Tag Archives: therapy

Alcoholism: Disease or Behavior

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Criterion A.2. of Alcohol Use Disorder, as presented in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is the foundation for my conceptualization of alcoholism as either a disease or a behavior.  Obviously a person who meets the criteria for a mental disorder warrants a diagnosis of a mental disorder, right?  Isn’t the DSM gospel?  Okay, so cynicism aside, the criterion of which I am referring is as follows: “There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.”  In short, if a person is behaving in a manner that they do not wish to behave, and they have put forth significant honest efforts to stop that behavior (or emotion, etc.) then they need help.  If help is most effective by way of mental health intervention, then I believe that the mechanisms should be in place for that assistance to be received (thus a diagnosis be present within the DSM).

It is in the assessment of the criterion of reference where the distinction is made between people who are engaging in an irresponsible manner versus a person who is “ill”.  I would almost go as far as to say that the criterion should be listed separately from the others and be required in addition to “at least two of the others.”  The reality is that due to its subjectability, the criterion is not a foolproof method for determining “disease.”  What a person says they have done to stop, cut down or control alcohol is unfortunately not always factual in nature.  This in itself creates a conflict with therapeutic approaches that the clinician accepts the client’s reality (regardless of truth), similar to the process of dealing with victims of violence or abuse.

Gaining an understanding of the hopelessness a client feels is often a prerequisite for intervention (which sometimes proves therapeutic in itself); however, validation of the hopelessness should not be required of a clinician.  With this thought process in mind, which is often best, clinicians commit due diligence to understanding the problem as the client sees it, and make some efforts to validate the claims the client makes with regard to their unsuccessful efforts to control their alcohol use.

During this validation process it is useful to understand the means by which the client has presented themselves to therapy.  Was it court-ordered, were they pressured or did they come on their own accord?  The reason for a client sitting in your office is oftentimes a predictor of the level of expected success, though asking the client directly may be illuminating as well.

With the work of Michele Weiner-Davis in mind, a therapist should also search for evidence of pretreatment change.  These are all factors that are associated with determining the “classification” of alcoholism and more importantly the need for intervention.  Regardless of how it’s classified, as a clinician, with a client sitting in front of you, you have an obligation.

Consideration of the factors mentioned above may also serve as a guide to a therapist evaluating which approach to intervention may best suit a particular client.  Due to my affinity for Marriage and Family Therapy, I would be remiss if I didn’t mention an assessment of the effects of the alcohol use, regarding the family (if present), should also be a factor in determining the goals of therapy.

Jordache Williams

 

Jordache 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.

 

Counseling with Cultural Competence

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Cultural competence is, without a doubt, required of clinicians who provide therapy to culturally diverse clients.  The acquisition of both knowledge and skills, but moreover, the ability to deal with powerful emotional reactivity and unconscious biases associated with race are incumbent (Sue, 2010).  When counseling clients who are culturally different, the competent therapist must be aware of the possibility of being uncertain regarding therapeutic discussions of sensitive topics.  In order for a clinician to be culturally competent and provide effective therapeutic assistance, one must be knowledgeable of cultural needs, to include language, religion, food, racial identity, and customs (Allain, 2007).

Throughout your professional career a continual effort should be placed on seeking total cultural competence, especially concerning the cultures that will primarily comprise your clientele.  As I have not exactly nor assuredly settled into my foreseen client-base, for comparative purposes I will refer to Fairfield County, South Carolina in this composition, as this is the location of many of my relatives.  The demographics of this area (as interpreted from the United States Census Bureau) possess a different skew than the United States, as well as the state of South Carolina, in that African Americans at 59% of the population are the majority race, followed by Whites at 39%.  American Indian, Alaska Native, Asian and multiracial individuals comprise less than 2% collectively, while an estimated 1.5% of these individuals are of Hispanic origin.

In addition, the percentage of poverty in Fairfield County is 24%, whereas the United States average is near 15%.  While Fairfield County is diverse, it is so in its own right.  The dynamics of this population create cultural norms that are not necessarily reflected by the perception of American culture at large.  A therapist working in this area must understand the intricacies of the cultures, to include cultural beliefs and values based on race, poverty and the availability of resources.

