Handouts

To encourage folks to visit my website, I am making the following handouts available. New handouts will be posted at irregular intervals. You may use them in your work as long as you say where you got them and don’t re-sell them.

Setting Achievable Goals in Therapy

Achievable goals consist of clients, actions or conditions that can be brought about by clients’ actions. Often they include time elements: how often (frequency); when (date/time/deadline); and, how long (duration).

Define the goal in terms of final resolution of the therapy concern or of enough progress to terminate or take a break from therapy.

The goal must be mutual. If there is more than one client, or the customer (the person who initiated therapy and is motivated to make things change) is not the client, all parties must agree that the goal is relevant and achievable.

Translate vague, non-sensory-based words and phrases into action-based language. Goals are more checkable if clients state them as if they could be viewed/heard on a videotape player. Find outer (observable) correlates for feelings and inner states/qualities. Sometimes quantifying inner experiences or qualities by rating them on a scale is helpful. Then find action steps the client could do that would improve the rating to the desired level. Example: On a scale of 1 to 10, where would you rate your current or recent feelings of self-esteem and where will it be on that scale when you have reached your therapy goal successfully?

Provide multiple choice answers when clients hesitate in stating clear goals or when they continue to answer your queries about their goals with vague words and phrases.

Sometimes it is important to inform clients that you are searching for an achievable goal and give them a rationale for your search. Example: I keep going back to this issue of how we’ll know when we’ve been successful and can stop meeting because I want to make sure we’re working on your goals, not mine.
OR: I get concerned that what we’re doing in here could become (or has become) part of the problem instead of the solution. I think defining a goal will help avoid that because we’ll have a clearly defined stopping place.

OR: Sometimes therapy becomes a slippery business. It’s like nailing jello to a tree. It can be discouraging wondering whether I’m really helping people change or just passing the time. So it would help me to pin down a specific goal.

Focus on the goal and a successful outcome as early as you can without alienating the client. If you are getting messages that the client is irritated with the focus on goals, either explain your purpose or back off and refocus on what they are indicating is more important to discuss. Example: This may seem a funny place to start, but I always like to know where I’m going, so I can listen better for what will be helpful to you. So, if you can, tell me what you hope will be happening in your life when we’ve been successful in here. What will you be doing after therapy? How will others know you’ve changed? How will you know? And if you can, I’d like to hear it in a way that I can imagine seeing on a videotape.

Assume that therapy will be successful. Use words like “will, “when, and “yet, when speaking about the clients therapy (or post-therapy) goals. Example: So you haven’t asked a woman out for a date yet and you’d like to be able to get into a relationship? Example: When you’re feeling better, less depressed or not depressed, you’ll be getting up earlier and spending more time with friends?

Evoking Client Solutions and Competence

The idea is not to convince clients that they have solutions and competence, but to ask questions and gather information in a way that convinces you and highlights for them that they do.

 

1. Ask clients to detail times when they haven’t experienced their problems when they expected they would.

  • Exceptions to the rule of the problem
  • Interruptions to the pattern
  • Contexts in which the problem would not occur (e.g. work, in a restaurant, etc.)

 

2. Find out what happens as the problem ends or starts to end

  • What is the first sign the client can tell the problem is going away or subsiding?
  • What has the person,s friends/family/co-workers, etc. noticed when the problem has subsided or started to subside?
  • What will the person be doing when their problem has ended or subsided different from what he or she is doing when the problem is happening or present?
  • Is there anything the person or significant others have noticed that helps the problem subside more quickly?

 

3. Find evidence of choice in regard to the problem

  • Determine variations in the person,s reactions or handling of the problem when it arises. Are there times when he or she is less dominated by it or have a different/better reaction to it or way of handling it than at other times?
  • Have the person teach you about moments of choice within the problem pattern.
  • Resurrect or highlight alternate identity stories that don,t fit with the view that the person is the problem
  • Find out from the person (or from his or her intimates) about times when the person has acted in a way that pleasantly surprised them and didn’t generally fit with the view that the person is the problem.
  • Get the person (or intimates) to trace back some evidence from the past that would explain how or why the person has been able to act in a way that doesn’t fit with the problem identity.

