Help clients understand and break the lethal [wounds + unawareness] cycle!

Key Clinical-process Interventions

Help clients learn process awareness

By Peter K. Gerlach, MSW
Member NSRC Experts Council


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        This article is one of a series on effective professional counseling, coaching, and therapy with (a) low-nurturance (dysfunctional) families and with (b) typical survivors of childhood neglect and trauma. These articles for professionals are under construction.

        This series assumes you're familiar with:

        Before continuing, pause and reflect - why are you reading this article? What do you need?

+ + +

        Here, an intervention is some planned or instinctive behavior by a counselor or therapist which causes a meaningful change in a client system of subselves or people. Effective interventions reduce or resolve client's primary "problems" - i.e. empower them to safely fill their primary needs.   

       This is one of three checklists on effective clinical interventions with six types of divorcing-family and stepfamily clients. It is based on 26 years' study and live clinical experience with many hundreds of typical marital and family clients. The checklist assumes you are familiar with all five elements of this clinical model. The other checklists summarize key interventions with divorcing-families and stepfamily clients, and with individual persons (wound-recovery work).

        These reference checklists aim to help clinicians, supervisors, and consultants (a) plan effective treatment strategies and (b) measure progress in their work with a given client family. Links connect to background on the primary problems and/or to outlines and examples of each intervention.

        Premise: typical adults and children are unaware of their current internal and external processes - i.e. their thoughts, feelings, needs, body signals, and behaviors, and what these mean. They also are usually unaware of behavioral sequences and patterns (repeated behavioral sequences). Teaching clients to become more process aware - in and out of clinical sessions - can help empower them to fill their primary needs more effectively. Implication: to raise clients' process-awareness, clinicians need to be steadily process-aware themselves.

       Prerequisites to any of these interventions are (a) validating any "crisis" the client adults are experiencing, and (b) working to stabilize it. Suggestions on doing effective crisis intervention are beyond the scope of this article and series.

Selected Process Interventions

        Premise: Effective clinical outcomes (filling primary needs) are most likely if clinicians (a) automatically monitor three inter-related processes in every client contact, and (b) use this awareness to tune session dynamics to fit desired local and long-term outcomes. The processes are...

  • their own dynamic thoughts, feelings, senses, needs, and body sensations, and (b) whether their true Self is guiding their personality or not; and...

  • empathically sense these variables in each other person present; and monitor...

  • current verbal and non-verbal behaviors, and behavior sequences and patterns, among all people in each  session and across multiple sessions.

Skilled supervisors and consultants can help clinicians learn to be steadily aware of these three inter-related domains and how to use their awareness strategically. Clinicians with harmonious subselves are most apt to develop and use accurate empathy and process awareness.

Reality check: on a scale of one (I'm never aware of these three domains) to ten (I'm clearly aware of them all the time), my recent process-awareness skill is about a ___.

        See if you think that adopting any of these process interventions would significantly improve your clinical outcomes with any clients. Options -

  • try each intervention in different situations, and note the results over time...

  • use this checklist to promote constructive supervisory and/or self-critique guidance

  • modify this checklist, give a copy to clients, and ask for feedback on which of this interventions they find helpful. This can also act as a reminder to them outside clinical meetings, and a guide for teaching their kids to be process-aware..

__  1)  Process awareness - Teach clients to (a) be objectively aware of the three process-domains above, and (b) encourage them to help each other be aware of them at home. The more aware they are, the more options they have for accurately discerning and filling their current primary needs. Awareness is the most basic of seven learnable thinking and communicating skills. See Project 2 and its guidebook for many skill-building resources.

__  2)  Distraction-checks - Begin any clinical session by asking each person present to check themselves for physical, mental, or emotional distractions that might hinder with the work. One way of doing that is to ask each person "What are you aware of (in yourself) now? Is anything distracting you from being fully present here?" If the answer is "Yes," the clinician needs to decide whether to ask for more information and focus on reducing the distraction, or ignoring it. Option: to help decide this, ask something like "On a scale of one (little) to ten (total), how big is this distraction for you now?"

__  3)  Role definitions - Some clients - specially those dominated by a false self and/or who have never experienced professional therapy or counseling before - are unclear what their and the clinician's roles (responsibilities) are. This can cause unrealistic expectations and hinder effective session and overall clinical outcomes. Guard against this by saying something in the first meeting (and subsequently as appropriate) like - "Your family members are my employer now. I'm here to help you learn how to fill your primary needs without helpers like me." Some clients who are dominated by insecure or overwhelmed inner children fear taking full responsibility for themselves, and insist that the clinician and/or other family members are responsible for solving their problems.

__ 4) Session objectives (needs) - At the start of every session, ask each participating client to identify what s/he wants to get - specifically - from the meeting. This can sound like...

  • "What would you like to walk out of this meeting with?"; or...

  • "What do you need to get from this meeting?"; or...

  • "Pause and reflect - why did you come here today?"

