Quiz 3 - Intro to Helping

Insight

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

new perspective, making connections, gaining understanding

• usually slow gradual process not a big revelation

why insight is necessary

create meaning to transcend suffering

create understanding for a sense of coherence

make better choices

two types of insight

Intellectual insight -objective explanation (how it happened)

Emotional insight - creates a sense of personal involvement and responsibility (how it make me feel(

Integrative insight - both intellectual and emotional insight together lead to action

Markers indicting readiness for insight

affective distress/pressure about problem

statements of:

• awareness of a problem

• a lack of understanding

• desire to understand

markers indicating lack of readiness for insight

telling a story in a nonreflective manner (venting)

asking for advice (not taking responsibility for decision making)

blaming others

Psychodynamic theory of personality: id, ego, superego

Id: pleasure, primitive urges

Ego: negotiation with outside world, development of sense of self

Superego: development of morals and ideals

Psychodynamic theory of personality:unconscious, preconscious, conscious

Unconscious: outside of conscious awareness

Preconscious: can be brought to conscious awareness with effort (dreams, fantasies)

Conscious: readily available to conscious awareness

Psychodynamic theory of personality: defenses

an unconscious method for dealing with anxiety

healthy in moderation/heavy use is problematic

takeaways from psychoanalytic theory that are part of insight stage

1. make unconscious conscious

2. people are shaped by their childhood relationships

attachment theory

• the behavioral & emotional responses that keep young children in close proximity to caregivers

• secure vs insecure attachment

• experiences of attachment become a template for relationships

attachment theory takeaway for insight stage

therapists can become a secure base for the client

existential theory

existential concerns cause anxiety which is combated by defenses

existential concerns: values, identity, purpose, legacy, isolation

how psychodynamic treatment is different from cognitive behavior therapy

• Affect & the expression of emotion are emphasized

• Attempts to avoid distressing thoughts & feelings are explored

• Therapists help clients identify recurring themes & patterns

• Emphasis on discussing past experiences

• Focus on interpersonal relationships

• Focus on the therapy relationship

• Focus on fantasy life

treatment from psychoanalytic/existential perspective

explore unconscious conflicts to help client make better decisions

make the unconscious conscious

awareness of defense mechanisms

transference

projecting onto the therapist characteristics that belong to other people (with whom one has unresolved issues)

analysis and interpretation of transference can facilitate understanding of client’s relationships with others

countertransference

feelings form the helper toward the client that originate in the unresolved issues of the helper

awareness of these can facilitate the therapeutic process (damaging when unrecognized)

how psychoanalytic theories relate to the 3 stage model (exploration, insight, action)

1. childhood experiences are formative (but experiences later in life can also be impactful)

2. increases insight/self-understanding can lay the foundation for action

setting expectations in the insight stage

can be useful to educate or get clients consent before shifting into insight

“it seems like ___ is the issue. Can i push you on this? Can we go deeper?”

Skills of insight stage

challenging to foster awareness

• challenging discrepancies, thoughts, responsibilities

• nonverbal behaviors, silence, humor, and questions

facilitating insight

• open questions/probes for insight

• interpretation

• self-disclosure of insight

Working with the therapeutic relationship

• immediacy

challenge (helping skill)

points out maladaptive thoughts, feelings, or behaviors (or ones that have become maladaptive)

insight vs awareness

awareness - becoming cognizant of certain behavior, feelings, or thoughts

insight - understanding why we behave, feel or think a certain way

awareness → insight

rationale for challenges

raise awareness (ambivalent feelings, defense mechanisms, deeper level of self)

• allows for more intentional decision making

markers that indicate a readiness for challenges//awareness

ambivalence, things done out of “shoulds”

contradictions/discrepancies

client or helper confusion

feelings of indecision/ being stuck

types of challenges

• challenges of discrepancies (including nonverbal behavior)

• humor

• silence

• challenging language/responsibility

• two chair work

challenges of discrepancies

presenting two things side by side to make the client aware of the contradiction between them

“I’m hearing _____ but I’m also hearing ____”

“One the one hand _____ on the other hand _____”

guidelines for challenging discrepancies

• sensitively presented: timing & tone (gently, supportively, tentatively)

• emotional check in after: reflection of feelings, open questions/probes how it felt to be challenged

• challenge is nonjudgemental from a place of empathy and curiosity

challenging nonverbal behavior

• nonverbal behavior that might reflect underlying feeling

• raise awareness of what their bodies are saying

“You are wringing your hands a lot right now, what might that mean?”

two chair work (challenges)

each chair represents one conflicting perspective

externalizes ambivalent feelings to gain insight

humor (challenge)

can help soften the challenge or see it in a different light (as long as the client feels helper laughing with them not at them)

silence (challenge)

can encourage client to take responsibility for what they want to say/rely on themselves to examine their thoughts

can be damaging if relationship not solid/ reason for silence unclear

challenging client to take responsibility by changing language

to be used gently and infrequently (and with awareness of systemic oppression)

collective “we” → “I”

“can’t” → “won’t”

'“shouldn’t” → “I choose to”

challenging with questions

encourages clients to reflect on what they are saying (arrive to insight on their own)

“help me understand how you got there?”