 

4. Search for other contexts of competence

  • Find out about areas in the person,s life that he or she feels good about, including hobbies, areas of specialized knowledge or well-developed skills, and what other people would say are the person,s best points.
  • Find out about times when the person or someone he or she knows has faced a similar problem and resolved it in a way that he or she liked.

 

5. Ask why the problem isn’t worse

  • Compared to the worst possible state people or this person could get in, how do they explain that it isn’t that severe? This normalizes and gets things in perspective.
  • Compare this situation to the worst incident and find out if it is less severe. Then track why or how.

 

6. Get clients to teach you how to do what they do when things work

  • Could they teach you or someone else how to do what works?
  • Play other people in the situation and get them to coach you on how to act in a way that would produce better responses.

Assessment Questions

 

For the client

  • *How will we know when it,s time for you to leave therapy, when we,ve been successful? [Ask for a video description or get a scaling estimate.]
  • *What happened that gave you or whoever thought you should be here the idea that therapy would be the best place to sort out the difficulty (difficulties)?
  • *After you finish coming here, what kind of changes do you think you,ll make in your life?
  • *What,s the first sign you,ll be able to notice that therapy had been helpful to you?
  • *What,s the first sign others will be able to see when you start to (feel better; get better; feel more hopeful; really know you want to live; etc.)?
  • *If you,ve experienced a similar difficulty before, how,d you deal with it?
  • *How about one of the times when the difficulty started to devel-op, but you stopped it before it went too far? [If they don,t report any positive coping experience, reply, “So you can’t remember any time like that right now.]
  • *What was the high point of the last year for you?
  • *Can you remember a time recently when you pleasantly surprised yourself or did something out of character that pleased you?
  • *What medications or therapy approaches have worked best for you, if any?
  • *What hobbies or interests do you have or have you had in the past? What was interesting or valuable about those activities?
  • *What kind of work do you do or have you done?
  • *(For adolescent) What was/is your favorite subject or class in school? Why?
  • *(For reports of previously overcome problems) You told me you used to use drugs or alcohol and then stopped. How did you do that? or You told me you were suicidal last fall. How did you get through that time without harming yourself or doing yourself in?

 

For the referral source/family member

  • *What gives you the idea that the person needs to be in treatment?
  • *Who has been most upset or vocal about the client,s behavior?
  • *How will you know that treatment has been successful and that I have done a good job? [Get a video description.]
  • *What has been the most pleasantly surprising thing you,ve seen or heard from or about the client recently?
  • *What would you like me to do to keep you informed on the client,s progress or to keep getting your input?

Solution Oriented Strategies with Couples

1. Summarize, validate and soften

This strategy ensures that the therapist is listening adequately, as well as validating each person without taking sides. In addition, through slight word changes, the therapist can soften what might be a blaming or discouraging communication from one partner to another.

2. Self-disclosure/storytelling

This strategy has several functions. One is to join and more equalize the relationship (we all have issues and struggles in relationships, not just clients). Another is to normalize by helping couples realize that others may have the same kinds of issues, points of view or feelings. The last element of this strategy is to suggest new possibilities for actions or points of view.

3. Identifying and tracking problem patterns

This strategy, often combined with getting specific, helps the therapist understand what the couple or one partner is concerned about and how he or she experiences the problematic situation. In addition to getting an idea of the problem, the therapist is searching for typical patterns in the problematic interactions or situations.

4. Identifying and tracking solution patterns

This strategy, again often combined with getting specific, is used to evoke and highlight more helpful actions and points of view related to the problem based on the couple,s past experience.

5. Suggesting possibilities

This strategy offers ideas from the therapist,s experience that might be helpful in the future, either based on what the couple has said so far (usually derived from the solution patterns) or based on some ideas the therapist has. It is important to give these suggestions in a tentative manner, not to impose them on couples. But it is just as important not to leave the therapist,s ideas out of the conversation in the name of neutrality or a non-expert position.

