In our final discussion post - please offer any practice examples from your internship where you have questions. Are you able to see and experience the application of some of the techniques we have discussed this term?
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At my internship I have had the experience to do several intake assessments with patients coming in for 28 day detox programs and 90 day programs. They are all at different stages of change, so I have found motivational interviewing to be very beneficial. Open ended questions allowed me to gather information that I needed for the assessment, allow the client to feel that it was a safe environment to open up and share information, while letting me get to know the client. That in itself was rewarding, as I see the clients in the hall and they smile, waive and will come up to me and ask me how I am doing. It makes me feel as if I was not just an intern completing paperwork. I was gaining knowledge of people, the struggles the went through, the path that they chose which brought them to rehabilitation and their future goals to chose a different path when they leave.
ReplyDeleteWhile conducting the assessments I tried to use summarization to ensure I was accurately capturing things in the clients own words and also letting them know I was supportive and listening. Most of them thanked me for listening or apologized for talking too much. I told them to not apologize, this was their story, their time to tell it and I was here to listen. One woman said "I am afraid to open up on the floor and talk about these things and I feel very comfortable sharing these things with you". Just knowing that I was able to help her express things she had been holding in and she felt better after, made me feel better after.
While building rapport with some clients I used affirmations. I maintained appropriate eye contact, kept a relaxed tone and changed my tone to show empathy, as a demonstration of understanding and I providing positive feedback. Most of all I was supportive and nonjudgmental.
I have utilized many other skills throughout this class and have learned that some can be used interchangeably.
Christine McGovern
Hi Christine,
DeleteIt sounds like you have really absorbed a lot of valuable information through this class. I really enjoyed hearing how you are incorporating skills we discussed in this class into your work. I can envision you using affirmations and empathy when working with patients.
Have you found any skills or approaches difficult to incorporate into your work?
Christine G.
Hi Christine -
DeleteIt sounds like you have had a great experience so far. Have you had to implement any disciplinary action (ie: not following house or group rules, etc) and if so, do you think this has affected your rapport with some of the clients? I know that when I use to work in residential I was a stickler for the rules and some of the clients would get angry because I would issue warnings, however, when I was leaving the particular program a variety of the clients thanked me for holding them accountable and felt as though it was an important part of their recovery.
Rebecca
Christine,
DeleteSo far all the techniques that I have utilized have worked well as the clients who are here working on their recovery are also for the most part dealing with mental health diagnoses that surface after they get done masking their feelings and emotions with the substances that they were so used to using for so long to make themselves numb. DBT I guess can be hard for some clients as it in a way pushes clients to reach their full potential, when they sometimes feel they are worthless and have nothing left to give. It is important as social workers that we show them that we are there, be supportive and help them to recognize the potential we see.
Christine Mc.
Rebecca,
DeleteWhen enforcing the rules, that can be a struggle, especially in the beginning we the clients looked at me as just the intern. When the realized that I had just as much authority to give warnings as the rest of the staff, I received a lot more respect. I have had some get angry and then come back to me and apologize. Saying they understood if I allowed them to break the rules, then I would have to let everyone. I praised them for being able to recognize that and for recognizing how the unit would be without rules and order.
Christine Mc.
Christine its wonderful how much your clients trust you and i'm sure a lot of their process depends on their relationship with you- I really sounds like you are working with vulnerable people and its great that you can help them open up. I continue to look forward to hearing about the work you are doing! Hope you get a break and can enjoy the holidays with your family :)
DeleteAnnie,
DeleteIt is rewarding work and clients can open up if they feel they can trust up, making it easier for us to support them. Hope you have a nice holiday too, thank you:)!!
Christine McGovern
Hi All,
ReplyDeleteI can't believe we are at week 8 already!
Over the past 3 months, I have worked with a variety of patients. I have worked with kids with behavioral issues, aggression issues, kids on the spectrum, kids going through the grief process, kids with trauma history, kids with abuse/neglect and kids experiencing severe mental illness. When I first started this internship, I thought my background in DBT was going to aide me in working with my assigned patients. I quickly discovered that my DBT training could only carry me so far.
After working with a young woman experiencing severe psychosis, I was humbled in seeing the limitations of only having one "tool" in my "toolbox". This experience happened at a great time (the beginning of this semester) and I have been able to really open my mind to other approaches and really try to absorb as much as possible.
Over the past 8 weeks, I have seen moments where each approach would be helpful and I now understand the importance of social workers being flexible and really understanding their patients in order to best serve them.
