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Therapy Models That Work

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Atlas Concepts LLC_Fields of Knowledge Blog_Therapy ModelsDespite a therapists’ ability to categorize issues, disorders and presenting problems, it is largely agreeable that all clients are unique. There are a plethora of reasons why a therapist may seek to gain familiarity with a specific therapeutic approach. Sometimes that reason is based simply on the therapists’ effort to best serve a local service population.

Herein are a few examples of how various therapeutic models may be used in particular instances. If you find yourself working with clients whose presenting problems are similar to the issues described in the examples, it may be beneficial to take some time to learn a little more about the model presented in that example.

Several approaches to therapy are very broad-based and may be used in a variety of contexts. It is possible for a therapist to become comfortable in such an approach, most likely because it works. Yet it is critical to understand that it is your responsibility as a helping professional to continually educate and professionally develop yourself.

The most basic benefit of researching other approaches is to build your knowledge-base.

However, through new understandings you are actually afforded opportunities to increase your level of experience. This process enables you to become a better therapist…efficiency via competence. While you don’t necessarily need to change your “style”, a new tool or technique may come in handy. Perhaps, take a look at some of the “classics” for inspiration…

A husband and wife are unable to agree on how to discipline their two small children. The wife grew up in a family where there was violence and child abuse. The husband’s father had a very demanding job and his mother was socially engaged.

Due to the distinct family of origin issues described, Bowen Family Therapy may be a viable approach to assist this family.

Using Bowen therapy, both parents should be assessed to discern if they have a healthy level of differentiation. Because they are having difficulty disciplining their children (a process in which the children are likely involved), they may run the risk of perpetuating the lineage of negative multigenerational transmissions. The conflict between the parents in regard to disciplining the children can result in triangulation as well as cutoffs.

In addition, because there are two children involved, therapy may include dealing with sibling position; in the event that this concept is budding while the children are “small” it would be prudent to address the issue in a timely manner.

Having the parents construct a genogram of their respective family of origin may prove helpful in a reasonably short amount of time. Through assisting these clients in dealing with unresolved issues, I believe that they would also find the disciplining of their children more agreeable and, in effect, they would be empowered to control their family’s multigenerational patterns.

An 8-year old girl has been wetting her bed for the last four weeks. Her parents began to argue frequently several months ago concerning the family budget. They are both frustrated by the bed wetting and desire an immediate solution.

Behavioral Family Therapy has its origin in parent’s modification of children’s actions. Not only does it appear at a glance that the parent’s discourse is responsible for the child’s bed wetting, but it seems that they have a problem with it as well. The parents need to know that they harness the ability to foster an environment for change, and, through training and empowering the parents, the therapist can allow the parents to take credit for working together to resolve the bed wetting issue.

By simply defining the problem behavior and then explaining the behavioral patterns to the parents, both the therapist and parents can monitor that behavior and as well monitor the child’s bed wetting habit as a means of marking progress.

It is foremost irrational that the parents believe that their child’s behavior can stop immediately; however, when concentrating on the dyadic parent relationship they will find that the family in its entirety will benefit.

A 12-year-old boy began displaying temper tantrums around the time his divorced mother announced she was going to remarry. She and her new husband are having a difficult time dealing with the situation.

One may lean upon the experiences of Minuchin (Structural Therapy) to assist the family in this scenario. By observing the patterns in this family, the therapist would hope to gain knowledge of the family’s structure. As well, it may be important to determine what may be different about the family structure once the mother remarried.

It is apparent that the divorce and second marriage were stressful times for the child. The child’s outcry could be in part due to the demolition of a coalition with his father. Though the family underwent a marital (or legal) restructuring, it may be necessary to restructure the “living” system in an effort to make the family stronger.

It may be plausible to address any incumbent boundaries caused by the marital shift. Due to the new “executive” system that is in place, it is necessary to evaluate the cohesion of that system and examine any residual effects. Additionally, this parental union may have to be alerted of the signs of triangulation as well as the methods for its avoidance.

The structural approach involves the technique of reframing, which can also be useful in assisting the child with coping with his “fits”. In short, there is a basic need for this family to redefine its boundaries to deal with the relevant stage of development. If appropriately applied, the Structural Approach may prove to be of assistance to this family.

A 34-year old female physician began getting anxious in elevators about 7 months ago. She became progressively more anxious in a variety of situations. Now she cannot cross bridges or go out to crowded places.

Cognitive-Behavioral Therapy, having roots in the social learning theory, would be a solid approach to this scenario. Cognitive restructuring may be a beneficial technique to accomplish modifying the client’s behaviors.