“really?”, “hhmm?”, “oh yeah?”

general guidelines for challenges

timing

• close proximity to client behavior with enough time for exploration

cultural considerations

• principle of dominance, culturally awareness w delivery/phrasing, and response

transference & projection

• be prepared for client to become hurt/angry or project

observing client reactions

• client might not show negative feelings after challenge → probe

• client might dismiss in which case we back off until we have more evidence/issue comes up again

difficulties in using challenges

• not challenging enough (out of fears)

• using challenges inappropriately, too often or too harshly

• cultural issues

• difficulty knowing how to respond when clients disagree or challenge helper in return

rationale for interpretive skills

• direct way of facilitating insight

• collaboratively constructing meaning

interpretive skills

open questions or probes for insight (prefered)

interpretations

disclosures of insight

open questions and probes for insight

• invites client to think about deeper meanings for thoughts, feelings and behaviors

• good first step/preference is for clients to make their own connections

guidelines for open questions/probes for insight

ask about aspects of the narrative that do not fit

gently and with curiosity

questions one at a time w time to respond

varied w other skills to avoid sounding repetitive

interpretations

offering your best hypothesis for meanings/explanations of behaviors, thoughts or feelings so help client gain insight

rationale for interpretations

a conceptual framework that explains a problem makes problem feel more manageable (sense of relief/security)

interpretations are culturally bound

interpretations - psychoanalytic theory

interpretations replace unconscious processes with conscious ones

early childhood serves as template and is often the focus

interpreting transference

interpretations - information-processing theory

• interpretations reveal discrepancies between therapist and client views

  • client accepts helper view, client changes helper view, client discredits helper

• if the client views the helper as expert, attractive, trustworthy clients are more likely to accept helper’s interpretations

interpretations - cognitive psychology

• schemas store all knowledge/behavior

• interpretations attempt to change the structure of schemas

• action or behavioral changes might be necessary to consolidate schematic changes

narrative therapy - interpretations

rewrite stories in a more productive way

exploration = clients tell their narrative

challenges = disrupt problematic narratives

interpretations = help clients rewrite their narratives and think about concerns in new way

data for interpretations

verbal content of client’s speech

• listen for compartmentalization and connections

past experiences

• how past interactions have influenced them//transference

defenses

• why and how they use them/ what their role is

developmental stages

• important developmental milestones (culture bound)

existential & spiritual issues

• client’s have existential concerns (culture/religion bound)

unconscious sources

• dreams, fantasies, slips of the tongue

types of interpretations

• making connections

• pointing out patterns

• explicating defenses, resistance or transference

• offering a new perspective to understand thoughts, feelings or problems

guidelines for interpreting

• work collaboratively to construct interpretations

• phrasing: direct statements, tentative or a question

• just slightly beyond clients awareness

• can be extended to a variety of situations

• interpretations is only a working hypothesis

• observe client reactions

accuracy of interpretations

whether client agrees or not is not a good indicator of accuracy → do they bring up new material that shows insight?

being accurate is secondary to going deeper and gaining insight

difficulties in using interpretations

helpers cultural background

fears about offering them (upsetting client, being wrong, harming relationship)

too many or bad timing

intrusive or too eager/aggressive

not making it collaborative

difficulty formulating // demonstrating how pieces go together

disclosures of insight

helper revals a self -understanding of their own personal experiences to facilitate client’s understanding of themselves

rationale for disclosing insight

can be less threatening than interpretations or challenges

modeling or normalizing effect

bridges the gap in cross-cultural dyads

can alter power balance or lead to more client participation

guidelines for disclosure of insight

• intentions are clear (focus on insight)

