Counseling Quiz #2

Insight Stage

-Seeing things from a new perspective, making new connections, and/or having a new understanding of why things happen as they do

●Sometimes clients hit a gold nugget of insight, but more often, there is a smattering of gold dust as they work hard to gain insight over time

Why is Insight necessary

-We need to understand why things happen so that we have a sense of coherence

-Insight leads to the discovery of new facts and a recognition of their significance

-We can make different choices in the future

-We can transcend suffering and find meaning in existence

Intellectual vs. Emotional Insight

Intellectual Insight: Objective explanation of a problem

•Emotional insight

oConnects affect to intellect & creates a sense of personal involvement and responsibility

•Insight typically must be intellectual and emotional (integrative insight) to lead to action

How to facilitate emotionally charged Insights

●Yalom talked about developing “rabbit ears” to listen for how interpersonal patterns develop in the here and now.

Markers of Readiness for Insight

-Clear statement of awareness of a problem

-Statement of lack of understanding

-Stated eagerness or willingness to understand

-High level of affective distress experienced as pressure to resolve the problem

Psychoanalytic Theory

Psychoanalytic theory began with Freud and has evolved

emphasizes the significant influence of the unconscious mind, early childhood experiences, and internal conflicts in shaping personality and behavior

-Efficacy of psychodynamic treatment

-Results endure & increase over time after psychotherapy

-Teaches clients a new way of being

Existential Theory

Existential psychotherapy

Existential psychotherapy is a therapeutic approach that focuses on exploring the human condition to help individuals confront anxiety and find purpose in life's inherent challenges

(Yalom, 1980)

Existential concerns of the human condition cause anxiety, which is combatted by defenses

Existential concerns:

Death anxiety

Freedom

Isolation

Meaning in life

Treatment from a psychoanalytic and Existential Perspective

Make the unconscious conscious

Doing an “archaeological dig” to determine the early reasons for current behaviors

Work with unconscious conflicts to help clients become more rational and intentional rather than acting on primitive impulses

Awareness of defense mechanisms

Goals of Insight Stage

-Challenging to foster awareness

Challenge discrepancies

Challenge thoughts

Humor, silence, challenge responsibility, nonverbal behaviors, and questions

Facilitating insight

Open questions/probes for insight

Interpretation

Self-disclosure of insight

Working with the therapeutic relationship

Immediacy

A change from Freud’s time

Therapist is not a blank slate for the client to project issues onto (one-person psychology) but plays a key role in the therapeutic relationship (two-person psychology)

Less emphasis on his psychosexual stages

Therapist and client both contribute to the relationship based on their own issues

Client transference and therapist countertransference are not separate issues

Working on the therapeutic relationship can be a central change mechanisms within therapy

Rationale for Awareness Raising Skills

●A set of skills designed to raise awareness so that clients can be more intentional in their lives

○Challenges

○Chair Work

○Humor

○Silence

Encouraging Responsible Language

Challenges

A challenge points out maladaptive thoughts, discrepancies, or contradictions of which the client is unaware of, unwilling, or unable to change

Awareness: cognizance or attentiveness about behaving, thinking, or feeling in a certain way

Insight: understanding why we behave, think, or feel in a certain way

Awareness = Insight

Intentions behind Challenges

Help clients see discrepancies in their thoughts and behaviors

Increase awareness of defenses, ambivalence, and irrational ideas

Deal with resistance

Yalom, Chapter 18 Example (Louise)

Challenges are designed to raise awareness, not to figure out why the issues exist

Markers of Readiness for Awareness

•Ambivalence

•Contradictions

•Discrepancies

•Confusion

•Feeling stuck

•Being unable to make a decision

Observe and listen for things that do not sound right, make sense, fit, go together, actions performed because of “shoulds,” cause ambivalence, or result in struggles

How to Challenge

•Observe the client for inconsistencies and maladaptive thoughts

Determine appropriateness of challenges based on the type of client or the client’s readiness

•Should not be a criticism or judgmental, but rather an encouragement to examine oneself more deeply

General Guidelines for Challenging

•Observing client reactions

•Observe client reactions

•Observe nonverbal behavior

•Don’t expect that you will necessarily know if clients feel badly after a challenge

•Helpers often have to ask clients how they reacted to the challenge and probe beneath the surface

General Guidelines continued

•Timing

•Challenges are most effective if used in close proximity to the client’s behavior (as long as you have enough information)

•Cultural considerations

•Think about your own culture and your client’s culture

•Transference and projections

•Most of us are very sensitive to challenges because of our past experiences with people in power

Challenging through Questions

•“Encourage clients to reflect on what they are saying

•“Really?”