It is plausible that the client is dealing with issues regarding her beliefs and reasoning in a fashion that has affected her behavior. Through desensitization the client may be able to overcome the unnecessary anxiety that is associated with the situations described in the vignette.

By enhancing the client’s problem-solving and behavior-change skills she may be empowered to overcome her anxiety through a self-renown confidence. Additionally, a specific technique such as shaping could be employed, as it appears that the client has reached an extreme level of anxiety. It may require the client to take gradual steps towards such goals as crossing bridges and going into crowded places before she can achieve these feats.

A 43-year old male, recently unhappy with his career, sees himself as a failure and has begun to isolate himself because of a lack of confidence.

In dealing with this man’s career issue, one may employ the Strategic approach. In the vignette there is a clear problem that needs to be resolved or removed. It is beneficial to begin by defining the problem and then moving towards evaluating what the client has done to fix the issue.

By defining the necessary change and implementing a strategy for achieving that change, the client could be propelled to a more virtuous cycle. Additionally, the client could benefit from the reframing techniques practiced in Strategic Therapy.

By emphasizing positives and assisting the client through encouragement and direction, he may also begin to see his career in a different light. It seems the issue is rooted in his malcontent with his employment. In this instance I believe the lack of confidence may be a residual effect of his job situation. However, through combating his isolation through actions, he may be able to perpetuate his own confidence and gain a new awareness of his ability to acquire a job that may be more conducive to his happiness.

Another way the Strategic Approach may prove helpful is by utilizing the ordeals technique; in this instance the client may discard his isolated ways as he realizes that this behavior is not constructive.

A 24-year old male who is high functioning with no obvious diagnosis is confused about his goals in life.

Due to the over-functioning nature of the male depicted in the vignette, I believe that Experiential Therapy may be of most benefit, especially considering that there is no “obvious diagnosis”.

The Experiential approach is helpful because it relies on the personality of the therapist more so than that of the client. In this case, there is not much known about the client thus, the Experiential approach allows for the therapist to guide the therapeutic environment in an effort to learn more about the client. One manner in which the therapist can begin to assess the client is by evaluating the client’s level of individuality. An Experiential therapist can achieve this by fostering a warm climate in which the client feels respected and accepted.

As well, it is important for the client and therapist to work towards determining the nature of the client’s confusion (i.e. what about his life goals is confusing). The therapist has the ability to help the client see his confusion as meaningful. The client should be led to understand that it is productive to have goals and that his confusion pertaining them may only be a result of his personal growth.

By utilizing alternatives to reality, the therapist can allow the client to assess whether or not his goals are feasible, thus eliminating goals that are too vague or nested in improper judgments. The more excitement the therapist shows for the client’s progress, the greater stimulation the client is likely to experience, in turn providing the client opportunity for personal existential encounters.

While I may not be able to teach you more than you already know about these approaches, my effort is simply to remind you of the validity and importance thereof. If graduate school is the last time you encountered one of these models, consider this written for you.

Atlas Concepts, LLC_Jordache WilliamsJordache Williams is currently based in Rock Hill, SC and is the Program Manager for Atlas Concepts, LLC. He is a Certified Life Coach and holds a Master’s Degree in Human Services.

Case Notes: Task or Tool?

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Fields of Knowledge_Case Notes

If you have been providing therapy to clients with any longevity you have at some point questioned whether your approach to a given case was the culprit responsible for therapeutic stagnation. You may have chosen to switch your approach, integrate tenants of other models or refer the client(s) elsewhere.

You’re not alone in your desire to be the one who gets to witness a client’s transformation. However, most therapists understand that there is inevitably a time where they are not adequately equipped to handle a specific case. Unless there is an ethical dilemma with a particular client, therapists should (using good judgment) accept the clients that arrive for help.

I believe this because the person seeking help is present and in action. Any time a client leaves there is no guarantee that they will be back. Likewise, once a client is turned-away there is no guarantee they will contribute a similar effort again.

With this said, it is incumbent upon therapists to be equipped to supply the demand. At the least, the consultation process should include active listening, empathy and the sharing of hope and optimism. Whether the next step is session number two or a referral, therapists should feel that they have done everything possible to leave the client with a realistic impression of the therapeutic process.

Sometimes it’s further along than the initial consultation when therapists come to the realization that they are in over their head. Before throwing in the towel, therapists may seek guidance and advice from colleagues, mentors and other helping professionals.

Therapists can often learn a great deal from understanding how their colleagues’ approaches differ from their own. Even when colleagues share that their approach would have been the same, they may still be able to provide suggestions for your consideration.