6. Getting specific/action descriptions

This strategy involves getting the couple to tell the therapist about specific incidents and actions, so the therapist can understand the couples situation without having to project or interpret as much as would be necessary with more vague descriptions. This often involves the use of what I call “videotalk, that is, having couples describe the situation as if it could be seen and heard on a videotape.

7. Naming classes of solution or problems and initiating searches

This strategy involves using vague, general words or inquiries to facilitate the evocation and organization of problem or solution categories or specific incidents that could be examples of those categories.

Externalize symptoms and problems and ideas about blame, determinism and “unchangeable” problem identity ideas.

Motto: The person is never the problem; the problem is the problem.

1. Name/Personify‚

Talking to the person or family as if the problem was another person with an identity, will, tactics and intentions which often have the effect of oppressing, undermining or dominating the person or the family.

  • Example: “When Paranoia whispers in your ears, do you always listen?”
  • Example: “So Depression has moved in with you for the last month?”
  • Example: “How long has Anorexia been lying to you?”

2. Find out how the problem has affected the person and others‚

Finding out how the person has felt dominated or forced by the problem to do or experience things he or she didn’t like. Be careful about using causal statements (“makes,” “causes,” “gets”).

Investigate areas of: 1. Experience, feelings arising from the influence of the problem; 2. Tactics or messages the problem uses to convince people of limitations or to discourage people; 3. What actions or habits the problem invites or encourages the person or the family to do; 4. Speculations about the intentions of the problem in regard to the person or relationships; 5. Preferences or differences in points of view the person has with the problem.

  • Example: “When has jealousy invited you to do something you regretted later?”
  • Example: “What kinds of foods does Anorexia try to get you to avoid?”

3. Find moments when things went better or different in regard to the problem‚

Finding out about moments of choice or success the person has had in not being dominated or forced by the problem to do or experience things he or she didn’t like. Inquire about differences the person has with the problem.

  • Example: “Tell me about some times when you haven’t believed the lies Anorexia has told you.”
  • Example: “How have you stood up to the Temper Tantrum Monster?”

4. Use these moments of choice or success as a gateway to alternate (hero/valued) stories of identity‚

Encourage the person or his/her intimates to explain what kind or person they are such that they had those moments of choice or success.

  • Example: “How do you explain that you are the kind of person who would lodge such a protest against Anorexia’s plans for you.”
  • Example: “What qualities do you think you possess that give you the wherewithal to oppose Depression in that way?”

5. Find evidence from the person’s or families past that supports the valued story‚

Finding historical evidence explaining how the person was able to stand up to, defeat or escape from the dominance or oppression of the problem.

  • Example: “What can you tell me about your past that would help me understand how you’ve been able to take these steps to stand up to Anorexia so well?”
  • Example: “Who is a person that knew you as a child who wouldn’t be surprised that you’ve been able to reject Violence as the dominant force in your relationship?”

6. Get them to speculate about a future that comes out of the valued story‚

Get the person or the family to speculate on what kinds of future developments will result if the path of resisting the problem is continued or expanded.

  • Example: “As you continue to stand up to Anorexia, what do you think will be different about your future than the future Anorexia had planned for you?”
  • Example: “As Jan continues to disbelieve the lies that delusions are telling her, how do you think that will affect her relationship to her friends?”

7. Develop a social sense of the valued story‚

Find a real or imagined audience for the changes you have been discussing. Enroll the person as an expert consultant on solving/defeating the problem. Situate the problem in a current social/political/values context.

  • Example: “Who could you tell about your development as a member of the Anti-Diet League that could help celebrate your freedom from Unreal Body Images?”
  • Example: “Are there people who have known you when you are not depressed who could remind you of your accomplishments and that your life is worth living?”

Brief Therapy Assumptions and Assessment

Escalating Interventions for Destructive/Harmful Behavior in Relationships

Clarify the limits and requests in the area of dangerous behavior.

Clarify accountability.

  • Make sure each person is held accountable for his/her actions.
  • Clarify the boundaries for acceptable behavior in videotalk.

Change the patterns around the problem.