Taking a look at Fairfield County’s majority.  When any helping professional provides counseling to an individual of African American culture, there are several factors one must keep in the forefront in order to reach successful therapeutic treatment.  The primary factor is that of cultural competence, as it would be when counseling a member of any culture.  However, the therapist’s cultural competence is vital to the treatment of African Americans as it is quite common for an individual from this cultural background to be misdiagnosed, and subsequently incorrectly counseled.  This is often the result of the impact their culture’s history, racism, and oppression have had on their individual personality, as well as to their entire group as a national minority.  Although the clinician, no matter their race, will be unable to dispel any opinions the African American individual may harbor regarding discrimination, it remains their responsibility to aid the individual in attaining cultural acceptance—within their cultural group, as well as all others—and ultimately establishing their autonomy.

Therapists should abide by an obligation to aid the client in constructing the framework leading to development of the client’s autonomy.  This is especially the case when counseling individuals in the African American culture, where it is vital for them to become self-aware and fully autonomous as this quality will allow them the capability of personally conquering the effects of discriminatory encounters and the spectrum of microagressions they are guaranteed to continue facing.  In order for a clinician to aid in the process of developing racial identity in persons of color, the therapist must guide them in establishing a passive acceptance of the self as inferior, and then facilitate the client to overcome internal racism and develop a self-affirming identity (Constantine, 2005).

When the minority is the majority, such as the case of African Americans in Fairfield County, the therapeutic approach and methodology to counsel these individuals cannot be based solely on their role as a United States minority group, but also their role as a regional majority.  The primary adjustment to therapeutic intervention regarding this cultural group involves understanding the effects of, and relationship between, the national and regional cultures through the eyes of the individual.

The national majority.  For a clinician to successfully treat members of the Caucasian American culture, they must again utilize their cultural competence when formulating the framework to develop the well-being of these individuals.  In regard to the general population of the United States, Caucasians are the majority culture group.  And in this light, the therapist’s objective would be to guide them in becoming more culturally aware, as well as to increase their own self-awareness.  This would allow them to gain understanding in their typecast role as “oppressor,” acknowledging their unearned assets that constitute White privilege, and adjust their viewpoint with the goal of eliminating any harbored microagressions.

The therapist should assist them in understanding that the source of their conscious or unconscious racism is a result of their culture’s attempt to earn societal prestige through the control and dominance of cultures dissimilar to theirs.  And, according to the Psychoanalytic approach, racism surfaces to serve as a defense mechanism of the ego and superego out of one’s fear of loneliness (Utsey, 2002).  For Whites, as well as other groups, the attribution of cultural differences to minorities is a hidden expression of racial prejudice (Vala, 2009).

The majority as a minority.  Often referred to as the majority, the Caucasian cultural group in many smaller communities represents the minority.  In these instances, therapeutic approaches need to adjust due to the fact that many of these individuals have difficulty dealing with the sense that they are seeking racial acceptance from the majority culture, while they are experiencing discrimination.  In many instances, one’s racial attitude is an attempt to manage an underlying anxiety associated with one’s intolerance of the dissimilar (Utsey, 2002).  A therapist in this situation may find members of the White culture to be anxiety-ridden due to their inability to control the majority culture—which will in fact be a national minority group.  Many of the areas where these inverted racial demographics exist are more likely to be impoverished.  With a poverty level higher than the United States national average, some of the predominant issues for Whites in these areas are the difficulties stemming from their socioeconomic status.  In these situations, it is likely that a great deal of Caucasian individuals are dealing with the denial of their Whiteness because of their shared socioeconomic status with African Americans and other national minority groups.

White privilege in these regions relies predominantly on one’s financial success; and because many Whites have not attained any substantial financial successes, it is more difficult to identify White privilege (Sue, 2010).  Also, when Whites are the minority group, they are likely to be self-conscious of appearing racist; for example, it is highly unlikely that one would exhibit overtly racist behaviors if they are one of only seven White children in a class of forty-five students.

The Hispanic population.  When functioning at a high level of cultural competence, a therapist treating an individual with a Hispanic cultural background understands the importance of being perceived as a knowledgeable and authoritative therapeutic professional.  Likewise, these individuals should be aware that Hispanics are a heterogeneous culture, in that it comprises Cuban, Mexican, Puerto Rican, and several more ethnic groups, each with their own cultural values.  Therapists must be knowledgeable of these various cultures, and that their primary similarity is that of sharing the same language; this makes effective intervention and treatment contingent upon understanding the dimensions of the specific client (Altarriba, 1994).  The culturally competent clinician is also cognizant of the importance of addressing familial issues with the father of the family system, as Latinos are a highly patriarchal culture.  In addition, the clinician should understand the significance of the structure of the entire extended family, as it is common for Hispanic households to include other family members, not solely the nuclear individuals.  This family environment also plays a large role in the socialization of the children (Altarriba, 1998).