I suggest that this dialogue, which is essentially a version of professional development, involve evaluating the effectiveness of your approach to tell the client’s story. In essence, this is a method for understanding how your therapeutic approach depicts your client(s). If your approach does not tell the client’s story, perhaps you can make a special effort to address the gaps in future sessions.

With the permission of your client(s), have a colleague review a version of your case notes, which outlines what approach and tools you have used and the effects that you hoped to, have gained. Have your colleague explain (back brief) the family’s situation as they see it as described by your notes, almost as if they were introducing you to the client(s) or transferring the case to you.

The picture they paint of the family may give you insights on the validity of the therapeutic model and techniques you have employed. Here are two examples using differing therapeutic approaches addressing a single vignette. Do the respective approaches to therapy tell the same story about the family? As we all know, there is rarely a single approach that can be considered “best”. However, you are always making the right decision when you approach a given case ethically, efficiently and effectively.

So while the model of therapy you have chosen to work with may not be wrong, you may be employing it ineffectively and thus having little effect assisting the client with positive change. These types of reviews assist clinicians with evaluating the effectiveness of their approach, and can be accomplished with a colleague or alone.

Example Case Notes – A

By implementing a structural approach, I understood that the relationship hierarchy needed to adjust significantly before the family’s optimal functionality could be attained. As a combined result of Jack devoting so much of his time at work, and Jill being the parent who has been more consistently present, of course Johnny would develop a more closely emotional relationship with his mother. However, this relationship is magnified because Jill has spousified Johnny in order for her to fill the emotional vacancy caused by Jack’s frequent absence, so obviously a large portion of Johnny’s anxiety results from his mother’s “need” for him to be present for her own functionality in the family. Also, a possibility for John’s extended absence could be the result of the fact that, with all of the children now away at school, he is experiencing his own anxiety as this will be the first time in twenty four years that he and Jill have been the sole members of the household.

The primary objective has been to eliminate Johnny’s panic attacks regarding his beginning college by minimizing his anxiety about being separated from the home. With the ideal situation being that the foundation is established for all relationships in this system to progress toward a healthy functionality. To accomplish this, a restructuring of the family is necessary. The relationship between Jack and Jill must become more developed. Jill must allow Jack to fill his spousal role—the role that she has encouraged Johnny to occupy. This will be done by basically reacquainting Jack and Jill, as well as reestablishing what their needs and goals are in their marital relationship, not simply their roles as parents. Boundaries should then be determined in order to stabilize each newly restructured role. An aspect of this technique that would be beneficial to use regarding Johnny’s anxiety would be to strengthen his relationships with his siblings. Since both Sue and Carl have years of experience away from home and in a college environment, their guidance would be tremendously helpful for Johnny’s elimination of his separation anxiety.

Example Case Notes – B

I have chosen to utilize Psychodynamic/Family of Origin therapy with this particular family. In the most basic triangle of this family, Johnny and Jill are the closest relationship with Jack as the outsider. By having knowledge of Jill’s position in her family of origin, it is understood that her own emotional over-involvement with Johnny has resulted from her attachment to her own mother, whom she could never obtain an ideal relationship with as she was consistently vying for her mother’s attention against her step-father and other siblings, so she is now severely attached to Johnny—the most constant figure in the home. Jack’s position in his family of origin placed him as a likely caregiver and source of support for his younger siblings, so he most likely feels a strong sense of responsibility to provide adequately for his nuclear family. Thus, he allows himself to spend an increasing amount of time involved with work.

The overall goal would be to establish positive functionality for this system by developing each member’s differentiation of self, and adjusting the emotional triangles. The initial technique to implement would be to sketch a comprehensive genogram in order for each member to understand the origins of the system’s emotionality. This would allow Johnny, Sue, and Carl to objectively view Jill and Jack’s familial positions and relationships with their respective families of origin, and provide them with a new understanding behind their current system’s functionality. Jack, Jill, and Johnny will all need treatment to improve their levels of differentiation in order to prevent their emotional dependencies from creating a multigenerational pattern. I plan to have Jack, Jill, and Johnny voice what their wishes are for their relationships and then be confronted with aspects of their situation which they may be oblivious. I believe that this will be an effective technique for this family as it seems apparent that they may not currently acknowledge to themselves what their needs are in each of the relationships.

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You can see how, despite the use of varying approaches to working with this family, that items such as the family dynamics are synonymous in each. Adversely, the priorities, techniques and goals differ and in such light, differing details regarding the family are presented in each set of notes. These types of notes give enough detail to your colleague to enable them to relay back to you “how they see the clients,” and may spur a discussion involving “what I would try is….”

