LINI AL REFLE TION : CLIENT DIRECTED OUT OME INFORMED PRA TI E By Benjamin John Laurie B. . Tr nt ni r ity 2007 THE I UBMITT DIN PARTIAL F LFILLM THE R QUIREME T F R TH D REE MA TER OF 0 IAL WORK UNIV RSITY OF NORTH RN BRITI H July2013 © B njamin 1 hn Lauri , 2013 T F OL MBIA A b tract In thi r p rt I ynth at T u h t n iz th amily ciati n. I pr ent tw m taph r t chang . The fir t m d 1 n by the eli nt to th 11 r. Th un g I gain d thr ugh a clinical practicum kill and kn ptualiz th th ra utic pr c nd m d 1 n n eptualiz th rap utic a ag graphy intr due d ptuali ze th r lati n hip b tween thought, em tion, and b ha i ur a a framew rk to help me vi ualize th client a th y m v toward change. The e r fl cti n are upp rt d by a lit rature that find that po itive therap utic outcome ar attribut d t c nt xt and r lati n hip. II CLINICAL REFLECTIONS TABLE OF ONTENT .. Ab tract Tabl f 11 ontent 111 Li t of Figure v Acknowl dg 1nent Vl Introducti n 1 hapter ne Heading outh Rationale for Practicmn Goal for Growth My Theory of hange Limitation of the tudy Definition of Term Writing tyle 3 5 5 5 7 7 9 Chapter Two Touchstone Fan1ily A oc1at1on Client Directed Outcome Informed Practice Therapeutic Alliance Outcome Rating Scale Session Rating Scale 17 19 21 Methodology 21 Literature Review Attaclunent Theory mnplex Trauma Family yst ms 22 23 10 ]1 Chapter Three hapter Four hapter IVe Model 1: linical Geography G al etting R f1 cti n 25 2 CLINICAL REFLECTION Chapter IX R hapt r ourc Analy i Par nt hild Play ollab rati Pr bl m olving Duluth Mod 1 boriginal pproa h t H alth Motivati nal Intervi wing 42 42 45 49 52 56 v n M d 1 2: P ychological Thought motion Behavi ur A Tr e in th F r t cology 60 64 65 65 66 Conclu ion 68 Reference 70 Appendix A 76 Appendix B 77 Appendix C 78 IV CLINICAL REFLECTIONS Li t of Figure Figur 1 lini al 4 ography igure 2.1 P ych logical 62 Figure 2.2 P ych logical c 1 gy 62 Figure 2.3 P ych 1 gical 62 cology v CLINI CAL REFLECTI ON p itiv & Wamp ld (2011) d u tcome . f e id n -ba d th rapy r lati n hip and pati nt' di rib f:D cti th rapy a th r ult -ba d tr atm nt adapted t ea h id n rd rand hara t ri tic . Th tr attn nt i ndar t th uality f relati n hip. In rd r t pn ritiz th m d l that I u t M taph r perm at rgamz th th ffecti int each e 1 principle that drive the c ur r I will bar tw c n eptual ry and t hniqu that und rpin my pra ti thi pap r. Thi wa work a I 1 arn way t and t chniqu li nt in tead fth f thinking r fl t th way my mind 1 j in an w rk with li nt t bring h lpful theorie n. The fir t m d 1 th ' clinical g graphy,' r v al the fth rapy fr m a utc me In:D rm d li nt Dir ct d (CDOI) per pecti e. The econd mod llik n people to plant t help m orient t th client' thought emotion , and behaviour . Th e model provide the fram work t under tand peopl within the contexts and relationship of their live (Bi hop, 2002 ; Mullaly, 2002 ; Zapf 2009) . Thi i akin to examining the health of a leaf by looking at the tr e and the fore t that the I af i a part. To further thi metaphor, tree literally share ugar , nutrient , and chemical ignal directly through naturally grafted roots and myconhizal n twork (H nry & Quinby, 201 0). Although not apparent to theca ual ob erver, the health of a leaf i related to the overall health of the fore t. More complex example f the interconnect d nature of cologi cal y terns e i t in the marine based nitrogen fl und in core ampl N rthwe t. f w t n1 hen1lock in th Pacific p to 24% of core ample c ntain a particular nitrog n i ot pe :D und nl m marine ource , namely ahn n (R imch n & Math w on, 2002). Th r i a direct CLINI CAL REFLECT ION S Acknowledgements I am grat ful to all of the pe pl I' v w rked with a eli nt , oll agu up rvi or . ion umer u c n r ati n hav hap d my d v I pm nt and per onality in ating lunch during upervi i n and th grateful to my cormnittee. rant and diting of thi rep rt. I am particularly r bman fl r patiently witn ing my gr wth through clinical up rvi ion. Joanna Pi rc for upp rting my 1 amingj umey d pit being on abbatical. Indrani Margolin for your nthu ia m and upp rt fl r my work. CLINI CAL REFLECT IONS Introduction ut m inti nn d th rap i th r c ntribut t p iti th rap uti ut m ult f br ad r ear h int th .R nzw ig (2002) fir t pr r ti a1 ap r a h and r quir att nti n. th rapeutic outc m in th ntemp rar m ta-ana1y i r ar primari1 th r ult f lient' life (Wamp ld , 20 11 ). of change are then tm ac unt fl r p itiv utc m ar h d m n trate that po itiv trath rapeuti fa t r in 1uding v nt h th rap uti allianc and th t ignificant fact r (Wamp ld 200 1). e i attribut d to a particular techniqu nt d th id am r approach ( rcr li nt ' xpe tancy than 1°/o f change & Wamp ld 20 11 · Wampold 2001). imilar to Ro nzweig' (2002) prediction the common factor of a safe therapeutic alliance, collaboration, and working from th client' fram of ref! renee account more toward po itiv outcome than theory or technique (Duncan & Moynihan, 1994). Approaching clinical work from thi outcome inform d per pective prioritize relation hip and u es the client' fra1ne of reference in a collaborative proce toward change. These outcome informed findings are congru nt with critics of p ychotherapy. oilier (2006) warns that the limited adoption of Freudian p ychology contribute to individual pathology. Them dical model i not de igned to recognize the y temic determinants of health. Duran and Duran (1995) de cribe p ychol gy as 'objectification ... [and] n thing but ongoing ocial contr 1 and hegemony" (p.7) . Decade f therapi t and th ory driven int rvention , advan clini al trial d re ar h techniqu ugge t that fact r c 111m n t all th rap uti appr a h and are ignificant for CLINICAL REFLECTIONS p itiv utc m f e id n .N rcr &Wamp ld(20 ll)d -ba d th rap r Lation hip and pati nt' di rd rand chara t ri ti crib id n - . Th tr atm nt i f-[1 cti th rapya th r ult ed tr atm nt adapt d t ndar t th quality f relati n hip. In rd r t pn ritiz th mod 1 that I u t M taphor p rmeat rgamz th th into a h r l will hare tw nceptual ry and t hniqu that und rpin 1ny pra tic . thi pap r. Thi wa work a I I am way t effecti and te hniqu li nt in tad fth f thinking r f1 ct th reativ way my mind 1 j in and w rk with eli nt t bring h lpful th n n. Th fir t m d 1, th ' clini al ge graphy,' rev al th principle that driv th c ur of th rapy fr m a ( DOl) per p ctiv . Th nd mod I lik n p opl t plant to h lp m orient t the client ' thought lient ir cted utc me In[! rm d emotion , and b haviour . The e mod 1 provide the framework t und r tand people within the context and relation hip of their live (Bi hop, 2002 ; Mullaly, 2002 ; Zapf, 2009). Thi is akin to examining the health of a leaf by looking at the tree and the fore t that the leaf i a part. To further this metaphor, tree literally share ugar , nutrient , and chemical ignal directly through naturally grafted root and myconhizal network (Henry & Quinby, 201 0) . Although not apparent to the ca ual ob erver, the health of a leaf i related to the overall health of the forest. More compl x examples of the intercoru1ect d nature of ecological sy tern e i t in the marine ba ed nitr gen fl und in core ampl North we t. p to 24o/o of cor amp l of we tern h mlock in the Pa ific contain a particular nitrogen i otope D und onl marine ourc , nam ly almon (R imchen & Math w n, 2002). Th r i a dire t 111 CLINICAL REFLECTIONS c nn cti n b tw n th h alth fa n dl pawning alm n thr ugh a numb r f Human w 11-b ing i mpl t rn h ml ck and th abundanc imilarl influ nc d b numer u r lati n hip . P b twe n human and tr ne f th large t di c m1nunicat with languag . In t ad f taking ampl nutri nt cycle fa tre human ar abl t talk and th ir h alth. Talk th rapy i Th therap utic pr c f r lati n hip . int rp r nal and intrap r nal ial hi t ri al fa w n wa that pe pi p n n pi ha and p r epti n . i th hum n ability t f h artw d t under tand the pl r th r lation hip that affect ngag m hang . i guid db g al agr a 1 t client and c un ell r. imilar to a tree in a fore t d ciding wh r t gr w an w branch t catch unlight, effecti e change re ult from a trong therap utic alliance, cl ar g al creating an appropriate cour of action. utrient and apr ce of unlight, and en vir nm ntal factor contribute to th growth of a tree whil goal , r ourc , and upport can contribute to a client' de ired change. Chapter One Heading South I rein ured my 1987 Yolk wagen Jetta and headed outh on highway 97 from Prince eorge to Richmond. The route follow the approximate contour of the Fra r River. For the la t two years I have enjoyed living down tream from the confluenc of the ras rand Nechako river . Prince have met fl r ov r a thou and year . The eorge i a hi torical place where wat rand p 'h dli T' nneh p opl ple all d thi plac h m I ng befl r there w re railway and highway . My de tinati n wa th t wn of Ladn r, CLINICAL REFLECTIONS n w part f uth D Ita uth m ide fwh r th n th pit th di tanc I :D lt c nn c an. D t ra r m et th Pa ific t m partn r rg m my aura in Prine n wh m. Dri mg uth in arl ice br ak up nth lily pad and th tt nw had w now wa replac d b n ar ninth back 1 ar cut are p n nc pril wa an a d ri f tr r, th ugh th lak ftru k a f n w. urther outh, the n wh r b th n wm bil f th highway. Th fore t are account d for in th 1 g yard and pile ti and can e wath f mi mg f pulp at the numer u mill awn and hipp d to b c m lumber, particle board and paper. Both raw log and fini hed product ar of Prince Rupert a large fr z n nth high a n al ng b th id throughout the interi r. Th fi r h ld n t th 1r 1 h ld th r maining patch gra . Thi i th f pring. I n tic d th hipp d by road and rail to th p rt quami h, and Vancouver. I ee an economic model that break down the complexity of a fore t into the smalle t component to be reshaped into particleboard, laminated b am , paper, and cardboard. In a social ense, Cree cholar Michael Hart (2002) de cribe ocial work in similar way , as ontological imperialism characterized by y tem predicated on "breaking ecologies down into the smalle t ideas, object and/or event po ible, o that each part can be cia sified and defined' (p . 29) . Now, to be fair, I mn biased. Many people are mploy d and mo t p pl e perceive the fore t indu try a pro perou . I paid for my und rgraduate degree b y planting tr e p nding up to 14-hour day in cut bl ck and :D r t road . But, th r ' a CLINICAL REFLECTIONS ffl plain th b auty form in wh 1 ne . I will t k am m nt t ta 1 that I mad with tny partn r Laura and my dad a an e ampl Wh n I wa young I li mmunit d with m famil in P rt Hard nth n rth nd fVan u r I land. In th mid 1 a h d up n th b ea h a unu uall y larg not ri u fl r b ing diffi ult t w rk with a it i umqu r th ne t thr plank with u 0 r a t rm. my dad fl und an r u tu w rp and plit a it dri enthu ia ti carp nt r m dad mill d thi tre int b ar th a mall indu try ba d . n with hi chain aw . We m ved decade b autiful tabl P opl ft n touch th table up n entering ur h u e. The time w the wood nhanc th intri at d ign and family appr ciate th tabl , our inv col ur and hap of th ted tim b c me pent w rking rbutu . A fri nd pportunitie fl r t ry. I began contemplating working with pe pl in way that re p nd to individual needs and trength . The time we inve ted brought a unique beauty, function , and meaning that i incomparable to a tabl made from 2X4 and plywood . Ju t a time and intention brought the coffee table into being how can I work with people to creat change in their own unique circumstanc ? The ocial di integration characteri tic of re ource ba ed town (Schmidt, 2000) is imilar to the trauma expeti need by the fore t and the trees. an this explain people' reluctance to eek coun lling, a a fear of being ' run through the mill'? I aspire to work with p ople in way that realize th e uniqu beauty, needs, and abi liti e of each p r on I work with. CLINI CAL REFLECT ION Rationale for Practicum take multipl r 1 ial w rk pr -D gr up th rap int r and cap pm nt and indi i ual communit d tin w rking with indi i ual gr u and famili un IZ hi t ri influ nee np pi ' fun ti ning. W rking at p n nc gr wth nd t tm llier, 2 0 lling ( ct th nth in luding p li y, my ial , and tru tural h n . My i t ad an thr ugh a pra ti clini al kill and in r dible pp rtuni t t iti en t b an traj ct ry f c ntinued learning thr ugh ut m car r. Goal for Growth Two br ad goal frame m int nd d 1 arnin g. Th fir t wa t work to trengthen my linical kill thr ugh practic . The ngag in clinical c nd wa t create a practice framework to help guid my clinical under tanding and c nfid nc . Thi wa partially motivated by Duran' (2006) de cripti n that a umption and bia e become " hadow "that are unknowingly projected a pathology (p.37). I hoped to become better able to help people and not be overwhelmed by client ' inten circum tances or experiences. Using metaphor to mod 1 the therap utic proce helped orient me to appropriate clinical judgments. These learning goal were conducive to the DOl approach I had been immer ed in at TFA. Thi initial goal to create an ontological n1odel b came focu d on the way that the clinical proces was shaped to help the client r aliz chang in their li-D . My Theory of hange oal exi t within an impli cit the ry f chang . In my ca I had prop d that a combinati n of practice, r :fl cti n, up rv1 1 n, w rk h p , and rep rt writing would CLINI CAL REFLECT IONS facilitat my d id n c mpl pr 1 pment a a d by th incr a ing d n ity f m eli nt t ward p en to b an in r dibl A I b cam awar iti hi wa an ffi cti un 11 r. ut aluabl t m linical f my wn th n e and my a ility t w rk with . xpl nng 1 that I ha th ory f hang a li nt the ry f chang ha 1 am d during m practicum. ry f hang I a th r a n 1 ha pur u d nal devel pment and clinical kill in my pri r w rk lit! . Wh n I b gan thi pr gram, I pur u d cour ew rk and pra ticum t guid m clini al d 1 pm nt. The rec gnizing my wn impli it th mp wered met rec gnize and addr eli nt ' th ry f chang ha ry of chang . Thi i imp rtant a p nenc om time a p r f n ' th ry f chang may contribute t th probl m that they face. I tl el m re competent a a coun ellor now that I am able to r cognize th di advantag ou role that a per on theory of change can play in their change proc Limitations of the Study This i a reflective report of my practicum exp rience and i not meant to be in tructional or authoritative. A a written docmnent thi report repr ent the reflections and per pectives that I have had during the mnmer of2013. I anticipat rer acting thi report in the years and decade to come a a snap hot of my development and perspective at thi point in my b fe. Definition of Terms here are a number of term u ed to describe h lping profe ionals throughout this report. Barker (2003) broad ly define a coun ellor a apr fe ional r v lunt pr vide coun elling rv1 . Bark r d tine a therapi t a a pr tl r ho ional who "ha had CLINICAL REFLECTION xten ive training and upervi d p n n an :ft n u p ializ d t chniqu tool medication and r ourc "(p. 434). Th r pi t i comm nly u d in th bt ratur and i u d through ut thi paper a a r f1 cti n f th lit ratur . I id ntify a a coun 11 r. Th therap uti proc i d cri d in th lit ratur in nmner u way inclu mg c un lling, th rapy, and p ych th rap . arker (200 ) 'procedur " oft n u d in clinical cmnmuniti