The role of the therapist also includes being open to alternative approaches to therapy, such as prayer and incorporating priests, as often the role of religion has a significant impact on the Latino family.  It is also necessary for the culturally aware clinician to formulate the aspect of immigration into his or her therapeutic approach.  Even in cases where the family or individual currently seeking counseling may not have immigrated into the U.S., there is the possibility that they have family members residing in their native country which impacts their current emotions and viewpoints.  Furthermore, those who have immigrated have suffered through geographically separating themselves from many social or familial support systems which were previously established (Smart, 2001).

The therapist’s role, when working with Latinos, is also to aid with their assimilation with other cultures of the region, this includes the therapist and client being linguistically compatible.  In many instances, Hispanic immigrants deal with their own language barrier within their household, as the parents tend to prefer speaking Spanish in the home, and the children (especially if born in the U.S.) may primarily speak English.  The problem this presents to bilingual therapists is that the clinician tends to serve as merely the interpreter for both parties.  Another risk associated with the bilingual therapist is in the aspect of dialect—if the therapist’s predominant language is English and they had to learn the Spanish as a second language, they must be fluent in a manner that displays the same authority and competency while speaking in the client’s language (Sciarra, 1991).

Although Hispanics represent the largest minority group in the United States, there are communities where the Hispanic population is less representative such as in Fairfield County, SC where they comprise less than 1.7% of the population.  One objective for the therapist, when counseling a member of Hispanic culture, is to foster the client’s cultural awareness of their own cultural group as well increase their awareness of other minority and majority cultures.  In essence, the therapeutic approach should include efforts to establish their acculturation.  Hispanic individuals may need assistance from helping professionals simply because there is not a large preexisting population of Latinos where they reside, or in the surrounding areas.  The primary discriminatory encounters they experience will originate from their skin color, illegal immigration, and reliance on physical labor due to the persistent language barriers (Smart, 2001).  In areas where they are the overwhelming minority, the root of their cultural issues often resides in their constant search for acceptance and sense of belonging within the community, and among the other cultural groups.

Multiracial groups.  Aside from the African American, Caucasian, and Hispanic cultures, one must also consider multiracial groups, as they hold 1.7% of the United States population.  Individuals in this group tend to have their own issues, to include having several identities and not being one-dimensional (Allain, 2007).  When requiring therapeutic assistance, they tend to bring a complex set of issues.  The concept of culture will remain critical to therapists, as cultural roots are often maintained through parental socialization (Leong, 2010).  When working with multicultural groups, therapists can generally model their approach by assessing the client’s racial and cultural identity development and forming a therapeutic alliance by gauging the client’s sensitivity to verbal and nonverbal cues.  The therapist also formulates his methodology by assessing how the client identifies themselves collectively, individually, as well as how one’s family values affects the client (Delgado-Romero, 2001).

Often, in order for a therapist to develop a financially successful professional practice, it is essential to provide adequate therapy to both majority and minority cultures as well as cultures which differ from their own.  To progress in doing this, it is necessary to conduct research to develop knowledge in a systematic way (Arzubiaga, 2008).  In therapists’ attempts to obtain cultural competence, many run the risk of being superficial and counterproductive if they remain underdeveloped in the area of cultural sensitivity.  The implementation of cultural competence and sensitivity offer a more rigorous and reflective methodology and therapists must keep that in mind.  It is not necessary to become an expert on any particular culture, but rather to concentrate on being aware of one’s own perspective.  As therapists, the utilization of critical thinking is vital to understanding how one’s own perspective can affect their ability to acknowledge and understand differing perspectives (Allain, 2007).  Finally, be aware that culture is not simply race, and it is my belief that economic status in many instances holds an equal, if not greater, effect on ones manifestations which define their cultural identity.

References

Allain, L.  (2007).  An investigation of how a group of social workers respond to the cultural needs of black, minority ethnic looked after children.   Practice, 19(2), 127-141.

Altarriba, J., Santiago-Rivera, A. L.  (1994).  Current perspectives on using linguistic and cultural factors in counseling the Hispanic client.  Professional Psychology: Research and Practice, 25(4), 388-397.