At any course, your colleague is immediately able to pick up on your therapeutic hypothesis and the techniques you have, or plan to employ, as well as the family dynamics, presenting problems, and direction of therapy.

It is through the dialogue that follows where you may learn from the assumptions about the family that your colleague makes based on your notes. Likewise, you may find that their concerns for the client(s) may not align with your own. Perhaps your colleague has questions for you regarding the client(s) of which you don’t have answers.

You may also be enlightened to the fact that your colleague or mentor would prioritize the goals of therapy different than you and the client(s) have. In addition to being used as a tool to garner support from other professionals, these types of notes are a great way to provide yourself with a summation of your and your client’s work.

Atlas Concepts, LLC_Jordache WilliamsJordache Williams is currently based in Rock Hill, SC and is the Program Manager for Atlas Concepts, LLC. He is a Certified Life Coach and holds a Master’s Degree in Human Services.

Locating an Internship Site

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Fields of Knowledge_Locating an Internship Site

For graduate students who are required to display competency through a clinical experience, you will inevitably undergo an integration process at a site which will facilitate this chapter of your educational journey. If your academic institution has partnered or is contracted with a site (or multiple sites) guaranteed to facilitate your clinical experience, then consider yourself fortunate.

For many graduate students it is not that simple. In some cases, those institutions which do provide sites for students actually require that the student work with the site(s) provisioned. Not one scenario is necessarily better than the other, as all offer advantages as well as disadvantages.

So, if you are a student who has been provided a list of potential sites, been left to figure things out on your own, or are seeking a secondary site to supplement the experience of a site predestined by your school, here are a few thoughts from my experiences.

Review potential sites. If your advisor or other faculty present you with a list of potential sites, it’s probably a great place to start. At some point in time you’ll probably try an internet search engine or attempt to “show up” at a place you’ve heard about.

In this age, technology tends to seemingly ease the burden of learning about potential places to intern; however, the information provided by a computer or smart device is not always inclusive. So after you have tried 50-60 keywords in Google, a few hundred pages of opportunities on websites such as Monster.com, signed up for newsletters, participated in forums, reached out to groups on social media such as LinkedIn and prayed to the internet god for mercy…understand that you will at some point have to remove yourself physically from the comfort of your favorite chair and the soulful sounds of Kenny G.

My academic institution estimates that it takes 66% of its students 3-4 months to locate a suitable site and a willing supervisor, with the remainder having to search for over 6 months. With this said, understand that the effort may take time, so plan to be thorough and deliberate in your search.

Keep a sharp lookout for supervisor candidates. A great choice for a supervisor is a supervisor candidate. These individuals include those who are pursuing the Approved Supervisor designation with an organization such as the AAMFT. They are licensed professionals who are seeking opportunities to train, educate and, in essence, supervise individuals working towards a graduate degree or licensure.

The AAMFT provides a list of Approved Supervisors on its website; however, it is not as easy to locate candidates working towards fulfilling the requirements necessary for approval. Oftentimes by contacting Approved Supervisors you can accomplish a great deal.

You can inquire about opportunities to work with that individual in particular (who is “on paper” the quintessential supervisor), ask about opportunities they are aware of in surrounding communities and also ask them specifically if they are working with any supervisor candidates or are aware of any such candidates who may be of assistance.

Organize your effort. Make a list of potential sites, keep track of the “who, how and when” concerning your contact with each potential site. Keep records of individuals you have networked with including their contact information, how they may be able to assist you, where they work and/or volunteer and any leads they may have referred you to.

Additionally, look for ways to ensure that you stay relevant to individuals in key positions. This may be done by attending programs in which the individual is involved, joining them in volunteer experiences or stopping by to ask if there is anything you can do for them.

Prepare yourself. Yes, you are a student and you are locating a site to assist you with an educational experience, but I can almost guarantee that during the course of your search for a site and supervisor you will be asked questions pertaining to your personal interests and objectives, the models and theories which you plan to utilize with clients, any professional association affiliation and your level of participation with each, as well as inquisition pertaining to your level of experience. Yes, the last one got me too.

The first time I was faced with explaining my experience, I thought…“I’m a student, what experience do you think I have?” Preparing for such questions is critical to your ability to garner the support you need, and at the least can leave a good impression. You can always mention the experiences you have had during your academic coursework with classmates in mock sessions. Additionally, having experience in a counseling setting (even administratively), having personally attended counseling or having held a position (at a job, within an organization, etc.) which included coaching, teaching or mentoring are all great ways to build your credentials.