In the future, I hope to learn more about short term social worker and the best way to serve patients when only working with them for 7-10 days (what I am doing now at my internship), the medical model and also approaches when working with individuals with severe mental illness. I believe this last population continues to be the most difficult for me, due to lack of experience.
Thank you all for another great class!
Christine George
I have been utilizing a lot of motivational interviewing recently, especially with clients that have arrived in the ER with alcohol related problems or have overdosed (often times requiring revival with the use of narcan). Asking open ended questions regarding openness to treatment and if they are interested in receiving information about local treatment programs appears to come off less invasive and truly allows the client to feel in control of their situation. I can imagine that they are embarrassed by being in the ER in this condition so I feel like giving them a choice perhaps eliminates some of the shame and guilt they may be feeling. As mentioned in other posts and classes, I have been struggling with the idea of secondary trauma. Nothing too specific or unbearable, just occasional restlessness or dreams about some of my experiences at the hospital. I have learned that as a result of this, self care is more important now than ever, especially when I have been witness to a traumatic situation. Being able to care for myself is essential in keeping me healthy both physically and mentally to help care for my patients.
ReplyDeleteIt again has been a great class with a fabulous cohort. I enjoy our teamwork and am so thankful for the support offered from each and every one of you. No doubt I will "see" you in a future classes and look forward to our continued worked together.
Rebecca
Hi Rebecca,
DeleteYour use of open ended questions and other MI techniques seems very appropriate when working with individuals with SA issues in the hospital. I think it is very important that you are keeping in mind the possibility of guilt and shame, as they are very powerful emotions.
I am sorry to hear that you are dealing with secondary trauma, however, it sounds like you are taking steps to take care of yourself and giving yourself room to think and feel as we all need to.
Enjoy your holidays and "see" you in January!
Christine
I have seen so much this term because of this class...which accounts for the thought that a bit earlier in our course work this information would have been helpful, but would also have been incorporated earlier in the field to giving flesh to the all important aspect of practice and experience. Anyway, very grateful for the MI module and video demo, as well as the CBT. I thought the play was right up my alley and appreciated the articles, videos and the role play.
ReplyDeleteI am drawn to Frankl's work in Meaning Therapy or Logotherapy. I see a great deal of suffering as do the rest of you, and for myself I know my search for meaning has a direct impact on how I am as a social worker.
I appreciated this week's Tegrity and YouTube videos- I have to confess, to see the video on "Not Remembering" was encouraging and a relief. I was surprised that I seem to be just swallowing everything up like dogma, when in fact, it is, in the end, an eclectic approach and truly person-centered approach which each of us will use. And Lee said as much- a bit of everything. I have no idea why this is suddenly underlining in red and it appears I do not have enough smarts to figure it out. So for now, adieu.
Hi Gail,
DeleteI also wish this information was given to use last year during our first internship. However, I am appreciative of the opportunity to absorb and discuss all of this now. I look forward to our last couple of classes, as I am sure they are as applicable as this class. Enjoy your holidays! "See" you soon!
Christine
Last week I joined another clinician in leading a DUI group. Many of the clients are there because they have to. Many are angry and not really wanting to learn anything, they are just counting down the sessions until they "show up" at 20 meetings. Tonight while the same people complained and blamed everyone else for their problems I kept thinking, this would be a great time to try Solution Focused Therapy. I changed the conversation from the endless list of problems being discussed to asking each client to come up with the solution. Every time one of them started to again talk about only the problem, I would redirect. While I do not think I made a huge change for anyone, I did change the way this group was thinking and what the focus was. With a lot more practice I could see myself using SFT more often.
ReplyDeleteI also had a chance to meet with a client today who is working with a therapist on Narrative Therapy. I am very interested in learning more about this technique. Is anyone else using Narrative Therapy? From what I understand, its a way of rewriting ones story and changing how the client sees their life. It changes the picture from one of trauma to one of hope.
Hi Jen,
DeleteI am using Narrative Therapy with a young man with trauma history, IDD and a genetic disorder called Prader Willi.
He has the awful story that he is "no good, bad, no one wants to be with him because he is unlovable, he will never be belong, etc."
When we are able to pinpoint anything that is contrary to his story, we re-write his story....He had a long term issue with abandonment and come of his care giving family signed up for a once a week class out of the home on Monday nights. In the beginning he got very angry and acted out- he is intense and can be violent. However, over the course of a few weeks the story stayed the same: What were you afraid of? him: "Thye left me for good" Did they come back? "Yes" Every time? "Yes" So is it fair to say they are not interested in leaving you? "Yes" How do you feel about that? "good" So, do you think that maybe they kind of like you and want to stay living together? "yes" Sure, cause you are a likable person..... and so on.
