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CFN9885 - SECTION 12: INTERVENTIONS

 

Types of Interventions

All counseling theories agree that the primary goal of counseling is identify presenting problems and to help clients to initiate and facilitate the desired changes. However, how the problems are conceptualized and how the changes are to be accomplished will differ depending upon the characteristics of the clinician, the counseling theory or approach that is being utilized, the characteristics of the client, and any limits that are placed on the counseling process (i.e., type and number of sessions, etc.).

Interventions need to be designed jointly between the client and the clinician. A first step in this process is to ask clients about times in their lives when the issues or problems they have identified have not existed or have been less severe and what are some the reasons why these issues or problems were not as significant as they are now.

In this regard, clients can be asked what they have tried in the past to address these issues or problems and what has worked and what has not worked and why some of the things they have tried have worked or not worked. This process helps both the client and the clinician identify the types of personal and interpersonal resources or strengths the client possesses and how existing resources or strengths can be better utilized or help the client find new resources or strength to address their problems or issues.

What resources or strengths will be used will depend upon the client’s strengths or weaknesses and the types of problems or issues they want to address.

Interventions may include the following:

- Affective interventions: help clients to control or change their affect, feelings, or emotions surrounding the problem.
- Cognitive interventions: help clients to control or change their thoughts, beliefs, and attitudes about the problem.
- Behavioral interventions: help clients control or eliminate existing behaviors and/or develop new behaviors or skills.
- Systemic interventions: help clients to address relationship patterns, that is, help clients to change or better utilize their social environment.

With most clients, interventions would involve addressing a number of these areas.


Factors that Influence Types of Interventions

Choosing the most appropriate intervention involves adaptation. It is important to approach selection of interventions judiciously and be prepared to change or modify interventions when they are not working. Clinicians need knowledge, practice, and supervision in using specific interventions with clients with particular characteristics, paying particular attention to the client’s reaction to the intervention.

In considering which interventions to use, the clinician may want to consider the following factors:

- A description of all relevant and potentially useful treatment approaches
- A rationale for each procedure that will be used
- A description of the clinician’s role in each intervention
- A description of the client’s role in each intervention
- Possible discomforts or risks that may occur as a result of the intervention
- Expected benefits that will occur as a result of the intervention
- The estimated time and cost of each intervention
- The client’s expectations and preferences
- The client’s previous attempts to solve the problems
- The client’s characteristics and resources. (Cormier & Nurius, 2003)


Finally, clinicians need to be willing to admit when the approach they are using is not working with a client. There needs to be good fit between the clinician and the client. Most books on working with clients discuss methods for reducing client resistance or noncompliance. However, such discussions assume that clinicians always know what is best for their clients and it is the responsibility of the clinician to confront and try to overcome client resistance.

Another way to look at resistance is that it is the way in which clients are telling clinicians that they do not like what is being done in counseling. It is also possible that the therapy is not working because you are the wrong clinician for this client or you are doing a poor job with this client. If this happens, then clinicians need to discuss with clients why they feel the counseling is not working and what each of them can do to improve it.

You may also want to consult with your supervisor or another clinician to get their insight on the situation. If this is not successful then clinicians need to refer clients to another clinician.

Counseling Lessons

The type of counseling relationship we have with our clients and the types of interventions we use may depend on the client’s level of functioning or competence. Much of the work in this area comes from Beavers and Hampton (1990) and their analysis of family functioning. They have developed assessment tools that classify families from successful or healthy family functioning to severely dysfunctional family functioning.

Some individual and family clients want and need a clinician who will - at least initially - take a more authoritative and guidance style of doing counseling. I have found that this is particularly true with clients who are experiencing a significant crisis in their lives or with clients who have trouble taking control of their lives.

With other clients or with some clients after we have established some stability in their lives, I may adopt a more partnership style of doing therapy. I have found that I do not want to have a style of therapy where my clients become dependent upon me. Basically, I want to work myself out of a job. While initially I may be directive with some types of clients, with all of my clients I ultimately see my job as empowering them to live their own lives in a way that is meaningful for them.

Because most clients come to therapy to address a content area, I have found that I need to be able to show them early signs that their presenting problems are being addressed. I can help them better understand and express their feelings and learn some of the reasons why they do certain things, but if I do not help them solve their presenting problems, they will typically see counseling as not very useful.

A client gains little if they merely have a better intellectual understanding of their problem, but they are not able to make meaningful changes in their life. Clients need to be able to put these new insights and understandings into constructive action that improves their life.

I remember a single mother and her 10 year-old son came for therapy because the son, while very bright, was not doing well in school and there was a great deal of conflict between them over his school performance. My colleague and I immediately decided to emphasize process (the mother’s relationship with her son) over content (practical ways to help him do better in school and practical ways to help their relationship).

While we made some improvements in the relationship between the mother and the son, his school performance declined and the mother was questioning the value of therapy. We decided to pay more attention to practical ways to help the mother and the son’s relationship and practical ways to improve the son’s school performance. When we paid more attention to the content areas, the mother and her son responded very positively, they were more responsive in therapy, and their relationship improved.

On the other hand, if we had only focused on content areas without addressing the process areas, the improvements might have been short lived. For the change to be sustained, the process areas needed to be addressed as well.

It is important for us to be flexible in the ways in which we work with our clients. I learned these lessons with one of my early traineeship clients. He was a single man in his mid-40s who had developed agoraphobia primarily around driving on freeways. Since he lived a significant distance from our office, I began doing therapy with him over the phone and sending him materials to read and complete.

I did therapy this way with him for three months until he began to lose some of his fears of freeway driving and he was able to come to my office for therapy. Initially, therapy was primarily cognitive-behavioral since I felt this orientation would work best with his initial presenting problem of agoraphobia. However, as the therapy progressed and he began to work on, and address, his agoraphobia, we began paying more attention to the underlying sources of his anxiety using primarily an object relations perspective.

It is my belief that too many clinicians and therapists feel they need to have one theoretical orientation, become an expert in that orientation, and use it on all of their clients. I have found that the problem with this approach is similar to the problem of the little boy with a hammer who is constantly looking for things that “need” hammering.

Because of their personality, life experiences, and clinical training, most clinicians will likely be naturally more attracted to some theories and orientations than others. However, I feel it is the characteristics and needs of my clients that should be the primary determining factor in what theory or orientation I use with them.

 

 

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