by giving ad ic information (Bark r, 200 tor m dy or cur fin un lling a a ial w rk t guid indi idual , fmnilie , group , and delin ating alternati arti ulating g al , and providing p. 100). Therapy i defin d a a y t mati c pr c m di ea di ability r probl m (Bark r 2003). P ych therapy connote experti e of a th rapi t trained in p ific typ f p ychotherap y t which a "th rap utic relation hip i e tabli hed to h lp r olve ymptom p ycho ocial tres , relation hip problem d ign d f mental di order, and difficultie coping in the ocial environment" (Barker 2003 , p. 349). The therapeutic work I've been part of during my practicum at TF A i defined in parts of each of these definitions, as the work take place in an intentional therapeutic alliance, is ystematic, and involves individual , couples and familie . These term will be used synonYJnously throughout the paper to describe the nature of my work at TF A. Multiple names are a cribed to the people accessing coun elling. Client i mo t commonly used at TFA to desc1ibe an individual, couple, or family engaged in counselling. Patient is u edina medical context and appears in the literature. I prefer to use the term client or per on. It is important for me to acknowledge eli nt a people, a the work happens between p ople not technician and probl m . Both client and p r on wi ll be used to identify the individual and fmni li s that I work with. CLINI CAL REFLECTIO NS Writing tyle I' part of m h n to writ thi r p rt in the fir t p r n t t ry. Thi i itnportant tom truth. I mbra e th 111 itabl ubj multipl truth . ri Mai 1 (20 12 meaning in th ir p y hoi gi al lifi than thi . "Th ace ti it a Id n t f a b n fit in pur uing o j ctive en nc and th ugg t that p p n n itu te thi inti 1mati n a pl ha ng ing cr ati n f diffi ulty a pting ut fan inn t fi r that th rei n't m r t w uld rath r that meaning r id that place or under tand it than t ha e it li m wh r n if th y can't right in id them a an artifa t f exi tence' (Mai 1 2012 p. 69). Thi r p rt i part f my t ry and per pectiv f the human experi nee. The reflecti e pr ce of thi practicum report i conducive t pu hing many of the norms pre ent in the dmninant vernacular epit mized by the Diagn Manual (DSM) of mental di order (AP A, 2000). tic and tati tical lient and th rapists are both human. Both may have degree and diagno i . Duran (2006) de cribes diagnosi a a naming ceremony that can contribute to difficulty and hard hip. Theca ual voice I write with i my attempt to be human and accessible. Power hides in the ways word work together by holding assumptions that perpetuate certain truths as univer al. It is my hope that there is space for the reader to interact with these words and be aware of thi . I use metaphor throughout this paper to communicate complex idea and meanings. Psychology is saturated with 1netaphor in order to de cribe the human experience. Duran (200 ) remind the reader that psyche, feeling, soul , depre ion, and anxiety are all ways of de cribing the hmnan experience. Metaphor can b u eful in therapy by engaging creativity and effectively na1ning cmnple e peri nces (Witztum, CLINI CAL REFLECT ION Hart & Fri dman 1 de p n and d crib th hwnan It i n t m (2007) re p cted c rmn uni at ). M taph r an d by ith r li nt r c un n m th r a ld r J an tt r f anything. In an int rvi w with Hall 1m tr ng d n a dial gu t h nam mmunicat with th how I a pir t 11 r t p n n int nti n t kanagan intr du ly, n dr "naw'qinwi w" (p . ), de ribe wat r drippin g r all 1 that f th t ol, at a tim . Thi water i dropping nt th t p f th h ad , r m untain . hi acti n f dripping wat r nt th h ad i a mutual pr ach other e that p pl d :D r a h th r t put kn wl dg into y tem f th ught mind in a way that i a 1 w infu i n int th (Arm trong & Hall) . Throughout thi r port I draw parall 1 b tw ecological exp rience . I will compar th m untain while hiking to the clinical en ibiliti n ocial, p ych I gi al and ring kill and intuition that I u I have learning to u e t navigate through ach client' clinical geography. Ju t a water re pond predictably to gravity haping the land and plants eek the energy of unlight, there are clinical principle that inform effective therapeutic proce e that upport people in cr ating de ired change. I invite you to join me creatively in the hope of meeting each other in the complexity of human xp ri nee a gardeners working to nurture and upport the growth of unique and unknown plant . Chapter Two Touchston e Family Association A provide individ ual, fmnily, and group coun Richmond lling in the c01nmunit of . As a non-profit, community ba ed ag ncy, T offer oun elling and CLI NI CAL REFLECT IONS c nflict r polic Richmond addicti n fami ly pr rece1 lution t th community thr ugh partn r hip with M FD Ri hmond frunily rv1c and the li it r gen ral f B . p rt fth rvation and r unificati n t am I w rked with n n-mandat d cb nt . I d lini al up rvi i n fr m participat d in r gular t am m rant r bman a r gi t r d clinical p y h logi t, and ting . Client Directed Outcome Informed Practice Outcom in£ rrned th rapy valuat clini al int rv ntion a m a ur d by po itiv chang of th th rap uti pr ce . h rapy i m r ft ctiv than n n-tr atm nt, however there i contenti n cone ming what i re p n ible forth e p itiv outcmne (Wampold, 2001). Medical model tudie de ign d tot t the fficacy fth rapeutic appro ache provide inconclu i ere ult , while contextual under tanding f therapy ugge t that factors common to all therapie attribute to po itive outcom (Wampold 2001). Medical model tudies typically compare different therapie and techniques to discern evidence toward a theory or teclmique effective for particular client demographics. These studies eek to detnon trate effective therapy by i olating active therapeutic principles. Clinical trials are conducted with manualized treatment procedures to determine effective treattnent approaches. Technique and theorie have been compared and tested for efficacy for decade . In an article first published in 1936 Rosenzweig (2002) suggested that factor common to all therapies were re ponsible for change. Rosenzweig ugg st that the complexity of psychological events overwhelm any one theoretical interpretation. In tead of earching for a conclu ive theory he uggest that all th rapie are relevant to a greater, r le er degr e, and ar worth con iderati n. CLINI CAL REFLECT IONS R nzw ig' (2002 p rc pti n f ITilTI n fact r xpl r d in r c nt m ta-analy i . m ta- naly i M ody 7) :fl und littl dif:fl r n tich B n n and Ahn ( 1 th rapie . Thi In ta-analy i in lud d tudi p ychoth rap utic treatm nt .P ntinu t b ndu t d by Wamp ld M ndin, tl in utc 1ne mp ring tw el ct d fr m r put bl j umal tati tical r 1 an tudi dir f th rapy ch th rapi n tw p cific n 1 70 and 1 w r c n id r 5. r levant if admini ter d y a ma t r d gr e lini ian w rking with a tr atm nt plan tail red t the pati nt. Treat1n nt had to b d crib d within th artie! with r :fl rene t p ych 1 gi al proc , a tr atm nt manual mu t ha b n u d t guid th p y h th rapy and the activ ingr dient of the treatn1ent d fined and r :fl r nc d. Wampold et al. (1997) found minimal dif£ r nc b twe n therapeutic approache or technique. le imilar to Ro enzw ig' (2002) arli r ugg ti n th finding ugg t that than 1o/o of outcome are attributabl to the p ychoth rapeutic appr ach u ed (Wampold et al., 1997). The author conclude, howev r, that "it i not appropriate to conclude that every treatment i equally effective with every patient" (Wampold et al., 1997 p.211). Improper research de ign can confu e the effect of cmnmon factor with a clinician's efficacy. Studies that attribute change to particular approach or t chniqu are unable to account for therapi t effects (Wampold, 2001 ). tudi s de igned to account for therapi t effect reduce the ignificance of appr ach and technique to in ignificant lev 1 herapi t effect are attributed 6 - 9% of outcmne, while 1% or d = .20 i attributed t therapeutic approach (Wampold, 2001 ). CLINI CAL REFLECT ION Larnb rt and Barl y (200 1) pr contribute to po iti nt a r akd wn of th rap uti fa tor that outc01n . Th larg t fa t r (40%) i attribut d t fa t r out ide of th rapy (Knight 2012 · Lamb rt & Barl y, 2 01 · Martin ntan Th ar k i , 2000). u r mi i n [! rtuit u e ent , upp ti and ituational change . omm n fact r ace unt [! r factor ar defined a th & D li nt ' p rcepti n f a[! t 0 /o f change. cial mm n tru t, and c nn cti ninth th rap utic allianc . It i imp rtant to n t that thew rking allianc i the ingle large t factor within th clinician' c ntr 1 to affect p itiv chang in thi r gard. p cific techniqu client account [! r 15 o/o of outc me while th remaining 15 % i attribut d to the perspective ofh p and e pectancy £ r chang (Duncan & park , 2002; Lambert & Barley 2001 ). The e finding are con idered to b un cientific and impli tic by Wamp ld (2001) . Through exten ive meta-analysis Wan1pold (2001) attribute th majority of change (87 o/o) to extratherapeutic factors . The remaining 13 % attributed to psychotherapy is attributed to cormnon factors (70%) specific effect (8%), leaving the remaining 22°/o unrelated to a11y specific ingredient. Wampold (2001) emphasizes the ignificance that technique and theory account for less than 1°/o of change of the 13 o/o of outcome attributed to the therapeutic encounter. For example an Atnerican study examined the efficacy of CBT, Interpersonal Psychotherapy (IPT) imipramine, and a control group of case management (Wan1pold, 2001) . The research was conducted at three sites with therapi t train din each modality. Manual were used to standardize treatment of larg samples" Wampold report , "n ne of the difB rene ample ize. "In pite of the large between the treatment vagu ly CLINICAL REFLECTIONS appr ached ignificance' (p. 107). Th r p rt d f:D ct iz :D r c tnpl t r fa oured IPT by 0.13.lndividual ariable rang din ffect iz from 0.02 t 0.2 (Wampold, 2001). R lati ely qual numb r fp pl b nefit d fr m a h appr a h including placebo c ndition medicati n and th rapy lea ing in li nt percepti n n lu i f th th rap utic allian r ult . ar relat d t utc me. h m t advanced clinical trial c nduct din 1 96 :D und c rrelati n b twe n arJy and m an rating of th rapeutic alliance, relat d t p rating of the therapeutic all ian nth third iti utc me (Wamp ld , 2001 ). he pati nt i n account d :D r 0/o f varianc in outcome, while the mean alliance rating accounted for 21 % f variance in outcom (Wampold 2001 ). Treatment typ a count d :D r 2°/o of outc m variance, th ugh thi 1 a weak finding a the tudy included a ca e management control group. Most recently the American P ychological A ociation (AP A) conducted a metaanalysis with a panel of expert to reach a con en u on the con istency of the numerous meta-analyses (Norcross & Wampold, 2011). Thi meta-analy i required tudies to have: (a) a minimum number of upportive studies, (b) con istent result , (c) a mea ure of the magnitude of positive relationship between therapeutic element and outcome, (d) a direct link between element and outcome, (e) experimental rigor, and (f) external validity. The task force found that low quality alliance when working with individual , lack of cohesion in group therapy, and discordance with couple or fmnilies , characteriz poor outcomes (Norcross & Wmnpold, 2011). Clinical trials that pit one therapy against another in a quest to find the be t approach are no longer relevant. ffective therapy i the function of an inclu ive, evolving therapeutic alliance. It i within thi relation hip that teclmique and approach b come effective. Be t practice i no longer centered around CLINICAL REFLECTION th therapi t and th ir kn wl dg ut r aliz r lati nal pr by w rking with th eli nt. Th tr ng t fin ing fr m th P r lati n hip t parti ular p ti nt hara t ri ti Adaptati n t th eli nt r d p iti copmg ut om i nh nc tr atm nt ffica y. ultur fr m th r p tp d pti n t ffl ti that " nd r ligi pirituality li n t tag f hang and da ti n t li nt p ct ti n and uffi i nt re ar h to u Wampold, 2011 ). Th ta k fl r e c n lud th rapy relation hip and an di gn tan w r fl un t b pr babl atta h m nt r th t adapting th th rap uti tud tanti n urr nt u & ffi acy ( f vid n e-ba d idence-ba d tr tm nt adapt d t th pati nt' di ord rand charact ri tic i lik ly t g n rat th bet ut m ' ( rcro & Wamp ld 2011 , p . 129). Clinical trial that involve manual ba d 'pur ' appr ache t att nd t a ingle di order do not reflect p ychoth rapy in real life practic (Duncan 2002) . orcro and W ampold (20 11) comment that "given the larg numb r of factor contributing to treatlnent outcome and the inherent complexity of psychotherapy, w do not expect larger, overpowering effect of any ingle facet" (p. 131 ). Th re are a nmnber of helpful facets that have small and medium effect towards outcome in the form of adapting therapy to the per on seeking help. Prioritizing the c mmon factor of therapy help client create ndogenou change rather than theory dri ven chang of them dical model (Duncan, 2002). By creating pace for the client' voice thr ugh ut the cour f therapy the client: CLINICAL REFLECTI NS m rge a a thinking d and th b t iding ag nt wh fa ti n ar r a ur d li erati n ab ut hi a1uating th rap b p c lla i ti ut rati n with li nt ar f utm Dun an and M b li f: ttitude th th rap uti pr or th ori pr ce in which t fu1 utc m 111 lient' ar r ali ed y 1ud f th 1r r blem. th 1ient' ffl tiv emb dd d within th hniqu c llab rati n betw en c un ell rand client b fl re . Thi i th c ntral tenant t Duncan (2002) d crib healer. u c r ab ut th ir i tuati n. Thi th rap utic r 1ation hip that pri ri tiz techniqu ). fu ing th ignifi an and fl eling ab ut th natur th rapy i th re ult fa r ati 2 p. t imp rtan w rking fr m th eli nt' infl nna1 th th ught un an 2 r- a1 that r 1ati n hip and m nihan (19 4) m ha iz th fra1ne f r fl rene t gm ut d a part fan na 1 and well n lu i n r h r lifl D I therapy. thi a a hift from xpert te hnician to c llaborativ hange re ult from within th client with th help of the coun 11 r rather than theory. Duncan ugg t that the coun ell r mu t hold the eli nt a central to the therapeutic proce in order to acce the endogenou knowl dg , trength , and e p rti e of the client, which outweigh any model r technique. Working collab rativel , th client i able to bring an incredible amount of extratherapeutic knowl dge into increa e clinical efficacy a the clinician ha increa d ace to 7o/o f ion. Thi tratherap utic factor attrib uted to change (Wampo1d , 2001). My xp rience working from a D I approach at TF prev1 u ly intuitiv pri rity ofre1ation hip and curio ity. oun ha on rcti zed m lling i not a treatment CLINI CAL REFLECT IONS f hang that i 1i nt and th rapi t w rking t g th r a ali i (Duncan & An xp ri nc during up rv1 1 n earl in m pr und r tanding of D I in m pra ti e. I d a eli nt c nn ct with a d thought that h I ping p Grant i1nply mak rib d t p m ti n during a fir t pl b park , 2002). ti urn a rant my uperv1 r h w I h lp d i n. I :fi lt r ud . t th tim I m in t u h with then1 el mm nted that he wa uri u if thi nt r d into by uld a an bvi u u ce h lpful :fi r th client t hang in hi li:fi . I topp d in m track a I r aliz d that I act d n an a urn d th ry f chang . I becmn aware that I a um d that m ti nal experienc