I have to say, he has really enjoyed re-writing his story and has grown in tolerance and courage. We have pictures of positive events, his life with the family, his room and own bathroom- his new story.
It has helped to get rid of some of some of the spiral negative thinking and helped him come to see that he belongs, which is his real fear.
Gail
Hi Jennifer,
DeleteI have heard of narrative therapy, but I have never used it. I would imagine that this might be a great tool for clients who are extremely introverted or have anxiety when discussing certain topics and/or events. Please keep us updated as you continue to work with this client.
I think your use of SFT is great. By you redirecting the conversation, it may help to change the culture of the group over time. Rather than being a place to complain about problems, individuals will know the expectation is to strategize solutions as well. Good luck, it can be very exhausting to run groups where members are stuck in these thinking patterns.
Christine
Jen,
DeleteI think SFT was perfect to use in this group. It is hard when people are in the mind frame of blaming others and it takes awhile to change their thinking, change does not happen overnight, but we have to start somewhere. Great use of redirection to steer the conversation away from the negative.
I have never used narrative therapy and I would like to learn more about it too. I will have to research it more and add it to my library of techniques if it will fit in with the clients I work with. If not I will save it for future work.
Christine Mc.
Okay, I've got a question. Actually, it's more of a request for advice. I had a client come in to see me today who was sporting some pretty serious suicidal ideation. (We ended up calling the ambulance to take her to the hospital.) I did the best I could in the session, but I feel like I could have handled the situation better. So I'd sure appreciate some feedback on the conversation and ways I could have been more helpful to her.
ReplyDeleteI was going to attach the process recording...but I don't see any way to d that in this blog. So I'm going to reply to myself here with the conversation from the process recording. Word of warning...it's kind of long.
Me: So tell me about Saturday.
DeleteS: I tried to kill myself Saturday. I OD’d; I took too many of my pills. Like 20 of them? 28?
Me: Can you tell me a little bit about what was going on then?
S: I don’t know. I don’t want to think about it. (pause) I just felt exhausted. I was exhausted. There was so much going on and I just couldn’t deal with it.
Me: So there was a lot going on and it made you feel overwhelmed?
S: Yeah.
Me: What was going on?
S: My neighbor spreading lies about me. She says I was having a two month long incestuous relationship with my cousin, which is a lie. He raped me. That’s different. But she’s got the whole building thinking all these things about me, and they’re all turning on me and it’s just making me feel like I’m garbage. I’m suing her, I’ve got the paperwork right here; do you want to see it? It’s for defamation of character. But it costs 20 bucks to file, and I don’t have 20 bucks. I have maybe 5 bucks, that’s all I’ve got to my name, so I have to wait before I can file. And they told me it could take up to a year before it goes to court. And that sucks because I want her to pay for what she’s doing right now. I want people to know she was lying. I just want to tell them that it was a rape it wasn’t consensual, and he confessed to it, so I’m not making things up. I want to tell them that, but I’m afraid it’ll mess us the court case if I do. Do you think so?
Me: (surprised) Do I think it will mess up your court case?
S: If I tell that woman what he said; that he confessed to it. Do you think it would mess up the trial?
Me: Well…I’m not a lawyer…
S: Right. You’re not a lawyer. I understand. But what do you think?
Me: …Um…well, like I said, I’m not a lawyer. So don’t take this as legal advice. …But…is this woman involved in the court case in any way?
S: No.
Me: Then I don’t think it would matter what you tell her.
S: Hm. Okay.
Me: But I’d like to talk about what happened Saturday a little longer, if you don’t mind.
S: You mean when I tried to kill myself?
Me: Yes, that’s what I mean.
S: Okay. What do you want to know?
Me: I…(pauses to think) I guess I’m trying to figure out what was going on with you when you made that decision. Can you tell me about it?
S: I just felt exhausted. I didn’t want to deal with all of it anymore! It was too much and I just wanted it over and done with.
Me: And how do you feel now?
S: About the suicide?
Me: Yes.
S: I don’t care. I don’t! I still feel exhausted. There’s just too much. And I tried to end it, and I don’t feel anything about that one way or another. I just took the pills and I figured either I’ll wake up or I won’t. And I did, and that’s fine. But it would have been fine the other way too. And that’s the way I feel right now. I just don’t care either way.
Me: Did you go to the hospital?
S: No. I woke up, and I got up and started my day. Same as always. I won’t go to the hospital. I’m done with hospitals.
Me: So you feel like you don’t care if you live or die?
S: I’m just exhausted.
There's more. The website wouldn't let me post it all in one go.
