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VII Processes
01. Engagement
a. Establishing a trust relationship
b. Establishing safety
c. Assessment of strengths and weaknesses
d. Formulating a behavioral conceptualization, and
e. Eliciting from the client the formulation of a vision and a plan for change
f. Emphasis to educate client about his/her own responses and the rationale behind the intervention strategies
g. Emphasis on interactive nature of the relationship
h. Establish helper as an expert in cognitive & behavioral principles, and the after effects of trauma
i. But, also establish client as an expert on his/her own fears, experiences and history
02. Assessment (the primary goal of initial assessment is to determine the factors that contribute to problems in living so that interventions can be planned)
a. Comprehensive multimodal assessment specifically including a functional cognitive behavior assessment [FCBA] that gathers data from all relevant stakeholders including the client
1) Concepts that must be considered include:
a) A view of child disorders as family and social system responses: A number of factors have been shown to relate to child competency. To iterate a few: maternal mental health, maternal anxiety, parental perspectives, maternal inactive behavior, maternal education, occupation of head of household, minority group status, family social support, family size and stressful life events [Sameroff, et al, 1987]. Additional, child management issues such as unstructured and laissez faire, authoritative, or autocratic processes likewise affect the child’s thoughts, feelings and behavior. Such child management practices occur elsewhere than the family, most clearly in the school.
Understanding the cognitive processes of both the child and significant others is essential to understanding and intervening with childhood disorders. In examining the link between family experience and children’s social competence, the strongest predictors of social competence were mothers’ biased expectations [attributions of hostile intent]. Pettit, et al [1988], suggested a developmental path running from maternal attitudes, values and expectation, to child social cognition to child social competence with peers.
Since the criteria for judging abnormality in children are to a large extent social in nature, what constitutes a problem and the likelihood of referral, will depend greatly upon the norms and expectations of key individuals in the child’s environment.
b) Exploration of the initiation, maintenance and locus of distorted [e.g., faulty thought patterns include distortions is both cognitive content (erroneous beliefs) and cognitive processes (irrational thinking) and faulty problem solving]. or deficient [e.g., the occasion of diminished competence includes the lack of a behavior repertoire which is adequate to expectation and may require skill training.] cognitive and behavioral factors.
c) The development of prescriptive competence training for all areas of systemic input
A broad conceptualization of how such dysfunctions develop is needed in order to gather and organize information for assessment and intervention. From a cognitive behavioral system perspective, childhood disorders are viewed as representing exaggerations, insufficiencies, handicapping combinations, inappropriate behaviors, or developmentally atypical expression of behavior that are common to all children at certain ages. For the most part, dysfunction is a matter of quantitative rather than qualitative variation in the expression of behavior and the principles underlying the development and modification of normal and abnormal behaviors are presumed to be the same [Mash, 1989]. This perspective also recognizes the importance of the reciprocal influences that occur both within and between individuals [Bandura, 1986].
d) The development and/or enhancement of natural supports to carry out the prescriptive competence training. The transient nature of many types of psychological disturbances in relation to these techniques have never been carefully evaluated [Kazdin, 1988]
e) Outcome expectation must exceed those of a ‘dead man’. The ‘dead man’ test, first attributed to Ogden Lindsley, is a means of determining if outcome objectives are properly specified. That is, if a dead man could fulfill the criteria, that objective is inadequate. Thus any focus upon reduction or elimination of excess behavior would fail the dead man test, since a dead man does nothing.
f) Genetically determined constitutional factors provide the medium in which psychological principles operate to produce both adaptive and maladaptive behavior. Studies find that biological risk factors are nonspecific, placing a child at increased risk for all kinds of problems, including both externalizing and internalizing disorders as well as substance abuse. Implicit in such findings is the notion that experiential factors in the family may mediate the expression of the disorder and should therefore be targeted for intervention.
g) People are goal-seeking entities whose behavior reflects their goals. This perspective makes the following assumptions:
• Behavior is organized around the pursuit of goals, with goals being defined as objectives toward which a person strives to obtain or avoid;
• Goals influence ongoing thought and emotional reaction;
• Goals exist within a system of hierarchically organized superordinate and subordinate goals where functioning in one aspect of the system has ramifications for other parts of the system; and
• Goals are accessible to conscious awareness, although there is no requirement that the goal be represented in consciousness while the person is in active pursuit of it. Conflict between goals is believed to have a deleterious effect on the well being of the individual.
