Developing Momentum in Therapeutic Relationships
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs Counseling CEUs and Specialty Certificates
Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery
~ Describe the ideal momentum in a therapeutic relationship
~ Examine causes of “stuckness”
~ Review phases of readiness for change and appropriate interventions to increase readiness
~ Explore issues in the therapeutic relationship that may lead to stuckness and interventions
~ What causes your client’s “stuckness?”
~ What does “stuckness” look like for your clients?
~ What do you do to keep momentum going?
~ Assessment: Client identifies problem, and is highly motivated to work on it
~ First session: Client actively participates and is open and willing to hear feedback and take suggestions.
~ Second session and beyond: Client thoroughly completes homework, arrives on time, participates actively and reports near continuous improvement
Reality for Many
~ Assessment: Client identifies problem and is highly motivated to have us fix it
~ First session: Client participates but often looks to the therapist to fix it. Expects what is done in session to be enough
~ Second session and beyond: Client rarely or partially completes homework, participates passively (reports problems, but doesn’t draw connections or look for solutions) and reports sporadic improvement
Stuckness vs. Plateau
~ Expect clients to experience plateaus where gains seem to stall.
~ A plateau lasting more than about a month in which the client has not reached maximal gains should be explored
~ Is something else going on and the client doesn’t have the energy resources to devote to counseling right now?
~ Or is has the client just lost steam?
~ Do treatment plan objectives need to be changed?
Causes of Stuckness
~ Client has competing priorities
~ Client is not motivated to abandon old behaviors
~ Wrong or incomplete problem/cause identification
~ Goals are too broad, poorly defined or complicated
~ Client doesn’t feel heard or understood (yes buts or the same issue repeatedly comes up)
~ Client doesn’t understand the importance of homework or connection to recovery
~ Client isn’t challenged through socratic questioning to arrive at own solutions
Readiness for Change
~ Precontemplation: Not ready
~ Contemplation: Realizing there may be a problem
~ Preparation: Trying to figure out what to do and decide if they are ready to change their behaviors
~ Action: Ready to change
~ Maintain progress on problem A while addressing B
~ Think about a change you wanted to make that lost it’s momentum.
~ What happened?
~ Why were the benefits of the new behavior not rewarding enough?
~ What did you miss about the old behaviors?
Not (Totally) Ready for Change
Change causes crisis and crisis causes change
~ Examine the benefits of the old behaviors
~ Ensure interventions meet the same need to a similar degree
~ Develop discrepancies between current behaviors and goals
~ Explore & address the drawbacks to the interventions
~ Increase frequency and or intensity of rewards for the new behavior
Wrong/Incomplete Problem Identification
~ Examine the problem from a biopsychosocial perspective
~ Examine what the person hopes to get out of the change (Miracle question)
~ Depression Treatment Happiness Relationship Improvement
~ Anxiety treatment Happiness Stop bingeing
Issues in the Therapeutic Relationship
~ Client doesn’t feel heard or understood
~ Client yes buts – I’m wondering what you think would work best
~ Repeats the same issue – This issue keeps coming up, help me understand what I am missing or what you want to change that isn’t
~ Shuts down – It seems like you might be on the verge of giving up. Tell me what you see as the most important issue to address right now and how you want it to resolve.
Issues in the Therapeutic Relationship
~ Client’s motivation/readiness seems to wane
~ Interventions implemented too quickly or too many at once.
~ Interventions target the wrong issue
~ Addressing relationship communication issues when one or both also have low self-esteem, abandonment issues and are projecting the past on to the present.
~ Interventions incomplete
~ Targets cognitions but not interpersonal skills or physical vulnerabilities/contributors
~ Clients must understand the importance of
~ Baseline and monitoring to see gradual improvements (maintains motivation)
~ Daily application of new tools to strengthen memory connections and effectiveness
~ Prioritizing doing the work to achieve recovery as they define it.
~ Why do you want to recover
~ How does prioritizing X over therapy help you achieve your recovery?
~ What needs to happen so you can remember to do your homework? (alarms, scheduled SMS messages, visual reminders)
~ Clinicians must remember to follow up on homework and help client see the importance and application at every session.
~ Tailor the homework to meet the client’s learning needs
~ Prose vs. lists
~ Free-form vs. worksheets
~ Videos vs. books
~ Keep it short.
~ Total time each day ~1hour including logging throughout the day
~ Help them work it in to their daily routine
~ Journaling/worksheets during coffee or just before bed
~ Listen to audio recording on the way to work or at the gym
~ By using socratic questioning clients strengthen the memory pathways to trigger using the skills on their own.
~ Why do you think you reacted the way you did? (looking for vulnerabilities and why old behavior is more beneficial)
~ What skills do you have that you think might have been useful in that situation
~ How might it have helped (identify the reward)
~ How do you think you can help yourself remember to use that skill in the future
~ Change requires a certain amount of momentum
~ Examine why prior attempts at change have failed and explore why and what you can do to address it.
~ Make sure goals are specific, measurable, accurate, realistic and time limited
~ As you learn new skills and ways of responding it is vital to practice them on a daily basis. Don’t expect immediate perfection.
~ Sometimes motivation and compliance can be increased by
~ Social support
~ Environmental reminders and changes
~ Identifying and regularly reviewing the benefits of the change as well as the drawbacks to the old behavior
~ Logging and reviewing progress on a daily basis