You Are Not the Only Therapist in Town

An excuse often offered for doing individual, couples, and family work interchangeably with the same people is that the people involved insist on it. Underlying their preference is their belief that you have done excellent work. This is ?attering, but not a convincing argument. Choosing to cross the boundaries and do the additional work can, in fact, undo some of the good work you did in the ?rst place. Avoiding dual roles, an ethical guideline present in all mental health professional ethics codes, includes avoiding being someone’s family therapist and individual therapist if being in both roles may cause you to lose objectivity .

Catering to the clients’ ideas that you are the best or only option is, in fact, not even necessarily healthy. Helping clients attain a more ?exible manner of functioning in the world and increasing their capacities for relationships are goals that undergird most forms of therapy. Encouraging an individual to try a different therapist because you were his or her couple counselor can be an important vote of con?dence in the client.

It communicates that you believe the client can connect with another professional and can use that therapeutic relationship to grow and change. It is rarely, if ever, justi?ed to 366 Interviewing Special Populationsallow or encourage client dependence on you as the counselor. Obviously, in some rural settings, managing multiple therapy relationships in one family may be unavoidable. In fact, you may not be the only competent therapist in town, you may be the only therapist in town .

Interviewing Couples and Families 341Now, I’m just making an appointment. Either he’ll come with me or I’ll come by myself.” Couples are notorious for engaging in what therapists refer to as triangulation. Triangulation occurs when one member of a couple relationship establishes an allegiance with a third party, usually to gain sympathy or power. Often, the person calling for couples counseling begins, even during the initial telephone contact, to actively seek sympathy from the interviewer. Triangulation frequently occurs in couples and families; it is generally viewed as a less than optimal strategy for increasing a person’s power in the couple or family system .

Often, the sex of the therapist is an important variable when couples call for an appointment. In training clinics, it can be possible for an opposite sex cotherapy team to work with couples and families. Although doing cotherapy can add therapist communication problems to the already complicated mix, it is usually seen as advantageous, especially in training clinics. Inexperienced therapists gladly look to each other for support and direction when they are unclear regarding how to proceed. In contrast, more advanced therapists sometimes regard cotherapy as a burden. Already con?dent regarding how to proceed, they ?nd comments from a cotherapist detracts from an ef?cient therapy process. However, assuming the cotherapists are theoretically compatible and capable of communicating well with each other, having two perspectives usually offers couples and families a more comprehensive service.

Unfortunately for clients, rarely do counselors work together in mental health clinic or private practice settings. There are exceptions, and even some theoretical orientations in which having two therapists involved is foundational to the work . Generally, however, it is too costly for two professionals to work jointly with a couple or family. In some training clinics, the option for either a male or female therapist is presented when couples counseling has been requested: Interviewer: “Sometimes, people who are coming for couples counseling prefer to see a male or a female therapist. Do you have any preference?” Client: “Hmm. Actually, she never said whether she wants to work with a lady or a man. I guess she’d probably rather work with a lady counselor, but I’d rather talk to another man about this. Yeah, you better schedule us with a man.” In this example, the husband brie?y struggles with whether to go with his or his spouse’s preference for a male or female counselor, then opts to go with his preference over his wife’s. This choice may represent an initial hope for triangulation. That is, the husband is hoping that a male therapist might see things more from his perspective than his wife’s perspective. Hoping for or attempting to enact triangulation, although a possible sign of couple pathology, is fairly natural for couples seeking therapeutic assistance. As usual, we recommend that interviewers make mental notes of ?rst impressions from the outset of their telephone contact, including whether the client who telephoned was trying too hard to gain sympathy or support from the interviewer.

In this case, it was obvious after conducting a thorough interview that the client was behaving in an unusual and disturbing manner. His behavior was rationally unjusti?able , statistically infrequent , disturbing , and maladaptive .

Now we are left with a ?nal question regarding the justi?ability of the man’s behavior. Namely, is his behavior culturally justi?ed or sanctioned? Think about this standard. Can you think of any cultural situations that might adequately justify this man’s rather controlling behaviors? We take up the issue of judging mental disorders in their cultural context to a greater extent in Individual and Cultural Highlight 6.2 and Chapter 13.

An Overview of the Interview Process Exploring Society’s Contributions to Client Problems That client problems must be viewed in their social and cultural context is an unarguable fact. Articulating this point for families in particular, Goldenberg and Goldenberg describe the discoveries made by renowned family therapist Salvador Minuchin .

As Minuchin and his coworkers began to accumulate research and clinical data and to rede?ne the problem in family terms, successful interventions involving the entire family became possible. Later research expanded to include asthmatic children with severe, recurrent attacks as well as anorectic children; the additional data con?rmed for Minuchin that the locus of pathology was in the context of the family and not simply in the af?icted individual .

Minuchin argued the importance of seeing individual client symptoms from the family systems perspective. In contrast, the DSM IV TR, although including a section on cultural issues with each major diagnostic category, continues to de?ne mental disorders as residing exclusively in the individual .

Inconsistency between a client’s and the therapist’s therapy goals is illustrated in the movie Ordinary People .In this case, during the initial session, the teenage client tells his psychologist that his goal is to “have more control.” In contrast, the psychologist views the client as overcontrolled, needing to loosen up, let go, and relax more. Popular books and movies, perhaps for purposes of mounting con?ict 20 Becoming a Mental Health Professionaland excitement, frequently portray therapists and clients as having different therapy goals .

As an interviewer, it is important for you to value the client’s perspective, while at the same time providing a professional opinion regarding appropriate goals and strategies.