and in ight 1 ad t gr wth and change. Thi de p n d awar n with eli nt to di cu all wed me to b tt race a1 1 of conv r ation th ir wn theory of chang . B ing aware f thi a umption enable me to engage in conver ation that increa collaboration and trengthen the therapeutic alliance. peaking at this level i particularly important a an a urn d theory of change can contribute to the problem. Working from the client ' frame of refer nee facilitates change (Duncan & Moynihan, 1994). Therapeutic Alliance Yalom (2002) de cribe the primacy of the therap utic alliance by tating "nothing take precedence over the care and maint nance of my relation hip to the patient" (p. 9). Research ub tantiate the importance fa trong th rapeutic alliance. Anker, wen , Duncan, and park (201 0) find ignificant r lation hip betw en therapeutic alliance and therapy outc me . Lambert and Barley (200 1) imilarl find a po itive a ciation between a afe, warm, and ur therap uti allian e and p iti CLINI CAL REFLECT ION S th rapeutic outcom . The trongly relat d to u tc me than nun n fact r ar p cializ d tr atm nt int rv nti n . A th rapi t' c ngruency unconditi nal p r gard and accurat facilitat mpathic und r tanding, n a therap utic r lati n hip that p1n nt. th p t ntial for change and d An xperi nc d T urag itiv clinician di u d with m th imp rtan e f b ing in pired by the p ople that I w rk with. ''If y u can't find om thing in the p r n that in pir you that you can lo e ab ut th m" h mnebody 1 aid 'th nth y ar b tter ffworking with . Thi wa apr fl und th ught fl r me. e pecially if they ar a 'difficult eli nt' i a p iti cce ing are pect £ r th p r on, urc of nergy to work from. I can think of a client I work d with in the pa tin which hi ability to urvive wa th a pect that I loved about him de pit th way that he chall ng d m . Duncan (2002) upport thi entiment by urging the reader to refu jargon and labeling in order to involve clients a equal, worthy, and essential parts of the treatment team. Working from a place of genuine love and re pect is part of the foundation to achieve collaboration. Person-centered therapy hares some principles with a CDOI approach. Carl Rogers (1965) articulates the need for clients to realize autonomy and elf-determination in their lives and in ession. This require a belief in the client' inherent capacity to "move away frmn maladjustment and toward psychological health" (Corey, 2009, p. 169). Yalom (2002) describes the elf-actualizing force within the client as an acorn. Given the opportunity to sprout and mature an acorn become an oak tree. The therapi t helps create the space for growth by reducing and removing obstacle while the client directs the process of growth. The therapi t must believ that the client know , j u t a th acorn, how to grow. CLI NI CAL REFLECT IONS The per on not th probl m i th fl u . R g r (1 of a trong therapeutic alliance t ffl cti f th rapy mp w r the eli nt to aft! ct p re urc king rath r than in ight and ability t a c 11111 in con tact with what th y ar writ ur then ce ity ly r aliz chang . Th collaborativ iti t mal an wer . rr 5) 1npha iz tructur chang a th y draw n int mal hang ( am bert m rg a the li nt gain Barl y 200 l ). pen ncing at th pre nt m m nt, 1 p r on "mor bound in the pa t", orey (2009) i "freer to mak deci i n , and increa ingly tru ting in them elve to manag th ir own li ' (p. 172). In thi way h alth d crib being centered in ne ' life. Outcome Rating Scale TFA u e two tool to help the client be at th c nt r of therapy: the Outcome Rating Scale (ORS) (Appendix A), and Se sion Rating cal ( R ) (Appendix B) . The ORS i used at the beginning of each se ion to measure the client ' previou week related to their goals of service. This guide the therapeutic proces relative to the client' identified goals (Miller, Duncan, Brown, Spark , & Claud, 2003). The SRS is us d at the end of each session to evaluate the quality of therapeutic alliance (Duncan et al. 2003; Martin et al., 2000). The client evaluates the therapeutic process and alliance to facilitate feedback for the clinician and create accountability (Duncan, 2002). Duncan (20 11) presents these in a manual designed to help front line clinicians adopt evidence ba ed scales. The The RS i structured in four cale with a cumulative core of 40 (App ndi A). R i used in each se ion throughout th cour e of therapy, which create a vi ual graph of the client' ubjective change in relation to their goal . Dun an (20 11) de cribe CLINI CAL REFLECT IONS a r qui ite ultur f£ dback with th eli nt. Thi m an that th practiti ner 1nu t g nuinely b li v that th eli nt Duncan (20 11) d crib the fl h and bl p rc pti n and th th R d of th ir e p ri nc a ''a bar trajectory of chang m rg of change matt r. t n t which eli nt mu t add int whi h they br athe life with their p rc pti n "(p. 24). Th fl ur bar b n ocial and 4) overall w 11-b mg. cor n al m a ur 1) individual 2) r lational ar t tal d and track d n a graph. ) ver tim a whi h can b hel ful in r cognizing the work that ha tak n plac ov r time that may not fe 1 apparent t th li nt at any particular mom nt. beginning of each nth client and I u e th prevwu week in term f their g al in relation to th graph d trajectory f chang t th R a at uch t ne to evaluate the mce their intake. An online v r ion of the tool automatically graphs the core over the cour e of therapy. Downward trend can be a rich source of infonnation. The online instrument allow for a view of each scale over the cour e of treat1nent. "I notice that you have ranked yourself a little lower than last week, and it ee1ns like the family cale moved from 7.8 last week to 4.5, does this make sense to you?" It ha been my experience that this simple tool can help clients remain goal centered , increasing the efficiency and potency of their work. Research supports the fficacy of these tool . Norsworthy and Rowland (2009) conducted a study with 74 therapists. Each therapist acted as their own control measuring client outcomes without u ing feedback mea ures , and then u ing the OR and R . Repeated use of the mea ure re ult din statistically ignificant improvement of d = 0.51 and d = 0.4 compar d with non-u . CLINI CAL REFLECT ION Ses ion Ratin g Scale li nt p r eption f th rapi t-pro ided variable ar the mo t con i t nt pr dictor f improv m nt (Duncan & M ynihan, 1 d velop d to be a therm m t r that mea ur (Duncan, 2011 ). The t Ii tructur d th R wa 4). th temp rature f th th rap utic alliance am a th R and th fi ur al valuat th relation hip, goal and t pic appr ach and In th d and o erall c nn cti n (App ndix B). Th R i compl t d at the nd f ea h e i n. ach intuitiv ly by th eli nt on and i graph d cor r th are i1nilarly cal ulated out fa p our al i 1nark d f therapy. ibl 40 p int and graphed over the cour e of therapy. Thi graph i a touch tone to chart difference between e ion to guide the therapeutic proce s in a direction that lead to change. Th r i a cut off line at 36/40 that i con ider d to be the range for a po itiv alliance. Instance wh re the alliance i rated below that mark are discu ed to i1nprove the ways you are working together. Thi epitomize the culture of feedback as it normalizes immediacy and b ing able to talk through dynmnics in the therapeutic alliance. An alliance that strengthens over time is a significant predictor of positive outcomes (Duncan 2011 ). Chapter Three Methodology In the spirit of relationship reflected in DOl approache to therapy that valu the humanness of the therapeutic alliance I hav engaged in a per onal reflecti e practic ver the duration of thi practicum to di til my learning. Montigny (20 11) champion reflective ocial r lati n a a living practice to discov rand e plor th nuance and CLINI CAL REFLECT ION ntradi ti n including t d in a numb r f w try r p ar h n er ati n with c II agu p n r f1 Thi th p pi that I' m t n ti ha h n ur rk d ith. I ha unt rand 1 arn b ut m m ra th ompl it d a r f1 ti pr lf. Thi abilit t fm ti ti c un Th writing f thi r p rt i a culmin ti n f the r f1 tiv ntinu with my ra ti f my day . Thi in lud a a p ri nc and that ha all w d my lf in n w way 1 an If r f1 attri ut th twill ent r f1 uperv1 wn pe r up rv1 1 n w t bing my tap d J um aling and int ra ti n . I ha f n itting with li nt , a -facilitating a r ll r. t rativ ju tic circle attending w rk h p up rv1 wn and clinical meeting . upervi i n with Grohman pr f th mo t a celerating compon nt ed t be n I to k the opportunity to r rant f gr wth and r flecti n. i w and r f1 ct on a number f linical re urce . The e were each larg ly n w to me and the intention of including them in thi report help me incorporate the1n into my practice by de p ning my under tanding through writing. The e include a parent child play re ourc (Bratton Landreth, K llam, & Blackard 2006), collaborative problem olving (Green et al. , 2004· Green , Ablon, & Goring, 2003), the Duluth model , motivati nal intervi wing (Miller & Rollnick 2002), and aboriginal approache to healing (Duran, 2006 ; Hart, 2002). Chapter Four Literature Review ffective therapy r quir Yal m ' (20 2) acorn requir m re than more than a afl th rap uti all ian , ju t a il and wat r t genninat and matur into th CLINI CAL REFLECT IONS giant ak tr I pictur in my mind. M ntal health p r onal gr wth, and rnaturati n are hap d by appr priat interventi n within tru ting, tabl r lation hip . Ju t a am ndm nt ar an in f:D ctiv r p n corn1num ati n t hniqu [i ran ak apling o 1nay b ineffecti il rgraz d by foraging deer, with a per n wh la k th ability t r gulat . f[i ctiv int rv nti n appropriate] y addre th n d Jf- f the per n by starting with th eli nt' p rc ption f the pr blem and their in:D rmal the ry f chang . Th parall 1 of plant and p opl i h lpful [i r m a it n itize me to the hi torical cont xt of ea h per on I w rk with. Wh n c rtain plant in 1ny vegetable garden ar truggling I r pond with th know] dg I have to hape th conducive for it particular n nvironment to b d . When there i cr p failure, I inv tigate the environmental variable over the cour e of the ea on , to make en e of the plant' struggle. There are a number of way to contextualize people in their live . Attachment theory makes sense of human infant needs for table attuned parenting (Neufeld & Mate, 2004). Trauma informed approache under tand the effects of disrupted attachment and the neurological affects of chronic stress, anxiety, and abu e (Haskell & Randall, 2009; VanderKolk, 2009). Families are si1nilarly understood as emotional systems that shape a child's self concept and relationship with the world. We will look at these theoretical underpinnings to understand people within their life cour e. Just as it is unreali stic to expect a plant to thrive despite environmental or experiential adver ity thi literature informs the helper to the needs and functions of the people I work with. Attachment Theory. Attachment theory understands the nature of parent -child, adolescent, and adult relation hips. hildren need phy ical, motional, and p ychological proximity early in life. Attuned parenting provid s xt n1al ern tional regulation for a CLINI CAL REFLECTIONS child wh r parent m1rror c ntaining and ac pting fl ling a an important and w rthy a pect of a child elf. hildren rai ed in afl pr dictabl r lati n hip characteri tically mature int adult abl t maintain table relati n hip and dem n trat lf- nfid nc (Mat ', 200 ). attachm nt b ing "at th heart f r lation hip and P itiv attachm nt with one exerci c nflict re lution kill , uflld and Mate (2004) d cribe ial functi ning' (p . 1 ). primary car giv r cr at the fl undati n for a child ' ability to elf-regulat . It i imp rtant t n t that Oo/o fa child ' brain developm nt ccur during th fi r t year f life (Mat ' 2008). Pr dictabl attuned parenting facilitate thi d v 1 pment. An ab en e of attun d parenting adv r ely affect a child ' ability t develop a healthy elf-concept and capacity to elf-regul ate. Thi can manife t a di ffi culty 1naintaining relation hip a a child and a an adult. The lack of capacity pl aces children at a disadvantage to mature into healthy adult and are associated with an increased likelihood of adverse experience later in life (Tafet & Bernardini, 2003). Attachment styles establi bed in childhood are predictive of adult health. Bifu lco et al. (2006) find a predictive relationship between in ecure attachment styles during childhood and adult mental health disorders. "Even adults who are relatively selforienting can feel a bit lost when not in contact with the person in their lives who functions as their working compass point" (Neufeld & Mate 2004, p. 19). In a tudy examining stress responses in adults, Levine and Heller (2011) test th affect of adult attachm ent between adult partners by giving an el ctri cal hock to one partner alone and with the company of their partner. The experim nt m asured parti cipant' blood pre ure, heart rate, hormones, and rate of re piration a they received an lectri al hock. 11 of CLINI CAL REFLECT! N th In a ured ph hand wh n r g1 al indi at r w r r du ing th tta hm nt th and R ndall (200 ) d h ub tan urv1 nu rib th mpl t, nt tramna re ulting fr m Indian R id ntial mpl apr D Bruyn, 2000) . Th r tand int rg n rati nal trauma. H a kelJ d t un trauma" (p. 74). In ig n u pe pl a r d th di rupt d atta hm nt fIR m1 u ch 1 gi al H 11 r, 2 11 . m ry ha 1 (IR ) a a ' anada h p h ck ( d wh n parti ipant h ld their partn r latil al nt a m num r u way . f urviving (Bra n ir nm nt and r lati n hip ping m chani m p rp tuat adv lc h 1 and heart & r at d by th pcrien e fi r th ne t generation . tualizing maladapti e b ha i ur chall ng path 1 gy and create opp rtunitie fi r g nuin healing interv nti n . Di rupted attachment can pre ent in a myriad of way a children matur int adult . To under tand ymptom a tnaladaptiv b havior and coping behavior focu intervention to addr a per on' inability t elf-regulate in th context of a p r on' lifi . Left unnamed thi pattern can b confu ing and contribut to furth r cultural dysfunction (Duran, 2006) . From thi attachment per pective parental b havior i not a umed to be rational choice but a reflection f th parent' p ychological needs and coping behavior . Therapeutic experience that bring choice, direction, and meaning, offer an opp rtunity t build th nece ary kill to li v m new way. Complex Trauma. Adver e hildh inten e, p r i tent, r uncontroll ble ituation d xpenence ( ) are characteri ti all f threat or di tre in a child ' attachment b nd are described a complex trauma (Van d r Kolk, 200 ). ompl e trauma ha a dual effe t f creating h ighten d em ti n whil r du ing on ' abilit t CLI NI CAL REFLECT IONS lf-r gulat and b cur in th w rld (Mat ' 200 ). H ight n d m ti n with a deer a d ability t ub tanc abu elf regulate, an 1 ad t maladaptiv behavi ur (Mate 200 ) m ntal health (Van d r K lk 2001 , 200 anti ocial b haviour including iol nc ( c01nbin d uch a 2009), and urt i , 200 ; Mikulincer & hav r, 200 ). H u r and Hinri h-Lamm r (200 ) find that th perc pti n f threat can aus a tre reaction that lead t a h ightened internal e p ri n . TaD t an Bernardini (2003) find a trong correlation between e pen nee f hronic tre , anxiety di ord r and maj r depre IOn. A longitudinal primat tudy of three group intergenerational