Online & In-Person Counselling, Therapy & Supervision

Supporting clients with therapist interventions (Grawe, 2007). Planning

1. Perspectives: disorder symptomology, inconsistency, clients treatment goals.
2. Requirement for validated approach(es).
3. Where there is increased incongruence (e.g. comorbidity, many treatment goals, high incongruence) do incongruence analysis and determine access points in order to change the most important ones.
4. From these incongruence access points which ones does the client want to improve the most?
5. Rank the access points for change and select goals most beneficial for client.
6. When formulating the therapy goals ensure only the approach goals are selected, never the avoidance/negatively expressed ones.
7. Select the goals that have maximum motivation for client.
8. Determine the clients most important approach and avoidance goals.
9. Do a resource analysis of the client – strengths, positive aspects that can be utilised, activated and incorporated into therapy.
10. Determine which motivational goals are being activated in the therapeutic relationship.

  Process

1. Therapist approach:

• warm hearted
• extroverted
• optimistic
• confident
• positive posture – still, open, relaxed, leaning toward client, calm and warm tone of voice that is professional, confident, safe, free from fear, arms open, hands relaxed on lap, nod repeatedly, accompany statements with gestures, legs uncrossed preferably (empathy, positive attachment relationship)

  2. What implicit perceptions is client currently experiencing? Current events in life, motivational goals, needs. Focus on content (what you’re discussing) to process level, i.e. clients mental processes. 3. Focus on how you (therapist) speaks and acts, not on what you say or do 4. Remember the clients attachment need is activated and you need to offer them a  positive experience. The client will have negative attachment from childhood and will be sensitive. They are hyper-sensitive to rejection, judgment, approval. Allow the client to feel and know they are at the centred of your undivided attention and show this with eye contact. 5. Help client experience maximum number of positive perceptions to their need for orientation and control. Identify goals for each session and how they can be achieved involving the client in this. Help the client know/feel they are pursuing a goal. If the client has reservations, hesitations, resistance listen more carefully to the client and give options for them to choose by eliciting their control need and attachment need. If you think you are going to say something that will elicit a negative reactions (fear or sensitivity) then prepare them for that before you say it. 6. Provide situations for the client to experience self-esteem enhancing perceptions. Engage them about interesting and positive aspects of their life and their activities. Show interest in all sides of their life. Waking hypnosis (seeding, suggestion, imagery, metaphor, archetypal narratives) help the client develop some right brain activity. Raise positive meanings connected to their goals. Emphasise respectability of their activities, views, ethics, optimism, expectations. Don’t let client’s defensive and minimising reactions to derail the process. Convey, in response, self-esteem enhancing perceptions to client. Any defensiveness/minimisation is self-esteem protection and are avoidance goals – they need to be explored, analysed and reframed. 7. Ensure there are pleasant states in the session – laughing, appreciating success etc. Ensure positive emotions are acknowledged. Where trust is difficult use hypnosis, self-guided training, relaxation exercises, positive imagery, meditation. 8. Each session must have a clear focus on one problem at a time. Changes in synapses only happen when they’re lastingly, intensively and repeatedly activated. 9. When a problem is relevant for a therapy goals push the activity forward into a change event, e.g. better understanding, coping strategy, mastering a certain difficulty. ALWAYS TRY TO ATTAIN A CHANGE EVENT. 10. When a problem is activated and processed conduct approach priming. Identify a need-satisfying experience and activate positive goals and emotions. Anything that may trigger negative emotions refer to the positive goals/emotions and create need-satisfying perceptions related to addressing the negative emotion to increase tolerance. 11. Activate the motivational goal before exploring problem-focused interventions. Role-play, visualisation, will activate the motivational goal that will release adrenaline and/or dopamine while it establishes the new neural patterns. Refer to the approach goal again in dialogue. 12. Plan and discuss opportunities for reinforcement of session learning after the session in life. Begin each session exploring any experiences that relate to the last session. If nothing transpired ask why nothing came up, by repeating any of the goals that might trigger memory. They may have forgotten or not given much time to reflection. Emphasise commitment to the pursuit of necessary experiences, planned exposures, exercises and conversations. Transferences Transference offers the opportunity to see relationship patterns – violations of attachment and control in early relationship leaves deep traces in the neural system (stress reactions, emotional challenges, dysfunctional regulation of autonomic arousal, easily triggered avoidance systems). These neural circuits require inhibition and replaced with need-satisfying neural patterns. New situations can be created in therapy and planned in the clients life.   Summary interventions:

• Develop a secure attachment relationship with client
• Emphasise positive perceptions of motivational goals and their activation
• Utilise motivational goals
• Trigger positive emotions
• Increase the client’s competency to inhibit their anxiety
• Clarify expectations and concerns
• Provide successful case studies to the client
• Personal modelling
• Practicing self-statements and anxiety-mastery thinking
• Emphasise goal-oriented actions
• Reflect on cause-effect patterns
• Reward
• Rule learning and establishing the conditions required for rules, rewards, needs, instincts
• Gain confirmation from the unconscious through listening to both negative and positive emotions, dream interpretation and confirmation, how projections and transferences can be read and understood as coded communication from the unconscious, syncronicitous events and how to read them
• Reading feedback of attainment of motivations goals and needs
• Need to address avoidance and conflict schemas in current relationship and interpersonal experiences
• Explore direct consequences of attachment need violations in early years of life where stress tolerance was reduced, poor emotional regulation was established, reduced self-efficacy expectancies, reduced self-esteem were all created.
• Identify goals for Problem Mastery/Symptom Reduction, Interpersonal Goals, Well-being improvements, Orientation Meaning, Self-actualisation/Self-Esteem, Seeking Joy and Avoiding Distress.
• Identify disorder-specific therapy
• Interpersonal therapy must focus on problematic avoidance schemas, reduced stress tolerance, reduced emotion dysregulation, unfavourable consistency-securing mechanisms, reduced self-esteem regulation, basic needs.
• Need for control in goal-achievement, creating positive control experiences in session and outside session.
• Develop coping mechanisms.
• Therapist must be a model of positive attachment: being available, sensitive, responsive.
• Avoid focusing on anxiety and focus on positive outcomes – reframe, positive suggestion, visualisation, meditation, relaxation, energisation, exercise, nature, arts, music, social engagement, service to others.
• Address shame and guilt thoroughly as possible.
• CBT and use of citalopram showed significant improvements in fear and phobias showing reduced activity in the amygdala, hippocampus and right brain. Brain activation had changed permanently.

  © Martin Handy 2022