance of language becomes more apparent. An example is saying, Joe has schizophrenia, rather than Joe is schizophrenic. The strength-based model is mindful that the client is not the illness, though they are diagnosed with the illness.





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Thursday, June 5, 2014

Sexual abuse treatment for victims, perpetrators, and their families


Sexual assault is a traumatic event from which many victims never fully recover. Victims often develop problems with post traumatic stress disorder (PTSD), depression, poor self-esteem, interpersonal difficulties, and sexual disorders. PTSD is overwhelmingly the most common disorder related to sexual abuse.

Children may have some symptoms that are different from adults such as agitated behavior, repetitive play involving trauma, frightening non-specific dreams, and reenactment of the traumatic event.

Long Term Treatment Goals
•        Ensure safety from further victimization.
•        Help client understand and control the feelings and behavior that accompany the assault.
•        Build self esteem.

Short Term Treatment Goals
•        Establish therapeutic rapport and open communication with client.
•        Assess the level of symptomology.
•        Obtain medical assistance (forensic examination).
•        Obey child abuse laws (mandatory reporting)
•        Assess for suicidal tendencies.
•        Have client tell their story.
•        Identify and express feelings about the abuse.
•        Decrease feelings of guilt and shame.
•        Increase feelings of empowerment.

Therapeutic Interventions
•        Write out what happened including feelings.
•        Play Therapy
        o        Angry tower: build tower, then verbalize while throwing things at the tower, watching it topple, to allow feelings to emerge.
•        Mutual Story telling
        o        Client and therapist take turns telling stories (may use puppets dolls or stuffed animals).
•        Art Therapy
        o        Associate color with feelings
        o        Draw different scenes for different feelings
•        Letter
        o        Have client write letter to perpetrator that describes feelings about the abuse. Process the letter.    
•        Develop personalized Safety Plan
        o        Self defense classes
        o        Safety escape routes.
        o        Who to call in cases of emergency
        o        Domestic violence safety plans can be searched for online.
•        Challenging Beliefs
        o        Discuss myths and realities
        o        Reduce feelings of shame and guilt
•        Encourage group work

Family Interventions
•        Encourage parents to reassure child that they are not angry at family member/victim.
•        The best things parents can do is believe the client.
•        Encourage the whole family to find support, as well as being a support for each other.
•        Establish safety for the whole family.
•        Have parents request and advocate.
•        Encourage the family to make sure client knows they are not to blame.
•        Discuss myths as a family.
•        Tell families to make sure they take care of themselves too during this difficult time.






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Thursday, May 29, 2014

Emotional Focused Couples Therapy


Introduction
Emotion is the music of the dance between partners, learn to change the music and change the dance.
What is EFT?
•        EFT expands experience and interactions.
•        It is the accessing and reprocessing of emotional response underlying partner’s interactional position. The reprocessing of inner experience is used to expand the interpersonal context. In turn the structuring of new interactional events expands and redefines each partner’s inner experience.
•        It facilitates a shift in positions towards accessibility and responsiveness- which are the building blocks of secure bonds.
•        It creates new interactional events that redefine the relationship as a source of security and comfort for each of the partners.
•        When EFT is successfully implemented, each partner experiences the other as a source of security, protection, ad comfort.
•        Each partner can then assist the other in regulating negative affect and constructing a positive and potent sense of self.
EFT Structure
•        Step 1: Assessment- Create an alliance and delineate conflict issues in the core struggle
•        Step 2: Identify negative interactional cycle.
•        Step 3: Access unacknowledged emotions underlying interactional positions.
•        Step 4: Reframe the problem in terms of underlying emotions and attachment needs.
•        Step 5: Promote identification with disowned needs and aspects of self and integrate these into relationship interactions.
•        Step 6: Promote acceptance of the partners experience and new interaction patters.
•        Step 7: Facilitate the expression of needs and wants and create emotional engagement.
•        Step 8: Facilitate the emergence of new solutions to old relationship problems.
•        Step 9: Consolidate new positions and new cycles of attachment behaviors.
Foundations of Marital and Family Therapy
1940
Theodore Lidz
Study of families of schizophrenics
Introduced concepts of
Schism= division of family into two antagonistic and competing groups.
Skew= one partner in marriage dominates the family as a result of serious personality disorder in one of the partners.
1950
Nathan Ackerman
The Psychodynamics of Family Life
Began treating client mental disorders through family process dynamics.
Gregory Bateson
Formulated controversial yet influential theory of dysfunctional communication called the double-bind.
Two seemingly contradictory messages may exist on different levels and lead to confusion or schizophrenic behavior on the part of the individuals receiving those messages.
Milton Erickson
Established Brief Therapy
Carl Whitaker
Risked violating the conventions of traditional psychotherapy
Published work in dual therapy or conjoint couple therapy.
Murray Bowen
Began holding therapy sessions with all family members present as part of a research project on schizophrenics.
Elaborated theory on the influence of previous generations on mental health of families.
Emotional Reactivity    
Found that when troubled families were brought together they had difficulty maintaining their identities
Described this as an undifferentiated family ego mass
Worked to help them establish appropriate relationship boundaries and avoid projecting or triangulating.
1960s
Jay Hayley
Began to formulate Strategic Family Therapy.
Emphasis on gaining and maintaining power during treatment.
Edited Family Process, first journal in field of family therapy.
Salvador Minuchin
Used his own form of family therapy with urban slum families
Reduced recidivism rate for delinquents in school.
Training local members of the black community as paraprofessional family therapists.
Cultural differences often makes it difficult for white middle class therapists to relate successfully to urban black and Hispanics.
Virginia Satir
Social work background
Gained prominence in Mental Research Institute
Unique in being only woman pioneer of family therapy.
Focused on importance of self esteem, compassion, and congruent expression of feelings.
John Bell
Started using group therapy as a basis for working with families
Structural program of treatment that conceptualized family members as strangers.
1970s
R.D. Laing
Coined the term mystification
Describes how some families mask what is going on between family members by giving conflict and contradictory explanations of events.
Rachel Hare-Mustin
Feminist Approach to Family Therapy
Goal of working with a families
Facilitate the growth of a strong woman who have enhanced control over resources
Increase the ability of women to work together politically to make societal changes.
1980s
Women came to forefront
Monica McGoldrick
Carolyn Attneave
Peggy Papp
Peggy Penn
Cloe Madanes
Fromma Walsh
Betty Carter
1990s
Steve deShazer
Narrative theory
Bill OHanlon
Solution Focused




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