effect of chronic tr f mother-infant pair illu trate the . a h group f m th r-infant pair lived with different abilitie to acquire food. One environment had con istently easy foraging, another con i tently difficult foraging, and a third unpredictable food upplie . Th tre s experienced by mothers in the unpredictable situation exhibited inconsi tent, dismissive, and erratic rearing behaviours (Mate, 2008) . The infant of the e mothers gr w up to be anxious, less social, and highly reactive adults while the infant in the con i tently ea y and difficult environments matured into healthy adults. The environmental condition became emotional experiences of disrupted attachment, which increases the likelihood of further emotional distance in the next generation. Experiences over time shape the way our brain develop and function. Chronic stress affects the litnbic system and the Hypothalamo-Pituitary-Adrenal (HPA) system. he litnbic system i the etnotional center. Real, or perc ived, perience of chronic tress over stitnulate the sy tern causing emotional dy r gulation (Tafet & Betnadini, 2003; VanderKolk, 2006). hi s 1 ads to compromi d rational functioning and a CLINI CAL REFLECT IONS deer a d ability t apprm appropriate r p n cial ituati n , r r trie aluate c p1ng trategi impl m nt informati n (Taf-D t & Bernardini, 2003). imilar t the way that matur ak tr ar abl t ac n ugh unlight In i tur , nutri nt and with tand nvir run ntal adver ity, pe pl with tand adver ity through ari u c ping m bani m that may includ community upp rt, or i olati n. p n n piritual practic , ub tance u e, f c mpl uffer d by a apling that alter the pattern f gr wth and plant later in life. trauma ar akin to damage mpr mi e the tructure f the hildren ace unt for p ych 1 gical damage and are abl t thrive in adver e ituation . ertain m a ur ofp ych logical protection are c nd ned by ociety. Th e include workahoh m drinking alcohol to exc televi ion and movie . Other 1nea ur urviv , and , and indulgence of that include aggr ssive b haviour, intravenous drug u e, and exual promiscuity are viewed as per onal character flaw (Mate, 2008). All of these behaviours make ense in th context of each per on' life. Limiting pathology and engaging with people curiou ly is the first tep to becoming helpful. A controlled study of the i1npact of prenatal stress and fetal alcohol expo ure of primate infants found that these early stressors contribute to altered biological substrate , gene expression and brain functioning that significantly alters an individual' development trajectory (Schneider, Moore, Kraetner, Roberts, & DeJe u , 2002). The effects of these developmental disturbance present as decreased attention pan , reduced mobility and exploration, increased irritability, and alt red tre s respon e . The prenatally stre sed m nkeys were le s re ilient under ocial and environm ntal tre they show d disturbance behaviours of clinging to peers, d crea ed exploration, and decreased time u ed -D r play. wo hour after tr ful e p tienc the chr nically a CLINI CAL REFLECT ION tre ed gr u had 1 at d rti I whi l th c ntr I gr up did n t. ( chn ider et lle a1. 2 02). Th P ra entri ular H p thai mu (PV ) i r p n ibl fl r r 1 a mg c rti the d . Thi natural tr p r n r lax aft r a tr di a thi natural inabilit t ngag r p n ful natural fi ed a k 1 p that h lp a i m diat d nt (H u Hinri h r lf-r gulati n lf-r gulate (Mat ' , 200 ). M th d pamm (Wein ch nk 20 12). Thi Family y tern . an de amm r , 2 0 ). hr ni u 1 p int an ttachm nt patt rn tre au ing hyp r ar u al and an d alt ring eha 1 ur and u th an 1 int tan e u p n n e fhyperar u a! d t maintain a high'. an b d within the family a an emoti nal y t m (Br wn 1999 200 · Dattili , 200 · Farmer & II r 2005) . Functi nal familie ar characterized by motionally differ ntiated memb r abl to ex peri nee and re olv m tion and conflict. Platt and kowron (20 12) d crib differentiation a the "intrap ychic . .. ability to eparate thought from feelings and the ability on an interper nal 1 vel to balance intimacy and autonomy with th r " (p . 3 7) . Dy functional family sy tem create chronic tre undifferentiated per on (Bartle-Haring, Ro en, & or anxiety in the tith, 2002) . Thi an iety i generally expre ed in three way , including emotional r activity, emotional cutoff, and e1notional fu ion with other (Hooper & D Puy, 201 0). The most ba ic family tructure is a triangl . Triangulation i a k y oncept that de cribe apr ces by which a dyad , typically a couple, will include a third per on, typically a child, a an em tiona! reference p int. h wever the third member fthe triad ti k b hi i n 1mal human functionin g, ming in olv din unh alth wa b CLINI CAL REFLECT IONS b commg rune bed 1 ing a differ ntiat d n e of elf orr c iving projection (Farm r & G 11 r 2005). Any change in th y tern will cau v ntual goal of h althy differ ntiati n (Br wn, 1 Thi furth r chang with the 9). y t m appr ach 1nay e pand ur frmn ofrefl r nc fr m th w 11 -being of a ingle tre to that of an ecological y t m . In thi way w Interventi n addr an e alm n in the tree . r lati nal patt rn within the y t m to £ t r h althy d velopm nt. It i not nece ary to work with the 'probl m' m mb r of the fmnily to help th change to achiev y t m ympt m reli f. Healthy em tiona! diffl r ntiation between family member i the goal of therapy. Thi i marked by 1 reactivity, elf-re pon ibility, and emotional freedom (Brown 1999). Schwartz (1995) applie thi family y te1n under tanding t make en e of personal p ychology a the inner y tern and outer y terns tend to mirror each other. In an interview with Pedigo (1996) Schwartz describes how a per on' internal functionin g naturally reflects their family sy tern, which is a reflection of larger social tructures. Just as a family is cmnpo ed of numerous people, individuals are an aggregate of parts rather than a cohesive whole. Working with an individual require working with each part of the person as one would work with a member of a family. A fictitious example to illu trate this approach 1nay be a 1nan named J a on who attends counselling at the request of his girlfriend. Sh describes Ja on as motionally closed, silly, and unable to engage in conver ation. Ja on grew up with a father addicted to alcohol. Jason develop a keen awareness of social cu that led to difficulty creating trusting friend hip . Ja on' withdrawn nature wa adaptive within hi fmnily, but contributed to hard hip lat r in hi life. There i a part of Ja on that he itate b ing CLINI CAL REFL ECT! N vuln rab l . Ther a 1 k intimacy and want t b 1 ng and b an th r part that pt d. a h part i 1m u d with it intenti n . hwartz int m 1 r lati n hip li wn n wl dg , a pirati n that h lping a li nt r rgamz and diffi rentiat th th fun ti n fth t u th ir int mal 1995). ). T 1mpr nng r li f and larit (P dig th goal i t 1 cat th part y t m . r man I fa eli nt in rd r t differ ntiate th art fr m f part and t f part are under t he int mal r a tj n , and d t pla n th b undary under tanding elf by re rgamzmg tr m p iti n ( chwartz, f thr · manager exile , and firefight r . Manager k p th per n afi . Thi i th part f ur int mal y t m that make ure that the y t m ( elf) remain balanced and functi ning. In J a on' a e, th manager i the part that keep people at arm ' 1 ngth to n ur that h would n t be vuln rable. Thi i the funny part of Ja on. Ja on u humour to n ure that exil d part do n t disrupt the elf. Exile are p rceived a dangerou o manager control the ut ide world a be t they can to en ure that exile are c ntrolled. Manager don't take ri ks. There i a part of J a on that need to make j k Another internal part wi h which help him feel at ea e. that he could imply relax and get t know hi friend rath r than hor e around all the time. Ja n' e iled part may be the boy wh want to be accepted and afe. There ar part of J a on th t perceive that he will be judg d and firefighter c met put out the danger. Thi rna e th part of Ja n that giv up and run away. R al or p r eiv d danger of thee il d pmi b ing a ti at d i r pond d t b CLINICAL REFLECTIONS th part that i too c 1. 'F rget thi , y u lat r may b th way Ja n 1nak ur h i n't hurt by th w rld. Appr a bing eli nt a a umulati int mal runbivalenc f part can facilitat an pl rati n f c nflict or di cord . Thi take th form of interviewing and expl ring th numerou part fa per n rather than th individual as a c ncr te whole. Th r lati n b tw n part i the aggr gat part of a p r n an h lp re ol xp ri nc of the p r n. Int rvi wing th di cord between part . To recogniz and dif[i r ntiat th ir "part " help the client re rgamz th ir internal y tern to function appropriat to ituati n (P digo 1996). Ju t a boundru-ie in a family ' trengthening ub y t m facilitate improved functioning f that sub y tern, helping an individual differentiate inten1al conflict between parts of thetn e]ve bring relief and new po ibilitie for change and growth. Exploring the different part of a per on nonnalize ambivalence and accepts internal contradictions. It i important to prioritize afety and connection it i thought that parts will emerge through conversation. Parts can also be named and invited into ses ion. For example a counsellor may make a reflection such as "it seems that a part of you really needs me to know how hard you 've worked in the past to succeed . Can we talk to that part of you that i fighting so hard to be heard, your confident part, and give her space to talk?' The conversation may continue to explore when thi confident part come out. When does the confident part get to sp ak . With whom . Psychological part can b hum ru1ized and given characteri tic such as knowledge, intuition, deci ivene , intention, and r action. CLINI CAL REFLECT IONS 'What d th c nfid nt part want fl r y u .' 'Wh n d e th fighting p rt fy u kn w wh n t ' Wh n d Th y ur qu p ak up. nfid nt part g t ti n per diffi rentiat part nify trait nd hara t ri ti a part gi ing fi lf. Ju t a a iffi r ntiat d famil diffi r ntiated indi ual an find clarit and r li fb ackn wl 1 u t a let find re ol e a ging and und r tanding th ir part . I ha exampl n ti d th n nnalizing f-D t f int rvi wing th part fa p r n. or p aking with a li nt: oun 11 r: ' your bo ' a part f y u that eem t b fru trat d and angry with that mak it tempting to w rk from home and ther ' an th r part that want to b in the office b cau e he really care ab ut your taff. ' Client: 'yeah, thi might ound contradictory, but th r ' a part of me that want' nothing to do with tho two p opl , but another part that care ab ut my taff. " We continued to explore the e contradicting part . Being able to normali ze the client' internal conflict create pac for him to increa e in ight and approach re client attributed his strengthened relation hip with hi on to there I e. Thi lv h mad e with thi profe ional dilemma. My thought about IF remind me of the novel Life f Pi (Mart 1, 2001 ). Th tory follow th j urney of a boy and a tiger that c i t in a life raft for a numb r of week . De pite the animo ity and danger f thi pairing th y find wa y t c final chapt r the main chara ter ugg t that th urviving him elfwhil b ing at i t. In the hol gi al metaph r f . Th ti ger r pre nt a i 1 nt, angr , and ~ nfli t d CLINI CAL REFLECTIONS part of him elf. Alth ugh thi part i dang r u , to kill a part of hi lf. Th b y credit the int n e anim th imp rtan f n rmalizing and ity to hi elf i to kill hi urvival. Thi pecting multiple part t ry r mind n1e fa eli nt a a urce for id ntifying and nurturing client' m ti ati n. Chapter Five Model 1: Clinical Geograph y In order to hold the eli nt in th center of th th rapeutic proce th coun elling proce I c nceptualiz a a walk through a fl r t. Thi allow me t conceptualize th cour e of therapy in relation to the eli nt while drawing from relevant theory within the context of th therapeutic alliance. Thi include the client' fram of reference, perception of the problen1, re ourc and motivation. The landscape, plant , and animal of their geography repre ent the factor and dynamic that con titute the client's situation. These may include the client's perceptions, resources , relation hip , and p yche. I vi ualize the client in their geography both in session and while writing case notes to inform the course of therapy. The client' s desired outcmne is the destination of the hike, which i the top of the mountain. The client's theory of change is the route they choo e to get there. By walking this path together the client and I have opportunity to learn about the obstacles and opportunities of their psychological landscape. Together we explore opportunitie and setbacks involved in each path. Again I want to not that I help the client lead thi proce s, and that I follow in a spi1it of curiosity. CLINI CAL REFLECT IONS Figur 1. Mountain Impa abl Thick bu h River pa abl Figur 1. r pr nt th clinical g graphy in which the client and c uns 11or work toward de ired outcome repr nt d by a mountain peak . There are b tacl e and difficulties t achi ve goal . Thi conceptual mod 1 h lp frame the proce of therapy. The way a p r on b have in their geography i a rich ource for curi Reflecting que tioning or exploring the ity. can hape the proces toward th client' goal . A client, for example wa pointing out numerous exan1ple of how h r on had 1nisbehaved in the previou week. I perceived this to be imilar to her examining numerou plants despite stating that she wants to hike to the mountaintop. I questioned how naming numerou examples helped u work towards her goal and she realiz d a pattern of thinking that contributed to part of the rea on that he felt overwhelmed with her son. We chose one example to work with and refocused our work. The client's theory of change 1nay not result in their desired outcome, or perpetuate the situation they are trying to change. This creates oppo1iunity to elect a new route. There is a trust and safety built through th therapeutic proce s whereby a number f clients have asked me for advice. Other con1e to alternative approach on th ir own, and with others the pr cess of exploring inform multiple mall change that can re ult in desired utcome . CLINICAL REFLECTI NS Ther i part f m that want t ha th eli nt I w rk with lik a dri unanti ipat d e fi r utd n appr nt happen . r nthu i n a ingl J urn landmark P unit in a ar t guid and tra k th th rap utic ch an pre an u if th y numb r f y t , I h ar a rep rt n t ft r tra elling cam P d r u ing intuiti n. a map f what t d and wh r t g with r ag , wh -n B t fun ti n ran P unit b cam a ai la fa gr up f n wm radi r 10 kil m t r . Th gr up had b il r wh n tra king th ir and had n t b n u mg h ir d p d w rking and th gr up b came I mm n en by n tieing t fi r a c n idera 1 am unt f time. T and an b u eful, but they mu t be u ed within a wider t f kill . Duncan park (2002) c nclude that go d rapp rt i in ufficient t achi v p sitive re ult . kill with ut rapport are ineffi ctiv . Techni al kill embedded within a good imilarly therapeutic alliance make for effi ctiv th rapy. Thi i akin to u ing mountain ering n ibiliti in combination with GP A GP techn logy. 111ap, plant identification b ok hiking boot and a na k are u eful in their own way . U ing the ere ource with comm n mountaineering principle cr ate a afe, enjoyable experience that will lead to a view. Mountaineering principle are leatned and intuitive way of knowing how to mov aero the land. By und r tanding th way water shapes a land cape, one will have a en e of wher impa abl or dan gerou ar a may be. It will als be evid nt wher th bu h will b to thick for ea y tra vel. h R mea ure the alliance f the hik r , gi ing pportunity t communi ate if the relati n hip need to be att nd ed t ( ppendi ). Th c nver ati n ab ut the dir cti n f tra ). 