•“Oh yeah?”

•“Hmmm?”

Guidelines for Challenging Discrepancies

•Need to do it in a way that clients can hear the challenge and feel supported rather than attacked (collaborative)

•Challenges should be given carefully, gently, respectfully, tentatively, thoughtfully, and with empathy

•Do not make judgments; all of us have discrepancies and irrationalities!

Format for Challenging Discrepancies

•“On the one hand   , but on the other hand   .”

•“You say   , but you also say   .”

•“You say   , but nonverbally you seem   .”

•“I’m hearing   , but I’m also hearing   .”

•Sometimes the first part of the discrepancy is implied and you only need to say the second clause.

•“But you said he was angry at you”*

Difficulties in using challenges

•Helpers not challenging enough

•Worrying about being intrusive, offending clients, sounding accusatory/blaming, destroying the therapeutic relationship, causing clients to feel unsupported, or leading to clients not liking them

•Using too many challenges

•Using challenges too harshly

•Difficulty knowing how to respond when clients disagree and potentially challenge the helper in return

Other skills used to Foster Awareness

•Chair work

•Humor

•Silence

•Challenging clients to take responsibility by changing their language

Chair Work

•Client sits in one chair and tries to experience and express feelings from one side of the client or from a significant other

•Client moves to another chair and talks from the other side with full expression of feelings

Humor 

•Using humor can help clients objectify or gain distance on a problem, which helps lessen defensiveness and helps clients see experiences in a different light

•Incredibly important that rapport and trust are established

•Consider timing

•Use sparingly

•Not everyone can get away with this

Silence 

•Helper challenges clients to take responsibility for what they want to say

•Sometimes increases discomfort and forces clients to rely on their inner resources and examine their thoughts

•Can be damaging if there is not a solid therapeutic relationship and an understanding of the reason for silence

Owning Responsibility

•Helpers can identify whether clients are owning responsibility by listening to their language

•Use gently and infrequently

•Examples:

•Using “I” rather than “you” or “everyone”

•Using “won’t” rather than “can’t”

•“Stand up to my boss? Are you kidding me? I can’t.”

•Using “I choose to” rather that “I shouldn’t”

•“Oh, I really shouldn’t have gone out last weekend. I should have been studying.”

 

Immediacy

•Helpers inquiring about the client’s feelings regarding the therapeutic relationship or disclosing how they are feeling about the client, the self in relation to the client, or the therapeutic relationship

Rationale for Immediacy

•Understand more about how clients come across in relationships

•Helping relationship provides a microcosm of how clients relate with others in the outside world

Getting “Hooked”

•When helpers become aware of feeling hooked, they can begin to understand how other people react to the clients in interpersonal relationships

•Helpers can behave in a different, more therapeutic manner

•Clients can have a corrective relational experience

Markers of Readiness

a.Client seems distraught, particularly quiet, unusually talkative, more vague than usual, or acting hostile or too friendly

b.Client mentions references to other people that might be a reference to you

c.Client might directly confront you

Types of Immediacy

1. Open Questions/Probes about the Relationship

2.Helper’s Statement of Reactions to Client

3.Making the Covert Overt

4.Drawing Parallels with Outside Relationships

Open Questions/Probes about the Relationship

•Helper invites the client to share feelings about the therapeutic relationship

•“I wonder what reactions you had to the session today?”

•Please, tell me more about how you feel about our sessions.

Helper’s Reaction to the Client

•Helper expresses feelings and reactions in the moment and generally follows these up with an inquiry about how the client feels

Making the Covert Overt

•Often the client is saying something to the helper indirectly, and through this intervention, the helper attempts to make the client’s intention more open

Drawing parallels with outside relationships

•When clients talk about things that bother them about other people, they may be covertly referring to things that bother them about the helper

•Helper wonders aloud whether the client has reactions to the helper that are similar to those the client has to others

Guidelines for using Immediacy

•Use “I” statements and acknowledge your contribution

•Relatively easy way to use immediacy is to open and close sessions with it:

•“How are we doing today?”