Altarriba, J., Bauer, L. M.  (1998). Counseling the Hispanic client: Cuban Americans, Mexican Americans, and Puerto Ricans.  Journal of Counseling & Development, 76(4), 389-396.

Arzubiaga, A. E., Artiles, A. J., King, K. A., Harris-Murri, N.  (2008). Beyond research on cultural minorities: Challenges and implications of research as situated cultural practice.  Exceptional Children, 74(3), 309-327.

Constantine, M. G., Warren, A. K., Miville, M. L.  (2005). White Racial Identity Dyadic Interactions in Supervision: Implications for Supervisees’ Multicultural Counseling Competence.   Journal of Counseling Psychology, 52(4), 490-496.

Delgado-Romero, E. A.  (2001). Counseling a Hispanic/Latino client—Mr. X.  Journal of Mental Health Counseling, 23(3), 207-221.

Leong, F. T. L., Leung, K., Cheung, F. M.  (2010). Integrating cross-cultural psychology research methods into ethnic minority psychology.  Cultural Diversity and Ethnic Minority Psychology, 16(4), 590-597.

Sciarra, D. T., Ponterotto, J. G.  (1991). Counseling the Hispanic bilingual family: Challenges to the therapeutic process.  Psychotherapy: Theory, Research, Practice, Training, 28(3), 473-479.

Smart, J. F., Smart, D. W.  (1995). Acculturative stress of Hispanics: Loss and challenge.  Journal of Counseling & Development, 73(4), 390-396.

Sue, D. W., Rivera, D. P., Capodilupo, C. M., Lin, A. I., Torino, G. C.  (2010). Racial dialogues and White trainee fears: Implications for education and training.  Cultural Diversity and Ethnic Minority Psychology, 16(2), 206-214.

Utsey, S. O., McCarthy, E., Eubanks, R., Adrian, G.  (2002). White racism and suboptimal psychological functioning among White Americans: Implications for counseling and prejudice prevention.  Journal of Multicultural Counseling and Development, 30(2), 81-95.

Vala, J., Pereira, C., Costa-Lopes, R. (2007).  Is the attribution of cultural differences to minorities an expression of racial prejudice?  International Journal of Psychology, 44(1), 20-28.

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.

Therapists Differ and so do Their Approaches

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In the most basic sense, therapy is a form of treatment for disorders.  However, not every person that seeks therapy meets the full criteria for a clinical diagnosis, thus therapists are often engaging a client regarding presenting problems.  These issues may or may not lead to diagnosis, but more often than not, are affecting the individual’s overall functionality.  So, while you as a client may feel that you need therapy, understand that you may not be receiving treatment for a disorder. In many cases, at the request of the client, therapists seek to assist the client with restoring or increasing the client’s level of functionality (often recognized by the client as balance, happiness, meaning or fulfillment).  This process typically includes a clinical assessment of the client’s level of functionality, and a determination on whether or not the client’s thoughts or actions meet the criteria for diagnosis.

In order to provide therapeutic assistance, therapists use their experience and expertise, which may be derived from a variety of tools, techniques, theories and models.  Because of the vastness of the research, experiments and studies that have occurred over time, there are an abundance of valid (proven) approaches to therapy that may be chosen by a given practitioner.  While there is no identified “best” approach to therapy, the client’s situation and the therapist’s competence play a large role in determining which model the therapeutic engagement will follow.  If you are interested in seeking therapy, it may prove helpful to understand what specialties potential therapists claim, as well as what approach(es) to therapy they practice.  Below is a comparative look at a few popular therapeutic models.

Reality Group Therapy versus Structural Family Therapy

While applying the Reality Group Therapy method, the therapist focuses on the individual’s control of their behaviors.  The clinician aides the client in performing a self-evaluation in which they identify the quality of their behaviors, then determines what the contributors of their failures are.  The therapist’s role is to guide the client through the process of developing a plan of action to eliminate these behaviors, and then hold them accountable throughout the execution of the devised plan by confronting them and identifying any possible deterrents or reasons for any incapability of completing the plan.  The therapist and client work closely together to formulate the plan of action for the client to modify the behaviors causing their negative emotions in order to reach the desired outcome.  Whereas, in Structural Family Therapy, the therapist emphasizes the dysfunctions of the family as opposed to strictly the individual’s control of the issues.  Abiding by the Structural approach limits the therapist’s overall involvement as he is not used to establish intensive reparative for the family members, but to simply outline the framework, develop the foundation for reframing, and then encourage the family to continue a positive progression of growth.  The Structural therapist’s role is to be an active agent in the process of restructuring the family, emphasize clear boundaries, facilitate the unearthing of hidden family conflicts and then outline the manner in which the family can modify them.