1 ( pp ndi R fa ilitate a n lndi idualiz d r ice Pl an CLINI CAL REFLECT IONS (I P) i cr at d with ach eli nt arly in the th rap utic pr c at TFA to guid th cour of therapy. h I P con i t of tw or three goal with a bri f plan for each. Thi b mn the individualized map for ach lient. The plan and p cific goal cha1i ur route to the de ir d outcome. I hav found that client' g al mu t b u d a invaluabl t ol to focu th clinical w rk in way that hold th eli nt r p n ibl . F r e ampl a client truggling with being overwh lm d bynum r u tangential thought a h v nt in her li£ would pr ent num rou p k in e ion. By reflecting thi behavior within h r goal to sleep b tter we were abl to focus on addre ing her per everating thought pattern in se ton a they related to one of the main rea on he attributed to her poor sleep, her thought . De pite having difficulty creating change on their own the client is the best person to introduce me to their per pective , experience , and knowledge. uriou inquiry can deepen the work as the client' way of being in e sion com1nunicate the ways they are in their life. Attending to the meta-cormnunication contribute to both building the therapeutic alliance and becoming comfortable with the client's unique geography. It is through multiple trains and vulnerabilities that intimacy is created between client and counselor. As the client shares past experience of change, ob tacl e to growth, and precipitating factors , I gain valuable insight into their geography. Thi s collaborative route finding process i the heart of a DOl approach . The client i in the best position to be th xpert, and learning how to acce thi knowledge increa es the efficacy of th rapy. For exampl a client wanted to improve communication with hi on. During th £ urth ssion the client b gan talking about CLI NI CAL REFLECT IONS tr at work. Thi med to m that we were heading away from hi goal. I inquired how work place tre s i relat d to our work t g ther. The eli nt identifi d per ev rating thought contribut to hi irritability and relation hip with hi equality and fain1 the fom1 of tr on. Thi deep b li fin und rpinned hi di ati facti n at work and ran through hi h ad in ful conver ation at h m fl r th previ u three month . A w continued w rking t geth r the h art f th w rkplace tre rev lved around competition with a colleague ab uta promoti n. H didn 't really want the j bas it required more managerial work but he a1 o didn t want to e hi colleague receiv a promotion. By forcing hi ambivalence the eli nt cain to r aliz that h did not wi h to pur ue the promotion. Then xt w ek the client rated a higher OR core, which he attributed to reduced workplace anxiety and an experience of having fun and joking around with his son. Previous to this session we had been exploring communication techniques and parenting styles without ignificant changes in the ORS. Th right kind of change required me to step back and listen to the client's own understanding of what wa in the way of achieving his goal and moving from where he was tuck, not where I perceived he was stuck. By trusting the client in his own geography we were able to move towards hi goal in a way that worked for him. By exploring the tangential nature of work place tre s in relation to hi ex pre sed parenting goals we located a significant source of stress that contributed to hi short fuse at home. Working from a motivational interviewing frame of reference empowered him to make a deci sion that freed up en1otional pace to pursue po itive faiTiily interaction . By tepping ut of the way of directing th rapy and holding him a countable to hi goal CLINI CAL REFLECT IONS I witn ed m m nt and gr wth. By rienting th pr intuiti 1 kn w what n t ward hi g al h d d t chang . H n uring th li nt a guid he]p d u a e th appr priat path t ward hi g al. ffe ti g an dri the th rap utic pr c I ing apa ilitie fa eli nt t expl r and a hi lini ian. Pat r ld n and K u c n f chang . Thi training i f th audi 1 ctur and ur Goal ettin g. Pat r net al. 200 ) fram pro h nge th rwi the pr unkn wn t th h 2 0 ) utline an effe ti e way f r ating ful g al u ing th eli nt' lumbia and a op m way that acce ffi r d acr Briti h packag wa made available t m . hang a an int nti nal goal oriented t chang th ught and acti n . Probl m can b n a ultimate g al . omplaint contain goal . ' I'm totally out f hap ' can be r framed by aying I want to feel fit'. Thi utcom to feel fit i the mountain de tination f model 1. A number of immediate goal will lead to a chi ving thi . Immediate goal en i tize the per on to the actual change that th yare making that will coal ting their de ired outcome. c into m The acronym MART i u ed to frame appr priate goal . MART tand for; pecific, my own action oriented, realistic and time defined. pecific goal require a ingle st p to achi ve. Th xampl of g in g for a bike ride is u ed in the 1 cture as an example of a big goal. This goal i made into an immediate goal by specifying a new goal f pumping the tir f th bike. ucce ful goals are ' my own '. Thi ha two part . Th goal n ed t be mad e by goal mu t b p the per on wh is g ing bik riding. with ut the inv lvement f oth r . or example, t ride bik ertrud ' participati n. ' my wn' g l w uld , t in it ibl to a with ertrud mpli h rtrud , requir n a bik ri d CLINICAL REFLECT! N A ti n ri nt d g al r qmr d ing which i diffi r nt than fi ling al willlik ly n t fi el nJ yabl p int and ugg t gi m g n g al i t d . Thi r x iting. Pater If p rmi nt a n tal. (2 pt n r thinking. ) mph iz thi fi ling a th y an e a the mplifi d y a g al f taking a r la ing b th. Th g al n ed t b t t k a bath. R ali tic g al ha a hi m nt any g 1 b ha i ur 1 t rrn cl ar and a hi e bl fini h lin uld b c n id r d a failur . an nd p int fi r a g a l. it may b r ali tic t g fi r a bik rid . . With ut cl ar ehavi ural fining a 1 ar fini h lin in nee the bi cy 1 tire are pump d and r ali ti c g al m ay b t rid m y bi cycl fi r 5 minute . Tim d fin d g al are particularl y u eful to contain vagu g a! . If the bi cycle required m r maintenan than the pumping up f th tir a MART goal m ay b to p nd twenty minut to check bik and m ak ali t fta k . Tim d fin ed g al in vite particular time fram to m ake g al m re pecific uch a I will a k G rtrud e to go fo r a bike ride on Tue day. Thi acronym may e m impl e a pr s nted her in th Reggie, however, it is the impli city that contribut xampl e of Gertrud e and to it effecti v ne . M ART goal are reali tic becau e they require acti on fro m the p er on wh mak the goal. People become pow rful wh en able to exerci e abilitie within th eir locu of contr I. Reflection . arl y in the practi cum I poke with a FA coun ell r ab ut h w I enJ y u in g th a ked a qu R with cli ent . I de ribed how it help d me remain g al p ti n that di ann d me. " o how did y u w rk with li ent b [i r ific. H " CLINI CAL REFLECT IONS A I write thi rep rt I cann t itnagine w rking with ut clear goal . I have com to appreciat th way collaborating with eli nt to tnak efD ctive goal cr ate e plor and hape a p r thi th per ry of chang pace to n ' the ry f chang . Thi i of parti ular importance b caus an c ntribut to th pre enting problem. Tak , fore ampl , a n wh want t c mmunicate better with hi their xpectation i that th r ceive a haircut to how nn n . Thi i a gr at g al. H wever if d to g t their act together, top u ing drug , and m r pect, th n th parent ha an unhelpful th ory of change that willlik ly n t a i t with communication. Goal-ori nt d conver ation can cr at pac to xplor the client' a umed theory of change. Counsellor: o your goal i to communicate with your on in a calm way? Client: Ye , the arguing i n ' t good, and we often end up yelling at each other. Counsellor: how do you imagine getting from yelling to communicating? Client: well , I'm not sure, I guess I need help thinking about how to cormnunicate without blaming hitn, because he always say I don ' t understand what he's going through. I also have so tnuch anger at his dad, and he just needs to calm down. Counsellor: so learning some cmmnunication kills and working through orne anger are two ways that you imagine moving you towards better communication with your son? Client: yeah ... ounsellor: I'm going to w1ite th e idea down a part of our plan to realiz your goal to communicate with your son. A we're thinking ofwa to do thi w ne d t remember that ur plan need to be within your control. I get the n e that CLINICAL REFLECTIONS y ur on an ntribut t th r a int n but ifw wait fi r him t thing hang at h m . li nt: y ah, I d want him t h w t n t g t tri gg r d n that th argument happ n and ar hang wh kn w h w 1 ng it'll b b for hang , but 1 gu hi ang r and di re p ct wh n w ' r talking. un ell r: c rtainly. Par nting i lik a th rrn ffi cti e if y u 'r abl t b h u t tat n t a th rm meter. Y u will t and ta ili ze th rath r than r a tan match y ur wing d wn th pr it ' imp rtant fi r me t 1 am m tional lim t in th n ' ' t mp ratur '. a c !lab rati e plan r pr nt an invaluable 1 ammg that I am taking fr m thi p n nc . I am grat ful D r th effectiv in my work. Th c nver ati n fram th therapeutic proce confrontational appr ach de crib d a ben ficial by xpen nee and I feel mor and n n- and Wamp ld (20 11). The client i at hom in th ir p ychological g ography and a a curiou vi it r the coun ellor can gain in ight into the eli nt' frame of r fi renee. Ju t a I would a k somebody about a plant in their garden I inquire about people' that like moving to truggling?" xperience . "what wa anada by your elf?" "What ' th re for you when you ee your on uriou question may be If-explanatory, however the point i not to know, but to give opportunity forth client to name and proc their e perience. Tru t i built and maintained through genuine curio ity. Appr aching therap a a ene of pportunitie t explore with the client can b a pro s that build intimacy and connection. The wh le idea of talk therapy is to be abl to talk through chang . Thi pr ces ften reveal po ible inc ngru ncie b tween moti n and c gnition , which may c ntribute t th pre enting pr blem . nd er tanding the ir d ut m from th CLINI CAL REFLECT IONS client' fram of r fer nee and th change. ry f change unearth rich opportunities to create ffectiv g al 1n biliz a eli nt' p rc ption re ourc s and opportuniti to uhninate in g nuin chang . Thr ugh my work at TF A I ha e had pp rtunitie t 1 an1 h w to u a MI, P t ol uch and IF to help peopl navigat th ir p ychol gical ec logi . Technique and th ory enhanc my confid nee and ability to r main fo u ed whil working with client . I'm not expect d to know all of th an w r r be an xpert. I d n 't need to know all of the plant to reach the d tination of a hik . It i through the pr ce I have learn d to w rk with the client to a ce f th rapy that the nece sary information and detail within the goal driv n proce s. I have gained kill , but mor importantly I have learned how and when to u e them while working with people. Chapter Six Resource Analysis Below are a number of resources that I have explored over the duration of the ti1ne that I've spent at TF A. It is important to note that theory and technique are u ed in relationship with each client. I find an increased potency by adapting these resources within the context of each client rather than using the pure form in a psychoeducational manner. The principles are adopted for each per on in the language, metaphor, and therapeutic alliance. I have drawn on these resource while working with clients. Child Parent Relationship Therapy. Bratton, Landreth, Kellam, and Blackard, (2006) author a child parent relation hip re ur called hild Parent Relation hip Therapy ( PRT). Thi t n-week erie of group ' help parent relat with th ir childr n CLI NI CAL REFLECT ION in d v 1 pm ntally upporti e way . Th par nt i an e1notional thenno tat, not a therm m ter. Through tructur d playtime th par nt 1 ams how to r pond to th ir child in tead of r acting to th hild. W rking within th attachm nt r lation hip mp wer th child to di cover th ir pa i n and devel p into their own, unique, diffi r ntiat d If. tructur d w kly 0-minut playtim i the n ironment to mpower th child to be at the center of hi r her li:B (App ndi ). The phy ical and emoti nal environm nt i criti al fl r a child and par nt to r alize an moti nally table environment. Bratton et al. (2006) d cribe that 'when a child i drowning, don ' t try to teach her to wim' (p. 21 ). Th tructured playti1ne i the opportunity to ' learn h w to wim' in a predictable regulated space. Parent are guid d to create a safe, uninterrupted pace to play on a blanket with special toys. Parents are upported through the training program to join with their child as a follower and use basic reflecting kill to verbally track the child ' s play. Parent describe what they see their child do, feel , and think. It is important to recognize the child ' s power and effort. Li1nits are finn and con istent, including the ti1ne li1nit regardless if the child wishes to continue playing. Limits are presented as "if - then" choice . Thi helps the child learn consequences to certain behaviours. Bratton et al. (2006) give the example that "if you choose to use the play dough on the floor then you choose not to play with the play dough for the rest of the day". Inappropriate behaviour i addre ed tlu·ough the a ronym A T, which stand for acknowledge, communicate, and targ t. For example, ' itn n, ( ) I you want to swim in the puddle, but ( ) I'm c n rned that you may hurt your elf, (T) e CLINI CAL REFLECT J N 1 t' p la n th gra with th ball in tead'. a ru] ach part of thi c01nmunicati n rI p ifi and eha i ural in rd r [! r Bratt n t al. (20 )d n th a h uld b ten w rd mmuni ati n t be ffi cti pecial playtim n f limit a an n 1r nm nt in whi h hildr n predi ta 1 limit that r di rupti e b ha i ur aD ty thr ugh ha 1 ur cc m unn er da c pmg ld m 1 ad t p n nc . h p n n hildr n ma act out t achie e the ta ility and aD t th mp titi n 1n cur n e ary. d t [! l afe. urity, r aD ty for ther , and can p rp tuat un aD and unpr di tabl en 1r nm nt . D to ex rei pmentally appr priat ch are gi en to cr at opp rtunitie fl r a child th 1r ag n y. "Big ch ice D r big kid , littl ch ic al. 2006 p. for little kid ' (Bratt n t ). An exampl may b , ' do you want t w ar green or turqu i e to ch ol today rather than 'what do you want to wear'. Age appropriate ch ice emp w r children to facilitate a mea ure of control over their circum tance . " hildren who feel tnore empowered and ' in control' are more capable f r gulating their own b haviour, a prerequisite for self-control' (Bratton et al. , 2006, p. 41 ). hoice giving al o facilitate the development of th child' con cience, a children hav opportunitie to lea111 fr