  • Any of the people involved may make changes in the pattern, but make sure the person who has been doing the destructive behavior continues to get the message that he/she is accountable for the destructive behavior.

Help the family or the person set and apply consequences.

  • These consequences may be escalating from light to severe, including involvement of the legal authorities and severing the relationship.

Get the boundary violator to make amends and to reaffirm his/her commitment to staying within the limits.

  • Often this involves actions more than words. The boundary violator must show consistent trustworthy behavior over time to reestablish the others’ trust in the safety of the situation. Find out how long the person has gone in the past staying within limits and use that as a yardstick to measure progress. You may have to arrange for regular long-term follow-up to ensure that the destructive behavior is not recurring.

Five Levels of Intervention in Couples’ Therapy

1. Acknowledge/validate each partner’s points of view and feelings without necessarily agreeing with them. Get them to stop blaming, invalidating, closing down possibilities, and inviting, suggesting or allowing nonaccountability.

2. Get people to translate blame (attributions of bad intentions/bad character), vague, mind-reading or characterizing (attributions of unchangeable and determining personality traits) statements/questions into “videotalk.”

  • *Action complaints
  • *Action requests
  • *Action praise
  • *Negotiated agreements

3. Gather video descriptions of patterns of interaction involved in or around the complaint and get both or either partner to change their part of the pattern.

  • *Change the location, time, nonverbals, etc.
  • *If it works, don’t fix it; if it doesn’t, do something different
  • *Import workable patterns from earlier in the relationship

4. Help to determine clear (videotalk) boundaries/limits for acceptable and unacceptable actions.

  • *Coach the person whose boundaries are violated to give consequences when boundaries are violated.
  • *Coach the person who has violated the boundaries to acknowledge and be accountable for the violation, reestablish trust and make amends.
  • *If appropriate, help the couple or individual design and carry out a healing ritual.

5. Do individual work when an individual within a couple has something they want to work on that would be relevant to achieving the goal(s) of the conjoint work.

Guidelines For Couples’ Communication

Action Complaints

  • Don’t give the person your theory/explanation (why they did what they did) along with your complaint.
  • Tell the person what they did that didn’t work for you.
  • Use videotalk. If the person can’t picture/hear it, you aren’t being specific enough to ensure your message will be heard.
  • Avoid blame, diagnosis and generalizations.

Action Requests

  • Use videotalk.
  • Ask the person to do something different in the future.
  • Don’t tell them what is wrong with them when you make the request.
  • Don’t assume they won’t do it. Give them a chance to show you.
  • Get specific about when or how often you would like them to do what you’ve asked.

Acknowledgment

  • Listening/acknowledging the other person’s feelings and points of view.
  • No rebutting. Just listen. See if you can understand what the other person is trying to communicate to you.
  • You don’t have to agree that what they are saying is correct, but don’t give them the message they are crazy for seeing things that way. Don’t dismiss or minimize.

Breaking Patterns

  • Change your part of any pattern that you notice isn’t working.
  • Do anything that is not cruel or unethical that would be different from what you usually do in the situation.
  • If it’s working, don’t fix it. If not, do something different.
  • Remember: “Insanity is doing the same thing over and over again and expecting different results.” -Rita Mae Brown

Conjoint Work With Couples and Families

1. Acknowledge/validate each person’s feelings and points of view without closing down the possibilities for change.

2. Move the discussion from complaints about things the couple or family hasn’t liked in the past to what they would like to have happen in the future.

3. Get people to translate blame (attributions of bad intentions/bad character), vague, mind-reading, invalidating or characterizing (attributions of unchangeable and determining personality traits) statements/questions into “videotalk.”

  • Action complaints
  • Action requests
  • Action praise

4. Identify mutually agreeable goals and plans in “videotalk.”

5. Gather video descriptions of patterns of interaction involved in or around the complaint and get any person in the relationship to change their part of the pattern.