• short and focus back on client

• disclose only resolved experiences

difficulties in using disclosures of insight

• projecting feelings or reactions onto client

• using too many

• using disclosure for own benefit

immediacy

discussing feelings that pertain to the therapeutic relationship (both client and therapist) “in the moment” with the client

overlaps with other skills

metacommunication

communication about communication

immediacy is about the helper’s immediate relationship with the client

helper responds to client differently than they are used to → one of most powerful interventions

rationale for immediacy

client can gain greater awareness of how they come across in other relationships and learn better how to resolve interpersonal problems

establish monitor maintain and resolve any problems in therapeutic relationship

getting “hooked”

a helper experiences the impact of a client’s behavior in interpersonal interactions (pushed into a narrow range of responses)

helper aware of feeling “hooked” → helper understands how others react to client → helper can behave in a way that is different → client has a corrective emotional experience

markers of readiness for immediacy

Client markers

• client acting different than usual (quiet, talkative, hostile, too friendly)

• references other people that might be a reference of you

• directly confronts you

Helper marker

• intense or unusual feelings (angry, incompetent, prideful, brilliant, sexual attraction)

• afraid or avoidant of certain topics or avoiding certain helping skills

helper awareness and immediacy skills

• be able to allow their own feelings without judgement (supervision can help)

• be able to seperate own, outside feelings within the therapeutic relationship

types of immediacy

open questions/probes about the relationship

helper’s statement of reactions to client

making the covert overt

drawing parallels with outside relationships

open questions/probes about the relationship

helper invites client to share feelings about therapeutic relationship

• what would you like from me right now?

• I’m curious what reactions you had to the session today?

helper’s statement of reactions to client

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

• I’ve been feeling a little disconnected from you today. I wonder how you’re feeling?

• I feel moved by how you shared your feelings so deeply. How has it been for you?

making the covert overt

helper attempts to make client’s intentions more open/ process something that happened in the relationships or something said indirectly

• you keep looking at your watch, i wonder if you are eager to leave?

• you’re late again today. I wonder if anything is going on in terms of your feelings about being here?

drawing parallels with outside relationships

things that bother client about “other” people → helper wonders aloud if the client has reactions to the helper similar to those the client has to others

• you say no one understands you - I wonder if you might be feeling that I don’t understand you?

• you say you are withdrawing from your friends lately - i wonder if that’s happening in here with me too?

guidelines for immediacy

• become aware of client’s nonverbal cues about distress related to relationship → comment on it

• be aware of what is happening inside you → do not react defensively

• balance challenge of immediacy with being supportive/protective of client self-esteem

• use “I” statements and acknowledge your contribution

• suggest to client to gather feedback from others on their behavior

difficulties in using immediacy

fear about making client angry

not trusting own feelings

lack of familiarity with immediacy in other relationships

goals for case conceptualization in the insight stage

client - recognize patterns and speculate about how the client came to develop patterns

therapist - gaining insight helps therapist have compassion

guidelines for case conceptualization

observations

• new info about childhood, family, current relationships

therapeutic relationship

• looking for similarities between outside relationships and therapeutic relationship

conceptualization

• data gathered - sources of problems, patterns, defenses, transference etc.

treatment plan

treatment plan

helpers want client to..

• understand origins of their suffering, how and why they developed defenses (to help them survive), distortions of current relationships based on past relationships

• feel a sense of agency, depth of their emotions

• have a corrective emotional experience

steps of insight stage

1. set the stage

2. conceptualize the client

3. engage in a collaboration process to facilitate insight

4. return to exploration and follow up

5. ask the client for current understanding

step 1 - set the stage

empathy, reflections of feelings and exploration create foundation for insigh

good bond between helper and client, client feels safe

step 2 - conceptualize the client

• underlying dynamics of caused/maintains the problems

• observe for markers that indicate they are ready for insight, awareness, or immediacy

• use clinical intuition

step 3 - engage in a collaborative process to facilitate insight

• curious, gentle, tentative, empathic

• observe client reactions and make modification as needed (nonverbal behaviors)

step 4 - return to exploration and follow-up

• insights need to be worked thru → single challenges, interpretations or immediacy rarely trigger new & lasting insight immediately

• cycle of insight → exploration→ insight etc.

step 5 - ask the client for current understanding

helper & client can be on different pages (client understanding more important)

useful for helper to ask the client to state their current understanding of the problem

caveats about using insight skills

• therapeutic relationship must be solid

• evidence/base of knowledge about client

• collaborative process

• interventions offered gentle, tentative, empathetic

• exploration before and in between

• insights are working hypotheses

• interventions may need to be repeated in diff ways over long periods

difficulties in the insight stage

• prematurely moving to insight

• not all clients need or want insight

• not being supportive enough

• feeling responsible or impatient for developing insight

• fear of insight

• getting stuck on one theoretical perspective

• not adequately conceptualizing the client

• ruptures

• countertransference

• failing to attend to culture

strategies for overcoming difficulties in insight stage

need for self-reflection

practice

process therapeutic relationship

acknowledge your part in relationship

supervision