•“How was this session for you today?”

Difficulties using Immediacy

•Fear about intruding and making clients angry

•Not trusting feelings (e.g., “If I were a better helper, I wouldn’t feel bored.”)

•Not familiar with using immediacy in other relationships

Interpretive Skills

a therapist's ability to go beyond what a client says to reveal deeper patterns, conflicts, and unconscious motivations by explaining or interpreting their feelings, behaviors, and dreams. 

Open questions/probes for Insight

•Invite clients to think about deeper meanings for thoughts, feelings, or behaviors

•Ideal for the first step into the interpretive process

Examples of Open Questions for Insight 

What are your thoughts about why you have trouble maintaining friendships with women?

I wonder what you think about that? That each time you hit six months in a relationship you back away?

How to format questions for Insight

•“What do you think might be going on…?”

•What do you think might be going on when you get the urge to steal something?

•“What is your understanding of…?”

•What is your understanding of your lack of interest in friendships?

Interpretations

Goes beyond what client has overtly stated or recognized and presents a new meaning, reason, or explanations for behaviors, thoughts, or feelings so clients can see the problems in a new way. 

Types of Interpretations

•Making connections between seemingly isolated statements or events

•“Could your anger at your husband right now be connected to your grief over your motherʼs death?”

•Pointing out themes or patterns in a client’s behaviors, thoughts, or feelings

Types of Interpretations continued

•Explicating defenses, resistance, or transference 

•Offering a new framework or explanation to understand behaviors, thoughts, feelings, or problems

Psychoanalytic view of Interpretations

Interpretations are the “pure gold” of therapy

They replace unconscious processes with conscious ones

Early childhood serves as template and is often focus of interpretations

Interpreting the transference

Data for developing interpretations-Verbal Content

Making connections in the content of what clients talk about

People often compartmentalize

Listen carefully to reveal connections between relevant things that clients have not yet put together

Data for developing interpretations-Past Experiences

•Think about how a client’s behaviors are influenced by interactions in the past with significant others

•When the client’s responses to the helper seem distorted because of experiences with others in the past or present, helpers have material for making a transference interpretation

•Be careful about using transference interpretations though**

Data for developing interpretations-Interpersonal Patterns

•Look at the client’s typical style of interacting and conceptualize what the client is trying to accomplish in these interactions (if people pleasing, why? if closed off, why?)

Data for developing interpretations-Defenses

•Work with client to understand the role that defenses play

•Help clients realize why they started using defenses and then make choices about the need to continue using them

Data for developing interpretations-Developmental Stages

•Life stage events are interpreted within the context of the client’s culture

•Are clients on or off course for mastering the developmental tasks that are important for them in their cultural context (e.g., separating from parents, completing school, developing a satisfying career)?

•Developmental stages are culture-bound

•When are they expected to move out?

•When are they expected to get married?

Data for developing interpretations-Existential and Spiritual themes

•Help clients understand themselves in terms of existential concerns (death anxiety, freedom, isolation, meaning in life)

•Clients often give clues about existential concerns if helpers just pay attention (Yalom, 1980)

•Consider culture, and especially one’s religious beliefs

Data for developing interpretations-The unconscious

•Dreams, fantasies, and slips of the tongue

•For example, using a parent’s name when talking about a mentor or having a dream about a rival.

Accuracy of Interpretations

•Accuracy is important for psychoanalytic theorists, but it isn’t everything

Whether clients agree or disagree with an interpretation is not a good indication of its accuracy; rather, the criterion should be whether clients subsequently bring up material that indicates they have gained insight into the problem

How to interpret

•Work collaboratively to construct interpretations

•Check in!

•Does that resonate with you? What’s your take on that?

•View initial interpretation as a working hypothesis

•Be non-defensive

•Observe client reactions

•Phrasing: direct statements, more tentative, or a question

Should be just slightly beyond client’s awareness (not too obvious or abstract)

Difficulties with interpretations

•Feels intrusive

•Fear of them being wrong or premature, upsetting clients, and/or harming the therapeutic relationship

•Inability to put all the pieces together to formulate interpretations

Disclosure of Insight