DeleteMe: (pauses for thought) Okay…um…All right. Let me ask you a question…
S: Okay. Ask me a question. Go ahead.
Me: Can you tell me the reasons you had that made you feel like killing yourself was a good idea?
S: I don’t want to talk about that.
Me: You don’t want to talk about it?
S: No. Why do I…you know, okay fine. What was the question again?
Me: What were you telling yourself when you decided to suicide?
S: I was feeling awful! I was just overwhelmed and I wanted to be through with it all! I just wanted to be done. I’m exhausted.
Me: So what was overwhelming you? You mentioned your neighbor.
S: Yeah, she’s spreading lies about me, that I’ve been having incest with my cousin! And now everyone in the building is thinking those things about me, and I kept thinking about that.
Me: Okay. So…
S: And! And they want me to start DBT therapy again, and that’s going to be all the stuff all over again. I know the skills! I know mindfulness and relaxation techniques and all that shit, but they’re going to make me learn them all over again, and it’ll be just like going back to school, and it’s too much. I don’t want to do those things anymore; it’s too much. I’m just so tired of it.
(takes a quick breath and keeps going)
And they want that to start in two weeks, so they’re leaving me with nothing until then. They’re just throwing me out until then. I need more therapy than just once a week. I need therapy every day! Let alone in two weeks.
(keeps going without pause)
And then I got thinking about my brother and how he doesn’t care about me. And I don’t have no family that cares about me. I’ve tried to kill myself in the past and no one comes to visit me at the hospital. They never visit because they don’t care. I don’t have anyone; I’m all alone.
(pause)
Me: Wow Sounds like you’re going through a hard time right now.
S: Yeah, I’m going through a hard time all right.
Me: I’m sorry.
S: Yeah.
Me: (pause) So that’s a lot of things that are piling up on you, making you exhausted…
S: Yeah, I’m exhausted!
Me: So what’s the flip-side of that? What are the reasons you have to…
S: (interrupts) To keep living?
Me: Yes.
S: I don’t have any.
Me: You don’t have anything positive in your life?
S: Oh, I have positives, but they’re not really positive.
Me: Like what?
S: (annoyed tone of voice) Well, I have friends. Only I don’t really have friends. Nobody who really cares. Like I have my friend (name), and I called her up the other day, and I’m telling her about my neighbor and all the lies she’s telling about me. And then I get to the part where I told her I was raped. I said, “I was raped,” and she says, “I have to go.” Can you believe that? I tell her I was raped, and I need a little comfort, but no, she has to make another call, so she has to get off the phone. So she hangs up. Some friend.
Me: That’s rough.
S: Yeah, so that’s a “positive” (said scornfully) I don’t have any real friends. No one who will visit me.
Me: Didn’t you tell me last week that you had a friend over visiting?
S: Yeah, there’s (different name). She visited me.
Me: So…
S: But that’s just once in a while. It’s all like that. It’s always like that, and I have all this stuff on me, and I have medical problems too. (talks about her medical problems for a bit), so I decided to make it stop. So I tried to kill myself. I just decided to.
Me: Do you still feel that way?
S: You mean, do I still want to kill myself?
Me: Yes.
S: I don’t know. I don’t know from one moment to the next what I’m going to do. Maybe.
Me: Well, I’m concerned about you.
S: You’re concerned about me. Well, don’t worry. I won’t do it. Except I don’t know from one moment to the next. I just want it all to stop. I just want it to stop. I want everything to stop.
Hi Alice,
DeleteI do not think you were inappropriate to call an ambulance. However, I am curious if you talked with her about it or made the call without her knowledge? I could see this as a relationship "deal breaker" if this was something that was just sprung on her rather than discussed. However, I don't think there is any easy solution when someone is in this state, your first responsibility is to her safety and you did that. Good job navigating a difficult conversation.
Christine
HI Christine,
DeleteThe answer to your question is...sort of. I asked my supervisor for advice (when the client paused the session to go to the bathroom), and she suggested calling the ambulance. So she made the call while I went back in. So the call was already being made, but I told S that we'd done that.
It may have been a relationship deal-breaker. She didn't want to talk to me after that. She just kept saying she was tired--to tired to talk. I tried to re-engage her a few times, but she wasn't having any of it. So I jut sat with her for support until they people came. I'm not sure I handled that part of it well, either. Although she wasn't acting angry, I think she probably was...but I wasn't sure how to get her to talk about that. I tried confronting the resistance ("Are you angry with me for calling them? Some people would be", etc.) but she just denied it and then continued to clam up.