Person-Centered Therapy versus Strategic Family Therapy

The Person-Centered therapist is one who is congruent, removing all sense of authority and de-masking of professionalism.  To be an effective Person-Centered therapist, it entails revealing personal information if it is an accelerant to the progression of therapy.  Typically therapists have the general understanding of the limitations when involving self-disclosure; however, in Person-Centered therapy the clinician is transparent.  Person-Centered therapy is client-guided as they explore their life experiences, and with the aid of the therapist, analyze their history and the result is the client resolving their own issues.  In this approach, it is vital for the therapist to exude unconditional positive regard, providing no criticism, guidance for behavior, or discouraging them from any behaviors.  In opposition, Strategic Family Theory requires the therapist to employ guidelines and directives, no matter how ambiguous.  The Strategic therapist pays extreme attention to detail and accepts only the positive, whereas the Person-Centered therapist must accept all aspects of the client—positive as well as negative.  Therapists abiding by the Strategic approach also develop a distinct outline for treatment involving defining the problem, investigating all solutions, defining clear change to achieve, and formulating strategy for change.

Rational Emotive Group Therapy versus Psychodynamic/Bowenian Family Therapy

Rational Emotive Behavior Therapy contends that individual’s belief systems are responsible for emotional consequences.  In theory, a client’s irrational beliefs could be effectively refuted by challenging them rationally and inevitably reducing the conflict.  In a group setting, the therapist takes a lead role in attempting to change the minds of the clients.  The therapist can accomplish this without fostering a “warm” relationship with the clients.  In a group setting, there is potential for judgments to be made of group members by other members of the group, which may prove of benefit or detriment to the therapeutic experience.  Rational Emotive Behavior Therapy holds that humans have the equal potential to be rational or irrational, and both preserving and destructive.  Therapists must promote clients to confront their behaviors as well as accept their faults.   Additionally, Rational Emotive Behavior therapists claim that it is possible to assist clients with changing their behaviors as a means to restructure their way of thinking.  In this light, the therapist must continue to encourage self-discipline as well as self-direction.  The primary similarity between Rational Emotive Behavior therapists and Psychodynamic therapists is that the principle focus of both is essentially for the client to reach full self-reliance, and operate at a high level of differentiation by exploring and developing their own autonomy.  The Psychodynamic therapist accomplishes this not through confrontation, but through examining the client’s family of origin, constructing and dissecting a multigenerational diagram, and guiding the client to remove emotionality from their family system and begin approaching it from an objective approach in order to identify its highest level of functionality.

Because these comparisons are very general it may prove helpful to conduct further research regarding any approaches that are of interest.  Additionally, understand that there are a multitude of other approaches to therapy as well and the best interpretation for you to have regarding any approach is the interpretation used by your therapist.  Understand that even though some therapist’s practices are based on the same principals, each therapist will inevitably approach therapy in their own manner.  This is to say that just because a certain therapy model was unsuccessful in the past with a specific therapist, you should not necessarily avoid seeking help from others utilizing a similar approach.

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.

—–

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.

Understanding the Clinical Training Required for your MFT Degree

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That moment you realize that finding an internship site is much more of a daunting process than you imagined…

You feel like you have exhausted all options and the demands of life haven’t slowed down a bit. If you’re like me, you’ve amassed a great deal of lemonade from what seems to be an orchard of lemons. Now, if an opportunity actually does present itself, you’re worried that you’re too involved in other endeavors to attend to the demands of an internship with the necessary zeal. You are continuing to accomplish so many things, but the void left by what you ultimately equate to failure is notwithstanding.

As I continue in my effort to locate a site to complete the clinical requirements of the Marriage and Family Therapy (MFT) graduate program I attend, I can’t help but to question my own efforts as I reflect on the experience. It is my hope that in some way the information I present hereafter will prove useful to those wishing to pursue a graduate degree requiring a concomitant residency, others similarly situated and additionally serve as a calling to those positioned to supply the necessities of this demand.