  • Change the location, time, non-verbals, etc.
  • If it works, don’t fix it; if it doesn’t, do something different
  • Identify and encourage solution patterns

6. Help to determine clear (videotalk) boundaries/limits for acceptable and unacceptable actions.

  • Coach the person whose boundaries are violated to give consequences when boundaries are violated.
  • Coach the person who has violated the boundaries to acknowledge and be accountable for the violation, reestablish trust and make amends.
  • If appropriate, help the couple or individual design and carry out a healing ritual.

7. Co-design with clients task assignments to help translate in-session changes to the couples’ life. Give clients an idea of the kind of tasks you think would be helpful and elicit their collaboration in designing their specific task. Elicit any objections or barriers to carrying out the task(s) before it is finalized and agreed to. Write down the task and keep a copy. Follow up by asking about the task at the beginning of the next interview.

8. Use humor to help the couple or family lighten up and see the possibilities for change.

9. Do individual work when an individual within a couple or family has something they want to work on that would be relevant to achieving the goal(s) of the conjoint work. Make sure that you don’t imply that the person you are doing individual work with has the “real” relationship problem.

Complaints/Requests/Praise

1. Own your perceptions/feelings and distinguish them from “the way it is.” Skip labels and vague words. Let the person know how you feel about things and see things. Don’t take your point of view for granite (or granted).

2. Complain Effectively. State the facts (actions one can see on video tape) on which you base your conclusion or perception. [The action complaint]

  • The listener must be able to see/hear it on a video.
  • Focus on actions, communications, voice tones, voice volumes, specific words.
  • Talk about specific incidents.
  • Don’t assume you know the other person’s intentions or feelings.

3. Coach the other person on what would work better. State the alternative actions or communications (words, voice tones, voice volumes, facial expressions) that would work better for you or wouldn’t “push your button.” [The action request]

  • Avoid telling them to change their feelings, attitudes or personality.
  • Focus on “video” descriptions.
  • Include specifics about time (when, how often, etc.)

4. Negotiate a workable agreement by finding some actions that would work for both of you. [Negotiated agreement]

  • Make a counter proposal that would be more acceptable to you if the person’s request is unsatisfactory.
  • Find a different action that would satisfy his or her request.
  • Check at some agreed upon interval to make sure it’s working.
  • Fine tune it then if you need to.
  • Apply consequences if appropriate.
  • Keep your commitment.
  • Write a note to yourself, post a list on the refrigerator or put it in your appointment book if necessary.

5. Let the other person know when he or she does something that you appreciate. Again, make sure your comments are in video talk, so the other person understands specifically what actions you liked. [Action praise]

Breaking the Bad Trance Main Points in Working with Couples in which One of the Partners has been Traumatized

1. People who have been abused often get triggered into a “bad”/symptomatic state that is like a trance. They go on automatic and lose contact with their resources, often feeling dissociated or acting in a dissociated, in-congruent manner.

2. Couples often get into patterns of communication and interaction which trigger off each others’ bad trance. Typical patterns are communications that blame, invalidate, close down possibilities, vague/ambiguous language or interactions that are repetitive and negative.

3. There are three main ways of helping couples avoid getting into bad trances together:

  • Help them use “videotalk” and stop trying to analyze, change or fix each others’ insides
  • Change patterns of actions between the two of them
  • Use externalization to change the relationship of the couple to the problems/symptoms and avoid self-blaming or other blaming

Step parenting Hints

3 approaches to stepparenting that usually don’t work

  • You and your ex- screwed up these kids and now I’m going to fix them
  • We’re an instant family with instant love
  • “Why don’t you get your kids to . . .?” or “Do you know what your kids did?”