m their mi tak , they learn to w igh deci ion ba ed on pos ible con equence " (p. 41 ). The importance of honouring a child' choice i param unt. "Never do for a child that which h can do for him elf' (Bratt n t a!. , 2006, p. 51). Par nt mu t n ure that they are willing to live by th ir child ' choi . hoice mu t n t b g1 n m wa manipulate th child t ch o e th will f th par nt. r ating pp rtuniti that for th child CLINI CAL REFLECT IONS cr at to mak pportuniti fl r th child to devel p fl eling of po itiv elf- t em, omp t n e and u fulne . Thr ugh play the par nt 1 am ab ut their child cmnp t nci nd per onality. Th goal i forth child t exp n n e and engage with the world a an autonomou per n. Play h lp childr n p ri nc curi ity thr ugh thi proce f di covery and prob l m olving fa ilitated b the parent. Play i an opp rtunity t catch and nurture the park of a child' interet to d child' effort and pr c Parent 1 p pa ion fl r life. Prai i given to encourag the rather than the product. imilarly learn ab ut them elve thr ugh the proce of containing the play experienc . Thi i de cribed a being an emotional thermo tat in tead of a thermometer. Rather than matching the child' emotion the parent learns to accept, reflect and contain the child in their experience. A child' experience of hearing their parent's emotional reflections fosters emotional in ight foundational for developing elfconcept and emotional regulation. Collaborative Problem Solvin g. I had the opportunity to attend a one-day training with Ross Greene. I had already been influenced by Greene' Collaborative Problem Solving (CPS) approach as I had read three articles (Greene, Ablon, & Goring, 2003; Greene et al., 2004; Wolff, Greene, & Ollendick, 200 ) and acce ed online lectures through Greene's non-profit organization: livesinthebalance.org. The opportunity to engage with Ross was an illmninating experience that help d organize tny thoughts around disruptive and maladaptive behaviour and how to engage in effective change making processes. The effl ctivene s of thi approach is videnced by a tudy c nducted with children diagn ed with oppo iti nal defiant di order (Gre ne t CLIN ICAL REFLECT! NS al. 2004). w p rent hild gr up w r u B tt r ut m w r r rted fl r P rati n int rventi n ffl cti a um p pi u un mati beha d pr bl m an 1 gging kill . ha i ur- b cau d wh nth t ing b ha i ur relati nally. 1 ing ( p ) und r tand m ympt 111 of a p r P with parent training. at nd f tr atm nt and fl ur-m nth p tr atm nt whi h p int t th b nefit lla d t compar b ha i ur ar hav th ympt m n t cau t th mand kill t m ur a reene f th ir en ir nment. Maladapti e b ha i ur re ult fr m an n ir nment that d mand m r kill than an indi idu 1 ha . Thi difD r nc b tw n d mand and kill i de crib a d pr blem . an un nd r tanding a p r n ' p r pective ofth un 1 ed pr bl m i th fir t t p to und r tanding how to olve th pr blem. Pr bl m are d fin d in pecific behavi ural term . We will u e the example of an eag r tud nt that regularly di rupt h r ocial tudie cla . The t acher et a time and plac tom t with the tud nt that allow for privacy and genuine communication. Thi fir t tep requires naming the tudent ' behaviour in ord r to explore their exp rience. The que tion may be fram d like thi "Jane, you em to have difficulty rai ing your hand in ocial tudi , what ' up?" Notice that the ob ervation i fram d in t rm of the exp cted b hav iour of rai ing on ' peaking. Thi i different than "Jane, y u are calling out an wer what' up?" where the undesirable behaviour i named without the p cifi conte t of ocial tudie . W r yet, w uld b to confu an impul ive tudent, what' up ." Jan with h r b ha i r b aying, "Jane, tatem nt like thi will like! 1 ad t a defl n i reacti n and lead away fr m collab rati n. u ar CLINI CAL REFLECT ION r n de crib tru proc of exploring th p r on' concern a 'drilling'. luti n i not po ibl . With uta cJ ar idea of Jane' p rc pti n a mutually agre abl Drilling i important to g t Jan c nc m nd p rception f the un lved probl m on the table. Jane 1nay id ntify an ed to ucceed a the cau e £ r h r behaviour by aying "w 11 I don t u ually under tand my oth r c ur under tand ocial tudi and I ju t get o ex ited t prov that I and I want a go d mark' . D pening the conv rsation may re ult by refl cting the ineffectiv n of the behaviour. "W 11 , judging by the amount of tim you p nd in th principal' offic do n 't mak it eem lik houting ut the an wer i h lping your mark ". Th conv r ation c ntinue until a lagging kill is identified. Once Jane' concern are expressed the teacher' s concern are presented in pecific behavioural t rm . The teacher may ay "while I appreciate your eageme sin clas Jane, I am concerned that other students have difficulty focusing when you speak before it is your tum". This statement is void ofblatning, or making Jane wrong. The goal is for both parties to be able to talk about the behaviour in curiou ways to eliminate the need for the behaviour in the fir t place. Durable change is there ult of both people cooperating in solutions. Both versions combine to define the unsolved problem. With both Jane and the teacher's problems on the table they are now able to generate a plan to help her ucceed . The teacher may start this part of the conver ation by saying "I wonder if there i a way ... "Thi is the time to brainstorm people' needs. lution that are mutually agr eable and reflect b th CLINICAL REFLECTIONS An w rang f po ibilitie em erg from thi collaborative approach to lving probl m rath r than imply addre ing th negative b haviour . Jane may ugge t that itting clo r to th teach r during o ial tudi of an d to ek th t ach r ' att nti n by blurting out an w r . Thi i diffi r nt th nth t ach r unilaterally d contribut t anim 1nay h lp h r maintain focu and hav ignificantly iding t m v Janet the front that may ity, or re ntm nt t ward th t a her. By b ing part of th olution Jan i b tt r abl t w rk t ward h r own g al that mutually benefit the teacher and the cla . Th y may try thi solution and it may not work, however the tru t and empathy e tabli h d through the collaborative proce bett r po ition th m to ucc d. Thi contributes to a tronger relationship and creates a foundation to di cu Engaging in the proce new olutions. i a ucce sand movement towards po itive change. Durable solutions emerge by addre ing the kill required for Jane to ucceed in the social studie classroom. In addition to trengthening the relationship between teacher and student, Jane experience opportunitie to grow and learn the skill he is lacking through the process. In concert with strategies to help Jane ucc ed, the trengthened relationships and skills will mitigate or eliminate further situation of inappropriate behaviour . This won't happen overnight, however through the process of olving problems Jane and the teacher will develop approaches that work for the cia s, for the teacher, and for Jan e. Jane 's principle lagging skill is diffi culty considering th con equen e ofh r action . She al o has difficulty interpreting ocial cu and classroom rul . ial tudi CLINI CAL REFLECTION may b n fa nun1b r of plac tudie will affl ct h r ability t that Jan truggl . an1ing th kill to handle ocial lf-regulat in other area of her lifl . I am in pir d by thi approach that tran fl rm a hi rarchal r lati n hip of paren child, coun !lor/client, or teacher/ tud nt int a co perativ r lation hip of bared re pon ibili ti and 1ight . ach p r on ha th r pon ibili ty to ucceed and the right to be involved in planning for ucce . tabli hing a r p ct fl r both p opl ' aut nomy create th opportunity t h lp a truggling per on ucc d, it tr ngth n th relation hip and affirm ind pend nt I p rceive If-concept . P a a maturation proc s whereby people become autonomou cmnmunicative problem- olving individual operating from th ir own ag ncy and unique place in th world . Through thi proce people may become aware of where one ' self ends and the other begins. Thi 1nay be part of a foundational understanding of e1npathy that underpins personal interdependent autonomy. More extren1e behaviours such as swearing, blackmail, or as au1t, are more severe, than the example of Jane. CPS may not alway be appropriate, but healing and negotiation are possible when conflicting needs and lagging kills are addres ed. Built on principles of sovereignty, interdependence, and elf-re ponsibility, experiences of CP may inform the next generation to become healthy members of ociety. Dulu th Model. A series of wheels developed by the domestic abuse intervention program in Duluth, Minnesota. The e psycho-educational tools ar acce sible online and are useful in naming the way power is exerted through th way peopl relat . Identifying coercion and power is pre en ted a a critical component of changing CLINI CAL REFLECTIONS manipulativ or abu iv behaviour. An equal numb r ofwh el addr healthy and abu iv charact ri tic of relati n hip. The wh 1 ugge t that p rp trat r engag intentional patt rn that maintain p w rand contr 1 in r lati n hip . U f fl rc and th thr at of fore characteriz th power and control wheel. Th e includ c rei n, intimidation, i olati n, 1ninimizing, denying blaming, withh Iding finance , and cultural norm of rna culin domination. Each ofth b havi ur denie an itnpli d independen e, or overeignty, of th partner to exi t a hi or her own uniqu per on in th world. The equality wheel pr nt approache to relation hip that honour differenc and de1nand r pon ibility which r pect the ther per on' right to b th ir own per on. Thi includes behaviour uch a negotiation, li tening creating safety upport, accepting re pon ibility for elf, baring parental respon ibility 1nutual agreement, and making deci ions together. It is important for both partner to engage in simultaneou change frmn a confrontational power over' way of being to a 'power with' way of being. Two wheel focus on abuse and nurturing relationship with children. Threat , intimidation, isolation, put down , using adult privilege, and withholding basic need ar all inappropriate ways to control a child's behaviour. Manipulative interactions with children disrespect a child' inherent right to be their individual per on. The nurturing children wheel explicitly natnes the right for children to have their own fl elings, friend , activities, and opinions. The caregiver is held responsible to contribut to create genuin physical and emotional safety for the child. Power permeates all relation hip . The Duluth mod I i a p ych approach to challenging unh althy behaviour. Dutt nand ducational orvo (2007) th roughly CLINI CAL REF LECTIO NS critique th Duluth mod I a an ineffective and clinically un und approach to interper onal vi lenc (IPV). A a p ychoeducational approach the 1nod l a ume IPV re ult from g nder n rm and th rational acti n p w rand f tn n again t w men t maintain ntrol. " videnc that patriarchal belief: cau e viol nee ha very little empirical upport' (Dutton & rvo 2007, p . 62). Per onality di turbanc i a b tter predictor f IPV than g nder. Thi i evid need by the recent] y relea ed hoenb m report following th murder of thr e childr n by th ir mentally un table father in 2008 (R Y, 2012). Dutton and rvo (2007) areal o critical of the implicit a umption that IPV i a unilateral flow of violenc from a perpetrator to a victim. Thi doe not repr impli tic view of IPV nt the relational nature of IPV. Dutton and Corvo ugge t IPV is better understood a mutual violence a evidenced by a national survey conducted by stet and Straus (1992) . Behaviours are not entirely rational. The things a per on does reflects cultural norms, neurobiological development, interpersonal and intimate relationships, and destructive behaviours that result from early trauma experiences (Courtois 2008). VanderKolk (2009) site a tudy that reports 75o/o of perpetrator of child exual abu e report to have been sexually abu ed in their own childhood (p. 3). The e characteri tic are considered cmnorbid conditions rather than part of a comprehen ive exploration f the antecedents of IPV to infonn effective interventions. Thi is not to excu behavior, but to challenge simplistic understandings of IPV that inform ineffective intervention . I appreciate the way that the Duluth m del present abuse a the tran gre ion of a per on' autonomy to be an ind pendent life force. Framing power in term of the re ponsibility to nurture, upport and create afety for tho in on ' car i an e ell nt CLINICAL REFLECTIONS tarting p int -D r an int rv nti n. H w c ntent d on er ati n . If IPV r ult fr m m re entrenched p r int rper nal pattern f alati n th n p y h that it i 1mp rtant t criti all r Dutton nd th rap uti P y h then rmati p w r th t m n h ld in rv ' (2 07) ugge ti n that th anadian uluth m d ]lack a nal reality and the int rp r nal uple. du ati n i in ufficient t alter the r lati nal pattern f abu f em ti nal dy r gulati n that p rp tuat in tanc c nt nt f th Duluth m d I, p ych Dutton and nal and ducati n will r main in ffective. l agr t chang th p rp trat r intraper r ality f th etiol g er th rapeuti interventi n r qUir m r than rvo (2007) ugg unacceptabl . They cite a ducation i inad quat t f IPY and th . De pit the u eful reat meaningful change. t that th 50o/o recidivi m rate by ne uch group i BT approach to working with perpetrat r achiev d a 16% recidivi m rate ba d on wive report at 2.5 year p f IPY that t treatm nt. A 21% recidivi m rate 11 y ar prior to completion ba ed on police report (Dutton and Corvo, 2007). Aboriginal Approaches to Health. ree ocial work cholar Micha 1 Hart (2002) frame healing a a journey toward mino-pimati iwin. Thi concept i de crib d in numerou way that capture a complex under tanding of th good life. Min pimati iwin i broadly characterized by non-interfer nee, non-judgement, and determination. The colonial proce i ba ed on principle f greed , elf-ri ghteou n and dominion over other . Health and healing happen in imultan u wa m rgm g ial hang within fr m individual and c llecti ve chang th t int ract familie and n ti n . The way t ward health and who! ne If- t h n g and r i t th CLINICAL REFLECTIONS col nial fore a Hart (2002) write ''th y ar fore d upon u but a they exud from u " (p. 4). Health and h aling ar imultan ou ly dir cted by external and int mal r alms wh re ea hindi idual i at on autonom u and a part of family community, and nation. oll cti gratification r p n ibility i addr d through ut Hart' (2002) finding . " elf- nvy and j alou y mu t b r placed with upport and a commitment to one another' (p . 