Similar to most careers, becoming a helping professional is possible through a variety of avenues. Despite the source of your motivation, the resources and support you have accumulated and the advantages of your genetics, you can be assured that the licensure process will create challenges that, despite any preparation, will test your fortitude.

The licensure process is the stretch of the pursuit that canalizes candidates to evaluate competency.

In many cases, the consideration of a graduate program is one of the first steps towards garnering the competency necessary to embark on your journey. While you carefully consider your options you may be taking into consideration the programs offered, the institutions proximity to your home or place of employment, tuition and associated costs and even the school’s reputation.

This thought process is normal, and is closely related to the process you went through during undergrad; however, consideration of a graduate program (especially a counseling related program with a clinical training requirement) requires specialized thought.

So, while you’re mapping out the coffee shops on campus, make sure that you take a moment to get your hands on some extremely relevant information.

Clearly understand the following:

The accreditation(s) held by the academic institution. Regional accreditation by one of the regional accrediting agencies recognized by the U.S. Department of Education and the Council for Higher Education Accreditation, ensures that specific standards are upheld at the institution, and that credits earned are more likely to be transferrable to another institution. Furthermore, the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) is a specialized accrediting body within the American Association for Marriage and Family Therapy (AAMFT) which accredits MFT programs at academic institutions. The COAMFTE is purposed with evaluating the level of competence of the graduates of institutions which volunteer for accreditation.

The requirements for internship sites and supervisors as set forth by your institution. You may find that aligning these requirements for a particular site is more difficult than you imagined. You may have to compromise concerning one or the other, or both. For instance, you would ultimately prefer to work with an approved AAMFT Supervisor but may find that there are few, if any, located within a reasonable distance.

Often when you do locate such an individual you find that they cannot take on any more interns or limit their expertise to interns who already possess the requisite degree. Though as a graduate student you are obviously striving for excellence, understanding your academic organizations minimal requirements for both the site and the supervisor is key to complete and careful consideration of potential sites.

If the academic institution has partnered with local organizations to provide clinical sites for its graduate students, you should spend some time learning about those sites and what is offered and expected. Understand that many academic institutions cannot guarantee placement at an internship site even in cases where partnered organizations exist. Also note that it is not farfetched to intern at a qualified site under the supervision of a qualified professional who is not affiliated with the site you are located.

The expectations concerning competency and the academic requirements of the clinical experience. The academic institution likely requires both clinical experience hours and supervision hours for completion of your clinical training. Understand that the site you choose should be able to provide the hours you need for your degree within the confines of your academic semester. During this planning process you must consider the likelihood of the unforeseen such as no-shows, changes in personnel at your site and the stability of specific programs at your site which may affect your ability to accomplish your academic requirements. You may find that, in order to meet your goals and the academic requirements, you may require support from multiple internship sites concurrently.

Your state’s licensure board requirements. In many cases state licensure requirements are similar; however, it is critical that you understand the requirements in the state(s) which you plan to practice. Consider the application process and transferability of licensure in reference to neighboring states and states you may plan to reside in the future.

Don’t save a review of these requirements for a later date, thinking that they only concern those who already possess a degree and are seeking licensure. The reality is that states often have educational requirements that specifically pertain to your graduate work. Through careful consideration, it is possible to align yourself with an organization and/or supervisor which can support you, not only through your graduate experience, but also throughout the post-graduate licensure process as well.

While this information is structured for those seeking a MFT graduate program, the processes and structures are similar to those associated with other helping professions as well. If you have read this and are wondering why such a review and careful consideration is necessary by the student, it may prove helpful to understand that my MFT academic experience has been online.

Thus, in my case, the pursuit of a site and supervisor includes a great deal of footwork, phone calls, emails and, ultimately, networking. I chose to attend an online program during active duty with the military, and this approach was the best (and realistically only) method for continuing my education at the graduate level concurrently with my military obligations. I do not regret taking the time to pursue a higher education while serving in the military.

I will admit that there were challenges during the pursuit; none greater than having left service with only the clinical portion of my degree remaining. Despite the rise in popularity of online courses, certifications and degree programs and the growing acceptance of these forms of education, clinical degrees present specific, unique challenges regardless of the institutions mode of education.

Continue to follow this blog to learn more about finding an internship site, approaching potential supervisors, the advantages provided through innovative technology and the unforeseen challenges of completing the clinical training requirements of your online MFT graduate degree.

 

Atlas Concepts, LLC_Jordache Williams Jordache 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.