She nearly refused to go with them too ("Against Medical Advice")...she changed her story when they asked her questions and just kept saying she was just overtired. But just as they were packing up to leave, she asked one of the guys whether he thought she should go to the hospital, and he said in his opinion it'd be helpful...and that changed her mind. She went with them. I hope it was helpful.
She wanted to be in a safe environment and wanted someone to chase after her (you know that feeling when you are playing chase with someone and you are running, running away and you keep looking back to se that they are chasing? remember how sad it was when you looked back and they had given up?)
DeleteAlso, when we were talking about transference and counter transference- can you see where that fits into play with this client? DO you think maybe you were absorbing some of the "blame" because she put it on you and you...maybe...are use to accepting it?
Alice, this is her problem , nit yours- you are there to support her and work for her- and you did what you were suppose to do - you had no choice.
I do not think this person will not be in relationship with you because you cared enough to chase after her by calling the ambulance.
Hi Gail,
DeleteYou raise a good point about counter-transference. I certainly did feel badly, and it is very possible that I was projecting that feeling onto her reactions.
Especially because she came into the Y briefly today, and was fine. The experience at the hospital wasn't a good one (she had a panic attack while she was there...and apparently they treated her for the panic attack and then released her...without follow up for the suicidal ideation? What's wrong with this picture?) ...However, while she wanted to talk, she was in a more positive place than she'd been on Weds and she didn't seem to be holding any grudges. As for the SI...she said wasn't going to do anything like that...and she certainly seemed more positive. I hope things continue to be positive (she has very labile emotions). This is my last day at the YWCA, so I won't be able to follow up with her in the future. She does have a new therapist she'll be meeting with in a week at some other organization, though. So she won't be cut off from support.
Hi Alice -
DeleteThis is a tough situation that I unfortunately have encountered many times. I think when people present with suicidal ideation it is always important to ask about plan, intent and means and assess if the situation requires further action. I agree with Christine that I wouldn't call an ambulance right away, unless of course the person was incapacitated and appeared to not be able to make decisions for themselves. Also, I always get a supervisor involved when these situations arise to just make sure I handled the situation appropriately, especially if further intervention is needed. Lastly document, document, document. Make sure progress or encounter notes document the individuals SI and whether they had a plan, means or intent and how you handled the situation. This would become especially crucial if something horrible happened to your client you want to make sure that you did everything in your power at the time to properly assess the client's safety.
Rebecca
Sorry about the length there.
ReplyDeleteSo...question: Were we jumping the gun calling the ambulance for her? 'Cause she got kind of mad at me when they came.
Hi Alice,
DeleteShe would have ben mad at you if you didn't!
You were not jumping the gun by calling the ambulance, or whoever did. The following is from the American Psychological Directorate,
https://www.apa.org/education/ce/suicide.pdf
The following are common behaviors that indicate suicide risk:
Past attempts. Disrupted sleep patterns. Increased anxiety and agitation. Outbursts of rage or low frustration tolerance. Risk-taking behavior. Increased alcohol or drug use. Sudden mood change for the better. Any talk or indication of suicidal ideation or intent, planning or actual actions taken to procure a means.
Your client is in trouble and you did a wonderful job bringing her back to talking with you about it, being empathetic, supportive, and caring for her by getting her help.
You may want to read that link above.
Take care, you are well, and did well,
Gail
Thank you, Gail. I appreciate that. :-)
DeleteI enjoyed learning about all the different therapeutic models and I wish I was able to have more time to be able to really have training and practice in all of them. When I was in Far Rockaway I was able to work with children using play therapy and recently with my GABI training I was for the first time exposed to how psychotherapy can be used during group work. I found Motivational Interviewing to be very interesting and I also would of liked some experience in CBT which I really haven't had. With the knowledge that I have gained from this class I can apply these techniques but in terms of training, I feel like time is running out and I am in my final training. Hopefully as we continue on in the final semester of our MSW we will continue to be able to learn and apply some of these techniques.
ReplyDeleteHi Annie,
DeleteThank you for verbalizing the pressure that I am also feeling. We really are in our final stages of "training" and I feel like there is so much to absorb and work on. I try to remind myself this career is a journey, not a destination and it is about progress, not perfection. The only person who expects me to be "on my game" every moment, is myself. Be well knowing we are all in this together. Enjoy your holidays.
Christine
we are absolutely in this together and I also feel the pressure being in the final stage, but its only just begun! I hope this work is forever evolving. Happy holidays to you too!
DeleteWhile I am just getting going at my internship the staff here has impressed me with their reflective listening and summation skills. I would not have noticed as much a year ago.
ReplyDelete