Clients often respond with surface generalities like "to feel better," "to fix my problem," "I want to talk about..."; or "I want (someone present) to understand (something general)." The second half of this process intervention is to help clients "dig down" to discern their underlying primary needs.

        If the clinician asks awareness-raising questions like these at the start of several successive sessions, clients often will become self-motivated to walk in the door with a clear idea of what they need from the meeting.

__ 5) Need-blocks - Once clients identify their primary needs from the session (vs. overall), ask them "Why did you need to come here to fill that need? What prevents you from filling your need outside this meeting?" A related question is "What do you need from me in this meeting?" Doing some version of this can illuminate one or more unidentified primary problems (needs) - e.g. "Well, this is the only place my partner and I can talk without distractions." - which suggests the real problem/s are (a) one or more people are ruled by a false self, and/or (b) one or both partners don't give high priority to "talking together" for some reason/s.

__ 6) Session-process options - (a) Teach participating client adults the different process options you and they can select from, and (b) facilitate their awareness of which of these options they're choosing as the session unfolds:

  • venting - needing to describe current thoughts, feelings, and needs, and be empathically understood and accepted. A common kind of venting is... .

  • explaining - clients usually need family members and the clinician to understand and empathize with why they did or didn't do something in some situation/s. This is specially true if a client feels misunderstood or blamed for something unfairly (feels criticized and/or attacked).

  • problem-solving (conflict resolution) - assessing primary needs and brainstorming win-win ways to fill them. As the work unfolds, help client-adults stay objectively aware of their process and avoid these common problem-solving alternatives. For instance, if clients get stuck in venting, explaining, blaming, or defocusing, interrupt them and ask something like "In the last __ minutes, have you (or we) been problem-solving, or doing something else? Is this what you came here to do?"

  • clarifying and/or affirming someone's perceptions, values (including priorities), needs, and/or goals

  • learning / teaching - clients and the clinician gaining new information from each other in the context of the presenting and primary problems - e.g. "Let me suggest the important difference between guilt and shame," or "Let me summarize the four types of addiction, and the purpose they all serve." Learning can be didactic and/or experiential ("Let's do a role play of __").

Option: review these options briefly at the start of a session, and ask "Which of these would be most helpful in our meeting?" If different family members have conflicting needs on how to use the session, use that to model cooperative prioritizing and win-win problem-solving. ("Let's explore how each of you can get enough of your needs met here...") Note that the phrase "I need to process  (something) with you" is a catchall phrase for needing several or all of these.

__  7)  Hearing checks - Premise: most client adults and all client children don't know how to listen empathically in conflictual, confusing, or scary situations - and they don't know they don't know. So a powerful process intervention is to (a) ask a client to "say back" what they just heard from someone in the session, or (b) observe that you (the clinician) just listened empathically (did a "hearing check.") When someone does a hearing check, invite the clients to notice the first speaker's reaction ("I see Alice is nodding her head now"), and ask the original speaker "Are you feeling heard well enough now?" If the answer is "Yes," affirm the listener ("Looks like that was an effective hearing check. Notice how you both feel right now...")

__  8)  Focusing - help clients grow objectively aware of where they and the group are focusing (a) recently (e.g. in the last 10"), (b) in the session so far, (c) across several sessions, and/or (d) outside the sessions. Variables:

  • time frame - discussing the past, the present, or the future - e.g. "How does focusing so intently on the past (or future) help you fill your current primary needs?"

  • person/s - focusing on the needs, traits, and/or behaviors of yourself, another person, or several other people. A related intervention is to discuss two or more clients' "awareness bubbles" in the session and/or elsewhere.

  • relationships - focusing on filling partners' needs in a marriage or a parent-child, sibling-sibling, ex-mate, or other family relationship;

  • topic - focusing on session (clinical) goal/s or something else - e.g. "I notice we started by focusing on reducing Marge's fear of bankruptcy, and now we've switched to your frustrations from the financial values-differences between Marge and Robert. Are you all feeling done with the first topic?"

  • process - which of the session-process options above are participants focusing on so far?

__  9)  Strategic silence - (a) the clinician's silence and/or intentional avoidance of eye contact, and/or (b) asking clients to be silent for a time, can promote useful personal and group awarenesses. This can be specially useful if a client is talking incessantly or obsessively, which usually indicates they're controlled by a false self.

__  10)  Awareness checks - at any point in the session, the clinician can say to one or more people "Pause, breathe, and reflect - what are you aware of now?" This can be more revealing than "What are you thinking or feeling now?" 

__  11)  Balance checks - at strategic points, ask clients something like "How do you feel about who's doing most of the talking in our meeting (or several meetings)?" If the clinician notices one or more clients choosing to be silent "too much," s/he can invite that person to speak, or ask "Is there something that would make it more comfortable for you to say what you feel and need here?".

__  12)  Outcomes - At the end of a session or series of sessions, ask clients something like "Are you (each) getting enough of what you came here for?" Alternative: "Do you feel we're making enough progress on your goals here?" Option: whether the answer is "Yes" or "No," discuss why.




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Created 04-30-2013