 

Finding a Good Therapist

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Fields of Knowledge_Choose a Therapist

Though they have dissipated in the last decade to a degree, there are still stigmas regarding the world of mental health. Of those exists the thoughts that therapy is for “crazy people”, “individuals who need medication” or “those who have way too much to say and no one else to talk to”. The reality is that therapy may or may not be for any of those individuals and likewise may be effective for those who are often considered normally (mentally) healthy. Growing up in South Carolina I am very familiar with the phrase, “if it ain’t broke, don’t fix it”. While this maxim has proven very true in many instances, there are times when it doesn’t necessarily apply. I believe therapy to be included in this list.

Let’s switch gears for a moment and think about a scenario involving an automobile mechanic (pardon the pun). You speak to a mechanic over the phone and discuss with him the fact that your headlights do not work. The mechanic schedules you an appointment. When your car is returned to you, you are told that the issue with the lights has been repaired, so you render thanks (i.e. $). Before you leave you ask the mechanic what the issue was and he tells you that the problem was corrosion in your car’s fuse box.

Hold on a minute…you came for your headlights and he spent the last hour working on your fuse box? The point here is that while there are common issues that arise with individuals and families, those “in the mix” may not clearly understand the root of those problems. The mechanic could have changed the light bulbs, installed new wires and even changed your tires, but until he fixed the actual problem with the fuse box, the headlights would have never operated properly.

Yes, as a client, therapy at times may seem like a process that involves “going around your hip to get to your elbow.” So how do you find a therapist? In all actuality, many people go about it very similarly to how they arrive at finding “their” mechanic. People often consider items like location, reputation and cost(s). And while this process is understandable, it may not be inclusive. All therapists are not created equal.

The mechanic analogy is a great one, because it applies in so many ways. Another example is that many auto mechanics have specialties, whether it’s a specific make of vehicle, a specific component, etc. This holds true for therapy as well, though there are some “jack of all trades” out there, therapists may be better suited to work with clients with certain concerns or issues. When seeking a therapist, I encourage you to conduct some amount of research pertaining to the specialties of the practitioner. This may include contacting them directly.

Some therapists have the ability to utilize objectivity and empathy with a nearly artful balance, allowing “hard truths” to descend at the rate of the feather on Forest Gump (1994). Therapists can be practical, eccentric, rigid, playful, exotic…you name it. A therapist’s “style” is typically a mixture of their personality and the model(s) of therapy they practice. As a client, it is critical that you are comfortable with your therapist but you must understand that while personable may be comfortable, it does not necessarily mean therapeutic.

Let’s face it, a person seeking therapy is looking for something which they perceive they cannot offer themselves. The client’s goal going into therapy is, to at the end of the session or through the course of therapy, feel better…BE better. Unfortunately, the best understanding a client will get of what a particular therapist can offer is to participate in the process. This means paying for something that may or may not work. Here are a few tips for narrowing your options through conducting research, telephonic inquiries or attending a consultation.

  1. Trained – Often you can learn a great deal about a therapist’s level of training from the internet. Company websites, business review pages, LinkedIn and other social media sites may offer insight into the level and type of training a therapist has attended. Consider the scholastic reputation of institutions of which the therapist is affiliated. Programs which are evaluated and accredited by notable organizations and entities may elude to the quality of the educational and training experiences thereof. In general, therapists are required to participate in continued education annually in order to maintain licensure. Because these educational experiences are chosen by the therapist, such experiences can reveal some of the therapist’s recent interests and/or concerns.

 

  1. Experienced – Not to be confused with how long a therapist has been in the profession. Time and experience can often be uncorrelated concepts. To determine the type of experience a therapist has consider what they claim as “specialties”. Experience in itself does not make a therapist suited for all clients; however, it may allude to a level of comfort and proficiency with their work, an ability to adapt and generally represent their “brand”. Therapists are as diverse as their experiences, a key to aligning yourself with an appropriate therapist is to discover their success with issues similar to your own. Experience is a progressive step from the training environment which leads to the next topic…

 

  1. Competent – Very easy to agree with but possibly not as easy to identify as one would imagine. Competence can initially be masked by accolades, fast talk and promises of success. While a clean and inviting office environment, polite administrative staff, short wait times and a nice business suit may allude to a professional environment, these may not necessarily be clues of therapeutic competence. Competence speaks directly to the therapist ability to use therapeutic intervention to assist a client with attaining goals. Testimonials and reputation are great gauges of competence.