3 ). Th way to tran c nd gr ed lf-righteou n s , and dominion i to en ur that that "children mu t once again b plac d in the centre f th famil y, community and nation" (p. 33). Ther i a deep en e of th e communal nature of minopimati iwin that i r alized through each individual per on ' abili ty to li v a good li fe ba ed on interdependence, humility and elf- determination. The good life i under tood as ocial and ecological balance at na6onal, cmrununity, famil y, and individual levels. Imb alance, discom1ection and di shannony are dynamic forces that require sustained intervention to create and maintain balance. Individuals are responsible to pur ue health in their own lives and contribute to enviromnents that sustain and perpetuate health. "When the cycles directl y involving people are in harmony, people are utilizing their own volition - hence power - to help the1nselves heal, learn and grow" (Hart, 2002, p. 53). Over this time the healingjoum y contributes to greater power and support for others to engage in healing, learning, and growth. The inseparable nature of individual and coll ective well-being and the coll ctive goal to realize a good life is unique to other approaches. -- duardo Duran (2006) describes diagno i a a naming cer mony in whi h pati ents bee me inflict d wi th a n wid nti ty of b ing ick that aturat their CLINI CAL REFLECT IONS p ychological mak up. Thi differ from the purp e of traditional naming c r moni that ain1 to "r tor a relation hip with the energy of the ickn antag ni ti purp f diagn in t ad of the fearful i in W t m h aling" (Duran, 2006, p. 32). Drawing from c nv r ati n and xperience with traditional healers, Hart (2002) de:fin healing a am v m nt fr m di conn cti n t onn tion. onn ction within a per on' thought and m tion d crib individual h alth. ocial w 11-being i realized wh n h althy individual relate with th r in non-interfering autonomou way . In thi way per anal well-b ing i central to realizing collective harmony and health in traditional h aling. Thi relation between individual and call ctiv health i a continuou proce that occur in cycles in re pon e to development. As ext n1al cycles in a per on's life are in harmony, a per on becmnes more effective in utilizing their own volition to engage in learning, growing, and healing. A good life describe this life long proce s of maturing in physical, e1notional, piritual, and 1nental aspect throughout a community. Well-being i understood from an inward focus of an individual through to interper anal healing between people. Collective health i a function of individual health. Particular healing interventions are communal in nature and take the form of circles. Four types of circles are described as talking circles, sharing circl , healing circles, and spiritual circles. This approach to healing and h alth is de cribed a a cyclical system that create an atmosphere of cooperation and equality. The mutuality and upport within the circle i the environment in which everyone becom able to make change in their own life. Acceptance, humility, autonomy, and elf-deten11ination provide th foundation for circle w rk. hi prin iple of autonomy and lf-determin ti n i th CLINICAL REFLECTIONS foundati n of circle . Hart d cribe autonomy mb died in th principle face ptanc , humility, and auton my. Hart (2002) li t a ample li t f parameter : 1) Y u b long her ju t be au e you ar h r and for n other rea on. 2) What i tru fl r y u will b d t nnin d by what i within you, by what you dir ctl fe 1 and by what you find making n within y u. The way in which you live in id y ur lf i important. 3) Our fir t purp 1 t make c ntact with each other. 4) We will try to b a hone t a po sibl in expre ing who we really are and what we r ally feel. We will atte1npt to xpr s a much a we can 5) We willli ten to the person in ide of each of u , and we will take ownership of our feelings. 6) We will respect and listen to everyone. 7) Everything discus ed in the circle is real, and we do not pretend that it i n't. 8) Any decisions made within the circle need everyone to take part in some way. 9) I am responsible for protecting each member's place within the circle. 10) I will ensure that everyone in the circle is provided with the opportunity to speak and will ensure that you are heard. (p. 79) Good conduct involves non-interference and a non-judgemental r lation hip with the affairs of other and their self-determination. lder Jim anipitatao ay "it i u ele to confront each other, my relatives. It is better to ask for unity, to work togeth r, to think of our grandchi ldren. Thi is the ree way" (Hart, 2002, p. 4 ). CLINI CAL REFLECT IONS Motivational Interviewing. M tivati nal Intervi wing (Ml) p r pective of change cmnplem nt a D I approach. Mill r and R llnick (2002) d crib MIa a that r pe t th au ton my f th eli nt. From a compa ionate collab rativ pro pirit f curi ity th coun 11 r j m with th eli nt to upport and guid th client thr ugh their chang pr ce . Th pot ntial for change. lient' beli f that hang i po ibl buoy the pectan y i a p w rful factor and i built thr ugh r lation hip. Moreov r, by working fr m th client perc pti n of the problem, th ory of change, and available re urce increa e their ability to cr at change. MI pri riti ze acce ing th client' motivation to change. Change i und r tood a a natural proce that i con tantly occurring. Durable change i th re ult of a client acting from inner motivation. A Miller and Rollnick (2002) write, change is "not about more treatment but more voluntary treatment. Something happen with continued motivation" (p. 5). Re istance is understood as a natural experience of reluctance or ambivalence. Resistance is conceptualized as both an interpersonal and intrapersonal phenomena. In this way interpersonal resistance is not an impediment to therapy, but the place where genuine work begins. Ju t as a journey starts with the first tep, the proce of therapy is an ever-emerging site of exploration and potential change. Far from being judged a a negative client attribute, resistance is understood to be a normal, healthy behaviour. Resistance may play an i1nportant function in other contexts of a p r on' life. Re istant behaviours include intenupting, changing th topic, not an w ring, and arguing. Th reluctant b haviours erve protectiv function in-D tm d by prior exp rien CLINI CAL R FLECT IONS xp n n beth it fr i tanc in f th ra it elf. T u - -w r wa u ed a am taph r thr ugh ut th t nal r i tan int rp r un li nt: 11 r: in th th rap uti allian e. u h uld r all ah but it n -day cour e t r pr nt ampl might c t p laming p pl . e n t reall matt r, th y' r n v r g ing t change anyway nfr ntati n an train and damag th th rap utic alliance and i kn wn t be in ffecti in r ali zing p iti th rapeutic utc m ( rcr & Wamp ld 201 1). MI ugg t that the c un 11 r put d wn th 1r nd of th r pe and curi u ly j m th client b pi ring their p n nee fpulling nth r p . MI i m a ociated with ub tanc m1 u e. For xample, a eli nt r t ft n ting pre ure to quit moking from hi family willlik ly n t benefit fr m a c un ell r i1nilarly arguing for change, and f£ ctively picking up the rope. From an MI per p ctiv th fir t tep i to join with the client and xplore their exp rienc ofbeing convinced . oun ell or: it ound like you face a l t of pr sure in your life to quit moking. lient: yes, there isn't a day that I don ' t£ el a harned of the habit, and often I' ll m ke to ju t calm down from the tre un ellor: it ound lik at h me. moking erve an important function 1ight now, and quitting could leave you mor tre ed out than you ar now . lient: w ll ye , but I' ve been coughing a 1 t and want to tart taking car of m y health so that I can be a g d dad £ r my kid , the ' r pr tt y ung till. In thi example the c un ell r j ined with th vert the licnt ' ide f th tug- -wart pull in th li nt metaphori all am dir cti n b g nuinel mg CLINI CAL REFLECTIO NS ugg ting that an attempt t hift fr m hi utright quit d e n t haract ri ti d fl n i po iti nand pre ent a de p r c nc m to be h alth fl r hi fa1nil . B r lie ing int rp r in trap c' nal re i tan pl r d fr m an 1 Th train r fram d th f c un onfid n 11 r un and unou ity, calmne und lik a g od id a. Th eli nt then pace 1 appr ach pre nt d in chapt r four. pirit fMI in ight principl nn p lor t dn , de cribed a the cr ativity, c mpa ion, clarity, urag (Mar hall , 20 12). Th ional t uch t n r nat with m and ar a r 1nind r t maintain my wn h alth including 1 ar differentiati n with eli nt . lient can em ti nally affect m and I find the c' effectiv remind r a I prepare my lf befl re each MI ngage chang a a natural phen men n . Readine , willingne are con idered to be the thr and ability c mpon nt nece ary for change (Miller & Rollnick, 2002). It i important to under tand wh re the client i in r lation to the e to work effectively. Procha ka, DiClemente, and Norcro (1994) conceptualize change a a 6- tage proces , including; precontemplation, conte1nplation, preparation, action, maintenance, and termination. hange doe not occur in a linear proce , and peopl may find them elve moving through the e tage in non- equential way . Thi mod 1 h lp frame the nature of appropriate intervention . Precontetnplation describe a per on who doesn ' t identify a proble common example is a per on who uffer fr m addiction who e family m mber ar con en1 d while the per on denie that there i a problem . I imagin thi precont mplativ an un prouted eed . or this r a n it i imp rtant to tat t me along id the li nt to - plor their experi nee and relation hip with change. Ju t a a d r quir peciti CLINICAL REFLECTIONS n ir nm ntal c n id rati n b fore it will prout, relation hip i th fir t nee tabli hing a collab rative ary tep wh n working with omebody who i precont mplati nt mplati n de crib change and r maining th a p r on wh arne. Thi i e both po itiv and n gativ a p ct t imilar t a newly prouted eed that i b ginning to grow, but ha neith r firm r ot nor fully d v lop d leave . Working with a per on at thi tage require pati nee a th eli nt explore th ambival nc within themselve between the option . Refl cting and validating the p r on' ambivalence upport the client to confront and r olve their internal re i tance. Paraphra ing and open- nd d que tion ar h lpful at thi point to xplore each pmi of the person (Marshall, 201 2). Preparation describ the client a he move towards are olv . Thi is vident in the way the client talks about change. This change talk include cmnplaints, optimism, convictions and necessity (Marshall, 2012). Recognizing and supporting change talk help people move towards the action phase. Confidence, ability, and willingnes are three components that are important to attend to . Often scaling questions can help the client prepare for a successful change strategy. When tran ferring a e dling from a greenhouse into a field, or garden, there i a process of 'hardening th m off. This describes exposing the plants to direct sunlight and wind during the day and protecting them at night in preparation for the um·egulated climate of the field. Once the per on is confident, willing, and able, then we move to the acti n pha e. Action requires continued upport of change talk through r flection and exploration with the client. Mar hall (20 12) ugge t a goal dti en proc ba ed on future expectations, pa t ex pcri nee, and wi dom. It i imp tiant to r m mb r that thi CLINI CAL REFLECTIONS n t a linear pr c proce and that change will ebb and flow. i 1nea ur d a ontinuing to engage in the ucc Maint nance d cribe building chang talk and monit ring goal and e pectati n. t thi point th li ent i m tivated and working toward change. upporting th per on by h lping them ac r urce and recognize opportuniti i th focu of th work. Thinking ab ut the e d m tivat d t grow the plant i now finnly e tabli shed and require 1ninimal care. hang i a liD long proce of making deci ions. Termination de cribe the ending of the coun elling relation hip . Chapter Seven Model 2: Psychological Ecology I conceptualize intrapersonal change in a separate mod el I describ as a person's psychological ecology where I liken the cli ent ' process of change toward s desired outcomes as the growth of a plant towards the sun. Framing psychological experi ences in ecological terms sensiti zes me to a number of nu ances of therapeutic interventi on . There are three main point of interventi ons when working with plants. A gardener can attend to the health of an individual plant by attending to the urrounding plants competing for un, nutrients, and water. The gardener canal o adj u t the environmental variable of water and nutri ents. All annual plant growth is predicated on seed germination. The phy iology of the indi vidual plant including geneti c makeup and the viability of the eed that the plant genninated from. CLINICAL REFLECTIONS Peopl i1nilarly xi t within cial context and relati n hip that influence the indi idual' well-b ing. Th r lation hip are beyond the control f either th coun ellor r the eli nt unl m inv lved for afety cone m . A coun llor i polic b i1nilar to a garden r a b th are limited by th autonomy of th p r on and plant re pectively. A gardener plant d with g d germination and att nd t the environm nt in which the plant live . A a gard n r adju t th nutri nt , xpo ur to unlight, and irrigation. A coun ell or xplore the client' w rld through their fran1 of reference. Thi may include the client' r ource , goal m tivation , abilitie xpenenc and n d , helping th , acce , and mov toward hi or her goal . However not all e d germinate and not all people are able to find motivation, make goals, and access resource . In the e instances I attend to the harmony, or disharmony, between the client' s thought , emotions, and behaviour . I've found that people become more aware of opportunities for change as they make conections between these part of them elves. At thi point in my career it seems to me that the ways the e three aspects of our psyche relate to each other reflect our ability to function and withstand stress. Duran (2006) uggests adopting Jungian typology onto figure 2.2 below. The three axis' represent six directions and the point of inter ection repre ent a eventh, inward direction. Figure 2.2 vis ually represents the surface of figure 2.1. CLINI CAL REFLECT IONS Figure 2.1 Figur 2.2 igur 2.1 r pr ent thought , em ti n , and behaviour as a continuum on each apacite af£ ct the whole. The piritua] elf i a 1 . Imbalanc b tw en th repre ent d by the eventh inward direction wh r the three axi ' int r ect. Figur 2.2 repre ent th xten1al hape of the mod l. The pherical hape reflect a balance between the thre capacit of thought, em tion and b haviour urrounding the piritual cor . Each axi of figure 2.1 repre ent two mirror image point . Th middle of each line repre ent low int n ity, and the end of each line represent an extreme po ition. Vigerous exercise are repre en ted by an outward movement toward each end of the physical axi . An experience of intense emotion and behaviour, without in ight, are pictured below: Figure 2.3 Figure 2.3 shows the shape of a heightened emotional experience, with inten e behaviours, and limited reflection or insight. Notice the asymmetry between the a i '. This three dimen ional model helps me think about the cli ent in a dynamic way. The flat shape depicted in figure 2.3 is less resilient to e temal e ent then th balanced shape depicted by figure 2.2. I imagin an appropriate re ponse to an inten pen n as an equal height ning ofbehavioral, emoti nal , and cognitiv fun ti n depi ct d of CLINICAL REFLECTIONS figur 2.2. D calation fr m an arou d xperi nee can i1nilarly b imagined vi ually in thi way. I th eli nt able t engage th e part of th m elve equally? Which part cau e pr bl n1 . What i it lik to think about thing all of the time. Balanc d in ten ity on ach axi cr ate th ball hape of figure 2.2, which r pr nt a tabl en of lf. A ball or egg hap , ar re i tant to xtemal force . Larg imbalance b tween th axi cr at a non-circular hap . Th e hape ar 1 re ilient to xt mal pre ur and r pr nt di harmony and di r gulation. In my expen nee the identifi d imbalance need t b attend d to in ord r to help a per on take direction in th ir li£ . Thi mod 1 is dynamic and changing to reflect the way people re pond to experience throughout their liv s and represents strength and well-being a a dynamic tate of being in both interpersonal and intrapersonal contexts. Ju t a a eed germinate in certain condition , effective coun lling results from an alliance that creates a space for a person to sprout. In this way coun elling can be con idered to be a greenhouse where the environm ent is regulated to entice people to find , nurture, and shape the direction they decide to pursue. In my experiences of organic farming there comes a point where the plants need to be moved from the greenhouse and planted in the fi eld. We must remember this, as our work with clients i to foster and support growth that will serve them to be autonomou , self regulating, and capabl to continue to grow throughout their lives beyond the regulated pace of an agency or office. People are hap d by experiences over time. This is evid need by the lit ratur that attributes malad aptive behaviour, m ntal health, and ub tance abu context of lived experience and coping trategi (Mat ' , 2008 ; Tafet within th 8 rnardini, 200 CLINI CAL REFLECT IONS Van d r Kolk, 200 ). A lack f per onality di order If-regulation di torted thinking, anxiety, addiction, r 0 D, may b functional barrier to achieving one' goal . Thoughts. Thinking trap and unr ali it goals can perpetuate the fe ling of being stuck. BT approach addre help hape int n e, or extre1n th cognitive axi of figur 2.1. Goal can effectively thought into mor moderat th ught c nducive to change. llik n the relation hip b tw An effecti n goal to the way the un guide plant to grow. goal can be u ed a an ord ring principl to k ep emotion and behaviour in check. Goal directed coun lling canal o bring opportuniti for change into focu by eeing th relation hip between part of one's life. To under tan.d the rea ons why a branch grow from a certain part of a tree is b t under tood by lookin g at the neighbouring foliage and openings in the canopy where there is acces ible sunlight. Sitnilarly goal centered counselling may result in unexpected change for the client. The counsellor has direct access to the client's goals, and must work collaboratively with the client, as only the client is able to access there ources in their life. If there is an absence of nutrients then it 1nay be unrealistic to promote change or growth and the focus may shift to building resources. It is important to explore thoughts that obstruct a client's ability to realize their goal. It has been tny experience that careful attention and genuine curiosity to unhelpful thoughts connect to unresolved event , or relationships, that obstruct a client' ability to think in clear ways. Emotions. Emotions are important indicators. Feeling afraid dming turbulance on a plane is an appropriate respon e to a ituation out ide of one' control. However, chronic anxiety throughout the duration of a flight de pite the tatistical safety f flying in anada, i maladaptive. xp ri nee of chronic el at d emotion an r ult fr m an CLINI CAL REFLECTIONS inability to lf-r gulat for a number of r a on . Figure 2.2 ymboliz the ways ur xp nenc and p rception can hape our thought , emotion , and b haviour a the elf c ntain an intrap r onal en ironment. In my p rience at TF , r li f can r ult from expre ing inten emotion . It ha b n imporiant fl r m t r m mb r not to a ume what an experi nee mean for a per on. F r xample, if a client' fath r di d it may be ea y for me to a mne that thi wa a negativ xp n n . However, by exploring that experience by a king "how was the funeral for you ." I may l arn that thi re entment or adn vent brought great relief, or perhap . The importance of genuine curio ity i to create opportunitie for the client to lead me through their life in way that they may recognize parts of the1nselves in new way that regulate the relationship between thought, e1notion, behaviour and pirit. Behaviours. Behaviours shape interpersonal reality and can be a concrete area for change. Paterson et al. (2006) suggest that behavioural change is nece ary to create and maintain healthy thoughts and feelings. If a person waits until he feel like exercising it is likely she will never exercise. On the other hand if she decides to exerci for thirty 1ninutes three time and accomplishes the e three goals she may create po itive fl elings about exercising. Collaborative problem solving illu trate the importance of behavioural change. Articulating a specific behaviour like ' raising your hand in ocial studie ' contain the conver ation to pecific, ob ervabl e in tan ces. Thi re p ct th p r on' autonom a they are given the pace to be the expert of th ir e perience of th e event and their CLINI CAL REFLECTIONS r p n . ploring th int raction between a p r n' b haviour thought, and feeling can h lp peopl 1nake chang in any of the e area . Figur 2.2 h lp u c nc ptualiz th e 7 dir ction within th expenenc of Th boundary of hold memory lf repr lf. nt d in th ball shape can be under tood a a container that If-concept and knowl edge gain d ov r tim e. Thought b haviour af£ ct th way a p r motion , and n function . A Tree in th e Fore t Talk th rapy i one of the many ite of ocial Work. A I reflect on om of the numerou way of h lping individual and familie create change, I al o think about how to fo ter ocia1 and cultural change. one ptualizing ociety a a fore t, or gard en, represent a hi torical -intergenerati onal p ychology. This is beyond the scope of thi paper and is mentioned here a a comment toward the adoption of CDOI approache for ocial work in the realm of cmnmunity development. Prechtel (2012) describes nature as knowl edge manifested by the ordering principles of the sun. Plant communiti es respond to the sun and the particular characteristics of their immediate environment. Cyclical processes result from the pattern of the seasons and foster diversity with the capacity to "absorb di turbance and reorganize while und ergoing change o as to till retain e entially the same function, structure, identity, and feedbacks" (Bergamini et al. , 20 13, p . 10). Particular pattern etnerge that facilitate complex elf-organizing ecologies re ilient to adversity. Hart (2002) sugge ts then ed for a c 11 ctive purp e for health that tran cend difference. Healing becomes po ible through a har d motivation that b gin within ach indi vidual. In thi way we ecome re pon ible for our wn health and t contribut t CLINI CAL REFLECT IONS coll ctiv health. Th r i tr m ndou potential for cial change a individual realize their p r onal r p n ibility for coll ctive well-being (Hart, 2002). Th c 11 ti e pr ject f cultural change i not addre sed while working with indi idual or famili d terminant de pit the imp rtan f h alth . D the f under tanding cial and co nomic anadian cultural c nt xt promote health? It i time to expand the con er ati n to understand ulture and community a part of the int rventions we u e in clinical context . A t 1npting a it may b to chip tree to make plywood or u e ne theory to guide ach th rapeutic encounter, ther is an elegance and trength to hand made furniture and client direct d therapy. How do we cone ptualize the forest for the tree ? I individual and family th rapy the mo t effectiv way to att nd to experience of contemporary living? I believe that talk therapy i an important component within a larger proce of cultural change and collective healing. It may be helpful to conceptualize collective healing processes as environmental reclamation. Individual and collective health are important and interrelated. How can we better help individuals engage in systems that revitalize and maintain individual psychological ecologies? In my mind the goal is to create ocial communities capabl of absorbing external shocks and adverse environments. Attention i paid to increa e individual resiliency, yet there seem to me that there is a lack of congruency between agencies to create syste1ns that foster individual and collective well -being appropriate to time and place. CLINI CAL REFLECT IONS Conclusion I et out to improv 1ny clinical kill and confidence through thi practicum xp n nc . I can ay with c nfidence that thi approach ha b abl t R n a ucces . I fe 1 b tter nceptualiz the work with each eli nt and I am comfortabJ u ing the OR and with client to guid th cour ftherapy. I mn grat ful to have engaged in th creative project of articulating my practice fram work and col gical p ychology model to help guid my clinical work. I feel more confid nt a11d b tt r abl t j in and work with eli nt . Th re are broad implication for social work practice. I it po sible to understand clinical work at a ociallevel, a social and cultural realitie are determinants of individual health (Ha k 11 & Randall , 2009)? What could a Community Directed Outcome Informed approach to community develop1nent look like? Client directed approaches to therapy are effective by working from the client's perception of the problem and theory of change. Working from the client's frmne of reference creates space for the client to learn new skill by participating a the central figure in the process of change. What might this look like at a cmnmunity, provincial, and national level? The ORS and SRS are two concrete tools that can empower client to remain at the center of their care. How might population mea ur satisfaction be measured? of well-being and urrently GDP and economic growth are mea urement assumed to reflect well-being. The nearest 1nea urement of a social R may be voter turnout at elections, which communicates a cl ar di interest to the politi cal y t m touted to erve our need . The fractur d natur of ial r lati n i t tam nt to the CLINICAL REFLECTIONS iati nal c mmunity li:fl d cribed by N u:fl ld and Mate (2 04) a th atta hm nt illag . I gr t p t ntial :fl r ut m r arch to xpl r th 1nmunit -ba d int rventi n . Fr m my xpen n p r nal int r dir t d appr ach ffi ctiven f w rking with gr up , and my mmunit w rk I hyp the iz that imilar finding that c mmunity tin t n ighb rh d and ommunity d el pment may be m re ffi ctiv c mmunity direct d approach gr unded in rig r u than in ti tuti nal r p n ut uld b 1 ter funding and att nti n t th imp rtance fa ociation of m- r ar h peopl w rking t m t mutual need , rath r than y tern approache whereby pr fe i nal h lp eli nt (M Kni ght, 19 7). Wher a the field f p ychol gy, it i time for le D I practic ha em rg d from cia] work t explore imilar principle at a cial 1. Hart (2002) frame the interrelation b tween individual and collective w ll -being in the ree cone pt of Mino-Pimatisiwin. DOl approache t therapy have deepl y affected my clinical practice and approaches to helping pe pl e. Th lack of community direct d intervention and re arch are worthy of further re earch. Working with individual 's and familie can nly becom e mor ef:fl ctive in collaborati n with community dir ct d re pon e t community need . It i my h pe that my r fle ti n and th ught behind c nc ptualizing th therapeutic geography (figur 1) and th psych logical ecology (figure 2. 1; figure 2.2) influ nc th r ader' th ught to in pir creative re p n e t th force that hape ociety toda . 1 ha matur d thr ugh thi practicum and am better ab l to work effl tively with client . l ha c b haped thr ugh my w rk at and I am grateful [i r thi pportunit . n ignificantl CLINI CAL REFLECTIO NS Reference Am ri an P ychiatric A ociati n. (2000). Diagnostic and statistical manual of mental 111 di order (4 ed. , t t r v.). doi: 10.1176/appi.b ok .9780890423349 Anker M.G. , w n J., Duncan B. L. & park , J. a. (2010) . Th alliance in couple therapy: Partn r influ nee, early chang , and alliance patt m in a naturalistic ample. 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(2008). hild & family b havior th rapy differential re pon e of children with varying degree of reactive and proactive of childr n aggre ion to two forms of p ycho ocial tr atm nt differential re pon with varying degrees of reactive and proactive aggr ion. Child and Family Behavior Th erapy . 30:1, 37- 50. doi :l0.1300/J019v30n01 Yalom, I. (2002) . Th e g~ft of th erapy: An op en letter to a new generation of th erapi ts and th eir patients. New York: Harper ollin . Zapf, M.K. (2009). Social Work and th e environm ent: Understanding p eople and p lace. Toronto : anadian Scholars Pre . CLINICAL REFLECTIONS pp ndix A n Rating cale ( R Y . .0) ----------------------- g (Yr ): ID# : M/F ------------------------ arne e 1 n# Date: ion by placing a mark fit y ur penence. I did not feel heard , understood , and respected . 1-------- --- ·---- ·- -- -· -- ·---- -- --· -- ---- --- -- ------ ·--·- -- -· - ·----- 1 Goal a d We did not work on or talk about what I wanted to work on and talk about. . I felt heard , understood , and respected . Opl S I------------ ·---- ·- -- -· -- ·---- ·-··--· ---------- ---- ·---· --· - ---· --··---- I We worked on and talked about what I wanted to work on and talk about. Approach or M t od The therapist's approach is not a good fit for me. I--------· -- -- ·---- ·- -- -· - --·---- ·-· --· -- ---- --- -- ------ ·--·- -- -· -· ----- I The therapist's approach is a good fit for me. Overall There was something missing in the session today. !------------ ·---- ·----·-- ·----·-··--· --- -----------·--- --- ------ .. ---- 1 Th e H art and o ul of hang Projc t . om 7 Overall , today's session was right f o r me. CLINICAL REFLECTIONS ut pp ndix B m e Rating cal ( R ) L oking back ov r th la t w k in cluding t day h lp u und er tand how you have b een feeling by rating h w well y u hav be n d ing in th foll w ing area f yo ur life, wh re m ark t the left r pre ent 1 w level and mark to th ri ght indi ate high level . ff y ou are fi llin out thi .form .for anoth r p er on p l a e.fill out according to how y ou think he or she i doing. Individually (Per onal well-being) I---- ----·--- ·---- ·- ---· -- ·- --- ·- ·--· -- ---- -- - -- -- -·--- ·--·- -- -· -·----- I Interpersonally (Famil y cl o e r lation hip ) I---- -- ---- ·--· - ·- -- -· -- ·---_.. _·--· -- ------- -- -· ----- ·--· - -- -· ------- I Socially (Work, school, friend hip ) I--------· ___ , ·---- ·- ---· -· .. ·---- ·-· --· -- ---- --- -- ------ ·--· - -- -· -· ----- I Overall (G eneral n e f well -b ing) I---- ---- --- ·---- ·- -- -· -- ·---- ·- --· --· ---- --- -- ·-- --- ·---- -- -· - ·---- I h leart and oul of hang Proj ct www .heartand o ul D hang . m © 2000, tt D. Mill er and arr L. Duncan 77 CLINI CAL REFLECT ION S Guidelin s for Appendix hild Parent R lation hip Therapy 1- et the tag 2- onvey "be with' attitude 3- Allow child to lead 4- Follow child' lead 5- Reflective re ponding to child a. Nonverbal play behavior b. V rbalization c. Feeling /want /wi h d. Match voice tone with child inten ity/affect e. Brief and interactiv f. Match facial expr ions w/ child ' af:D ct 6- ncourage ( elf-esteem re pon e ) 7- Set limit (ACT) (Bratton, Landreth, Kellam , & Blackard, 2006, p. 34) 78