b. Social and occupational functioning, coincidental conditions and
c. Any potentially destructive thoughts & behaviors.
d. Client’s strengths as well as weaknesses
e. Establish initial hypotheses regarding the client’s identified problems
f. Specify a point of intervention
g. History taking
1) Life before the event
2) Description of event
3) Adjustment (efforts to cope) since
4) Clarification of client’s view of events during and following trauma
5) Establishes bond, trust, sense of safety, reduction in shame
h. Identification of current maintaining factors (that can be linked to interventions)
i. Utilize a host of monitoring and observational strategies including directly asking both the subject and the subjects personal support and social network through an Initial Inquiry process as well as identifying ‘leakage’ from ‘self talk’ (information about the situations, thoughts, feelings, and consequences that impact various target behaviors).
j. Others:
1) Formal behavioral observations (e.g., viewing a client interacting with a others),
2) Observation of the client’s behavior during sessions with the helper (an essential component of behavioral intervention),
3) Self-monitoring between sessions, and use of journals and ratings of subjective units of distress [SUDS] reported on a 100 point scale ranging from not at all distressing to extremely distressing; probabilities of catastrophe; degree of anxiety; etc.) to track level of distress across situations as well as within and across sessions.
k. Trauma-specific assessments (e.g., for the survivor of childhood sexual abuse ask not only about current feelings of powerlessness and low self-esteem related to early traumatic experiences. Ask about the current antecedents and consequences of the client’s unassertive behavior and feelings of powerlessness. So we might start by asking him/her to identify thoughts, feelings, sensations, and behaviors associated with her experience of interpersonal powerlessness.
l. Example of questions:
1) In what situations does this behavior occur?
2) What thoughts/feelings typically precede this behavior?
3) What consequences follow this behavior?
4) What does the client tell him/herself about this behavior?
5) What kinds of rules does this client seem to follow?
6) What underlying beliefs are evident?
03. A comprehensive assessment includes predicting unintended consequences
a. e.g., if substance abuse is conceptualized as negatively reinforced by the distress it alleviates, one can predict an increase in distress when substance use is curtailed.
b. Therefore, concurrent skills training in distress tolerance might be indicated.
04. Well Formed Outcome Statements – An outcome should satisfy the following conditions:
a. Stated in the positive. Most often a client’s outcome will have the form ‘I want to stop doing X’. But in order to change what is, you must replace it by something else. It’s important that this replacement behavior be a deliberate choice and not one simply made by default.
b. Appropriately specific and contextualized. Typically clients will say things that are vague. A client’s initial outcome may be: ‘I want to make decisions more easily’. If the clinician merely assumes that s/he knows what the client is talking about, a great deal of time may be wasted.’ The clinician needs to ask ‘What are some examples of times when you have trouble making decisions? And what happens when you try to make a decision? And what do you mean by the word ‘easily’?”
c. Verifiable (in sensory experience). The typical question is: ‘If this change actually does occur, how will you know it?’ Sometimes once the client is able to answer this question s/he will realize that s/he already knows how to make the change in him/herself.
d. Initiated and maintained by the subject. The purpose of changework is to bring about changes in the subject, not in the subject’s environment. An example of an outcome that is not well formed in this respect is ‘I want my mother to love me’.
e. Secondary gain taken care of. Often efforts to solve a problem are frustrated because if the client no longer had his/her problem, s/he would lose various side benefits the problem gives him/her. This is called secondary gain.
f. ‘Ecological’ – One should think of a person as being a system. A change that seems desirable in and of itself will have ramifications throughout that system, and perhaps also throughout the relationships and other systems the subject is a part of. It is essential for a clinician to check not only that the desired change be worthwhile, but that all its consequences be worthwhile. Any changework training needs to use a multitude of examples to make students sensitive to this important issue.
05. Assessment as an ongoing process
a. Continues in order to determine efficacy of intervention and
b. To evaluate the accuracy of the conceptualization.