Liability insurance. From the moment an individual is identified as your supervisor, and throughout the course of that relationship, that individual is ethically and legally responsible for you. Though it is likely required by your academic institution, plan to, at a minimum, obtain liability insurance and keep it current throughout your internship.

One way to accomplish this is to join an association such as the American Association of Marriage and Family Therapy (AAMFT). The AAMFT offers malpractice insurance as a part of the benefits of student membership. Already being insured during the pursuit of your site and supervisor speaks to your level of commitment and proficiency, as well as your knowledge of the field.

Bring something to the table. Understand what you offer in addition to being able to articulate what you need. The sites you visit may not have opportunities posted for an internship or currently have a program specifically for interns. If this is the case, attempt to locate job postings at the organization to understand the type of information (e.g. curriculum vitae versus resume, background checks, etc.) that is required of potential employees. Think about it like this…if you qualify for a job (say minus the graduate degree) then you are in pretty good shape to be a candidate for an internship. Nearly any and everything you would do for a job…do for an internship. That includes over- versus under-dressing, updating your resume, brushing up on your interview skills and mustering up that necessary confidence needed to talk about yourself.

In the pursuit of an internship, oftentimes it’s those who can give that get. As I stated earlier, some potential sites may not have a program in place for interns, and may even find that entertaining such would be more burdensome than beneficial. Through careful consideration of the site, you may be able to present yourself as an individual who can provide a relevant impact to the site. This impact may be through providing support for programs that the site currently sponsors.

You can present ideas for programs that you could organize and maintain, or volunteer to help out administratively. You may even offer to dedicate yourself to establishing an internship program at the site, by charting your experience and through research and evaluation of other programs. You first have to understand your own potential, personal/professional interests, desires and qualifications.

Next, find ways you can be of benefit to the potential site and/or supervisor and articulate these ideas concisely. You must understand that when you approach a clinical internship your presence is not associated with benefits such as free or cheap labor. You are a legal and ethical liability, an administrative burden and ultimately take time away from an individual who is likely otherwise paid for it. Yet and still, they have been in your shoes, so stick your chest out, hold your chin up, shake with a firm grip and present your essence.

Staying afloat. Lastly, have a plan that includes a sustainable income during both your pursuit of a site and your tenure at the site. The reality is that paid internships are not always available, couple that with the fact that your academic clinical experience likely lasts for a year (or more) and the understanding that locating a site may take a significant amount of time as well.

If you are already living on a strict budget, then the worst-case scenario includes having to pay for supervision. In some areas, this may be your only option. In any case, you must evaluate your living situation, means of income and your costs of living and plan ahead. The commitment you are about to embark on will likely change a great deal of your daily routine, absorb a significant amount of your energy and time. Prepare yourself, employers and loved ones and ensure you rally the necessary support from each.

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As mentioned earlier, each journey towards graduation in a helping profession is unique to the individual student, however each academic institution approaches facilitating education and evaluating competency in a specific manner. In this light, my particular experience with locating an internship site has been highly influenced by two facts: I attend an online academic institution which is located approximately 400 miles away and I am a relatively new resident of the area which I am seeking support. Notice that I refer to these two circumstances as “facts,” not disadvantages or excuses.

It is my personal belief that I learn through each of my experiences every day. The experiences I have had during my efforts to locate a site are no different. I have been granted an opportunity to question the very core of my pursuit, asking questions such as, “Why did I choose to pursue a career as a therapist?” and “Is this still really what I want to do?” These questions are warranted, as I actually began pursuit of my M.A. in MFT in the spring of 2007.

So here I am 7 years later, now with a wife, now with a daughter, now out of the Army, now a business owner, now a certified Life Coach, now having been awarded a Human Services graduate degree, still working towards the same goal. Perhaps I made compromises that have elongated this process; there is hardly a time when a person “could have done no more.” Yet and still, the desire exists and a certain priority remains incumbent to the same. In closing, I would like to encourage you to continue your effort at a steadfast and deliberate pace, while continuing to grow through the experience and achieve in other endeavors as well. No matter your course, be holistically prepared for the journey and understand that not all “helping professionals” are interested nor capable of helping you! Moreoverly, none can help you more than you can help yourself!!!

Atlas Concepts, LLC_Jordache WilliamsJordache Williams is currently based in Rock Hill, SC and is the Program Manager for Atlas Concepts, LLC. He is a Certified Life Coach and holds a Master’s Degree in Human Services.