Striking this balance requires sensitivity, tact, and excellent communication skills.

Clinical interviewers are designated experts in the area of mental health and, therefore, have the responsibility to professionally evaluate or assess client problems before proceeding with treatment. The purpose of evaluating clients is to facilitate the intervention or helping process. A minimal ?rst session evaluation includes a thorough assessment of your client’s presenting problem, an analysis of his or her expectations or goals for therapy, and a review of previous efforts at solving the problem or problems that bring him or her to seek therapy. In most cases, if an initial assessment reveals that client and therapist goals are incompatible, it is incumbent on the therapist to offer the client an opportunity to work with a different therapist.

Premature interventions based on inadequate assessment have been linked to negative therapy outcomes . If a premature intervention is offered before adequate assessment is conducted and mutual goals are formulated, a number of negative outcomes might occur. These include, but are not limited to, the following:

• The interviewer may choose an inappropriate therapeutic approach or technique

that is potentially damaging to the client’s condition .

In contrast, sometimes clients show up in the therapist’s of?ce with little motivation.

They may have been cajoled or coerced into attending therapy sessions by someone else. In such cases, the client’s primary motivation may be to terminate therapy or to be pronounced “well” . Obviously, if clients are poorly motivated for therapy, it is challenging for interviewers to establish and maintain a professional therapist client relationship.

Clients who come to therapy for personal growth and development are often highly motivated to engage in a therapeutic process. Because they come by choice and for positive reasons, these clients can be particularly eager for therapy and easy to work with.

Establishing Common Goals

To establish common therapy goals with clients, therapists must use evaluation and assessment procedures. This means getting clients to participate in or articulate a personal self assessment. Early in the counseling hour, the therapist needs to interact with the client to help identify what the client thinks is wrong and what the client thinks might help. When the client and therapist agree on the client’s problem, establishing therapy goals is relatively easy and painless.

On the other hand, sometimes clients and therapists disagree about what should be accomplished in therapy. These disagreements may stem from a variety of sources including, but not limited to: poor client motivation or insight and questionable therapist motives or insight. Historically, more directive approaches to psychotherapy usually considered client motivation and insight as limited or suspect, while therapist motivation and insight was considered relatively infallible. More recently, perhaps because of an emphasis on ethical issues such as informed consent and therapist accountability, most therapy approaches place greater value on the client’s perspective than in years past.

Similar to person centered therapists, psychoanalytic therapists acknowledge that empathic listening may be a powerful source of healing in its own right: “Frequently underestimated is the degree to which the therapist’s presence and empathic listening constitute the most powerful source of help and support one human being can provide another” . However, for psychoanalytically oriented clinicians, empathic listening is usually viewed as a necessary, but not suf?cient, ingredient for client personal growth and development .

In contrast to person centered and psychodynamic interviewers, behavioral, cognitive, or solution oriented interviewers are more inclined to take an expert role from the beginning of the ?rst clinical interview. They believe that speci?c thoughts, personal frameworks, and maladaptive behaviors cause mental and emotional distress . Therefore, their main therapeutic work involves identifying and modifying or eliminating maladaptive thinking and behavioral patterns, replacing them with more adaptive patterns as quickly and ef?ciently as possible, thereby alleviating the client’s social and emotional problems. Kendall and Bemis describe the cognitive behavioral therapist’s directive orientation: The task of the cognitive behavioral therapist is to act as a diagnostician, educator, and technical consultant who assesses maladaptive cognitive processes and works with the client to design learning experiences that may remediate these dysfunctional cognitions and the behavioral and affective patterns with which they correlate.

Despite this description, most cognitive behavioral clinicians also recognize the importance of empathic listening as a necessary, although not suf?cient, factor in adaptive behavior change . Michael Mahoney , a renowned cognitive behavioral therapist, has stated that “a secure and caring 8 Becoming a Mental Health Professionalrelationship” constitutes one of the most basic “general principles of human helping” . Other cognitive behavioral practitioners have made similar statements. Notably, Wright and Davis, in the inaugural issue of the journal Cognitive and Behavioral Practice, state: “We ?nd strong consensus in the conclusion that the relationship is central to therapeutic change” and “Even in speci?c behavioral therapies, patients who view their therapist as warm and empathetic will be more involved in their treatment and, ultimately, have a better outcome” .

Or you may want to try strapping small, one pound weights with Velcro closures onto your wrists while you eat; they help in controlling tremor. These weights can be found in a medical/surgical supply store or can be ordered through your local pharmacy or hospital.

If, despite medication, you still have difficulty cutting up your food, you may want to ask someone to do it for you before you sit down to eat. Or you could invest in an electric food processor to help with the task. The food processor is a good investment because it can also help you become a creative cook, preparing many tasty mixtures of foods.

If you have a dry mouth (caused by certain medications) or have difficulty chewing or swallowing, you can also use the food nutrition that affects our lives processor or, to a lesser extent, a blender to mix your food with liquid and chop or puree it. Eat slowly and deliberately. Give yourself time to eat your whole meal. Of course, if you have difficulty swallowing, you should ask your doctor to refer you to a therapist (usually, a speech therapist) who can teach you how to think through the steps of swallowing and enable you to eat your meal safely. Swallowing food improperly may cause food particles to travel into your lungs, where any foreign matter can cause pneumonia. You don’t need that! Most people with swallowing difficulties know that liquid is even more difficult to swallow correctly than is pureed or well chewed food. It seems to be harder for the muscles to direct liquid along the right pathway, and liquid that makes its way into the lungs can also cause pneumonia. The speech therapist will teach you how to swallow liquids correctly.