Some hints about what might work

  • Beware the triangle-use one-to-one communication when possible
  • Circle the wagons-draw boundaries around the marital relationship and around the new/blended family
  • Take your parenting disagreements behind closed doors and present a united front with the kids
  • Don’t take it personally-Use action language and escalating consequences
  • Build up credits in the relationship bank before you make withdrawals

Remember that no one has a lock on “correct” parenting

If all else fails, try the roommate or friend models for being a stepparent

New Possibilities for Therapeutic Conversations

Characteristics of Traditional Therapies:

  • Conversations for true explanations
  • Searching for evidence of functions for problems (the functions attributed may be either benevolent or malevolent)
  • Searching for or encouraging searches for causes and giving or supporting messages about determinism (biological/developmental/psychological)
  • Focusing or allowing a focus on history as the most relevant part of the person’s life
  • Engaging in conversations for determining diagnosis, categorization, and characterization
  • Supporting or encouraging conversations for identifying pathology
  • Conversations for inability
  • Conversations for insight/understanding
  • Conversations for expression of emotion
  • Eliciting clients’ expressions of feelings and focusing on feelings
    “How do you feel about that?”
  • Conversations for blame and recrimination
  • Attributions of evil/bad personality or evil/bad intentions
  • Adversarial conversations
  • The therapist believes clients have hidden agendas that keep them from cooperating with treatment goals/methods
  • Using trickery/deceit to get the client to change
  • The therapist is the expert and clients are non-experts

The New Tradition:

  • Collaborative conversations
  • Clients and therapists are partners in the change process
  • Clients are experts in teaching the therapists about what they are experiencing, have experienced, what they want and what fits for them
  • Conversations for change/difference
  • Highlighting changes that have occurred in clients’ problem situations
  • Presuming change will and is happening
  • Searching for descriptions of differences in the problem situation
  • Introducing new distinctions or highlighting client distinctions
  • Conversations for competence/abilities
  • Presuming client competence/ability
  • Searching for contexts of competence away from the problem situation
  • Eliciting descriptions of exceptions to the problem or times when clients dealt with the problem situation in a way they liked
  • Conversations for possibilities
  • Focusing the conversation on the possibilities of the future/goals/visions
  • Introducing new possibilities for doing/viewing into the problem situation
  • Conversations for goals/results
  • Focusing on how clients will know that they have achieved their therapeutic goals
  • Conversations for accountability/personal agency
  • Holding clients/others accountable for their actions
  • Presuming actions derive from clients’ intentions/selves
  • Conversations for actions/description
  • Channeling the conversation about the problem situation into action descriptions
  • Changing characterization/theoretical talk into descriptive words
  • Focusing on actions clients can take that can make a difference in the problem situation

Collaborative Therapies

A collaborative therapy is one in which:

  • The expertise of clients is given at least as much weight as the expertise of therapists.
  • Clients are regularly part of the treatment planning process: Clients are consulted about goals, directions and responses to the process and methods of therapy
  • Diagnostic procedures, conclusions and case notes are available, transparent and understandable to clients (no jargon or theoretical or technical terms which aren,t explained in plain, simple language).
  • The therapist asks questions and makes speculations in a non-authoritarian way, giving the client ample room and permission to disagree or correct the therapist. Therapists give clients many options and let them coach the therapist on the next step or the right direction. If the therapist has an idea and is keeping it as a hidden agenda, he or she makes it public, putting it out in the conversation not as the truth or the right direction, but as an idea, a personal perception or an impression.
  • The therapist is wary of “theory countertransference. Theory countertransference is evident when the therapist continues to “discover the same kinds of problems in client after client (e.g. “unresolved losses, or Multiple Personality Disorder). This also means not imposing one,s beliefs and therapeutic values on clients, lives. The therapist claims no special knowledge about the best way for the client to live after resolving his or her therapeutic concerns (e.g., that it is best for clients to use “I messages or always express their feelings).
  • Other helpers are given respect and no attributions of bad intentions or wrong approaches are implied regarding their treatment. They are invited into cooperative relationships by inquiring about what their views of the situation are and what the outcomes they expect from treatment are. If they are willing to say, you can ask them about how you might help with or at least not interfere with their treatment. This does not mean that one has to accept or support everything other helpers do. The first loyalty is to the client(s). So, as usual, stories of impossibility, blame, invalidation and determinism are gently and subtly challenged by acknowledging their possible validity and introducing alternate possibilities.
  • Clients (consumers) are given the opportunity to comment on the process of helping (critiquing, appreciating or coaching) and to share their expertise with others, thereby elevating their status from passive needy recipients to active expert contributors.

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