 

  1. Culturally appropriate – While it is incumbent for therapists to be attentive to ethnic and multicultural diversity, the truth is that some therapists are more suited for a specific gender, race or ethnic group. This is not to say that you should strive to find a therapist who is similar to you because that is not necessarily the best fit based simply on racial identity. There are indeed individuals who are not “of” the group of which they work with best. Go beyond the surface when looking for a therapist, the best therapist for you may not look like you and may not be located on a side of town you frequent.

 

  1. Ethical – There is no greater must in therapy. The ethical considerations of the therapist should be outlined and discussed as a part of an informed consent process which precedes therapy. Though your personal ideals may not be directly aligned with those of the therapist, it is the therapist’s responsibility to conduct therapy in a manner that is not offensive or harmful to you (the client). The counseling professional you choose will likely be affiliated with a licensing body based on the credentials they hold. These licensing and professional organizations set the minimal standards for ethical conduct. Find more on ethics from the American Psychological Association, the American Counseling Association and the American Association of Marriage and Family Therapy.

 

  1. Credentialed – Often mistakenly equated with competence, in actuality, credentials more closely relate to training. I am adding a note regarding credentials because the list of acronyms associated with many of these professionals can be confusing. The truth is that the credentials of a therapist are more relevant to other counseling professionals than they should be to clients. These credentials essentially align counselors with specific governing agencies and/or organizations. As a client, you are protected by the organizations with which licensed and credentialed therapists are affiliated. Don’t be confused by credentials, or get bogged down trying to sort them all out. For clients, the most relevancy of a therapist’s credentials may be the limitations regarding insurance coverage or reimbursement. Additionally, clients should understand that they may contact relevant credentialing bodies to report unethical conduct of a therapist.

Atlas Concepts, LLC_Jordache Williams

 

Jordache 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.

Therapist Self-disclosure

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The matter of self-disclosure in the professional therapeutic setting is one that can be daunting to understand.  Foremost, disclosure in therapy is most identified as originating from the client.  Many of us picture a somewhat small, dimly lit office where the client is lying down with their eyes closed telling their personal secrets.  In many instances, however, this is not so.

Therapy has become so diverse that a generalization such as this can be very far from the reality a client faces when they enter the therapeutic setting.  So aside from not really knowing what to expect regarding the physical environment, clients are also leery about the process of therapy.

It is helpful for clients to understand that therapists have also undergone similar thought processes, such as the internal debate regarding how much of themselves they are to share.

Therapists teeter between disclosing too much and not enough about themselves to clients.  As a therapist, where do you draw the line? As a client, what are your expectations?

In general, self-disclosure should be used at the discretion of therapists with the intention of promoting wellness while avoiding harm at all costs (i.e. primum non nocere).  Self-disclosure is a natural (or promoted…or even integral) part of several models of individual and group therapy, thus for therapists practicing such models it is necessary in many cases.

Other models of therapy do not require therapist’s self-disclosure, and may even work more effectively if such disclosure is avoided.  So for therapists, the answer is to understand your model, and work within that frame…be comfortable and be authentic.

Hint: As a client, if you have the opportunity to research and select a therapist, you should consider what you perceive to be your presenting problem and evaluate the approaches of the potential therapists.

Not all therapists are created equally and some therapeutic models have been evidenced to work well with specific issues.  You also want to consider qualifications, credentials and reputation, but this will be covered more extensively in another blog.

As a client, you should expect therapists to be forthcoming with their particular intentions regarding the progression of the therapeutic experience, which may or may not include their intentions regarding self-disclosure.  At any case, therapists’ disclosure should be in keeping with the intent of the therapeutic experience as outlined during the process of informed consent.

The process of therapist self-disclosure is unique to each therapist, and clients who may have had previous experiences must understand that their own expectations can make their experience more or less productive.  If, as a client, you were forced to change therapists (e.g. because you relocated), you may be jaded.  If you discontinued seeing a therapist in search of a better experience, you may be disheartened by having to start over again (i.e. the administrative processes and the initial “introduction” sessions).

If you are completely new to therapy then your understanding of the uniqueness of therapists will prove helpful.  You are making an important decision in your life, and, in that regard, being informed is a process which you can directly influence…being informed is also something you should expect during the course of therapy.

In other words, be informed going in and be even more informed coming out.

Atlas Concepts, LLC_Jordache Williams

 

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