06. The principles of hypothesis-testing [all human service intervention is considered to be experimental]
a. Apply in clinical work as well as in research;
b. Any theory needs to be refutable and
c. The good clinician will be willing to consider alternative hypotheses if his/her predictions are not borne out
d. Time cycle requirements need to be met or justified [outcome predicted to occur within certain time limits, which does not occur, needs justification or change.
e. ‘Change orders’ come from the client.
07. Assessment is Systematic: Assessment is of the child/other relationships and is as much an assessment of the functioning of others as of the child. Significant change can be developed by social learning interventions with people other than the child. The child is NOT THE PROBLEM. The child is responding to a problem which is real or perceived and may have need for improved responses by increasing his/her behavioral repertoire or changing distorted thinking, but may also need a change in the environmental context. This is an interactive process.
08. Psychoeducation
a. Purpose: helping a client understand responses that s/he has found puzzling, unreasonable, and frightening.
1) Often it is important to highlight the function of emotional responses, and how this function can be derailed through a variety of learning experiences.
2) The fight or flight function of anxiety not only provides an excellent, easily explained example, but it also helps highlight the multiple components of anxiety (cognitive, physiological, behavioral) that clients will be asked to monitor (described below).
3) The helper may use this example to illustrate how the three components may interact to maintain and escalate maladaptive anxious reactions.
4) Having clients imagine a frightening situation and notice the bodily changes [sensory awareness] that accompany this image, even though they are fully aware they are not currently in danger (e.g., heart rate increases, sweaty palms) provides a vivid example of how thoughts and perceptions influence bodily responses.
5) Provide information about posttraumatic stress disorder, as well as other common difficulties associated with traumatic exposure.
6) Normalizing a client’s experience can be extremely helpful.
7) Provide information about the behavioral conceptualization of these difficulties and
8) Provide a rationale for any proposed interventions.
9) The clinician offers his/her ideas regarding the function of various problematic behaviors, and communicates observations regarding the salient antecedent, organismic, and consequent variables relevant to target behaviors.
10) Hypotheses are presented regarding relevant historical factors in order to validate the client and decrease self-blame.
11) Client feedback is elicited and consensus is reached regarding case conceptualization.
09. Monitoring
a. Purpose: the monitoring of stimuli, responses [including thoughts and submodalities], and consequences relevant to the presenting problem.
b. Focus: reflects the cognitive behavioral emphasis of individual experience.
c. Rationale: Be able to explore the function of each response in each given situation and therefore derive appropriate interventions.
d. Continued monitoring allows for the assessment of the impact of a given intervention and information obtained through monitoring is used to reconceptualize and establish new interventions in the absence of significant behavioral change.
e. Functions:
1) Serves to increase a client’s awareness of his/her ways of thinking and responding.
2) Helps client detect early cues of a particular cycle (e.g., “When I start tapping my fingers, I know I am beginning to feel anxious”)
3) Helps client become aware that early detection of the urge to avoid will help the person stay in the feared situation until anxiety and distress subside.
4) Combined with education, this awareness may also help diminish a client’s feelings of being “irrational” or “crazy” by providing a context for understanding seemingly unreasonable responses.
5) Serves a crucial function in maintaining the client’s safety.
f. Methods of Monitoring
1) Some type of journal or daily record sheet (of anxiety, depression or other target response levels at several points in the day)
2) Record various details about emotion-eliciting situations (e.g., situational cues, thoughts, emotions, responses, outcomes).
3) Can be expanded to include identification of distorted thought patterns, alternative ways of viewing the situation, and other forms of coping responses.
4) In vivo monitoring: clinician can have the client imagine him/herself back in that situation and ask him/her to attend to a variety of somatic, situational, emotional, cognitive, and behavioral cues in order to fully recall the situation
g. Use of these data:
1) Time is spent reviewing monitoring sheets in-session and
2) Helping the client problem-solve difficulties that emerge in completing monitoring assignments.
3) Methods of monitoring should be altered in order to increase clients’ success in completing the task
4) In-session monitoring of subtle changes in the client’s affect and calling attention to those changes will help the client recognize a number of external and internal cues for various emotional responses.
5) Information can be used to develop anticipatory metaperceptions to help inoculate against future problems.
6) Any observation made by the clinician must be framed as a hypothesis. The client remains the expert.